Attitudes, Habits, and Behavior Change.

Efforts to guide peoples' behavior toward environmental sustainability, good health, or new products have emphasized informational and attitude change strategies. There is evidence that changing attitudes leads to changes in behavior, yet this approach takes insufficient account of the nature and operation of habits, which form boundary conditions for attitude-directed interventions. Integration of research on attitudes and habits might enable investigators to identify when and how behavior change strategies will be most effective. How might attitudinally driven behavior change be consolidated into lasting habits? How do habits protect the individual against the vicissitudes of attitudes and temptations and promote goal achievement? How might attitudinal approaches aiming to change habits be improved by capitalizing on habit discontinuities and strategic planning? When and how might changing or creating habit architecture shape habits directly? A systematic approach to these questions might help move behavior change efforts from attitude change strategies to habit change strategies.

Understanding the nature of association between anxiety phenotypes and anorexia nervosa: a triangulation approach.

BACKGROUND: Evidence from observational studies suggests an association between anxiety disorders and anorexia nervosa (AN), but causal inference is complicated by the potential for confounding in these studies. We triangulate evidence across a longitudinal study and a Mendelian randomization (MR) study, to evaluate whether there is support for anxiety disorder phenotypes exerting a causal effect on AN risk. METHODS: Study One assessed longitudinal associations of childhood worry and anxiety disorders with lifetime AN in the Avon Longitudinal Study of Parents and Children cohort. Study Two used two-sample MR to evaluate: causal effects of worry, and genetic liability to anxiety disorders, on AN risk; causal effects of genetic liability to AN on anxiety outcomes; and the causal influence of worry on anxiety disorder development. The independence of effects of worry, relative to depressed affect, on AN and anxiety disorder outcomes, was explored using multivariable MR. Analyses were completed using summary statistics from recent genome-wide association studies. RESULTS: Study One did not support an association between worry and subsequent AN, but there was strong evidence for anxiety disorders predicting increased risk of AN. Study Two outcomes supported worry causally increasing AN risk, but did not support a causal effect of anxiety disorders on AN development, or of AN on anxiety disorders/worry. Findings also indicated that worry causally influences anxiety disorder development. Multivariable analysis estimates suggested the influence of worry on both AN and anxiety disorders was independent of depressed affect. CONCLUSIONS: Overall our results provide mixed evidence regarding the causal role of anxiety exposures in AN aetiology. The inconsistency between outcomes of Studies One and Two may be explained by limitations surrounding worry assessment in Study One, confounding of the anxiety disorder and AN association in observational research, and low power in MR analyses probing causal effects of genetic liability to anxiety disorders. The evidence for worry acting as a causal risk factor for anxiety disorders and AN supports targeting worry for prevention of both outcomes. Further research should clarify how a tendency to worry translates into AN risk, and whether anxiety disorder pathology exerts any causal effect on AN.

The (bitter) sweet taste of nudge effectiveness: The role of habits in a portion size nudge, a proof of concept study.

Seemingly insignificant daily practices, such as sugar usage in tea, can have a great accumulated impact on societal issues, such as obesity. That is why these behaviours are often the target of nudge interventions. However, when these behaviours are performed frequently they may turn into habits that are difficult to change. The aim of the current study was to investigate whether a portion size nudge has the potential to work in accordance with (instead of against) existing habits. Specifically, it was tested whether a portion size nudge would be more effective in reducing the amount of sugar added to tea, when people have a strong habit of adding a fixed amount of teaspoons of sugar to a cup of tea. The study (N = 123) had a mixed factorial design with teaspoon size (reduced size vs. control) as a within-subject factor, and habit disruption context condition (hot tea vs. cold tea) as a between-subjects factor. A paired t-test indicated that this nudge reduced sugar intake on average by 27% within subjects. When the context allowed for automatic enactment of the habit, the effectiveness of this nudge was moderated by habit strength. Surprisingly, the nudge effect was actually less pronounced when people had a strong habit. Implications for effective nudge interventions are discussed.

Predicting the restrictive eating, exercise, and weight monitoring compulsions of anorexia nervosa.

PURPOSE: Compulsions surrounding restrictive eating, exercise, and weight monitoring are thought to maintain abnormal eating behaviour in individuals with anorexia nervosa (AN). This study aimed to determine if AN psychopathology and trait anxiety explain the presence of restrictive eating, exercise, and weight monitoring compulsions in a mixed sample. METHODS: Participants were 31 females with AN and 31 age and gender-matched healthy individuals (HC). Restrictive eating, exercise and weight monitoring compulsion presence was compared between AN and HC groups. Multivariable poisson regression analyses, adjusted for diagnostic status, were conducted to assess the association of both AN psychopathology and trait anxiety with compulsions across the mixed group. RESULTS: Individuals with AN endorsed a greater number of restrictive eating, exercise and weight monitoring compulsions compared to HC. In adjusted poisson regression analyses neither AN psychopathology nor trait anxiety predicted compulsion presence: incidence rate ratio (IRR) for AN psychopathology = 1.15 [95% CI 0.84, 1.57], p = 0.39; IRR for trait anxiety = 1.01 [95% CI 0.97, 1.06], p = 0.50. CONCLUSIONS: Greater presence of restrictive eating, exercise and weight monitoring compulsions was reported by individuals with AN, supporting the conceptualisation of disorder behaviours as compulsive. The study was underpowered to robustly evaluate the association between predictors of interest and the compulsions outcome, largely owing to the small sample size. Further investigation is required, ideally using methods able to identify causal and mediation effects. LEVEL OF EVIDENCE: Level V, cross-sectional study.

Conscientiousness and (un)healthy eating: the role of impulsive eating and age in the consumption of daily main meals.

The present study aims to explore the relationship between conscientiousness and the consumption of healthy versus unhealthy main meals. Impulsive eating was tested as a mediator in this relationship, as well as direct effects of age on those constructs. A nationwide representative sample of 1,006 Norwegian adults (18-70 years) within a prospective design was used to test a theoretical model. The structural equation model (SEM), in combination with bootstrapping procedures in AMOS, was the principal analytical method. Conscientiousness was negatively associated with unhealthy and impulsive eating. Impulsive eating was a partial mediator between conscientiousness and unhealthy eating and a full mediator between conscientiousness and healthy eating. Age was positively correlated with conscientiousness and this relationship had an inverted U-shape form. Finally, age was negatively associated with unhealthy and impulsive eating, and positively associated with healthy eating. This study confirmed the relevance of conscientiousness for healthy, unhealthy, and impulsive eating.

A cluster randomised controlled trial of an intervention to promote healthy lifestyle habits to school leavers: study rationale, design, and methods.

BACKGROUND: Physical inactivity and a poor diet predict lifestyle diseases such as diabetes, cardiovascular disease, and certain types of cancer. Marked declines in physical activity occur during late adolescence, coinciding with the point at which many young people leave school and enter the workforce and begin to take greater control over their lifestyle behaviours. The work outlined within this paper sought to test a theoretically-informed intervention aimed at supporting increased engagement in physical activity and healthy eating habits in young people at the point of transition from school to work or work-based learning. As actively engaging young people in initiatives based on health messages is challenging, we also tested the efficacy of financial incentives in promoting initial engagement with the programme. METHODS/DESIGN: A three-arm cluster-randomised design was used. Participants were school pupils from Year 11 and 13 (i.e., in their final year of study), aged 16-18 years. To reduce contamination effects, the unit of randomisation was school. Participants were randomly allocated to receive (i) a 12-week behavioural support intervention consisting of six appointments, (ii) a behavioural support intervention plus incentives (totalling £40), or (iii) an information-only control group. Behavioural support was provided by fitness advisors at local leisure centres following an initial consultation with a dietician. Sessions focused on promoting habit formation through setting implementation intentions as part of an incremental goal setting process. Consistent with self-determination theory, all advisors were trained to provide guidance in an autonomy-supportive manner so that they were equipped to create a social context supportive of autonomous forms of participant motivation. The primary outcome was objectively assessed physical activity (via GT1M accelerometers). Secondary outcome measures were diet, motivation and habit strength. Data were collected at baseline, post-intervention (12 weeks) and 12 months. DISCUSSION: Findings of this trial will provide valuable insight into the feasibility of promoting autonomous engagement in healthy physical activity and dietary habits among school leavers. The research also provides much needed data and detailed information related to the use of incentives for the initial promotion of young peoples' behaviour change during this important transition. TRIAL REGISTRATION: The trial is registered as Current Controlled Trials ISRCTN55839517.

Reflective and impulsive influences on unhealthy snacking. The moderating effects of food related self-control.

This study proposes that snacking behaviour may be either reflective and deliberate or impulsive, thus following a dual-process account. We hypothesised that chronic individual differences in food related self-control would moderate the relationships between reflective and impulsive processes. The reflective route was represented by an attitude toward unhealthy snacking, while the impulsive route was represented by the tendency to buy snack on impulse. A web survey was conducted with 207 students and employees at a Norwegian university, and a moderated hierarchical regression analysis using structural equation modelling was used to estimate the theoretical model. The findings showed that both attitudes towards unhealthy snacking and impulsive snack buying tendency were positively related to snack consumption. Food related self-control moderated the relation between attitude and behaviour, as well as the relation between impulsive snack buying tendency and behaviour. The effect of attitude on consumption was relatively strong when food related self-control was strong, while the effect of impulsive snack buying on consumption was relatively strong when food related self-control was weak. The results thus suggest that while weak self-control exposes individuals vulnerable to impulsive tendencies, strong self-control does not necessarily lead to less unhealthy snacking, but this depends on the valence of an individual's attitude.

A relationship that makes life worth-living: levels of value orientation explain differences in meaning and life satisfaction.

When people talk about their values they refer to what is meaningful to them. Although meaning is associated with life satisfaction, previous studies report inconsistent results regarding the association of values and well-being. A cross-sectional study (N = 276) addresses the research question, do values influence experiences of meaning and subjective evaluations of life satisfaction? To assess whether providing a definition of "meaningful" is necessary when employing meaning measures, we assigned participants to condition where some provided their definition and others read a definition of "meaningful". All participants described a recent meaningful experience; they characterized it with sources of meaning; they read descriptions of 10 values and assessed the degree those were relevant to their experience; and they completed meaning and life satisfaction measures. Findings, which were unaffected by reading a definition of "meaningful", indicated that the most common source of meaning (Family) was associated positively with the value of Tradition and negatively with the value of Universalism. Latent Profile Analysis identified three profiles denoting participants' level of value orientation, which explained interindividual differences in average levels of meaning and life satisfaction variables. Participants who associated their meaningful experience with the 10 universal values at a high level scored higher in the meaning and life satisfaction measures than those who associated their experience to the 10 universal values at a low level. The present work advances knowledge regarding the relationship between meaning, values and life satisfaction and validates previous studies reporting on meaning as a marker of well-being.

Cognitive processes in autism: Repetitive thinking in autistic versus non-autistic adults.

LAY ABSTRACT: A core feature of autism is the tendency to do the same activity or behaviour repetitively. We wanted to find out if autistic people also experience repetitive thinking, for example, having the same thoughts repeatedly. We thought that there would be a link between repetitive behaviour and repetitive thinking. We asked 54 autistic people and 66 non-autistic people to complete questionnaires measuring repetitive behaviours and obsessive thinking. Next, participants were trained by a researcher to record their thoughts using a structured paper form. They then completed 5 days of thought recording, which they did each time a random alarm sounded on their mobile phone. We found that autistic people had more repetitive thoughts than non-autistic people, but they did not report having more negative or visual thoughts compared with non-autistic people. Autistic people who had more repetitive thoughts during the 5 days of thought recording did not report more repetitive behaviour. However, autistic people who reported more obsessive thinking, for example, more negative and unwanted thoughts, also reported higher levels of repetitive behaviour. We conclude that some repetitive behaviours may be linked to anxiety and that more research is needed to better understand repetitive behaviours in autism.

Identifying as someone who avoids virus transmission strengthens physical distancing habit-behaviour relationships: A longitudinal multi-national study during the COVID-19 pandemic.

Physical distancing remains an important initiative to curb COVID-19 and virus transmission more broadly. This exploratory study investigated how physical distancing behaviour changed during the COVID-19 pandemic and whether it was associated with identity with virus transmission avoidance and physical distancing habit strength. In a longitudinal, multinational study with fortnightly repeated-assessments, associations and moderation effects were considered for both overall (person-level means) and occasion-specific deviations in habit and identity. Participants (N = 586, M age = 42, 79% female) self-reported physical distancing behavioural frequency, physical distancing habit strength, and identity with avoiding virus transmission. Physical distancing followed a cubic trajectory, with initial high engagement decreasing rapidly before increasing again near study end. Physical distancing was associated with both overall and occasion-specific virus transmission avoidant identity and physical distancing habit strength. People with strong virus transmission avoidant identity engaged in physical distancing frequently regardless of fluctuations in habit strength. However, for those with weaker virus transmission avoidant identity, physical distancing was strongly aligned with fluctuations in habit strength. To enhance engagement in physical distancing, public health messaging might fruitfully target greater or more salient virus-transmission avoidance identity and stronger physical distancing habit.

Changes in virus-transmission habits during the COVID-19 pandemic: a cross-national, repeated measures study.

OBJECTIVE: The COVID-19 pandemic saw promotion of novel virus transmission-reduction behaviours, and discouragement of familiar transmission-conducive behaviours. Understanding changes in the automatic nature of such behaviours is important, because habitual behaviours may be more easily reactivated in future outbreaks and disrupting old habits may discontinue unwanted behaviours. DESIGN: A repeated-measures, multi-national design tracked virus-transmission habits and behaviour fortnightly over six months (Apr-Sept 2020) among 517 participants (age M = 42 ± 16y, 79% female). MAIN OUTCOME MEASURES: Within-participant habit trajectories across all timepoints, and engagement in transmission-reduction behaviours (handwashing when entering home; handwashing with soap for 20 seconds; physical distancing) and transmission-conducive behaviours (coughing/sneezing into hands; making physical contact) summed over the final two timepoints. RESULTS: Three habit trajectory types were observed. Habits that remained strong ('stable strong habit') and habits that strengthened ('habit formation') were most common for transmission-reduction behaviours. Erosion of initially strong habits ('habit degradation') was most common for transmission-conducive behaviours. Regression analyses showed 'habit formation' and 'stable strong habit' trajectories were associated with greater behavioural engagement at later timepoints. CONCLUSION: Participants typically maintained or formed transmission-reduction habits, which encouraged later performance, and degraded transmission-conducive habits, which decreased performance. Findings suggest COVID-19-preventive habits may be recoverable in future virus outbreaks.

Changing healthcare professionals' non-reflective processes to improve the quality of care.

RATIONALE: Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. OBJECTIVES: To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. METHODS: Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. RESULTS: From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. CONCLUSION: Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

Factors contributing to the experience of shame and shame management: Adverse childhood experiences, peer acceptance, and attachment styles.

Previous research has firmly established that some individuals experience shame more frequently than others. This study employed a cross-sectional design to explore factors that are related to the experience of shame. In this study, 240 participants completed self-reported assessments of parental care and expectations, maternal attitudes toward negative emotions, peer acceptance during childhood, attachment styles, and shame management. In particular, submissive shame management strategies (self-attack and withdrawal) and negative parental experiences were correlated with frequent experience of shame. In addition, a model was developed to depict the relationship between childhood experiences, attachment styles, shame, and shame management. The results suggest that negative parental experiences are contributory factors to the experience of shame, through attachment styles. The model illustrated how shame might be developed and how it might be managed.

Habit and Identity: Behavioral, Cognitive, Affective, and Motivational Facets of an Integrated Self.

Two studies investigated associations between habits and identity, in particular what people consider as their "true self." Habit-identity associations were assessed by within-participant correlations between self-reported habit and associated true self ratings of 80 behaviors. The behaviors were instantiations of 10 basic values. In Study 1, significant correlations were observed between individual differences in the strength of habit-identity associations, measures of cognitive self-integration (prioritizing self-relevant information), self-esteem, and an orientation toward an ideal self. Study 2 further tested the assumption that habits are associated with identity if these relate to important goals or values. An experimental manipulation of value affirmation demonstrated that, compared to a control condition, habit-identity associations were stronger if participants explicitly generated the habit and true self ratings while indicating which values the behaviors would serve. Taken together, the results suggest that habits may serve to define who we are, in particular when these are considered in the context of self-related goals or central values. When habits relate to feelings of identity this comes with stronger cognitive self-integration, higher self-esteem, and a striving toward an ideal self. Linking habits to identity may sustain newly formed behaviors and may thus lead to more effective behavior change interventions.

A systematic review of studies probing longitudinal associations between anxiety and anorexia nervosa.

The current study aimed to establish whether anxiety predicts subsequent anorexia nervosa onset and maintenance. A systematic review of longitudinal studies assessing the association between stable anxiety exposures (e.g. trait anxiety/anxiety disorder pathology) and anorexia nervosa development or maintenance was undertaken. Eight studies met inclusion criteria. Seven probed the association between anxiety and anorexia nervosa onset, and one assessed the association between anxiety and anorexia nervosa maintenance. Individuals with anorexia nervosa were more likely to report childhood anxiety compared to healthy individuals, but whether childhood anxiety explains unique variance in anorexia nervosa development is unclear. Current evidence does not support longitudinal associations between specific anxiety disorders (independently of other anxiety disorders) and subsequent anorexia nervosa onset, however anxiety disorder diagnosis in general may predict increased anorexia nervosa risk. The single study probing the association between anxiety and anorexia nervosa maintenance did not find evidence supporting a relationship. The quality of individual studies was fair to high, however the body of evidence was of low quality. Further research that minimises bias, allowing for strong conclusions concerning longitudinal associations between anxiety and subsequent anorexia nervosa outcomes, is required to inform anorexia nervosa aetiology. This in turn may promote improved prevention and treatment.

Accounting for the role of habit in behavioural strategies for injury prevention.

The limited success of behavioural strategies in injury prevention has been attributed to failure to properly apply behaviour change models to intervention design and the explanation of safety behaviours. However, this paper contends that many health behaviour change interventions do not succeed because they fail to take into account the habitual quality of most health and safety-related behaviour; a more complete model of behaviour change needs to be based on a better understanding of the role of habit. The overall aim is to contribute to better understanding of behavioural strategies for injury prevention. When habits are weak, attitudes and intentions predict behaviours, but as behaviours turn into habits, they become better predictors of future behaviour than attitudes or intentions. Furthermore, where habits are strong, individuals are less likely to act on new information, evaluating counter-habitual information negatively. Integrating the concepts of strong and weak habits with upstream and downstream strategies, a framework is presented for tailoring strategies to the habit strength of the target behaviour.

Anxiety and the development and maintenance of anorexia nervosa: protocol for a systematic review.

BACKGROUND: Several aetiological models of anorexia nervosa (AN) hold non-eating/weight-gain-related anxiety as a factor relevant to the onset and maintenance of the disorder. Longitudinal studies that allow assessment of this hypothesis have been conducted; however, the evidence has not yet been aggregated in a systematic manner. The proposed study will systematically review articles describing prospective investigations of the relationship between anxiety and AN development or maintenance, with the aim of providing a balanced summary of current understanding and identifying areas for further research. METHODS/DESIGN: Electronic databases will be searched for articles investigating the longitudinal influence of non-eating/weight-gain-related anxiety (anxiety disorders and trait anxiety) on the development/maintenance of AN. References of eligible articles will be searched to ensure the identification of all relevant studies. Two independent reviewers will complete the title and abstract, and full-text, screening, with a third independent reviewer resolving any conflicts at each stage. A systematic review will be completed, and the quality of the included studies, as well as the strength of the body of evidence generated, will be assessed and reported. DISCUSSION: Although there are limitations to the present review, understanding the current evidence for the role of non-eating/weight-gain-related anxiety in AN can direct future research that may ensure accurate aetiological models of AN and effective treatments. SYSTEMATIC REVIEW REGISTRATION: The study is registered on PROSPERO under the reference number CRD42017069644.

Mental habits: metacognitive reflection on negative self-thinking.

In 8 studies, the authors investigated negative self-thinking as a mental habit. Mental content (negative self-thoughts) was distinguished from mental process (negative self-thinking habit). The negative self-thinking habit was assessed with a metacognitive instrument (Habit Index of Negative Thinking; HINT) measuring whether negative self-thoughts occur often, are unintended, are initiated without awareness, are difficult to control, and are self-descriptive. Controlling for negative cognitive content, the authors found that negative self-thinking habit was distinct from rumination and mindfulness, predicted explicit as well as implicit low self-esteem (name letter effect), attenuated a positivity bias in the processing of self-relevant stimuli, and predicted anxiety and depressive symptoms 9 months later. The results support the assumption that metacognitive reflection on negative self-thinking as mental habit may play an important role in self-evaluative processes.

Predicting fruit consumption: cognitions, intention, and habits.

OBJECTIVE: To study predictors of fruit intake in a sample of 627 adults. DESIGN: Potential predictors of fruit intake were assessed at baseline, and fruit intake was assessed at two-week follow-up with self-administered questionnaires distributed by e-mail. SETTING: The study was conducted among Dutch adult members of an Internet research panel. PARTICIPANTS: A random sample of 627 adults aged 18-78. VARIABLES MEASURED: Attitudes, subjective norms, self-efficacy, expected pros and cons, habit strength, intention, and fruit intake. Fruit intake was assessed with a validated food-frequency questionnaire. ANALYSIS: Hierarchical linear and logistic regression analyses. Alpha < .05 was considered statistically significant. RESULTS: Sex, attitudes, subjective norms, perceived pros, different self-efficacy expectations, and habit strength were significantly associated with the intention to eat two or more servings of fruit per day. Age, intentions, and habit strength were significant predictors of consumption of two or more servings of fruit per day. CONCLUSIONS AND IMPLICATIONS: The results confirm that Theory of Planned Behavior constructs predict fruit intake, and that habit strength and different self-efficacy expectations may be additional determinants relevant to fruit intake. Because habitual behavior is considered to be triggered by environmental cues, fruit promotion interventions should further explore environmental change strategies.