Active and passive choices concerning lifestyle and medication: Integrating decision-making and behaviour change approaches

Many individuals have difficulty adopting and maintaining a healthy lifestyle. Low adherence to lifestyle changes and prescribed medication increases the risk of CVD and other non-communicable diseases. This has a significant global impact: annually, 19.9 million individuals die as a result of CVD. Additionally, it leads to high healthcare costs and societal consequences. Interventions implemented by Western countries to promote the health of the population are often based on behaviour change models, such as the Theory of Planned Behaviour, which assume that human behaviour is primarily driven by conscious, analytical thought processes. However, behaviour is also influenced by automatic thought processes, especially in the case of habitual behaviours. In recent decades, there has been an increasing consideration of automatic thought processes in ‘choice architecture’ and ‘nudging’ interventions, which often focus on passive decision making. Previous research has shown that the effectiveness of nudging varies by behavioural domain and nudging technique, and it remains uncertain to what extent nudging can contribute to sustainable behaviour change. Existing lifestyle interventions may also be too narrowly focused on informing and advising individuals. Typically, there is a desirable (healthy) choice that is directly or indirectly imposed by a professional/intervention. By integrating a decision-making approach, individuals could be encouraged to make more active, autonomous choices based on their personal values, goals, beliefs, and needs. In this thesis, active choices are defined as conscious and autonomous choices in which individuals weigh the pros and cons of different options and make a choice in line with their personal values. Sustained behaviour change could potentially be achieved by promoting both active, value-congruent choices and passive choices. In our CHOICE project, we integrated a decision-making approach and a behaviour change approach. The aim of our research was to investigate the influence of choice architecture on active versus passive decision-making concerning (a) choices related to physical activity and sedentary behaviour among physically inactive adults, and (b) choices related to lifestyle change and medication use among individuals at increased risk of CVD. We examined the effects of active versus passive decision-making on psychological outcomes, such as intentions and commitment, and behavioural outcomes, such as the level of physical activity. Our studies were theoretical and exploratory in nature since the integration of a decision-making approach is relatively uncommon in these behavioural domains. First, we conducted a systematic literature review on the effects of passive choice architecture interventions on physical activity and sedentary behaviour in adults. Our second study concerned a qualitative study into the values, motivations, attitudes, beliefs, and needs of office workers regarding physical activity and sedentary behaviour. Next, we conducted two online experiments to investigate the effect of promoting an active choice regarding health behaviour on psychological and behavioural outcomes. In both experiments, promoting an active choice was compared to promoting a passive choice. Participants in both experiments completed the online interventions independently, without the involvement of a professional. In the first experiment, the focus was on promoting physical activity. The second experiment focused on choices regarding lifestyle change and medication use to reduce the risk of cardiovascular diseases. Our findings showed that among choice architecture techniques that support passive choices, prompting was found to be an effective technique in promoting stair use. However, passive choice interventions seem to be insufficiently effective as independent, stand-alone interventions in the long term. Our experiments have shown that promoting an active decision-making process in which individuals weigh the pros and cons of options and reflect on personal values results in more commitment to behaviour change. The effectiveness of active choice interventions could be optimized by incorporating professional guidance and follow-up support.