Content uploaded by Benjamin Gardner
Author content
All content in this area was uploaded by Benjamin Gardner
Content may be subject to copyright.
Making health habitual: the psychology of ‘habit-formation’ and general practice
Benjamin Gardner*, Phillippa Lally*, Jane Wardle
All authors: Health Behaviour Research Centre, Department of Epidemiology and Public
Health, University College London, Gower Street, London, WC1E 6BT, UK.
Tel: 020 7679 1720; Fax: 020 7679 8354
Benjamin Gardner, Lecturer in Health Psychology (b.gardnersood@ucl.ac.uk)
Phillippa Lally, ESRC Postdoctoral Research Fellow (p.lally@ucl.ac.uk)
Jane Wardle, Professor of Clinical Psychology (j.wardle@ucl.ac.uk)
* Benjamin Gardner and Phillippa Lally made an equal contribution to this paper and are
ordered alphabetically.
Correspondence to Benjamin Gardner: b.gardnersood@ucl.ac.uk
Reference for citation:
Gardner, B., Lally, P., & Wardle, J. (2012) Making health habitual: the psychology of ‘habit-
formation’ and general practice. British Journal of General Practice, 62, 664-666.
Acknowledgement:
We thank Professor Wendy Wood for helpful comments on an earlier draft of this
manuscript.
Making health habitual
Abstract
Health professionals are being asked to ‘make every contact count’ by advising patients on
behaviour change. Yet, brief advice based on what and why to change behaviour typically
yields only short-term benefits. In this paper, we suggest that health professionals consider
giving advice on how to achieve long-term change, based on the psychology of habit-
formation. Habits are actions performed automatically with little forethought or effort, and
which persist over time. Habits form through repeated performance of an action in the same
setting. Brief advice on forming healthy habits is easy for clinicians to deliver, and easy for
patients to implement.
Making health habitual
The Secretary of State recently proposed that the NHS ‘take every opportunity to prevent
poor health and promote healthy living by making the most of healthcare professionals’
contact with individual patients’ 1. Patients trust health professionals as a source of advice on
‘lifestyle’ (i.e. behaviour) change, and brief opportunistic advice can be effective 2.
However, many health professionals shy away from giving advice on modifying behaviour
because they find traditional behaviour change strategies time-consuming to explain and
difficult for the patient to implement 2. Furthermore, even when patients successfully initiate
the recommended changes, the gains are often transient 3because few of the traditional
behaviour change strategies have built-in mechanisms for maintenance.
Brief advice is usually based on advising patients on what and why to change (e.g.
reducing saturated fat intake to reduce the risk of heart attack). Psychologically, such advice
is designed to engage conscious deliberative motivational processes, which Kahneman terms
‘slow’ or ‘System 2’ processes 4. However, the effects are typically short-lived because
motivation and attention wane. Brief advice on how to change, engaging automatic (‘System
1’) processes, might offer a valuable alternative with potential for long-term impact.
Opportunistic health behaviour advice must be easy for health professionals to give
and easy for patients to implement to fit into routine health care. We propose that simple
advice on how to make healthy actions into habits – externally-triggered automatic responses
to frequently encountered contexts – offers a useful option in the behaviour change toolkit.
Advice for creating habits is easy for clinicians to deliver and easy for patients to implement:
repeat a chosen behaviour in the same context, until it becomes automatic and effortless.
Habit formation and health
While often used as a synonym for frequent or customary behaviour in everyday parlance,
within psychology, ‘habits’ are defined as actions that are triggered automatically in response
to contextual cues that have been associated with their performance5;6: for example,
automatically washing hands (action) after using the toilet (contextual cue), or putting on a
seatbelt (action) after getting into the car (contextual cue). Decades of psychological research
consistently show that mere repetition of a simple action in a consistent context leads,
through associative learning, to the action being activated upon subsequent exposure to those
contextual cues (i.e. habitually) 7-9. Once initiation of the action is ‘transferred’ to external
cues, dependence on conscious attention or motivational processes is reduced 10. Habits are
therefore likely to persist even after conscious motivation or interest dissipate 11. Habits are
also cognitively efficient, because the automation of common actions frees mental resources
for other tasks.
A growing literature demonstrates the relevance of habit-formation principles to
health 12;13. Participants in one study repeated a self-chosen health-promoting behaviour (e.g.
eat fruit, go for a walk) in response to a single, once-daily cue in their own environment (e.g.
after breakfast). Daily ratings of the subjective automaticity of the behaviour (i.e. habit
strength) showed an asymptotic increase, with an initial acceleration that slowed to a plateau
after an average of 66 days 9. Missing the occasional opportunity to perform the behaviour
did not seriously impair the habit formation process: automaticity gains soon resumed after
one missed performance9. Automaticity strength peaked more quickly for simple actions
(e.g. drinking water) than for more elaborate routines (e.g. doing 50 sit-ups).
Habit-formation advice, paired with a ‘small changes’ approach, has been tested as a
behaviour change strategy 14;15. In one study, volunteers wanting to lose weight were
randomised to a habit-based intervention, based on a brief leaflet listing ten simple diet and
activity behaviours and encouraging context-dependent repetition, or a no-treatment waiting
list control. After 8 weeks, the intervention group had lost 2kg compared with 0.4kg in the
control group. At 32 weeks, completers in the intervention group had lost an average of
3.8kg 14. Qualitative interview data indicated that automaticity had developed: behaviours
became ‘second nature’,‘worming their way into your brain’ so that participants ‘felt quite
strange’ if they did not do them 10. Actions that were initially difficult to stick to became
easier to maintain. A randomised controlled trial is underway to test the efficacy of this
intervention where delivered in a primary care setting to a larger sample, over a 24-month
follow-up period 16. Nonetheless, these early results indicate that habit-forming processes
transfer to the everyday environment, and suggest that habit-formation advice offers an
innovative technique for promoting long-term behaviour change 13.
Making healthy habits
We suggest that professionals could consider providing habit-formation advice as a way to
promote long-term behaviour change among patients. Habit-formation advice is ultimately
simple – repeat an action consistently in the same context 12. The habit formation attempt
begins at the ‘initiation phase’, during which the new behaviour and the context in which it
will be done are selected. Automaticity develops in the subsequent ‘learning phase’, during
which the behaviour is repeated in the chosen context to strengthen the context-behaviour
association (here a simple ticksheet for self-monitoring performance may help; see Figure 1).
Habit-formation culminates in the ‘stability phase’, at which the habit has formed and its
strength has plateaued, so that it persists over time with minimal effort or deliberation.
Initiation requires the patient to be sufficiently motivated to begin a habit-formation
attempt, but many patients would like to eat healthier diets or take more exercise, for
example, if doing so were easy. Patients must choose an appropriate context in which to
perform the action. The ‘context’ can be any cue, e.g. an event (‘when I get to work’) or a
time of day (‘after breakfast’), that is sufficiently salient in daily life that it is encountered
and detected frequently and consistently. A cue located within an existing daily routine (e.g.
‘when I go on my lunch break’) provides a convenient and stable starting point 10.
Keeping going during the learning phase is crucial. The idea of repeating a single
specific action (e.g. eating a banana) in a consistent context (e.g. with cereal at breakfast) is
very different from typical advice given to people trying to take up new healthy behaviours,
which often emphasises variation in behaviours and settings to maintain interest (e.g. trying
different fruits with or between different meals). Variation may stave off boredom, but is
effortful and depends on maintaining motivation, and is incompatible with development of
automaticity 6.
Patients should choose the target behaviour themselves: progress towards a self-
determined behavioural goal supports patients’ sense of autonomy and sustains interest 17,
and there is evidence that a behaviour change selected on the basis of its personal value,
rather than to satisfy external demands such as physicians’ recommendations, is an easier
habit target 18. Patients need to select a new behaviour (e.g. eat an apple) rather than give up
an existing behaviour (e.g. do not eat fried snacks) because it is not possible to form a habit
for not doing something. The automaticity of habit means that breaking existing habits
requires different and altogether more effortful strategies than making new habits 12.
Patients should be encouraged to aim for small and manageable behaviour changes,
because failure can be discouraging. A sedentary person, for example, would be more
appropriately advised to walk one or two stops more before getting on the bus than to walk
the entire route – at least for their first habit goal. Small changes can benefit health: slight
adjustments to dietary intake can aid long-term weight management 19, and small amounts of
light physical activity are more beneficial than none 20. Moreover, simpler actions become
habitual more quickly 9. Additionally, behaviour change achievements, however small, can
increase self-efficacy, which can in turn stimulate pursuit of further changes 21. Forming one
‘small’ healthy habit may thereby increase self-confidence for working towards other health-
promoting habits.
Unrealistic expectations of the duration of the habit formation process can lead the
patient to give up during the learning phase. Some patients may have heard that habits take
21 days to form. This myth appears to have originated from anecdotal evidence of patients
who had received plastic surgery treatment and typically adjusted psychologically to their
new appearance within 21 days 22. More relevant research found that automaticity plateaued
on average around 66 days after the first daily performance 9, although there was
considerable variation across participants and behaviours. It may therefore be helpful to tell
patients to expect habit formation (based on daily repetition) to take around 10 weeks. Our
experience is that people are reassured to learn that doing the behaviour gets progressively
easier; so they only have to maintain their motivation until the habit forms. Working
effortfully on a new behaviour for two to three months may be an attractive offer if it has a
chance of making the behaviour become ‘second nature’.
Conclusion
Psychological theory and evidence around habit-formation generates recommendations for
simple and sustainable behaviour change advice. We acknowledge that health professionals
do not always find it appropriate to offer lifestyle counselling to patients: some patients can
become annoyed when advised to change their behaviour, and this reaction can threaten
patients’ trust in and satisfaction with the doctor-patient relationship2. However, in settings
where professionals feel able to offer behaviour advice, we suggest that they consider
providing guidance on habit-formation. Habit-formation advice can be delivered briefly, it is
simple for the patient to implement, and it has realistic potential for long-term impact. It
offers health professionals a useful tool for incorporating evidence-based health promotion
into encounters with patients. A sample tool for health professionals to use with patients to
encourage habit formation is provided in Figure 1.
References
(1) Lansley A. Response to NHS Future Forum's second report. Department of Health.
2012. URL:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalass
et/dh_132088.pdf
(2) Lawlor DA, Keen S, Neal RD. Can general practitioners influence the nation's health
through a population approach to provision of lifestyle advice? Br J Gen Pract 2000;
50:455-9.
(3) Jeffery RW, Drewnowski A, Epstein LH, Stunkard AJ, Wilson GT, Wing RR. Long-
term maintenance of weight loss: Current status. Health Psychol 2000; 19
(Suppl.1):S5-S16.
(4) Kahneman D. A perspective on judgment and choice. Am Psychol 2003; 58:697-720.
(5) Neal DT, Wood W, Labrecque JS, Lally P. How do habits guide behavior? Perceived
and actual triggers of habits in daily life. J Exp Soc Psychol 2012; 48:492-8.
(6) Wood W, Neal DT. A new look at habits and the habit-goal interface. Psychol Rev
2007; 114:843-63.
(7) Bayley PJ, Frascino JC, Squire LR. Robust habit learning in the absence of awareness
and independent of the medial temporal lobe. Nature 2005; 436:550-3.
(8) Hull CL. Principles of behavior: an introduction to behavior theory. New York:
Appleton-Century-Crofts; 1943.
(9) Lally P, van Jaarsveld CHM, Potts HWW, Wardle J. How are habits formed:
Modelling habit formation in the real world. Euro J Soc Psychol 2010; 40:998-1009.
(10) Lally P, Wardle J, Gardner B. Experiences of habit formation: A qualitative study.
Psychol Health Med 2011; 16:484-9.
(11) Gardner B, de Bruijn GJ, Lally P. A systematic review and meta-analysis of
applications of the Self-Report Habit Index to nutrition and physical activity
behaviours. Ann Behav Med 2011; 42:174-87.
(12) Lally P, Gardner B. Promoting habit formation. Health Psychol Rev. In press. doi:
10.1080/17437199.2011.603640.
(13) Rothman AJ, Sheeran P, Wood W. Reflective and automatic processes in the
initiation and maintenance of dietary change. Ann Behav Med 2009; 38 (Suppl1):S4-
S17.
(14) Lally P, Chipperfield A, Wardle J. Healthy habits: Efficacy of simple advice on
weight control based on a habit-formation model. Int J Obes 2008; 32:700-7.
(15) McGowan L, Cooke LJ, Croker H, Wardle J, Gardner B. Habit-formation as a novel
theoretical framework for dietary change in pre-schoolers. Psychol Health 2012; 27
(Suppl1):89.
(16) Beeken RJ, Croker H, Morris S, Leurent B, Omar R, Nazareth I, Wardle J. Study
protocol for the 10 Top Tips (10TT) Trial: Randomised controlled trial of habit-based
advice for weight control in general practice. BMC Public Health 2012; 12:667.
(17) Deci EL, Ryan RM. The support of autonomy and the control of behavior. J Pers Soc
Psychol 1987; 53:1024-37.
(18) Gardner B, Lally P. Does intrinsic motivation strengthen physical activity habit?
Modeling relationships between self-determination, past behaviour, and habit
strength. J Behav Med. In press. doi: 10.1007/s10865-012-9442-0.
(19) Hill JO. Can a small-changes approach help address the obesity epidemic? A report of
the Joint Task Force of the American Society for Nutrition, Institute of Food
Technologists, and International Food Information Council. Am J Clin Nutr 2009;
89:477-84.
(20) Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the
evidence. Can Med J 2006; 174:801-9.
(21) Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol 2001;
52:1-26.
(22) Maltz M. Psycho-cybernetics. New York: Prentice Hall; 1960.
Figure 1: A tool for patients
Make a new healthy habit
1. Decide on a goal that you would like to achieve for your health
2. Choose a simple action that will get you towards your goal which you can do on a
daily basis
3. Plan when and where you will do your chosen action. Be consistent: choose a time
and place that you encounter every day of the week.
4. Every time you encounter that time and place, do the action.
5. It will get easier with time, and within 10 weeks you should find you are doing it
automatically without even having to think about it.
6. Congratulations, you’ve made a healthy habit!
My goal (e.g. ‘to eat more fruit and vegetables’)
___________________________________________________________________________
My plan (e.g. ‘after I have lunch at home I will have a piece of fruit’)
(When and where) ___________________________ I will ___________________________
Some people find it helpful to keep a record while they are forming a new habit. This daily
tick-sheet can be used until your new habit becomes automatic. You can rate how automatic
it feels at the end of each week, to watch it getting easier.
Week
1Week
2Week
3Week
4Week
5Week
6Week
7Week
8Week
9Week
10
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Done on 5 days
or more?
How automatic
does it feel?
Rate from
1 (not at all) to
10 (completely)
