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Nudge-nudge, think-think

Chris Ross examines the personal complexities of human behaviour – and explains why fun, emotion and peer endorsement could be key to designing effective behavioural change programmes

Hevaiour change

“Fun can change behaviour for the better.” This was the strapline of Volkswagen’s infamous Fun Theory campaign, a series of experiments that showed how it’s possible to change people’s habits if we make the alternatives more exciting. One experiment revealed that 66% more people at a Stockholm metro station used the stairs rather than an adjacent escalator when the former had been converted to a musical staircase. Fun changed behaviour for the better.

However, the robustness of VW’s findings troubles me. If fun is a major driver of behaviour change, why, as a life-long supporter of West Bromwich Albion, have I not become bored by the drivel and swapped it for the thrills of Manchester City? Perhaps it’s the emotional connection that binds me; as the song goes, “my old man said be an Albion fan”. If only I’d known the rest of the lyrics when I was five. Forty years later, my football behaviours haven’t shifted and I haven’t experienced a lot of fun.

Apparently, one of the biggest drivers of behaviour change is ‘loss aversion’; people feel losses more than they feel gains. Loss Aversion theory says that humans are motivated more by their fears than their aspirations. 2002 Nobel Prize winner Daniel Kahneman described Loss Aversion as ‘the most significant contribution of psychology to behavioural economics.’ Moreover, when Richard Thaler, pioneer of the Nudge Theory, won the 2017 Nobel Prize, Loss Aversion featured prominently in his work. Only a fool would argue with a Nobel Committee. And yet – again – I find myself questioning the science.

In the past four months, Dr Michael Mosley’s 8-week Blood Sugar Diet has completely rewritten some of my lifestyle behaviours. My commitment beyond the 8-week period has been entirely motivated not by a fear of loss but by a burning desire to achieve it. It’s about loss conversion not loss aversion. There’s nothing remotely ‘fun’ about my daily fix of cauliflower rice (in fact, if anything, I’m running out of friends). And I’ve yet to uncover an emotional connection with courgette spaghetti. So what has motivated me to make such significant changes in routine behaviour? And how long will it be before I lapse back into old habits? Sustaining change is the ultimate ambition. That’s the difficult part.

Let’s face it, VW’s Piano Staircase may well have changed behaviours on the day the cameras showed up at Odenplan, but six years later, how many commuters have gone back to schlepping it up the escalator? It’s a fitting metaphor. Because human behaviours are like the steps on a moving staircase; they keep on moving – and just when they’ve reached the summit, they’re suddenly right back at the start again. That’s why successful behaviour change is not about reaching a destination. It’s about staying there for the long term. Understanding the science of behaviour in order to change it is not enough. You have to be able to sustain it.

Therein lies the challenge for global pharmaceutical companies that are increasingly looking towards the behavioural sciences to create programmes that sustain healthy habits. It’s tricky. Human behaviour is both complex and personal. Studying it has spawned an ever- expanding evidence-base – a Google search for ‘behaviour change’ throws up 530 million results – and fuelled countless buzzwords that are now ingrained in the corporate vernacular. There’s even NICE Guidance to help public health professionals and HCPs change people’s behaviours. Interestingly, those guidelines – reviewed in November 2017 – haven’t changed in more than a decade, despite rapid advances in culture, behavioural science and technological opportunity. Perhaps the need for behaviour change extends beyond patients and HCPs?

So how is pharma performing? Analysis reveals that the development of behavioural change programmes is slowly growing – but the potential of behaviour science remains largely untapped. So how do we exploit it? Here are five nudges to shape your thinking.

Nudge #1. Find the emotional drivers – and entertain

Plato said that all human behaviour flows from three main sources: knowledge, desire and emotion. However, more often than not, pharma focuses mainly on ‘knowledge’ – the ‘what’ and the ‘how’ of behaviour change. It’s time to be smarter in our approach. “It’s not enough to simply ‘educate’ people,” says Claire Knapp, Managing Director, Havas Lynx. “We need to remove every barrier to behaviour change adoption. Even with education, we need to make ‘knowledge’ convenient.”

A simple mechanism is to tie existing behaviour and knowledge to the change we’re trying to inspire. “Fire Safety did this beautifully when they tied a new behaviour – checking your fire alarm twice a year – to an existing behaviour: changing your clocks twice a year. Forty-one people didn’t die because of that initiative. This translates to health behaviours too, tying medicines adherence to brushing your teeth or annual health checks to getting your MOT. These are simple ways to minimise disruption. But knowledge alone is rarely enough to drive behaviour change, desire and emotion are key.”

Desire requires understanding individual drivers and motivations to ensure people actually feel rewarded for the behaviour change. A common UX feature is goal- setting, but companies must dig deeper than bolting long-term treatment goals onto their programmes. “We must factor in short-term desires too,” says Claire. “One mechanism is to add short-term feedback/rewards to long- term programmes. A good example is the NHS’ Stop Smoking programme. They found that regular motivational text messages doubled the chance of giving up tobacco. We’ve found that making these short-term feedback loops come from peers can be even more effective.

“The third element – emotion – is arguably the hardest. You can tell people what to change and why, but you’ve still got to get them to actually do it.” But whilst knowledge and desire are grounded in rational behaviour, emotions deal with the irrational. That, says Claire, makes it tough. “You have to make people feel something about the changes you’re asking them to make. You can leverage emotions like guilt or fear – but research normally shows linking it to positive change is most effective. Entertainment is a great way of stimulating behaviour change.”

A good example of this is the OuchieBand campaign for Junior Idiopathic Arthritis (JIA), where we combined convenience with entertainment. Children with JIA find it difficult to verbalise their symptoms and therefore often do not communicate their pain. This impacts their school and home life.

“We wanted to change children’s behaviour so they got into the habit of communicating their health whether they were at home or school,” says Claire. “We created a simple wristband; one side was white (signalling they were fine) and one side was red (signalling they were in pain). This mechanism – supported by an entertaining storybook featuring our character, Ouchie – facilitated behaviour change more than any booklet talking about ‘why they should communicate their pain’ ever could.”

Nudge #2. Follow the wisdom of the crowd

Phil Ford, Managing Director at Litmus Medical Communications, a Syneos Health company, believes there are three essential requirements to driving behaviour change: capability, opportunity and peer endorsement. “Primarily, we must increase understanding and capability. Often, people don’t do something because they don’t know it exists or think it’s too complicated. Developing capabilities is vital. But we should also ensure people can put those capabilities into practice. Sometimes, we explain an idea and motivate people to embrace it, but once they get back into their real world, they just don’t have the opportunity. For example, HCPs can often be excited by new pathways that transform care – but when they return to their day-to-day reality, they don’t have space or time to implement it. Behaviour change programmes can’t just focus on ‘need’, they have to create an environment that provides the opportunity to deliver it.”

The final element – peer endorsement – is often overlooked. Yet it’s arguably one of the most significant drivers of behaviour change. “Humans are hugely influenced by those around them – whether that’s a fellow patient, family or friends, a clinician or an eminent professional,” says Phil. “Evidence shows we’re more likely to effect a change if it’s been endorsed by our peers. It’s a classic ‘nudge’. The principle is at the root of KOL work – but it applies equally to patients. A good example is the recent story around Group Consultations in the NHS. It’s a controversial area – but pilots have shown that group participants have benefited from the support of fellow patients and changed their behaviours positively. Why? Because humans have a deeply ingrained need to conform to group norms. Behaviour change may start as an individual activity, but sustaining it is invariably a team sport.”

The power of achieving the triad of capability, opportunity and peer endorsement is evidenced by a recent study into how to avoid retrograde outcomes when switching patients from biologics to biosimilars. The study found that the combination of understanding, positive framing and a ‘managed programme’ helped mitigate barriers to changing behaviours. “The approach drove capability and motivation by talking positively around benefits, then created the real- world opportunity for patients and physicians to operate in via a managed programme,” says Phil. “Specifically, the programme deployed a ‘One Voice’ package of materials that got everybody speaking the same language – creating a consistent group norm and driving peer endorsement. Evidence shows the approach helps sustain beneficial behaviour change.”

Nudge #3. Make it realistic

Perhaps the most succinct advice is to ‘keep it real’. Caroline Burtt, Associate Director, GCI Health London, explains the rationale. “The community at large is becoming more aware of health and the things we need to do to maintain healthy lifestyles. However, how we move from ‘knowing it’ to ‘doing it’ is a crucial aspect of behaviour change. There’s a huge focus – across the industry – on how we can make progress in that key area to optimise finite health resources and improve patient outcomes. Our success will depend on making sure that the interventions we design are tangible and realistic for the end user. If we are going to change behaviours, we must recognise that change rarely happens overnight – it’s incremental. So we need to design solutions that walk patients through the various stages of behaviour change and help them make those small, incremental – and realistic – changes that ultimately add up to better health overall.”

The best behavioural change programmes, says Caroline, rely on a healthy dose of realism. A good example of this is international work to support diabetes patients who recognise Ramadan and want to fast during the Holy Month.

It’s an important area where ‘clinical guidelines’ and the ‘real world’ meet head on. “Guidelines recommend that diabetes patients abstain from fasting during Ramadan. However, many choose to proceed to fast without seeking support from their HCP. The initiative worked closely with the community to develop a programme that married faith and health needs in a culturally- sensitive way. The solution acknowledged the pushes and pulls on people’s day-to-day lives to establish how people living with diabetes can be supported through Ramadan. The strength of the programme came from its holistic approach – collaborating with multiple patient groups across different regions to co-create a solution that recognised needs on all sides.

“Ultimately, the programme has succeeded because it has been built by – and for – the people who need it, and is designed to reflect the reality of their everyday lives. The most effective interventions cut through because they’re built on a firm real-world understanding of the environment and the emotional connections that motivate behaviour change.”

Nudge #4. Consider behaviour holistically

Maria Fafouti, EY, Life Sciences, UK & Ireland, believes that taking a holistic approach to behavioural change can help pharma develop more action-oriented programmes that make a difference and encourage long-term results. “Traditionally, pharmaceutical companies have provided useful patient information online. However, this information focused narrowly on one or two factors relevant to the behaviour and wasn’t easily translated into action within the context of the patient’s environment. The onus was on the patient to access the information, read it, understand it and decide to apply it to their life. Moreover, although the information heavily focused on what behaviours could change, it didn’t offer a mechanism for feedback or monitoring those ‘new’ behaviours to inform the patient whether the approach worked for them. It’s widely accepted that the passive and restricted approach rarely has the desired impact. Today’s behavioural programmes must therefore focus on delivering practical, action-oriented content that addresses the range of key factors associated to patients’ behaviour at the times throughout their journey when it is most impactful – therefore encouraging the desired behaviours to be maintained.”

There are, says Maria, good examples of more holistic and action-oriented interventions emerging from big pharma companies. For instance, a digital programme aimed at managing diabetes includes health coaching, online group support, educational content and tools. Elsewhere, a patient surgery support programme addresses the emotional, physical and social elements of pre-and-post surgery to support recovery. “These examples comply with a fundamental requirement of behaviour change: if we want patients and practitioners to adopt and sustain new, healthy habits, interventions must consider all the holistic elements associated with the behaviour we want to change.

“Adopting a holistic approach to behaviour change is grounded in understanding the context within which current behaviours occur – through a range of research techniques – and supplementing this through behavioural science insights,” says Maria. “As such, companies should develop programmes that combine the valuable insights from science and reality, basing interventions on the latest studies in academia that have been tailored to meet specific needs of real-world settings.”

“The best interventions apply a clear methodology that considers the patient/ professional, the science, real-world practicalities, business capabilities and design thinking.” It’s important, says Maria, to ‘own the experience’. “The healthcare sector is incredibly fragmented. Helping to join up the end-to-end experience presents a significant opportunity for organisations to grow their influence within the ecosystem. Finally, don’t lose sight of business value. Every intervention needs to be tied to a measurable business impact, helping to allocate investment into scaling those that drive value. This requires an agile, iterative design cycle where interventions can be built, tested and implemented at pace.”

Nudge #5: Start with the human – and be clear about your goals

The industry’s focus on behaviour change is not new. “Communications have always been designed to evoke a change in attitude or behaviour,” says Gareth Morrell, Head of Insights, Madano. “However, through the behavioural sciences, we now have a systematic framework for understanding the techniques, nudges and interventions that can help us trigger and sustain behaviour change. We’re better able to look at those techniques in a coherent manner and choose the ones that are most appropriate to our specific challenges. Moreover, as the science evolves, academia is increasingly conducting systematic reviews of the relative effectiveness of interventions to share best practice. For example, a 2015 theory-led overview of behavioural change interventions concluded that the best interventions focus on a combination of education and action. According to the review, programmes that include educational outreach and ‘relational restructuring’ – reinforced by modified peer group norms that reflect the expectations of an external reference group – are most likely to change behaviour.”

But communication, says Gareth, is just one element of behaviour change. It’s a vital component to get right, but on its own it’s not enough to make an intervention work. The programmes themselves needs to be built on the right things. As such, behaviour change frameworks are useful in helping communicators establish the point at which effective communication stops and the effect of the intervention itself begins.

So what are the key elements of effective communication that creates the platform for behaviour change? “Plain English and the need to articulate social norms are essential,” says Gareth. “Similarly, the concept of the ‘trusted messenger’ is crucial. A good example is a recent study from Public Health England where the Chief Medical Officer wrote to a cohort of GP practices and simply explained that they were prescribing antibiotics at a higher rate than other practices in their area. Those practices quickly started prescribing at a lower rate than a control group that hadn’t received the letter. The combined use of a trusted messenger and plain English tapped into those human desires to conform with social norms – and it worked.”

Fundamentally, the best behavioural change programmes, says Gareth, are ‘people-centric’. “Our starting point must always be to examine how we work cognitively as human beings and develop interventions from there. We also need a clear understanding of the specific behaviours we want to change – and transparent metrics to measure success. In many programmes that purpose isn’t always evident. It’s only by establishing clear goals that we can demonstrate the value of communications in changing behaviours.”

The appliance of science

Human habits are deep-rooted – and changing them is always likely to prove challenging. However, it’s clear that the ever-expanding evidence-base of behavioural science is providing a compelling framework from which pharma is learning. The programmes steadily emerging across the sector reveal common elements that are steeped in the science – and they’re nudging pharma in the right direction. Yet there’s a long way to go. Ultimately, we will never change behaviours overnight. But with a better understanding and application of the science, and a willingness to co-create, it might just be possible to accelerate progress. The evidence-base is there and, despite the complexities of personal behaviour, we can exploit it to make a difference. My allegiance to West Bromwich Albion may never budge, but if there’s a programme that can help me commit to a lifetime of cauliflower rice, sign me up – before my enthusiasm, like my social life, disappears.

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