Do you ever ask yourself why you did something? It could be something minor, like eating too many biscuits or drinking too much the night before, or squeezing your car into a parking spot which is too small with inevitable consequences. Doing things without rational thought beforehand is part of being human. It has to be this way, otherwise our lives would be run in slow motion. Can you imagine having to weigh up the pros and cons of every single action you took before you did it?
People make non-rational decisions all the time. For instance, you can claim you live a healthy lifestyle when the contents of the fridge tell you something else. It is easy to be tricked into thinking that the product on ‘special offer’ at the supermarket provides best value for money; some canny mental arithmetic can show this is not always the case.
A healthy thought process
The same thought process and belief system applies to healthcare. How many people do you know who believe that antibiotics are required for a cold? Logically, many people understand that antibiotics don’t work on viruses, but when the illness strikes no-one at the moment currently tests for viral or bacterial infection to prove otherwise. Patients turn up at surgeries demanding antibiotics, and often receive them. What makes this worse is the fact that they then often stop taking the drugs once they start to feel better.
There is an irrational behaviour behind this; that antibiotics will work, therefore I don’t need to finish the course as they worked so well and I am now better. Hence next time, I will do the same again.
To change people’s behaviour you cannot just tell them what to do. If this was the case, we would all be fit, healthy and thinner. Giving people information and instruction helps a little, but fundamentally it rarely changes ingrained, irrational behaviour.
Most physicians I speak to believe that their patients largely do what they are instructed to at a consultation. However, according to a study headed by Robin DiMatteo, patients only retain around half to one-third of what was discussed at that meeting. In addition, if patients really did what they were told, why, according to the World Health Organisation, do we have mal-adherence rates of around 50 per cent?
Factors we need to address in understanding human behaviours
- Personal factors: what do people like me do?
- Social factors: what do people around me do? What is acceptable behaviour in the context in which I live?
- Environmental factors: how easy is it to shift my behaviour? What degree of effort is required?
To elicit behavioural change, you need to view the actions and perceptions of people through the lens of behavioural economics. This approach puts human behaviour centre stage, rather than their attitudes, beliefs and opinions. There are three key elements you need to assess: personal, social and environmental factors.
Once you get to grips with these, you can understand how to change that behaviour. Often, this is called the ‘nudge’ factor. For example, middle class drinking is a concern in the UK.
The stressed mother who comes home after a busy day, runs around after the children, cooking and cleaning as she goes and who ends up having a glass of wine or two once the children are firmly in bed. This glass of wine is often much larger than a standard measure, and is a daily ‘treat’. If you tell this mother not to drink so much, it will probably fall on deaf ears. She will think that a few glasses of Chardonnay here and there is hardly drinking vodka on a street corner.
Raising the price of alcohol also won’t help much. Instead, if you understand more about the context of her life and her social norms, you can nudge her behaviour in a different direction. For instance, she probably shares most middle class concerns about recycling and being green. By linking the volume she drinks into what she puts into her recycling bin and what others might think about her if they see the number of empty wine bottles, you are more likely to elicit a behaviour change than any education on the perils of daily alcohol consumption.
There are a number of key elements to this story. Firstly, the change in behaviour and the focus is only on a segment of the population. Not everyone who drinks too much has the same context and belief system. The same applies to other categories, for instance, if you want to shift perceptions about the need for antibiotics – you have to start with a homogeneous group. You can’t change all behaviours at once, you need to look for collective belief systems. It is the same for adherence issues, you can’t impact everyone, you need to nudge those who view the effort of adherence as easier than others.
Secondly, you need to take a very broad understanding of the subject. If you just do research to understand the middle class housewife’s drinking habits, you would never reach an understanding of her recycling habits. You need to understand the person as a whole, in the broadest sense. This is particularly important when it comes to health issues. All too often it is hard to see beyond the label of ‘patient’ to who the person is behind the condition. The simple fact of recruiting someone as a ‘patient’ conditions her to respond in a particular way, often more serious than, for instance, if she were recruited to discuss her use of technology.
The discussion that takes place with patients revolves around their disease, attitude towards medication and touches on their lifestyle. It is important to go beyond this and really understand the person.
Trigger points and context
When you design your research to understand the behaviours and context in which people do irrational things, don’t be satisfied with a series of questions asking ‘why’. I can perfectly justify my over-consumption of biscuits yesterday in a post-rational thought process, but this is not going to help you understand the trigger for why I really did this. I could have simply been not thinking about it at the time. You need to observe my behaviour to really understand what is going on.
Also, don’t believe what I tell you. If I say I am going to buy something, or am going to exercise more, or eat less, or take my medication as prescribed. This doesn’t mean I am going to do it, it just means that I have a positive view of that behaviour. I often talk to patients and ask them what advice they would give to someone who had just been diagnosed. Inevitably the advice they offer is rationally what that patient should do, but is a long way from their own behaviour. And they can rarely explain the discrepancy.
All behaviour is context driven. People surround themselves with those of a similar outlook to themselves. If you remove them from their normal environment their behaviour will change. If you conduct research in a sterile environment, for instance a viewing facility or online, you can miss the understanding of the environment in which they live their lives.
The secret of great moderation is to make the respondent believe you are part of that group…
Finally, the way in which people talk among friends and in their own group is quite different from the way in which they will speak to an external interviewer. If you put people into a community of likeminded people, for instance online, the discussions people will have with each other are very different from those they would have with an external third party.
The secret of great moderation is to make the respondent believe you are part of that group, not interrogating from a neutral position of no knowledge, without leading her down any particular pathway.
Great marketing has always used behavioural and cognitive framing to be most effective. For example, kitchen cleaner is marketed as killing 99 per cent of germs, not for allowing 1 per cent of germs to thrive. Insight generation can be better aligned to this need by looking at the context in which people live their lives. This is about breadth of understanding, not just depth.
Observation and immersion in the person’s world are vital to this understanding. Research should focus less on the post-rational ‘whys’ or the perceptions of what I believe I should or shouldn’t do. It needs to provide behavioural understanding, and trigger ideas for changing the context and current norms, not just tell you what people said.
The Author
Sarah Phillips is Head of Health at InCite. she can be contacted at sarah.phillips@incite.ws