Patient non-adherence is recognised by those in the healthcare delivery, healthcare policy and pharmaceutical industry as a major threat to individual and population health. Yet efforts to develop strategies to help people become more engaged in their own healthcare can be modestly effective at best. This is because the typical targets for these strategies – patients' knowledge about the disease and its treatments, symptom control, side effects, forgetfulness and costs – represent just a fraction of what drives human behaviour.
Other important factors lie beneath the surface. These may miss our gaze because of our own blind spots about 'what makes us tick' or because we falsely believe that we lack the tools to peer through the murky waters of what is human behaviour. Regardless, we all too often have common misconceptions of what is hidden.
Human mind as 'computer'
If the human mind was like a computer, healthcare consumers would collect all of the information available about a condition and its treatment options, judiciously weigh the short- and long-term gains and pains associated with each option and behave in a manner that maximises their physical outcomes, such as taking medication as prescribed, following a low sodium diet or exercising regularly.
Essentially, this is the basic premise of most patient education programmes. But humans are not computers and this is why standard patient support programmes, based on a knowledge-deficit model, do not always reach the objective of enhancing adherence.
There are many times when people know exactly what they should do, yet they do not do it. As Jonathan Haidt (2006) notes ('The happiness hypothesis: Finding modern truth in ancient wisdom'. New York, NY: Basic Books), the tendency to consider 'information processing' or 'rational choice' as a guiding framework for human behaviour is misguided in that it focuses almost entirely on the working of the neocortex and tends to neglect the older portion of the brain – the limbic system – which is responsible for drives, motivations, emotional learning and responding.
A developed neocortex provides the reasoning and problem-solving abilities that distinguish humans from animals, but without drive, motivation and emotion, there would be no force to propel people forward. They would be inert. Brains are 'hard-wired' so that pleasure is more important than pain and people live in, and for, the moment, not the future. Therefore, making sacrifices in the present for some uncertain benefit or to guard against an uncertain loss goes against humans' natural instinct. This is why it is so easy to spend money and so difficult to save it. And this is why people procrastinate and why someone might skip that blood glucose test or watch a film on the couch rather than go to the gym.
Haidt also suggests thinking of the mind as an elephant (the automatic system) and its rider (the controlled system) rather than as a computer. The rider represents controlled conscious thoughts and the elephant represents everything else, such as gut feeling, emotion and drive: '[The] rider [is] placed on the elephant's back to help the elephant make better choices. The rider can see farther into the future, and the rider can learn valuable information by talking to other riders or by reading maps, but the rider cannot order the elephant against its will.'
One of the implications of the elephant and rider metaphor is that, in order to enhance adherence, we need to better understand and leverage the affective and motivational underpinnings of self-care decision-making.
Uncertain gains are juxtaposed with the daily challenges of following a treatment regimen that interferes with people doing what truly matters to them
Pains and gains do not only manifest themselves physically or materially, but also emotionally. That is, people make healthcare decisions in response to how they feel or expect or want to feel. How might feelings come into play in the healthcare decision-making process? First, people tend to want to feel good about themselves, which leads to a self-serving bias. In the health domain, this manifests itself as the view that one is less susceptible to developing a disease than one's peers. Second, it is a well-established fact that for people to remember moderately complex material or perform moderately complex tasks, they need to be experiencing a moderate level of anxiety, which is neither too high nor too low.
The preferred approach to health communications then is to evoke moderate anxiety – for example, about the health risks of high cholesterol – and simultaneously provide information about how to reduce that risk; for example, by getting a cholesterol test. Third, anticipated regret, or the spectre of having to live with the consequences of one's actions (or inactions), is a powerful but underappreciated driver of health decision-making. For example, Chapman and colleagues (2006) found that anticipated worry and regret more strongly predicted getting vaccinated for influenza than did a perceived risk of the flu.
Critical factors in the healthcare decision-making process, and ones that do not receive enough attention in the research literature, are motivation and values. In other words, what truly matters to patients. While health may be very important to people, it is not the only aspect of their lives or themselves with which they are dealing. People are not only patients, they have several avocations and are parents, spouses and siblings. The demands of managing their illness are weighed against these other demands. For example, Meyerson and Setter Kline (2009) reported that, among heart failure patients, a major challenge to disease self-management came from perceived competing priorities. For example, one woman considered her congestive heart failure not to be a problem when placed in the context of her husband's recent death. For others, comorbidities presented competing demands.
Accordingly, it is critical to gain insight into patients' important goals and motivations. In addition to asking which treatments patients prefer, what they want treatments to do for them must also be deciphered. Instead of asking: 'Why aren't patients motivated?', ask: 'For what are they motivated?'. While patients' motivations are unique, Daniel Pink (2009), in his book 'Drive: The surprising truth about what motivates us', identified 'autonomy' (i.e. doing it my way) as an important human drive.
Healthcare regimens that give patients some latitude with respect to the when, where and how of medication dosing, for example, will appeal to their sense of autonomy. Another important drive identified by Pink is 'mastery' – the desire to get better at something that matters. It is the journey and not the destination that patients deal with on a day-to-day basis. It is not a 'good' blood pressure or blood glucose test that matters most to patients, but rather what they have to do on a daily basis to achieve it.
Mastery requires hard work. The path towards healthcare goals is difficult to follow and is filled with detours and uphill climbs. Furthermore, the terrain for each health condition is different. The challenge for healthcare providers and pharmaceutical companies is to think of ways to facilitate rather than impede their patients' journeys.
Healthcare consumers' decisions are shaped by a multitude of influences and by considerations that extend well beyond efficacy, symptom relief, side effects, costs and even quantity and quality of life in the longer term. These uncertain gains are juxtaposed with the daily challenges of following a treatment regimen that interferes with people doing what truly matters to them in the present, not the distant future. Add to this mix that some decisions stem from the need to manage one's emotional versus physical status and it is easier to understand how the waters of adherence can become quite murky.
Through the use of rapidly evolving psychological and behavioural sciences that continuously deliver new tools to help delve deep into non-adherence issues, more appropriate and effective services and methods that truly support patients' healthcare decision-making processes can be provided.
Dr Leora Swartzman is a clinical health psychologist and associate professor of psychology at the University of Western Ontario, London, Canada. She is also a research consultant with Self Care Catalysts Inc. Her research interests include: the interplay between cognitive, emotional and motivational determinants of health behaviour; how people construe their treatment options; the psychology of physical symptoms, plus placebo mechanisms in the context of clinical trials.
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