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The challenge of poor adherence in type 2 diabetes

How can pharma help address this growing problem?
Stoptober app

Stoptober has had success in helping people to quit smoking via its app

Let's cut to the chase, we all know the facts: the rising tide of diabetes is evident for all to see, the levels of adherence infamously low and the pressures on our healthcare system close to unbearable (think over £1.5m an hour or 10% of the NHS budget in the UK). While the pharma industry has been striving to engage patients with their treatment for years, these gloomy figures continue to soar. So what are we doing wrong?  One thing is for sure: “If we always do what we've always done, we'll always get what we've always got.”

Exercise, eat healthily, take your meds; we know the rules. If you are reading this article, the likelihood is that you are educated about the risks posed by a sedentary lifestyle and a poor diet, so are we. Yet do we cut out the snacks, go to the gym three times a week and manage our stress levels by working shorter hours? And dare we even ask about those pulmonologists who smoke and cardiologists who might not take their own prescribed amounts of exercise? If we can't comply with our own advice, how can we expect others to follow it?

Yes, people don't always do what is good for them. We make 'illogical' decisions and often fail to act in our own self-interest. This pattern has become critical in type 2 diabetes particularly in the context of lifestyle adjustments and compliance with medications. In fact, it is estimated that between a third and a half of all medicines prescribed for long-term conditions are not used as recommended. In the UK only, over a £1bn was spent on type 2 diabetes medications in 2012. Not only is this is a staggering waste of resources, more worryingly it leaves patients at even greater risk of long-term health complications associated with poor glucose control.

There is little doubt that the pharma industry is rising to the challenge of better supporting type 2 diabetes patients. Patient-centric companies are endeavouring to connect better with the end-consumer, to inform and engage, with the objective of enhancing the overall patient experience and promoting better compliance. But still the issue remains.

Understanding patients' behaviours

The first step in changing behaviour is to understand it, understand how and why people make the decisions they make. We are now more aware that our decisions are often made at a subconscious level, driven by our emotions and heavily influenced by the people around us. Behavioural Economics (BE) is gaining recognition as a framework which helps shed light on to the way we make sometimes suboptimal, choices. Crawford Hollingworth, founder of The Behavioural Architects, describes BE as “a scientific model for thinking about human behaviour and human psychology, a model which embraces and seeks to explain the seeming irrationalities of human behaviour. The concepts and frameworks not only more deeply understand current behaviour but also inspire simple ways to change it”.

There is certainly precedence in utilising knowledge from BE to help nudge and steer behaviour in the wider world. Consider public information campaigns, among others: tax evasion, saving for retirement, speeding or smoking cessation. All of these incorporate interventions derived from behavioural science theory. 'Stoptober', for example is a scheme which encourages smokers to stop smoking for the whole of October on the basis that stopping for 28 days will increase the likelihood by five, of stopping for good. It uses key principles drawn from BE; the results speak for themselves: in 2013, nearly a quarter of a million people in England and Wales turned their back on cigarettes, amounting to an estimated benefit of 4,700 years to their lives and £34.5m to their wallets.

'Stoptober' uses key principles drawn from Behavioural Economics 

1. Behaviour is heavily influenced by others
Making a public commitment to change significantly increases the chance of following through with the promise

2. Change is challenged by 'the power of now'
Short-term gratification is often chosen over long-term rewards, especially in hot, emotional zones. Short term achievements and rewards need to be highlighted.

3. Change can be daunting
The size of what is to be achieved can seem like an impossible mountain to climb, breaking up the journey into small, tangible steps such as daily goals and achievements helps initiating and maintaining change.

Creating effective interventions
To investigate what we could learn from BE inspired initiatives implemented by Government bodies and policy makers we teamed up with The Behavioural Architects and embarked on a pioneering experiment to assess the power of behavioural interventions in influencing type 2 diabetes patients' decision-making.

An initial qualitative deep dive into the world of type 2 diabetes patients highlighted key barriers to lifestyle and medication adherence including: low levels of positive behavioural feedback gained on a daily basis (it is difficult for type 2 diabetes patients to know how good they actually are doing and easy to 'trick' themselves), the lack of tangible rewards from adherence (many patients get by without medication, as the drawbacks outweigh the perceived benefits), the inspirational nature of the future (complications are seen as hypothetical, distant from their 'small' daily choices) or the lack of social support (patients keep their 'shameful' disease to themselves, missing an opportunity for support).

Using a BE 'lens', we identified cognitive biases which we could leverage through simple, logistically and financially feasible interventions. We designed a poster to be prominently displayed in the patient's home, the elements of which were designed using relevant BE concepts:

Commitment bias and anchoring: each patient signed a promise contract which included a realistic, personal goal (tangible and measurable) - countersigned by a relative.

Feedback loop: patients were asked to record their performance each day using a smiley face sticker code, mentally 'chunking down' the challenge, rewarding 'good' behaviour and providing feedback.

Visual saliency: the poster included generic eyes and the image of a loved one, simple primes to encourage 'good' behaviour, dialling up social norms via a System 1 (our fast, intuitive and emotional brain) shortcut.

How can behavioural insight help?

Our experiment ran for a month during which time we monitored adherence of type 2 diabetes patients on oral therapy: two weeks of a control period to establish base level behaviours and two weeks of an intervention phase using the poster. Information on lifestyle and medication behaviours was captured daily via mobile app which clearly resulted in artificially increasing engagement levels during the control period - a phenomenon known as the Hawthorne effect (individuals improve their behaviour when aware of being observed).

Despite this inevitable challenge posed by the study design, results showed an impressive increase in healthy behaviours (diet and exercise) of over 45%. Additionally, 7 out of 10 participants significantly increased their level of drug adherence, which reached more than 80% during the intervention period (versus 56% during the control period).

Of course, this study wasn't designed to evaluate the longer term, sustained effect of such interventions on behaviours, but the success of our own study should encourage us to question how we can harness the power of BE-inspired practices and principles, new to our industry yet established and successful in others. We have to ask ourselves how we can engage patients differently; as an industry isn't it time to shift our emphasis from understanding patients' experiences and needs and start to take some responsibility for actively promoting healthier behaviours? In order to achieve this, we have to learn to understand patients differently and be cleverer in the way we talk to them.

Isn't it time to change?

Aurora Albert is a behavioural insight director and Jeanette Hodgson is a partner at Hall & Partners

1st December 2014

From: Marketing, Healthcare



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