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Breaking free
Pharma’s ability to understand and modify customer behaviour is improving – but is it doing enough?
Behavioural change theory may be all the rage but its principles and purpose are nothing new for pharma. The industry has been trying to change its customers’ behaviours – whether that’s doctors, patients, governments or regulators – since time immemorial. It’s the job – and it always has been. In recent years, however, companies have upped the ante, clothing their strategies in the language of behavioural science and leaning on evidence-based models to influence change. As the science builds and companies learn from it, pharma’s ability to understand and modify customer behaviours is improving.
But is it doing enough? Or does its approach concentrate solely on achieving ‘moment-in-time’ change that all-too-often quickly relapses back to default behaviours? Analysis suggests that, despite making great strides in behavioural understanding, the industry must shift its focus if it’s to transition from temporarily changing behaviours to sustaining them for the long term.
Evidence that behaviour can be effectively modified through behavioural interventions continues to mount. But, according to a systemic review of behavioural theories, proof of sustained behaviour change in response to interventions is less forthcoming. The 2016 review – Theoretical explanations for maintenance of behaviour change (Kwasnicka et al) – suggests that the effects of behavioural interventions often diminish over time, citing high relapse rates for behaviour change programmes to lose weight, reduce alcohol consumption or stop sexual risk.
The paper urges a greater focus on ‘behaviour change maintenance’ and the increased development of interventions that promote ‘sustained change’ in health behaviours. It’s a message – and indeed a study – that could prove vital for pharma as it looks to take its application of behavioural theory to the next level.
Behaviour science: pharma’s journey
Pharma’s use of behavioural theory has advanced beyond buzzwords to become a common strategy to understand and respond to the psychology of behaviour. As ‘nudge theory’ becomes embedded in the business parlance of all industries, many pharma companies are exploring the science of behaviour to influence customer decision- making.
The approach is understandable; as the cost of healthcare and the global burden of disease increases, companies must do all they can to ensure people not only have access to the best treatments but they also exhibit lifestyle behaviours that make the most of finite health resources. Behavioural change theory has become an obvious route.
“The No. 1 thing we’ve learned engaging patients and professionals around the world is this: the message isn’t enough,” says Amit Dhir, Insights Lead at Syneos Health Communications Europe.
“Two of my colleagues – a behaviour scientist and a healthcare communicator – recently came together to write a book on this topic (Why We Resist: The Surprising Truth About Behavior Change) that shows that no matter how compelling the science, how clear the benefit, it’s not enough if you don’t understand the people. What motivates them. What gives them hope. That’s what opens doors and keeps them open for the hard conversations, new understandings and big commitments to change.
"However, unlike Silicon Valley’s guiding motto – ‘move fast and break things’ – pharma’s more deliberate ‘tread slowly, and build things’ approach extends to its understanding and application of behavioural science principles. Solid progress is being made but behaviour is an inherently complex and messy subject, and we still have a long way to go. With patients’ day-to-day behaviours, moods and emotions constantly changing, it’s only by understanding contextual factors that we’ll be able to design interventions that are nuanced, targeted and – crucially – used.”
This, says Amit, requires deep understanding of the patient experience. “If we want patients to behave differently, we need to identify the things that block or act as barriers to change, as well as the catalysts that can accelerate change throughout the patient journey. Regulation does make it harder for companies to understand what the patient might be experiencing, but it doesn’t make it impossible."
"For companies wanting to improve their performance in this area, the best thing to do is to talk with patients and, if possible, observe their behaviour through behavioural forms of research, such as ethnographic studies. These types of data-rich methodologies can help us understand what drives decision-making at each stage of a patient’s day-to-day journey.” These behavioural insights should be at the root of – and inform – all interventions.
“The essential steps to achieving behaviour change are relatively simple,” said Amit. “First, make things easy for people by removing frictions. Second, make them attractive. In some cases, make them ‘social’ – if everyone else is doing the behaviour, it signals that it must be a good thing to do. Finally, make interventions timely. This is most likely to trigger a behaviour change. Digital can help in all these areas and has the potential to accelerate change en masse. For example, apps like Headspace and Kaia connect millions globally and use simple nudge reminders to motivate people to meditate or exercise. They’re very effective.”
So how should pharma proceed? “First, be very specific about which behaviour you want to change,” said Amit. “Fully understand
where current behaviours are at, by measuring these through different research methodologies (implicit approaches, as well as explicit). Once you understand the gaps, you need a good understanding of the behavioural biases or frictions that might get in the way of behaviour change, as well as those that might encourage it."
"Then you need to map these out and test them in isolation, as well as in combination. The science of real behaviour change is a gradual one, and it’s something that requires a lot of testing, learning and adapting.”
A temporary fix?
The basics of behavioural change theory are now widely understood and generally well executed. However, there’s an argument that their effects are often more temporary than permanent. Sustainability is key. “There are more than 80 behavioural change theories across psychology, sociology, anthropology and economics, but many don’t explicitly address behavioural change maintenance,” said Craig Mills, Managing Director, Frontera Group.
“This is a crucial area, because whatever intervention you put in place, you need to be sure that the change you’re looking for on day one is still happening on day 500. However, it’s often difficult to understand what conditions are required to maintain the new behaviour and prevent relapse, or to re-establish the new behaviour after relapse. Many interventions base maintenance on ‘dynamic reciprocity’ – the misguided belief that human behaviour is influenced simply by exposure to a desired behaviour. In reality, ‘behavioural potential’ varies over time and is heavily influenced by context. Without a continuous loop of engagement and follow-up, behavioural relapse is a constant risk.”
The core principles of behavioural theory underline its complexities. According to Kwasnicka’s paper, individuals have various behavioural options in any given situation. These options – which may be intentionally or impulsively driven, or predicated by prior behaviour – ‘have a certain likelihood of being enacted at any given time, reflecting current individual (motivation, habits, resources) and contextual (cues, opportunity costs and opportunities) factors’. This likelihood is known as ‘behavioural potential’, and its variability is an ever-present barrier to behaviour change maintenance. So what can pharma do to overcome it?
Tech can play a significant role in ensuring new behaviours are maintained in the long term. “Leaders are recognising that digital can not only initiate change, it can help ensure that target behaviours become dominant over time,” said Craig. “However, to succeed, digital interventions need to consider all behavioural potentials and the probability of them becoming driving factors.
"Factors include maintenance motives, identity and self-regulation. For example, if individuals enjoy a new behaviour and are satisfied with the outcomes – for instance, weight loss and its associated health gains – motivation is reinforced and people are more likely to make positive self- judgements and sustain their efforts. Conversely, if an activity brings no satisfaction – such as
diet food tasting bland without salt or sugar – motivation is challenged."
Similarly, identity can be key; if a new behaviour leads to a more positive self-image, behaviour is again reinforced over time. Self-regulation – the ability to control behaviour by inhibiting dominant or automatic behaviours – is also important. Interventions must therefore help resist urges and habits and instead establish patterns that overcome situational temptations. Digital tools can enable an individual to develop a better level of coping – improving self-efficacy to help them respond confidently to behavioural barriers.”
One area where digital best practice is commonly cited is fitness trackers, which are now an established norm. The question is: do these interventions change behaviours for the long term? Perhaps not. Studies suggest that more than half of tracker owners abandon their devices within the first month.
“Fitness trackers are a great example of how the right behavioural support could lead to more sustained use,” said Craig. “To encourage long-term change, tracker devices should incorporate techniques that directly address the barriers to increasing activity – and that will only come through understanding individual user groups like the elderly, sedentary or those in low socioeconomic groups.
"Fundamentally, whether it’s a fitness intervention or a patient support app, success will come from identifying and addressing the factors impeding behaviour change maintenance – to help users set and measure goals, plan activities, overcome identity challenges and enhance motivating behaviours. Digital tools, properly designed and based on deep user understanding, can deliver against all these parameters and many more.”
The full ecosystem
There are countless examples where digital tools and technologies are being used to drive behaviour change among patients – and many of these have the potential to provide the foundations for change maintenance in the future. However, despite these interventions being specifically designed for patients, it’s their interaction and connectivity with the wider health ecosystem that will ultimately determine their success.
“Behaviour change doesn’t happen in isolation,” said Houda Kamoun Follot, Chief Strategy and Marketing Officer, Aptus Health. “Fundamentally, patients need help and support from within their ecosystem – and HCPs in particular have a huge part to
play. To inspire and sustain behaviour change, physicians need timely, high-quality information to ensure their recommendations are tailored to the person in front of them.
"Digital interactions – through personalised, targeted content – can help. We’ve seen numerous examples of this, such as a coordinated digital campaign featuring key opinion leaders aimed to enhance the conversation between HCPs and patients and educate them on the need to better manage risk factors. Analysis showed that the campaign yielded a 43% increase in awareness across more than 20,000 GPs and specialists. In addition, it generated as much as a 15% increase in how HCPs perceive a key risk factor when treating patients with diabetes.”
Naturally, many digital interventions are extremely patient-focused. “We increasingly see prescription support or patient support programmes that are designed to encourage medicine adherence or overcome barriers to healthy behaviours,” said Houda.
“These interventions are commonly mobile-based and use SMS, notifications and real-world triggers to nudge patients towards target behaviours. These tools not only counter the challenges of forgetfulness that often drive non-adherence, they can help overcome the fears and trepidations patients may have about their disease.
"Their impact on behavioural change can be profound in terms of prescription redemptions, long-term persistence and loyalty to the brand that offers these types of programmes. It’s all about using data proactively and responsibly to trigger prescription-related communications about renewals, coverage issues, usage tips and more – making it easier for the person on the other end to make better decisions about their health.”
The future of behaviour change maintenance will almost certainly hinge on personalisation. However, although behaviour is inherently personal, the influences on it stretch far and wide. Those influences must be leveraged, and digital provides a powerful opportunity to do that at scale.
“Technology gives us the chance to extend the doctor/patient relationship beyond sporadic engagements,” said Houda. “For example, in the US, consumers are increasingly opting-in to services that encourage them to digitally document their patient experience and share that information with their physicians in-between clinical visits.
"This real-world data significantly informs the next consultation, helping boost HCPs’ confidence that the recommended therapy is right for their patients, or providing the insight they need to adjust their recommended care plan. It’s a powerful way of influencing behaviour for the long term – and it’s a great example of what digital can do.”
The long-term approach
Pharma’s commitment to behavioural theory is proving increasingly effective in changing customer behaviours. However, the leaders of tomorrow will be those that look beyond moment-in-time change and explore approaches that focus on behavioural change maintenance.
Digital presents major opportunities to understand, track and shape behaviour continuously and at scale. If companies don’t harness it – and take behavioural understanding to the next level – then the time and effort invested in initiating a behaviour change will ultimately be wasted.
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