Stepping out

Back in the early 90s - while an aspiring thespian - a dance tutor once insisted that my inability to remember basic choreography would ultimately be resolved by ‘muscle memory’. She had failed to account for my two left feet. In fact, through the constant repetition of clumsy footwork and rhythm-less shapes, my muscle memory merely became a subconscious storeroom of bad habits. My final showcase made a cart horse look like Nuruyev at his peak. Some 25 years later - and despite occasional efforts to transform into Travolta - I’ve consistently found it difficult to break those old habits and learn new steps. The lycra has long since been retired.

The scenario could easily be an allegory for 21st century healthcare where securing behavioural change has become a global obsession that’s driving a step change in healthcare communications. As the need to maximise health resources intensifies, pharmaceutical companies are increasingly focusing on designing interventions that help patients replace harmful habits with health-enhancing behaviours to improve long-term outcomes. The notion is eminently sensible. But delivering it requires some pretty complex choreography.

Slow, slow, quick, quick, slow

Behavioural change is not a quick fix. Human behaviours are embedded in muscle memory built up over many years - and they won’t be changed overnight. What’s more, the fluidity of our behaviour means that even when it does change, it can - like a misplaced fleckerl - just as quickly land back in the wrong position. Real behavioural change is not a moment in time - to be meaningful, it has to be durable and sustainable. Yet we’re all susceptible to lapsing into old habits. How many of us join the gym, only to find the monthly direct debit lasts far longer than our commitment to the cause? How many give up smoking - every New Year’s Day? And how many have installed smart meters to monitor our energy consumption, yet still leave the lights on in every room? Muscle memory is a powerful beast even when the benefits of change are steeped in common sense.

Pharmaceutical companies, no doubt motivated by the potential implications of outcomes-based contracting, are increasingly recognising that a better understanding of human behaviour could uncover the solution to medicines nonadherence. It’s a solution they’ll need to find quickly. If companies are only reimbursed for the outcomes they deliver, interventions that ensure patients take their medicines are likely to become an imperative. However, those interventions will only deliver sustainable change if they’re built on an appreciation of the social, environmental and, often, personal contexts that influence human decision-making.

Capturing the emotion of the dance

Pharma’s success will undoubtedly depend upon securing deep behavioural understanding that can help reset the muscle memory of its target patients. But it takes two to tango; the industry must break its own bad habits too. “Companies are not yet mature in their understanding of how to deploy behavioural science,” says Aaron Bean, director, life sciences, UK & Ireland, at EY. “They’ve got 30 years of operational muscle memory that’s difficult to push aside. Companies have traditionally taken a very rational, ‘left-to-right’ approach in their communications. The way they create their content and messaging is all about pushing rational buttons, rather than acknowledging that humans are innately emotional and irrational beings. The challenge is to understand what are often deep-rooted drivers of behaviour. And that means getting far closer to patients.”

So what’s the trick? According to Aaron, there are five must-have capabilities: “The first is around customer insights and understanding the study of behaviour. Companies often think insight is about asking customers what they want and then designing programmes that reflect it. But the most effective insight comes through observing behaviours rather than simply relying on what customers tell you. Ethnographic research and response-time testing can get under the skin of what motivates customers and help identify deep-rooted drivers. Secondly, understanding the customer experience is vital. Healthcare is very fragmented, with patients journeying across multiple touchpoints through the course of their care. No-one really takes ownership of that journey. There’s an opportunity for pharma to tie all those threads together and provide end-to-end support for patients throughout their journeys. That would create better experiences and, over time, help drive sustainable behaviour change.

“Thirdly, service design is becoming critical. Companies are developing and piloting lots of innovative services, many of which are digitally-led and involve fewer personal interactions. The challenge is delivering them at scale. The fourth is customer engagement planning; how do you use insights to plan the timing, frequency, channel, tone and sequencing of content to engage your customer and build a two-way dynamic? And finally, underpinning everything, you need a content strategy that provides an engine for creating dynamic and responsive content that captures human emotions. The ‘one-size-fits-all’ approach will not change behaviours.”

An ensemble performance

Naturally, patients are the focal point of behaviour change programmes. However, patient-centricity is not about having a myopic focus, it’s about understanding and maximising all the various touchpoints that patients experience throughout their journey. The most obvious is the physician. “Patients won’t improve their adherence without getting the right communication from physicians,” says Fiona Hammond, managing director, Hamell. “For example, a recent study of pain management in Europe showed that some patients weren’t taking their medicines appropriately because they had concerns about becoming addicted. When they discussed this with their doctors, the doctors agreed - wrongly advising them to take their medications only when they felt it appropriate. This is a clear example of why behaviour change programmes should have a broader focus. Many pharma companies are investing heavily in programmes that focus entirely on patients. We see great work being done where banks of nurses and other resources are providing valuable information to support patients. However, if the next time a patient sees their doctor they’re told something completely different, that investment counts for nothing and sustainable behaviour change will not materialise. Often, the most resonant communication to patients comes through physician interaction.”

Behaviour change is complex and multi-dimensional. Approaches to it must therefore reflect that. “It needs to be viewed holistically and consider all the different facets that need to be changed to achieve sustainable behaviour change,” says Fiona. “Patients don’t exist in a vacuum; we’re all influenced by our interactions with HCPs, our peers and the media, and by what’s considered ‘normal’ in our society. That’s why it’s important to take a 360° approach - because all those factors influence how people behave. They might not all be very important, but some of them will be. The challenge is to work out which ones are - and then target your intervention.”

The means of achieving this are manifold. Many fall under the broader umbrella of the behavioural sciences, the exploration of which has become very popular in pharma. However, understanding of the behavioural sciences is - for the industry at least - still in its infancy, with some companies focusing on just one aspect of it. The one-dimensional approach, says Fiona, has limitations. “There’s currently much focus on behavioural economics, which gives you a really good understanding of how we are all programmed to respond automatically, unconsciously. This is obviously important information for behaviour change, and interventions based on this understanding - nudges - can be very effective in changing short-term behaviour. However, to really maximise the effectiveness and sustainability of behaviour change, we need to take into account all the other factors that drive our behaviour. It’s important to examine behaviour more holistically. Effective programmes take an empirical approach to identify an evidence-base for every aspect of what’s driving behaviour.  This is the foundation of effective interventions that can drive sustainable change.”

Modern dance

Another school of thought is that the industry needs to get better in its use of data. What’s more, it needs to get out into the real world and make the most of tools that other industries have long been exploiting. “Behaviour change is ostensibly a personal matter - and so if we’re going to understand it, we’re going to need to use data more effectively,” says Dennis O’Brien, CEO, Lucid Group. “In the wider world, data analytics is now much more sophisticated. For example, the online betting industry uses complex analytics to target gamblers at very specific times based on a deep understanding of their behaviours and how they use media. It’s now possible to analyse up to 13 billion online conversations every day and use that analysis to drive decisions and communication. The opportunities are endless - but I’m not sure we’re making the most of them. Through better use of data we should be able to get deeper patient insights; we can understand where they’re at, the conversations they’re having, where they’re having them and the choices they’re making. And we can use that understanding to tailor appropriate education interventions to change behaviour - whether that’s an intervention to improve awareness or a tool to support them through their journey of change.

“It’s time pharma got out into the real world. We need to stop thinking that patients are a different species - and stop designing support programmes that treat them differently simply because they’re patients. They are human beings - and we’re competing with the likes of Google, Apple, Instagram and Facebook to occupy a space in their minds so that we can influence them. Fundamentally, we’re competing with what people are doing in their everyday lives. We need to sit comfortably within that if we’re going to change behaviours.”

Ultimately, says Dennis, pharma needs to look beyond what it’s done in the past and think about patients as real people. “We need to understand that ‘human being experience’. Certainly, we need to understand and apply the science of behaviour - but we need to translate it into the real world. As an industry we shouldn’t become obsessed with data analytics or behavioural science - we should be obsessed by how we occupy a space in a human being’s mind. And we should be learning from the best to do it. That’s not pharma.”

The danceathon

Understanding human behaviours - and what inhibits or motivates it - is rapidly becoming one of the most important components of effective healthcare communications. As governments and public health organisations look to optimise resources and improve health outcomes, communications is increasingly being recognised as playing a crucial role in helping to change behaviours. But to make a difference, those communications must be built on a detailed understanding of what is a dynamic, multi-faceted human experience, weighed down by powerful muscle memory.

Sustainable behaviour change is a group dance that never ends. Achieving it requires complex choreography to correct old habits and bad footwork on all sides of the dance floor. It’s time to learn some new steps.