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Behaviour change theory

Behaviour change through teamwork – collaborating with stakeholders from across the health ecosystem. Chris Ross examines pharma’s adoption of behaviour change theories and finds an industry in need of a nudge in the right direction

Last month I stumbled across a 2019 article in the pharma press entitled ‘Does your brand need behaviour science?’. The central premise was that behaviour science is becoming a buzzword for pharma ‘because behaviour is a barrier to meeting brand objectives’. Hmmm. As an added boon for marketers, the op-ed proffered advice on how to ‘get patients or HCPs to do something different’. It left me feeling uncomfortable.

The piece was honest and well-intentioned, but its language and emphasis appeared to play to many of the things that have created a nervousness around using behaviour science in pharma – chiefly, the idea that marketers can use it to ‘get people’ to do something different and increase revenues. It doesn’t sit well.

Let’s be clear, behaviour science is increasingly important, but pharma’s route to success must surely be to focus on health outcomes rather than crude commercial gains? If you get the first one right, the second will naturally follow.

It’s all a question of emphasis: behaviour isn’t a barrier to brand success, it’s an obstacle to better health. If companies start there, they stand a better chance of commercial success. The real bottom line is much more important: behaviour change strategies should be patient-centred not brand-first. If pharma companies really do want to ‘get people to do something different’, they may want to look at their own behaviours first. Clarity begins at home.

The importance of behaviour science has, of course, been brought into sharper focus by recent world events. COVID-19 has facilitated behaviour change on steroids – forcing us to reshape our everything and exposing us to a glut of behavioural techniques and so-called choice architecture.

The most well-known technique – deployed throughout the pandemic, but familiar to many long before it – is ‘nudging’ – recently defined by leading behavioural economist, Cass Sunstein, as ‘an intervention that maintains freedom of choice but steers people in a particular direction’. According to Sunstein, a tax isn’t a nudge, a ban isn’t a nudge and a mandate isn’t a nudge. A warning – like ‘swim at your risk: crocodiles live here’…. that’s a nudge. It gets us to pay attention.

Over the course of the last 18 months we’ve all been nudged to kingdom come. The current drive for vaccine acceptance is an obvious example. For some, the apparent threat of serious disease is all the nudge they need. For others, the allure of $100 cash or 15% off a thin crust Hawaiian is more persuasive. The purists call it a nudge, some may call it a bribe. Either way, the point is made: behaviour is complex and the factors that trigger our decision-making are human, personal and nuanced.

There’s currently much ado about nudging, but it isn’t the only game in town. There are countless behaviour science theories, models and techniques, and as COVID has shown us, many of them can be applied to health. And so they should be – because behaviour, just like our health, is human. The two are often partners in crime.

According to David Williams, Chief Medical Officer and Head of Medical & Scientific Strategy, VISFO, it’s those human drivers of decision-making that make behaviour change so challenging in health. “The fundamental issue for human beings is that we are not resistant to change, rather we are resistant to being changed. There lies the problem for health interventions. Many of the diseases we are increasingly suffering from in our societies – such as diabetes, lung cancer and NASH – are mainly driven by our actions (or inaction) and the environment we inhabit. It is clear we have to change the trajectory of the health for millions of people. However, the challenges around this are many and complex, with very little attention being channelled to solve it. Traditionally, health systems have taken a didactic approach, with public health interventions having limited success. Obesity is a prime example. It keeps on rising in all countries, something COVID-19 has laid bare. Moving forward, healthcare systems must embrace a behaviour change approach, develop a strong policy framework and empower individuals to gain more control over making healthy lifestyle decisions.”

Pharma needs a bigger nudge

So where is pharma on the adoption curve of behaviour science techniques? Well, the term may now be a buzzword, but it’s still early days when it comes to its systematic application. “These days there’s broad awareness of behavioural science in pharma,” said Christina Jackson, Partner, Sprout Health Solutions. “Companies are generally familiar with models like COM-B and concepts like nudge – and we’re increasingly seeing these applied to influence patient behaviours. However, companies rarely apply the same principles when it comes to HCP behaviours. This is an enormous opportunity.

“There’s still a common assumption that if you give HCPs more information you’ll change their behaviour. It isn’t quite enough. Education is really important – because if HCPs don’t have the right information they cannot make informed decisions. However, just because you’ve helped a doctor to understand your data doesn’t mean you’re going to change their behaviour. You need to look deeper at what drives those behaviours. The answers are often human, emotional and multifactorial. Behaviour change techniques can really help – it’s just about choosing the right ones. That requires expertise and capabilities that, at present, few pharma companies have in-house.”

More than marketing

David Williams says that pharma has been practising behaviour change since its inception but has never perceived it as such, instead considering it ‘marketing’. Activity, he says, is typically marketing-led, with offerings largely confined to patient support programmes and ‘around the pill’ solutions that are generally driven by brand teams.

Jo Fearnhead-Wymbs, Vice President, Patient Engagement, Ashfield MedComms, agrees, arguing that a common failure to consider behaviour earlier in clinical development is a missed opportunity. “One of the biggest barriers to pharma applying behaviour change principles effectively is that companies still operate in silos – and only really consider behaviour at the commercial phase. For example, adherence initiatives are often driven by commercial teams looking to differentiate brands by providing value-added services. At this point, they often focus on behaviour change because they believe it will lead to better compliance and more revenue. However, efforts are typically focused on the drug and the indication – overlooking the fact that patients often have co-morbidities that  influence their behaviours. Shifting those habits isn’t just about the drug and the disease, it’s about looking at everything in the round. We have to move away from silo thinking. Behaviour change programmes start with a deep understanding of patients’ experiences and challenges with their health overall. That process must begin early in clinical development.

“If, for example, we look at patient behaviours in clinical trials, we’ll find clues that help us understand the challenges we might face if a drug is commercialised. We know there’s a big difference between clinical studies and what happens when the real world gets in the way. If we understand this early, we’ve a better chance of improving outcomes through better compliance. At present, this is rarely on the radar of medical teams where attention is focused on science not behaviour. As an industry, we need to open conversations about behaviour as it relates to general health far earlier – whether that’s in clinical development, clinical programme planning or medical affairs.”

According to Jo, greater cross-functional collaboration can help companies identify barriers and challenges proactively. “There’s much we can learn earlier in the cycle,” she said. “Health behaviours can be impacted by everything from the condition itself to co-morbidities, social support structure, where patients live or their proximity to health services. If we want to address a compliance problem, we can’t afford to wait until a drug is launching, we need to listen to what’s important to patients and engage them meaningfully in all aspects of clinical development.”

But there are encouraging signs. “We’re starting to see examples of clinical trials where there’s a behavioural component built into the study design,” said Jo. “This is a big step forward and we need to see more of it. If we’re going to improve adherence, we need to include the patient voice right from the start of clinical development and understand the complexities of behaviour that influence decision-making.”

Co-creation is crucial

With pharma’s adoption of behaviour change techniques still largely in its infancy, companies need to accelerate progress. But how? “The route to improvement is to keep the patient and their environment at the centre of decisions,” says David Williams.  “Many will say they’re patient-centric and have patient advocates and engagement in their business. That’s a brilliant step forward. But how many would say they study the three dimensions of influence: the patient, the healthcare provider and the pharma company dynamic? Perhaps not many. This complex interplay is where change should start. ORCHA in the UK has made great strides in assessing and challenging technology providers to develop relevant tools, with the first step they insist on being to ‘co-create with the patient’.”

But how do you go about it? A deep dive into behaviour is essential. “The basic rule is to understand who needs to change (the patient, healthcare provider etc) and spend time understanding, elucidating and mapping their current belief system,” said David. “A good route to this is to perform deep analysis of digital media and face-to-face discussions, cross-referenced with all the available published scientific data to give the most comprehensive situational analysis.  Best practice supplements this with real-world data – through forums and patient groups and discrete choice experiments – to fully understand attitudes, preferences, beliefs and mismatches. This allows you to determine the real challenges that need to be addressed, not the ones you think that need to be addressed. There’s often quite a difference.”

Education is important

When it comes to tackling patient adherence, it goes without saying that education is important. “Non-adherence can sometimes be driven by a lack of understanding about a given disease or avoidable misconceptions that get in the way of patients taking their medicines,” said Kirsty Mead, Account Director, Purple Agency. “Education – and communication between HCPs and patients – can be key to filling in those gaps and overcoming the obstacles to desired behaviours. Pharma can play a big role in providing tools and resources to facilitate those conversations and support patients. The development of those resources needs to be rooted in a thorough understanding of patients’ fears, needs and default behaviours, as well as insight into what drives HCP decision-making. It’s only once you understand existing behaviours – and what influences them – that you can design strategies to try and change them. Ultimately, communications is key – because no-one wants to feel forced into changing behaviour. It’s all about encouraging baby steps rather than pushing people to make massive changes really quickly. That never works.”

Behaviour change isn’t magic, it’s a process

Despite its clear benefits, behaviour change theory is at times still saddled with myths and misconceptions that have stifled its uptake in pharma. “There’s still a perception that behaviour change is some kind of magic thing that you do to people without their consent,” said Christina Jackson. “It’s an unhelpful myth. Behaviour change doesn’t have to be subliminal. It’s about bringing things out into the open and giving people the opportunity to re-evaluate things in the hope that it might spark something that changes a behaviour. It’s not magic, it’s a structured process.”

So what does that process look like and how do you go about it? “There are generally four basic steps,” said Christina. “First, define what you’re trying to achieve and which behaviours you’re trying to change. Then, conduct comprehensive research to understand what’s driving those behaviours. Thirdly, interpret your findings through a health psychology lens; identify the most common barriers to change and which psychological theories are the best fit with a particular challenge.

“Lastly, identify the most relevant behaviour change techniques to apply to overcome barriers. Then it’s simply a matter of prioritising, and developing content that incorporates the appropriate techniques.”

Within health psychology, there are more than 100 behaviour change techniques that have been written about so far, as well as a number of different taxonomies. “These are the ‘active ingredients’ that are proven to drive change,” said Christina. “They’re not rocket science and they’re not mysterious – they’re just names that have been given to things people already do. For example, ‘credible sources’ – the concept of using a known opinion leader to deliver information – is a technique commonly used in marketing. It’s not new, it’s just been given a label as a behaviour change technique. The trick is to find the right techniques and systematically apply them when appropriate.”

Look outward, look long-term

So what’s best practice? “The most successful behaviour change programmes have two common characteristics; they involve multiple stakeholders and they look long-term,” says Kirsty Mead. “Behaviour change takes time. For instance, the campaign to promote seat belt safety in the UK took years of consistent communication before the desired behaviour became the norm. Unfortunately, the long-term approach is challenging for pharma.

“Brand teams often expect change within six to 12 months. That’s never going to happen. Human behaviour is deeply ingrained. It takes patience and persistence to shift it.

“The message to pharma is to play the long game, and remember to look outwards too. Sometimes, pharma campaigns are developed in silos, focusing on functional internal goals rather than broader patient/HCP needs. This is a big missed opportunity. Successful public health campaigns involve large numbers of people from a wide range of stakeholder groups. They gather insight continually and take time to build their campaigns to ensure the message is right. And then they hit repeat – iterating when necessary – until the desired behaviour becomes ingrained. Pharma needs to take the same long-term, multi-stakeholder approach. In particular, partnering with patient groups is essential. Advocacy groups understand what patients go through and the things they need to make informed choices. Collaborating with them brings authenticity – and credibility – to any programme.”

Behaviour is a team sport

So how do you put it altogether to develop behaviour change programmes that work? Fundamentally, the systematic application of behaviour change theory in pharma is a team sport. “Success comes from having the right internal team – encompassing medical, marketing and commercial – engaged from the outset, within clearly defined parameters and terms of control,” said Christina. “In a collaborative process it may be necessary for some functions to relinquish aspects of control to others. That can be uncomfortable – but the alternative has the potential for an organisational paralysis that can leave projects gridlocked. If everyone is working   to shared goals relinquishing control shouldn’t be an issue.

“Finally, with in-house capabilities often limited, progressive companies generally bolster their team through partnership with external specialists. The most effective partners will have two key qualities: an academic understanding of behavioural science and demonstrable experience of its application    in healthcare.”

And so we circle back to the beginning and return to the killer question explored in the 2019 article: does your brand need behaviour science. The answer is undoubtedly yes. But if you’re   going to get it right, make sure your strategy prioritises health outcomes over commercial gains. That means collaborating early and comprehensively with stakeholders from right across the health ecosystem for your brand, and understanding the triggers driving the behaviours that lead to better health.

Chris Ross is a freelance writer specialising in the pharmaceutical and healthcare industries

13th September 2021

From: Marketing

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