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Can we change behaviour through medical education?

We often attempt to change our behaviour throughout our lives: we try to stop smoking, adopt a healthier diet and/or improve our fitness

We often attempt to change our behaviour throughout our lives: we try to stop smoking, adopt a healthier diet and/or improve our fitness. Sometimes it works, other times we are less successful. But what can be even more difficult is when we try to alter someone else's behaviour. This is the whole idea behind medical education.

When embarking on a new medical education programme, considerable time is spent brainstorming new ideas and methods to deliver key messages. But is this approach always successful? Instead, wouldn't it make more sense to explore the factors that dictate behaviour then use these as the basis for medical education?

New disciplines within psychology are being used to help predict health behaviour. This is supported by a wealth of peer-reviewed evidence that has identified the factors that are likely to trigger behaviour change. This growing interest has been driven by the fact that chronic diseases account for 60 per cent of the global disease burden and so it is imperative that we become more successful in changing attitudes to the risk factors associated with these diseases. Could some of this experience be used to help predict whether or not medical education programmes are likely to change behaviour?

Research by health psychologists has resulted in a number of theories and models. It is interesting to see if these can be applied to single projects or across an entire medical education programme. There is a range of theories to choose from including the health belief model; protection motivation theory; social cognitive theory; and theory of planned behaviour.

Lessons can also be learnt from cases where there has been a successful and unsuccessful approach to changing behaviour. Such as the two listed below.


The BSE crisis
The BSE crisis in the 1980s is an example of an unsuccessful attempt to change behaviour. Initial concerns, then evidence suggested that BSE or `mad cow disease' could spread to humans through the consumption of contaminated beef. At the time, the British public was subjected to a whole range of conflicting and confusing messages. The Minister of State for Health famously recommended beef burgers to his grandchildren on national television. Other messages advised people to avoid biscuits and gelatine capsules, because they contained gelatine from processed beef; and beef on the bone was banned.

The public was confused and the result was a range of random behaviour changes. Some people defiantly continued to eat their T-bone steaks supplied by `renegade' butchers. Others became vegetarians and avoided all meat. The plan, if there was one, did not succeed because of the lack of co-ordinated evidence, peer endorsement and infrastructure.

North Karelia Project
In contrast, the North Karelia Project is an example of a truly co-ordinated programme that resulted in radical changes in behaviour and health outcomes. North Karelia in Finland had one of the highest incidences of cardiovascular disease in the world. A project to address this started in 1972 and was carried out over 30 years. It can be summarised under three headings:

- Evidence In the Karelia case, there were clear information-based strategies that highlighted the evidence between risk factors and cardiovascular disease. The information phase also provided compelling evidence showing that changing behaviour could improve health outcomes.

- Peer endorsement The evidence was backed up and supported at a national level by the medical community and at an international level by endorsement from the World Health Organisation. The communities were asked to disseminate the information through public meetings co-ordinated by local organisations. Television and radio were used to reinforce the messages at local and national levels.

- Infrastructure Perhaps the most important aspect of behaviour change is to ensure that a supportive infrastructure is in place. For example, in North Karelia, local food manufacturers were involved to help develop low-fat dairy produce. New sausages were formulated to replace beef with mushrooms. Farmers were involved in education and training programmes to reinforce the need for increased production of berries and vegetables. There were community-based classes on preparing economical and healthy foods, and families were invited to these classes to create social reinforcement. There were `quit and win' competitions between villages to help smoking cessation as well as competitions at youth and school level.

Since the North Karelia programme was launched, the annual mortality rate of coronary heart disease among men under 65 has been reduced by 65 per cent. Men in this area now have their life expectancy improved by seven years and women by six years.


So what does this mean for medical education?
Ogilvy 4D learnt lessons from both the BSE and North Karelia Project then adapted the `theory of planned behaviour' to make it work in business. A toolkit was devised based on the three key drivers in the North Karelia Project: evidence, peer endorsement and infrastructure. This toolkit is used to create new medical education programmes designed to change behaviour, plus it can audit existing programmes to identify any gaps.

Success in practice
Ogilvy 4D recently used this toolkit to create a medical education programme to support the launch of a new medicine into a crowded market place. By ensuring a co-ordinated approach to the evidence, peer endorsement and infrastructure, it achieved considerable behaviour change:

- 85 per cent of the target audience recognised that the new product had advantages over its competitors.

- There was a 10 per cent increase in the breadth of prescribers within one month and a 40 per cent rise in prescribing within three months of the programme.

- Participants in the programme were twice as likely to prescribe the new medicine compared to those that did not participate.

There is a wealth of peer-reviewed evidence relating to behaviour change that can be use to drive medical education programmes. There are also some stark examples of best and worst practice to help guide success. It is this evidence that has helped shape Ogilvy 4D's toolkit and, as a result, its medical education programmes have benefited from more predictable outcomes on behaviour.

Kevin Mageean is Managing Director at Ogilvy 4D. He can be contacted at

2nd September 2008


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