Behaviour change is a twilight zone where theory and practice collide, with results that are tough to predict and sometimes even harder to explain. The confounding factors of personal habits, experience, influences and intentions make it a difficult subject filled with opportunities and setbacks.
Encouraging behaviour change to improve health outcomes is a vital goal, but its pursuit has been hindered by unrealistic expectations and modest results.
But fresh thinking and commitment to clearer understandings of the nuances that are at the heart of behaviour are starting to unlock the gains that could transform healthcare systems that are under huge pressure.
The pandemic, with its sudden sharp focus on the correlation between behaviour and health outcomes, has delivered a huge jolt to society, encouraging people to realise that behaviour is as important to health as the most innovative science.
Getting it right will see benefits radiating out across the pharmaceutical industry with therapy programmes reaching deeper into target audiences for better adherence and the public becoming more involved in their treatment.
It starts with the basics
“We need understand what influences people in everyday life as a first step,” said Rachel Rowson, of MHP Mischief, an agency that has been working with University College London’s Affective Brain Lab to develop The Networked Age, a project which explores the nature of individual thought and group behaviour.
“In The Networked Age, people are less willing to listen to ‘experts’ or engage in real debate – especially around health. The Affective Brain Lab has been experimenting with the differing influences of ‘accuracy’ vs ‘similarity’ when learning from other people. The results found that people are more likely to listen to people ‘like me’ rather than those who are experts.
“This lesson can be applied to healthcare when thinking about who to work with to share messages.
“The ultimate lesson is that we must see people as people, not patients. This means building campaigns on passions and pursuits, rather than bombarding people with problems they must overcome.”
Tailoring change to an audience
This learning should be applied across the healthcare spectrum, added Rowson. “Historically, behaviour change has often been focused on the public and patients. This only addresses part of the challenge. We need to focus on the behaviours of healthcare professionals (HCPs) and system leaders as well. As with any change, it is critical that the system, HCPs and patients are all aligned and working together to improve outcomes.
“The change that you are trying to effect needs to be tailored to the audience. An example of this is shared decision-making. It is essential to give patients the tools to advocate for themselves and to know how to make the decisions about treatment and care that are right for them. But if the HCPs they are working with are not open to talking about shared decision-making then this won’t happen.”
The scale of the challenge and the glacial slowness of behaviour change response has neutralised many past efforts, but the rapid development of COVID-19 vaccines combined with regulatory flex and digital’s transformative power have reframed what is possible.
“The pandemic has demonstrated that behaviour change can be applied to healthcare infrastructure as well as to the public,” said Rowson. “Many things were done differently and applying the principles of behavioural science to healthcare systems and regulators, and persuading them to accept different types of evidence and to allow technology to speed up processes, is long overdue.”
Deep dives into context, culture and community are needed to improve the chances of behaviour change programmes succeeding, she added, and this needs to be welded to strong planning that drives targeted interventions – one size only fits one person.
Digital technology is leading the way, but how it affects, and is used by, every segment of the population, rather than the early adopters and GenZ natives, is critical to success.
Rowson added: “There is a huge opportunity for the pharmaceutical industry in digital behaviour change in medicines adherence. Prior to the pandemic, medicines adherence was one of the main areas apart from prevention and public health where behavioural science has been applied in healthcare. Despite this, the WHO has said that in developed countries adherence to long-term therapies is only around 50%. Pharmaceutical companies should be looking at behaviour change in combination with user-centred design techniques to help build digital tools to improve medicine adherence.”
Is it important? Rowson is clear: “Behaviour change is the ultimate measure of success, so this is a critical element of any work done by the pharmaceutical industry. If you aren’t effecting change, then is the activity you are engaging in worth the effort?”
Understand, collaborate then change
Deborah Burrage, Programme Director at Lucid Group, believes that the pandemic has elevated the expectations of behaviour change programmes.
“It’s brought behaviour change, and drivers including personal motivation and social influences, to the forefront of a lot of people’s minds,” she said. “The route to the best impact for healthcare systems and our clients in the pharmaceutical industry is to focus on behaviours and their determinants, and understand the barriers to change in terms of capability, opportunity and motivation. Only then can you really see what can be feasibly changed.”
She highlighted a Lucid Group initiative that improved the delivery of multiple sclerosis services after collaborating with specialist nurses and taking the time to understand their issues.
“We listened to the specialist MS nurses and worked with them to bring about the changes they wanted, to the point they even influenced the behaviours of other people in their multidisciplinary team and drove real change in the whole system, which improved outcomes for patients.”
Behaviour change is an acronym-heavy environment with APEASE (Acceptability, Practicality, Effectiveness, Affordability, Side-effects and Equity) COM-B (Capability, Opportunity and Motivation Behaviour) and EAST (Easy, Attractive, Social and Timely) guiding policymakers, but the breadth of those factors underscores the high bar needed to effect change. And to add extra difficulty, change has to be achieved within costs and compliance frameworks.
Getting the mechanics of any behaviour change initiative is critical, observed Burrage. “There is a real emphasis on the discovery phase,” she said. “It is very human to make a lot of assumptions about why people are behaving in certain ways, and to imagine what you would do in certain situations. It is vital to take a step back from that and, as much as possible, observe what’s actually happening and challenge your findings. There are so many factors in play that may not be obvious on first look.
“You need to get right into the community and talk to people openly. If you don’t, you may well waste a lot of money in creating outputs that essentially don’t work.
Invest in discovery
“Sometimes, the answer will be that it is not going to be practical to change a certain behaviour and the resources would be better spent in a slightly different way or on a slightly different population.
“At Lucid, we really invest in the discovery and design phases, mapping out a series of candidate behaviours that can be targeted to ladder up to an over-arching outcome. But you can never assume anything will work exactly as planned so there is a need for constant testing. You need humility and flexibility in human behaviour change, and the ability to adapt and not to cling on to assumptions.
“This can be a challenge to pharma companies who will have gone through compliance and approvals and won’t necessarily be keen on changing direction but it is the best way to effectively use funds and get the best possible results for patients.”
Getting it right is rewarding and lasting
“It makes me incredibly happy and proud to think about the impact of our MS programme and the positive relationships we established,” added Burrage. “There was a lot of data generated but every one of those statistics can be related to a person and I know what that has meant to them. It was a privilege to work with them and create change.”
Behaviour Change Techniques (BCT) such as gentle ‘nudges’ to modify risk can have a major influence on lifestyle diseases and adherence to medication. But nothing is linear in behaviour change; the twists and turns across demographics, age groups and disease conditions could contort the clearest of intentions.
Evidence is critical
Evaluation is a fundamental component to maximise the gains and quickly jettison the ineffective, said Anthony Greenwood, director at Research Partnership, the healthcare market research and consulting agency, part of the Ashfield group, which has a network of behaviour scientists.
“Evidence is critical to driving behaviour change forward because we have countless examples of interventions made with good intentions that fall flat,” he said. “Teams construct their approaches convinced they will work and the results are completely different.
“A study in Texas showed recently that a road safety programme that placed warning signs on a notoriously bad stretch of freeway actually caused accidents and fatalities to rise by 4.5% because drivers’ brains were so overloaded with information that they weren’t concentrating on driving. It was well meant but acted as a distraction.
“There are tools, techniques and initiatives that can change behaviour but first we need to identify what might be influencing or limiting behaviour. We call it the hypothesis stage; it’s where we work with our clients to identify their behavioural objective, whether that is getting patients to come into clinics more rapidly or to try new products. We need to know the biases and influences that are in play and the specific aspects of the environment that are limiting that behaviour.
“We are constantly working on ways to test any premise or hypothesis we have within research
to identify the most meaningful influences on the desired behaviour, with (digital) ethnography becoming a critical element of our toolkit in helping to better understand the context surrounding decision-making.”
Behavioural science promise
Bottling these swirling influences requires a modern alchemy but the pandemic has put behaviour centre stage, with issues such as mask- wearing and vaccine hesitancy rates highlighting areas where education and information needed to be finessed across populations. The confounding responses – from overwhelming compliance through indifference to hardened resistance – exposed the complexity of behaviour patterns.
But Greenwood believes the see-sawing successes and failures have provided evidence that can inform future campaigns for pharmaceutical companies needing to identify and connect with small or diverse communities.
“COVID-19 has put an emphasis on behaviour change and there is more awareness of it in daily life through vaccinations, climate change, green initiatives and smoking cessation campaigns,” he adds. “The desire to change behaviours is omni- present.”
The impact of COVID-19 on cancer screening created a fertile ground for human behaviour research, with The Lancet reporting that 45% of people did not come forward for screening during the first phase of the pandemic, said Greenwood.
Applying the EAST framework, Greenwood and Research Partnership colleagues were able to assess how difficult it was to attend a clinic at a time when social movements were restricted and the immediacy of the pandemic superseded concerns about cancer.
Countering the impact – essentially changing behaviours back to pre-pandemic priorities – needs a combination of improved infrastructure and access to consultations (make it easy), efforts to reframe the risks of cancer relative to COVID-19 (make it attractive) and use present bias and people’s current emphasis on healthy behaviours to drive presentation (timely), he added.
“The need to change or influence behaviours, such as finding out why a doctor prescribes product A over product B, has been part of the challenge for a while but historically we’ve never put a label on it, or backed up results with literature from academia,” said Greenwood. “Influencing behaviour is becoming more prominent in the requests we get from our clients, with elements of behaviour change across most of the briefs we receive. In the pharmaceutical and healthcare space, we have always been slow adaptors and more risk-averse than colleagues in other sectors.
“We can’t just rely on cutting-edge science to enhance patient outcomes or meet commercial objectives; we need to incorporate other areas such as behavioural science to meet these goals.
“A future where the interconnection of these disciplines drives truly meaningful change is hopefully closer than we think.”
Danny Buckland is a journalist specialising in the healthcare industry