ISSUE 5
S POTLI G HT O N ...
B E HAVI OU R CHAN G E
Inspiring audiences. Motivating change. Thinking beyond. COUCH MEDICAL COMMUNICATIONS ©2017. All rights reserved.
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NOTE FROM THE EDITOR In this, the 5th issue of our spotlight magazine, we turn the focus on health behavior change. Now, if we are going to be really honest, we can all admit that changing health behavior can be tough, even when we know that it is the best way to reduce our risk of chronic disease, or manage any existing conditions. This is the challenge that H C Ps face every day, and sometimes it must just feel unsurmountable. Fortunately, there is a growing array of digital tools, including apps, gamification and wearables, that can help patients to understand why changes need to be made, and support, and encourage them as they make the changes. But this will only happen if the tools are useful, rewarding, or even just fun to use, and if they are tailored to the user. It’s no good giving a smartphone app to someone who hasn’t the dexterity to use it, or a paper diary to a teenager. In behavior change, patients are b oth the problem and the solution. Success is all ab out understanding human nature, with all its frailties, enthusiasms and complexities, and working with all of these and not against them. Now – if only there was an app for that… Within this in mind, I hope you enjoy this issue and as always I would love to hear your thoughts. You can email me ash@wearecouch.com or tweet me at @ash_rishi. Till next time.
Ash Rishi Managing Director C OUCH Medic al Communic ations
IN THIS ISSUE Why achieving health behaviour change is hard How technology can help influence health behaviour change How to design digital health behaviour change initiatives The role of personalised communications in behaviour change Measuring health behaviour change programmes Where is behaviour change heading?
WHY ACHIEVING HEALTH BEHAVIOUR CHANGE IS HARD As anyone who has tried to alter another person’s behaviour knows, achieving the desired health behaviour change can seem an impossible task. With so many variables to consider, from attitude, to health knowledge and context or environment, getting everything lined up properly can present an incredible challenge. The ideal model is to ensure people have the needed knowledge in the hopes that this will change their attitude and bring about the desired change in their behaviour. Unfortunately, circumstances in the real world are rarely this neat.
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A HCP’S WORK IS NEVER DONE
T HE HUMAN FACE OF HEALTHCARE
A large proportion of a HCP’s work involves trying to persuade patients to change their behaviour. This can range from simply encouraging them to keep their hospital appointments, right through to taking their medication as prescribed or giving up an aspect of harmful behaviour, such as smoking or eating too much sugar.
HCPs are generally highly motivated people when it comes to maintaining healthy behaviour. They understand better than most the consequences of incorrect procedure or practice. Here, context and environment plays a role; time pressures for instance, which can lead to the quickest option or route being followed.
Despite low adherence rates for following advice or instructions, persuading people to change their behaviour regarding health matters is the best way of reducing the occurrence of chronic diseases.
Being human, however, HCPs face the same challenges when trying to change their behaviour. The problem exists across the HCP spectrum. Nurses deviate from guidelines to control infection, dentists sometimes fail to adequately protect their patients during X-rays, and there is a high rate of error in care homes for the elderly.
H UMAN NATURE IS CONTRADICTORY Generally speaking, people are not averse to taking up healthy options when it comes to diet and exercise, or other activities relevant to good health. The sticking point in health behaviour change is when specific health regimens are prescribed. These prescribed regimens often take people outside their normal context, ask them to adopt behaviours that involve a change in routine or habit, and impinge on other aspects of their lives. Social and environmental factors play a definitive role in patterns of behaviour, with common behavioural patterns being evoked by the contexts surrounding them. Coaxing people into health behaviour change is often no more successful than getting people to stick to New Year resolutions. They may hold for a day or so, but the resolve soon fades.
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All this is not to say that health behaviour change is impossible. Devising programmes, however, takes special expertise and understanding of behaviour change theories and principles. These include addressing issues surrounding selfefficacy, and in finding ways to make the benefits outweigh the cost of learning new behaviours.
Coaxing people into health behaviour change is often no more successful than getting people to stick to New Year resolutions.
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HOW TECHNOLOGY CAN HELP INFLUENCE HEALTH BEHAVIOUR CHANGE In this article we look at the role of technology and how it can be utilised for successful health behaviour change. Gamification, in particular, is proving to be hugely effective in the treatment of patients. Unlike methods which merely aim to educate patients by traditional methods (or simply ‘telling them what to do’, at worst), gamification combines entertainment with education and, at the same time, hands over control to the patient as they learn to ‘master’ a game with their own skills and attributes. Games such as Zombies, Run! and Pact (in which players are rewarded by sticking to a particular diet) inspire the desire to compete and win – either against opponents or themselves. In this way, goals can be set and met in a ‘fun’ setting which distracts users from the ‘serious’ (or even tedious) business of accomplishing tasks which need to be done.
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Enjoyment in education is by no means a new concept, but more must be done to remove the stigma of self-punishment (or resisting old habits which are actually comfortable) from behaviour change. By taking on new challenges rather than merely ‘giving up fun things that do harm’, behaviour change becomes an optimistic prospect for patients. Yet gamification goes beyond the present, as it inspires individuality, creativity and resolve. These qualities can then be carried over into other aspects of the patient’s life, which include in no small part their ongoing treatment. For addictive personalities in particular, the flaws in character can become noble attributes which will lead to better health and happiness all round.
According to Accenture, gamification provides seven key elements: STATUS: Users feel proud of achievements among peers MILESTONES: A sense of progress as new targets are met COMPETITION: The natural desire to be better than others, or ‘former selves’ RANKINGS: Understanding one’s place in the hierarchy SOCIAL CONNECTEDNESS: Feeling part of a community of fellow users IMMERSION REALITY: Escapism in virtual worlds PERSONALISATION: Promotes a feeling of control over user’s own life Besides the personal qualities (to enable behaviour change) that gamification encourages, however, there is also success on the intellectual front too. Patients’ minds become more fertile ground for retaining knowledge about their conditions and
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medical matters in general, and this knowledge can further arm them to make changes in their lives – with confidence. Better still, the engagement with games can also encourage engagement with other forms of media such as videos, audio (podcasts etc) and research (googling etc), as well as signing up for email newsletters and posting to forums.
MAKING BEHAVIOUR CHANGE A SUCCESS For behaviour change to successfully happen, however, doctors, healthcare professionals (HCPs) and pharma companies must collaborate with patients, rather than work for them. For this to happen, each group must embrace their own behaviour changes. Our white paper ‘Influencing Behaviour Change’ outlines ways in which this can occur, including how notions of ‘roles’ must evolve with the times and how, just as patients, professionals must be prepared to discard ineffective habits and embrace new ideas and practices. There’s a wealth of resources and knowledge at our fingertips, and we’ll never be doing enough if we fail to explore all avenues.
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HOW TO DESIGN DIGITAL HEALTH BEHAVIOUR CHANGE INITIATIVES Over the past decade or so we’ve seen an explosion of digital health care advice, providing patients with ever expanding ways of investigating, managing and even diagnosing their own health concerns. For pharma, effecting digital health behaviour change can be a double-edged sword. On one side, there is the potential to reach many more patients, influence their choice of treatment or medication, and help them make sense of the medical issues in their lives. On the opposite side is the complexity of human behaviour and the myriad of influencers that determine digital interaction and engagement.
THERE’S AN APP FOR THAT The digital world changes almost daily, becoming ever more sophisticated and ‘smart’. It’s no longer enough to throw together a quiz or questionnaire, or upgrade to a flashy website design to engage patients. With internet access increasingly coming via mobile devices and wearables, pharma is finding new ways to effect behaviour change through medical/health apps. Wearables are increasingly varied, going far beyond the smartwatch, into clothing that monitors heart rate or breathing to insoles designed to help correct posture and balance.
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The problem with apps or wearables, however, is that while it’s easy to measure how often an app is downloaded, measuring its usage is altogether trickier. We still don’t know much about the effectiveness of digital interventions. And while it’s accepted that there’s around an 80% loss of users of apps, a review of such interventions revealed no effect or even a negative effect in a third of users. This is despite the ability for designers to programme in a high degree of personalisation.
W E’RE ONLY HUMAN Human interaction and behaviour is complex. There are many different perspectives, including intergroup, individual and societal. We need deeper interdisciplinary evaluations of digital health interventions, taking into account aspects of behavioural and computer science, engineering, and human/computer interaction. Humans will also ‘game the system’ if they can, for instance finding ways to inflate the number of steps taken per day, which adds to the general unreliability of user-centered data. Further, while we realise that reward systems don’t always work, we also don’t know enough about how cues work. Basic instructions and goal setting, while sounding simplistic, have proven effective, and if the desired behavioural change involves ‘losing’ something, then an equal or stronger gain needs to replace the loss. A good example is in digital initiatives intended to help people quit smoking.
M ATCHING CONTENT TO USER What is needed is a way to capture people at the right moment in their lives. In this respect, digital initiatives are most effective when they are part of a wider health approach rather than added on as an optional extra. Support systems for digital intervention initiatives should ideally align patients’ incentives with those of health care providers, working alongside both so routines are not disrupted. Time saving is also an ideal.
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A useful model to determine the factors involved in user engagement of digital or online interventions brings together research from different disciplines. Digital health behaviour change is most likely when all external and internal factors are blended together. First is the users’ environment: their time availability, their internet access and the environment they find when accessing the information. Environment relates to tone and function, and how it complements or contradicts similar information elsewhere. The next consideration is the user’s personal characteristics in terms of demographics, expectations and beliefs, self-efficacy and their current and previous health behaviour. Finally comes intervention, which determines how successful the initiative will ultimately be in effecting behaviour change. Persuasive design features such as praise and reward systems, strong arguments, a novelty factor, or peripheral cues such as aesthetic appeal or computer tailoring can help to encourage stronger engagement. Current approaches rely largely on influencing what determines behaviour change, but future digital health initiatives must look just as deeply into what stimulates engagement. Without engagement, digital initiatives don’t harness the full power of their potential.
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HEALTH BEHAVIOUR CHANGE STRATEGIES FOR PERSONALISED COMMUNICATIONS Human beings are complicated creatures when it comes to health, particularly if their wellbeing involves a change in either their approach or their behaviour. Persuading an individual of the need to adopt a healthy lifestyle isn’t hard. But leading that same individual to the point where they’re willing and able to undertake a change in behaviour is a tougher call. This presents pharma and healthcare with a difficult marketing task. Procedures, health products, and treatments are available to those who need them, as are preventive health regimes and dietary advice, but it’s not enough to simply tell patients they exist. In order to bring about permanent changes in health behaviour, marketers need to delve beneath the surface, right into the workings of the human mind.
Persuading an individual of the need to adopt a healthy lifestyle isn’t hard. But leading that same individual to the point where they’re willing and able to undertake a change in behaviour is a tougher call.
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HEALTH BEHAVIOUR CHANGE - NEEDED ELEMENTS An intriguing report written by consultation with senior NHS figures reveal the three elements need to come together in order to effect permanent health behaviour change. These elements exist in all areas concerning emotional or physical change, but especially in health, which is often taken for granted: The necessary skills and knowledge that make a person believe change is possible The opportunity to make the change, and this can include demographics such as location, income, employment, and other external factors The motivation to change habits, deal with negative emotional responses, set personal goals, and make positive decisions
Buried within those three principles are five behavioural factors that pharma and healthcare marketing should speak to, which are:
almost endless. But that information needs to be available in a multiple of formats and accessible at all times.
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Even very small barriers, such as not being able to find the answer to a question, can disrupt a patient’s determination to build new, healthy behaviours.
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Social and peer elements We’re not referring to your social media presence, but rather the important, motivational role that social and peer pressures play in influencing health decisions. Accountability is a strong mechanism in the goal-setting and achievement mix, so encouraging patients to form or join groups or take personal pledges regarding their health behaviour within their own social networks can prove a cost effective and efficient marketing strategy.
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The need for intrinsic motivation When the motivation to change is intrinsic (coming from within the individual because the change is personally satisfying), people are more likely to continue implementing that change, regardless of external motivations such as avoiding punishment or receiving praise or rewards from others.
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Understanding what motivates people to undertake health behaviour change guides the creation of marketing messages by encouraging positive values and boosting self-esteem among patients. Both states of mind are vital for patients to find their intrinsic motivation for change.
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Removing barriers Support, education, learning materials, websites, social media networks, leaflets‌ the list of ways in which healthcare and pharma present information to patients is
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Making change stick Making a start on changing unhealthy behaviour is relatively easy when compared with continuing a new regime or building a new habit. Once the novelty factor has worn off, the temptation to slip back into old ways is strong. In recognising this behavioural factor, the introduction of reward schemes, feedback or incentives are marketing approaches that promote continued healthy behaviour. Self-belief Before any health behaviour change can take place, patients need to believe that they can do it, especially when dealing with ingrained habits or addictions, or when learning new ways of living such as self-managing treatments for chronic conditions. Showing patients how to recognise and celebrate small personal achievements helps build confidence in their capabilities, and the inner strength to continue. Understanding why we behave in the ways we do is key to reaching patients on the emotional level that triggers a positive response, and promotes an inner desire for personal health behaviour change. Approaching marketing from this angle opens mental doors that otherwise stay shut when patients hear your message.
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MEASURING HEALTH BEHAVIOUR CHANGE PROGRAMMES Many of the methods in use today for measuring health behaviour change lead to confusing, sometimes contradictory outcomes. There is an ongoing search to find the value in medicine and healthcare, particularly value offered to the patient. Few in the medical community would argue against the need to improve patient adherence to medications or prescribed courses of action designed to alter behaviour. If a patient won’t do as the doctor orders, or won’t take their medicine properly, how are they supposed to get better? The ‘problem’ with patients is they’re people, and many people are naturally resistive to change. We’ve all had experiences where we’ve doubted our ability to live up to the expectations of experts, or occasions when we felt overwhelmed and unable to accomplish all that was asked of us.
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Therefore, there’s such a strong emphasis in medicine today on creating patient-centred programmes. By putting the patient at the heart of their own treatment, especially when it comes to persuading them to adopt sometimes challenging interventions, it is hoped they’ll take more responsibility as individuals and move towards greater self-management.
T HE PATIENT/PHYSICIAN DISCONNECT The real meaning of ‘patient-centred’ often gets lost in the drive to create new programmes and health interventions. Many surveys have revealed the difference between what’s important to patients and what’s important to doctors. Even dissimilar patients can have differing ideas about what’s important, so being patient-centred for healthcare professionals is far from a straight line between A and B. The value outcome of medicines is still largely measured against healthcare systems or general societal outcomes. To be truly patient-centred, programmes need to rather focus on value to the individual, and find a way of measuring health behaviour change at an individual level.
F OCUSING ON OUTCOMES Evidence-based guidelines are often followed when seeking to provide quality care. The guidelines are, however, measured more on the process followed than the actual outcome to the patient. This can put the patient at odds with the evidence-based approach, since if a programme is proven to work with the population in general, why won’t it work with everyone? Another way of measuring health behaviour change is to adopt a ‘goals’ oriented perspective within a programme that considers the patient’s point of view. Instead of measuring clinical outcomes alone, also measuring quality of life can result in significant improvements in patient outcomes.
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D EFINING GOALS Adopting a ‘goal-focused’ outcome, with the goal being informed by the patient’s point of view, allows for some flexibility and a more intuitive way of measuring health behaviour change, since the change needed is defined by the individual patient. Having identified the required behaviour change, barriers can then be explored and exposed, and a highly-targeted intervention designed with the final goal in mind. Such interventions offer immediate value and benefits to the patient. And because they’re so highly targeted, with clearly defined goals, measuring health behaviour change is simpler and likely to yield a more positive outcome for healthcare professionals and for patients. Patient-centricity is a trend set to continue for the long-term, and there is no shortage of innovation or enthusiasm in the medical community for designing new programmes. But the ways in which we measure patient benefits and value needs to be equally creative.
Adopting a ‘goal-focused’ outcome, with the goal being informed by the patient’s point of view, allows for some flexibility and a more intuitive way of measuring health behaviour change.
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WHERE IS HEALTH BEHAVIOUR CHANGE HEADING? How easy would life be if everything boiled down to ‘problems and solutions’? In healthcare, this would simply mean ‘for condition A, take medicine B’, and the world would be a happier, healthier and more prosperous place. In reality, however, cures and treatments are not the final solution – no matter how well they defy the power of infection. They face another obstacle – human nature – and, as we all know, this is infinitely more difficult to understand than even the deadliest epidemic.
fact – and it goes far beyond ‘informing patients’ to achieve better outcomes.
Cures rely on patient adherence to succeed, and health behaviour change in any non-compliant patient is essential before any course of treatment is undertaken. In other words, a patient is not just a bunch of atoms and organs. Obviously, drugs react with human bodies in a way that the patient can’t control, but they can decide how and when to ingest them – or even refuse altogether.
Treatment success relies not only on their willingness to adhere, but in their capacity to do so. In this case, ‘capacity’ amounts to ‘understanding’, and understanding can only be achieved with the help of doctors, HCPs and pharma experts. Yet it isn’t merely a case of supplying information; humans aren’t robots who simply digest facts and figures, as any teacher will tell you.
So without the conscious input of patients, treatments simply cannot work. Yet these treatments are still prescribed, and this means time and money is wasted on treatments which fail to meet their objectives. According to the Aston Medication Adherence Study of 2013, non-adherence costs the NHS £500 million per year – and that’s a lot of money that could be used to save lives. Quite rightly, the medical world is desperate to do something about this worrying
In order for understanding to occur, patients must be engaged with on their own terms – in their own worlds. It must also be understood that they are the masters of their destinies, and as such must be part of the discussions which concern their welfare. If erroneous health behaviour is to blame for non-adherence, then health behaviour change can only occur when the patient has good reasons. So how can these reasons be provided?
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PATIENTS: THE PROBLEM AND SOLUTION
Well, the medical world is already responding – and engaging with patients in a big way through social media, TV and all the modern channels. But besides looking into finding out where patients ‘hang out’ in the real world, listening is key to the relationship – and by this we don’t just mean listening to their specific symptoms, as doctors are trained to do. We mean listening to how they live their lives, what drives them, their fears, hopes and so-on. By listening, we form a more complete picture of an individual, and that is essential to understanding them. With this more complete picture, we can tailor messages to individual patients – we can learn their language, so to speak. If they hear us properly, they are infinitely more likely to undertake health behaviour change and, therefore, adhere to treatments.
TECHNOLOGY, TEAMWORK, AND MOVING FORWARD As we settle into the digital age, the medical world will learn to both adapt to technology and utilise it to maximum effect. In a biological sense, this means being able to understand patients’ physiological histories through molecular analysis, for example, to understand the effects of drugs and treatments on a case-by-case basis. This will open the door to tailor-made solutions in a big way, as it will hone in on exact dosages needed, frequency of ingestion and so-on. It also offers the chance for patients to keep on track with treatment courses with apps and gadgets (such as Fitbits etc), and so monitor their own progress and stay in control.
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Yet on a personal/psychological basis, technology offers us an unprecedented chance to communicate findings and share knowledge - i.e. to market in a way that other industries do. According to the MM&M annual survey of 2015, digital marketing is now the focus of 76% of pharma brands, and this figure will grow further. Tapping into consumer needs will also give better direction in providing incentives to wellbeing, such as reduced gym costs, health food vouchers and lower insurance premiums. Above all, however, is the capacity for teamwork between patients, HCPs, doctors and patients across the board. Technology makes systems run more efficiently – and both time and money are saved. With such efficiency, the £500 million figure could be drastically reduced and, in turn, money and resources could be freed up for other means – such as focusing on tailor-made solutions for individuals. These solutions, in turn, would bring about greater adherence and so, in turn, reduce wastage even further and free up more money for technology, which would in turn... well you get the point! The snowball effect would be endless. Health behaviour change is the essential ingredient in greater adherence, but – fortunately – it is not the sole responsibility of patients. With the continued efforts of pharma, doctors and HCPs, we face a bright future in which the drugs and treatments of tomorrow will work their magic with few – if any – obstacles to prevent it.
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