Behavioural science – the route to healthcare salvation?

Industry is urged to ditch the simple slogans and instead embrace the complexity, as delving more deeply could improve success rates

By Danny Buckland

Greek literature is littered with messengers who meet grisly ends for being the bearers of bad news and, even today, unscripted or poorly managed communications can have devastating health outcomes.

The lethal fury of such tyrants from mythology can be substituted with unresponsive patients and communities to emphasise the need to deliver the message with an acute awareness about how it might be received.

Decoding the genome may well appear to be a simple task when ranged against deciphering the intricacies and volatility of human behaviours that need to be addressed to improve the reach and efficacy of medicines and health awareness programmes.

Changing behaviour is the big challenge facing governments, healthcare ecosystems and industry, and the febrile nature of its response to the recent pandemic illustrated the difficulty of achieving connections across a spectrum of behaviour ranging from rapid uptake of vaccines and social distancing to a reluctance to engage with either, often with tragic consequences.

Altering or nudging patients’ behaviour for their own good is a complex undertaking – a journey through a landscape riven with personal, social, cultural, religious, economic and political fault lines. The imperative to bridge the potential chasms between messaging and understanding is now a strategic priority for the World Health Organization (WHO) and for organisations that want to maximise the efficacy of their products.

With budgetary constraints squeezing every factor from R&D to healthcare infrastructure, the quest to improve societal health is critical. But it is a far more demanding exercise than issuing instructions and slogans.

“Behaviour is clearly a determinant of health and well-being, from preventing ill health to managing chronic conditions, but we have to recognise that this is complex and about a lot more than advocating supposedly common sense approaches,” says Alicia Hughes, Senior Scientist at Sprout Health Solutions, which specialises in patient insights, research and action plans.

“It is a myth that you can simply pump out simplistic messaging and expect everyone to follow. It is easy to fall into the trap of thinking that people will react to information. The task is way more complex as, sometimes, our behaviours are not even apparent to ourselves.  We don’t know why we are doing X, Y or Z and there are elements of those behaviours that might be intrinsically linked to some deeper aspects of ourselves, such as identity. Relying on giving information is never going to really tackle the key drivers of those behaviours, which is why we need the science of behaviours to provide insights for genuine change.”

Alicia, a health psychologist with expertise in symptom experience and adjustment to long-term conditions, adds: “Behaviour change is a science and, thankfully, there is a lot of strong research that helps us map behaviour and create interventions that can be very effective.

“Yet, sometimes the science isn’t leading and it becomes easy to fall into thought traps that it is just about patients making good choices and common sense. This approach fails because it ignores the fact that people have habits and automatic processes that feed into a wider context of why people make decisions.

“One of the key areas of current research is to create a common language to talk about behaviour change in order to identify the key, active ingredients of successful interventions and examine them scientifically and academically so they can be shared effectively.

“Different behaviours will require a different set of techniques, depending on the context of the condition, treatment delivery and the patients.”

WHO’s European Region has created a rolling consultative and collaborative programme that is drilling down into behaviour change, its myriad influences and how it can be best used to tackle major health problems. At its core, it advocates for an evidence-based and structured approach to supporting behaviour change.

Hans Henri Kluge, Director WHO Regional Office for Europe, framed the challenge in the report, European Regional Action Framework for Behavioural and Cultural Insights for Health, 2022-2027, stating: “Behaviour is at the heart of health. Our lifestyles and the way we interact with health systems have extensive implications for our own health and well-being, as well as for health system capacity and costs. It is, therefore, crucial that we explore the complex factors affecting health behaviour and use this insight to develop evidence-based interventions that improve health and well-being and reduce inequity.”

The report, published in September 2022, added that individual behaviour and social circumstances account for 60% of factors determining health and warned that ‘behavioural and cultural insights in health remain underexplored and underutilised, and subject to modest investment in many places in the Region’.

Alicia identifies industry’s accelerating willingness to address human behaviour, as a central theme to its R&D and delivery, saying: “It is really shifting and clients are increasingly interested in examining the determinants of behaviour to develop deeper understanding that enables them to create successful behaviour change interventions.

“A lot of that is about taking a step back to check assumptions about patient behaviour which, in many cases, come from healthcare professional (HCP) input as opposed to direct patient experience. The work we do with clinical outcomes helps clients understand the most important factors for patients and what they feel has the biggest outcome – sometimes that is very different to the HCP view.”

Sprout’s techniques include interrogating why patients are not adhering to medication regimes and why HCPs aren’t prescribing particular products via a comprehensive assessment of research literature and market intelligence combined with active HCP and patient interviews.

“This allows us to understand what is driving their behaviour and map out behaviour change techniques. We can really drill down into behaviours, often in rare diseases and small patient populations, and create programmes for change. We help patients make changes by understanding the deeper impulses behind their behaviour,” adds Alicia.

“Patients often visit their doctor with symptoms and are prescribed medication and the relationship then becomes about adherence. But there are lots of reasons why they don’t adhere and addressing those is critical. If the two are not married up, an effective behavioural change conversation is not possible.

“We have done a lot of research into fatigue across a range of conditions and can see that its causes vary across a lot of factors, but that the common thread is that behaviour really drives the extent of fatigue that people experience, above and beyond other factors. For example, they might rest when they are fatigued then try to fit everything in when they feel more energetic, which, on the surface, appears to be common sense. But this boom and bust pattern of activity is a strong predictor of increased levels of fatigue going forward, so interventions that can change that are key to improving the day-to-day symptoms and adherence. All these things are interconnected and it is a shame if we miss the opportunity to target behaviours as they do have the potential to impact on so much of the person’s experience.

“Fatigue is a very real and debilitating symptom that can be triggered by a range of different biomedical factors, but what we do know is that, regardless of the cause of fatigue, the one thing that can help is altering people’s response to fatigue.”

‘With budgetary constraints squeezing every factor from R&D to healthcare infrastructure, the quest to improve societal health is critical’

The Centre for Behaviour Change at University College London is celebrating its tenth year with a conference in April exploring the benefits of a scientific focus and how the discipline has developed into a potent force in healthcare.

“It’s about understanding from the patients’ perspective what’s important to them and then getting their feedback to make sure the patients are at the heart of your intervention,” says Kristina Curtis, Founder of Applied Behaviour Change, a behavioural science consultancy specialising in digital health interventions, and Honorary lecturer and Associate at the Centre. “In order to change behaviour, we need to understand what the driving forces are behind that behaviour. It’s not enough just to educate people or diagnose someone with something such as being pre-diabetic.”

She believes patients should be involved in the process of behaviour change projects from inception, but that any changes should be careful not to infringe on personal freedoms, and she adds: “There has to be a balance between environmental changes or behavioural nudges and choice architecture, along with allowing people to make informed choices about their behaviour and supporting them to change their behaviours on multiple levels within the system, whether that’s at the government level, in the community or at an individual level.”

Kristina, whose expertise covers the development of digital behavioural interventions and their design and implementation, advocates for pharmaceutical organisations to invest in research to truly understand behaviours, the barriers to change and how they can support patients through evidence-based strategies.

“There is a shift towards behavioural research and some organisations are very much on board and innovating while others are much slower,” she says. “Behaviour is a broad field and involves asking how we can engage people in wanting to change, what is driving the behaviour and what support is needed to create interventions that have a real impact. But that does require investment.

“We know that properly researched and evidenced interventions can change patients’ lives for the better and lead to greater adherence to medication and take the strain out of healthcare systems. If governments and health organisations fail to make behaviour change a central theme then, unfortunately, the prevalence of chronic conditions will continue to increase at alarming rates.

“If organisations don’t take behavioural change into account when developing new products, tools or initiatives then they risk wasting a lot of resources on ineffective interventions and people will lose trust and become even more disengaged, and it is very difficult to get them to re-engage after that.”

Alicia Hughes echoes that momentum is building through digital interventions and artificial intelligence that can track behaviour and predict areas of concern. She observes: “This is exciting and one of our areas of focus. Taking fatigue as an example, we can use information captured around patient behaviours and use modelling to dissipate automatic behaviours. We can interrupt that problematic boom and bust activity, which could have a significant impact on people’s levels of fatigue. It can be run as self-reflection and self-monitoring along with a bit of nudging through notifications and prompts.

“Interventions can place a lot of responsibility on the individual without considering that their behaviours do not occur in a vacuum. There are cultural, societal and political contexts along with the financial constraints that people might face in different countries to access medications.

“It makes economic as well as moral sense to advance the uptake of behaviour change science and we should never assume that getting a drug to as many people as possible is the end of the journey – it does not end there.”

References are available on request.

Danny Buckland is a journalist specialising in the healthcare industry