Behavioural Nudges for Healthcare Adherence

Identify the right problem to solve, and solve the problem in the right way.

Written by Fiona Murphy • 15 minute read

Identify the right problem to solve, and solve the problem in the right way.

This maxim is used a lot in innovation strategy — but perhaps nowhere is it more applicable than the health sector. It highlights the need to understand the root cause of any problem in order to be able to effectively address it.

Medication non-adherence is certainly a significant problem for chronic patients, with approximately fifty percent of patients not adhering to their prescription after the first six months. This has a significant impact on patient outcomes and on the healthcare sector as a whole. As mentioned in a previous article by Frontend.com, non-adherence adds USD100 billion to the cost of the US Health Service each year, and in 2012, the US Surgeon General attributed over 125,000 deaths each year to non-adherence to medication. So we can agree that this is the right problem to solve, but what about solving it in the right way? To date digital health solutions have focused on monitoring the problem, recording missed doses or tackling non-adherence through reminders and alerts, all of which can help to a degree but fails to address the underlying issues at the heart of the problem – and subsequently fails to solve the problem in the right way.

Intent

Non-adherence can be classed as Unintentional or Intentional. Unintentional non-adherence is a little more straightforward to address, where patients either forget or are limited in some way. Taking multiple medications (polypharmacy) adds to this issue. Reminders and logs can go a long way to help but must be flexible to fit into patients’ individual routines. Attaching to an existing habit or routine can be very effective, however these measures assume that patients ‘want to’ adhere (are motivated) and are ‘able to’ adhere (physically, financially, and environmentally).

Intentional non-adherence is a lot more challenging, particularly with chronic conditions. This signifies that the patient is no longer engaged with their therapy and can have multiple root causes. Factors can stem from physiological, psychological, cognitive, financial or behavioural biases and often multiple factors are in play at the same time. Denial, thinking they’re cured, unpleasant side effects, thinking their medication isn’t working, thinking it’s too costly or inconvenient, general lack of support, etc can all result in non-adherence.

This is compounded by pressures within the healthcare system. HCPs through no fault of their own lack time and resources to provide comprehensive support. Particularly around communicating detailed information, monitoring adherence and managing complex regimes. It is no surprise that the adherence drop-off coincides with the period where regular contact with the Healthcare team starts to taper. While Patient buy-in is recognised as essential in the initial decision-making process, we also need to recognise where patients may falter and help support long-term positive behaviour. To achieve behaviour change in non-adherent patients we need to have a detailed and more nuanced understanding of the patient experience and their motives, and a range of available behavioural strategies to tackle them.

Nudge Theory

Nudge Theory is based on the principle that people do not always make rational decisions that are in their own best interest. Inherent behavioural biases can lead to individuals choosing to act in ways that are detrimental to their health, wealth and long-term wellbeing, not least in adherence to their healthcare or medication regime. However, understanding patients’ behaviour and working with or overcoming biases can help patients adhere to their health plan and hopefully self-manage their condition(s) over the long-term.

Frontend has done a lot of work in the healthcare space and have explored potential areas where behavioural nudges can be applied. We’ve also used nudges and persuasion techniques in other industries such as finance and consumer services where learnings can be leveraged. However, it’s important to appreciate that nudges are nuanced and hugely influenced by specific contexts; innovative nudges can be explored but it is important to evaluate them to ensure they are having the desired effect.

In the following section we will explore some of the areas where behavioural biases can lie and, how nudges could help.

1. Make it Simple

While it seems obvious, understanding their condition and therapy is an important step in patient adherence and self-management. However, often patients are unaware of risks of their condition and/or risks and benefits of their treatment – or focus on salient areas at the expense of a balanced overview. Clear, concise, and comprehensive messaging that is broken into consumable chunks is imperative. Consideration should also be given to the stage patients are at the clinical pathway. When patients have initially received a diagnosis they may need reassurance, clear facts and basic actions; avoiding information overload and developing trust is key. Some may even be in denial or subject to information avoidance where simplicity is even more important. Further down the line patients may be more accepting and open to deeper understanding, self-help support, making nuanced decisions and connection with a wider community. Understanding patients’ varied stages in their journey is key to supporting it.

Patients also need to be made aware of where they may falter in the future in managing their illness and the impacts. People typically overestimate their self-control and understate the extent of their behavioural biases. Reducing naivete about potentially damaging behaviours can help them recognise and implement strategies to combat them if they arise in the future. Again, simplicity is core.

Fundamentally, therapy delivery should be as easy and convenient as possible. Auto-enrolment into screening and regular check-ups, automatic monitoring (where possible) with red flags highlighted to the HCP, tele-medicine (for easy access), self-care (where possible), etc can all help the ease and convenience of managing a chronic illness. For example, for repeat prescriptions, a Canadian study demonstrated between six and fourteen percent of patients taking statins failed to fill their second prescription.[1] Auto-refilling prescriptions (if available) leverages status quo bias. When polypharmacy is present blister packs prepared by pharmacists are helpful.

Blister Pack

Blister Pack

2. Work with Present Bias

Present Bias (related to hyperbolic discounting, temporal discounting, cognitive discounting of future gains, etc.) basically refers to people’s tendency to prefer a smaller reward sooner rather than waiting for a larger reward in the future. This can have significant impacts on chronic illnesses and patient’s adherence to treatment plans. Particularly when current symptoms are not salient and/or the treatment plan or medication side effects are unpleasant. Often patients cannot envision their future selves and how adherence can improve future quality and quantity of life.

Loss aversion or negativity bias can be leveraged here, where people typically feel losses more than gains (prospect theory) by communicating what patients could lose in the future e.g. independence, mobility, higher financial costs, etc. Recent innovation in AI to predict and model our future selves is interesting in this respect, where the concept of a ‘Digital Twin’ can virtually demonstrate the long-term impacts of current behaviour. Already being used in cancer therapy it could be applied to many chronic diseases. ‘Anticipated inaction regret’ could also highlight to patients how they may feel in the future having failed to carry out the actions to keep themselves healthy. However, being overly negative can cause the ostrich effect, where engagement can be reduced (for example in the personal finance space, pension saving calculators often highlight to people that they are so badly prepared for retirement they disengage) – balance is required.

Focusing on benefits that can be gained sooner rather than later can help e.g. going to the gym for exercise can increase energy and improve mood (short-term benefits) while also combating heart disease or diabetes (long-term benefits). Having patients note the differences can make them more salient. Unfortunately, medication for chronic conditions such as diabetes, cancer, or heart disease typically don’t offer short term benefits, but if they do, they should be made salient. Gamification is something that can also be explored, but its effectiveness can be influenced by specific context, disease area, and patient profiles. But in the right scenario it could be very impactful.

Incentives in the short-term can be explored such as discounts on insurance premiums based on adherence, free screening and monitoring, loyalty programmes (that are well considered), etc. However, be wary of eroding trust and/or shifting motivation from the intrinsic to the extrinsic (see ‘Pros and Cons of Incentives’ below). Creating sustainable long-term behavioural change requires sustainable motivation, often from within.

3. The Power of Social

Humans have evolved to be social animals; our behaviour is deeply influenced by those around us. Emphasising what most people do or intend to do (social norms/social proof) has been shown to influence individuals’ behaviours, sometimes significantly. With tax payers, a single line in correspondence highlighting that most people pay their taxes improved compliance in numerous jurisdictions (in Guatemala interventional nudges with a test group in 2013 helped triple tax receipts) [2]. This can be helped even further by adding additional targeted information such as the percent of people who comply in the recipient’s specific area or other profile attributes that they can identify with. In the healthcare setting this could be a message such as ‘70% of people diagnosed with high cholesterol adhere to their medication’, or ‘X% of people aged over 65 in Canada diagnosed with osteoporosis adhere to their medication’, etc. During Covid 19 in many jurisdictions, social proof was utilised by delivering daily reports of the numbers of people vaccinated and/or badges that said ‘I’ve been vaccinated’, also making vaccination more salient. However, effectiveness remains uncertain at the time of writing, particularly amongst groups who had high hesitancy levels.

Encouraging patients to enrol in Patient Support Programmes or specialist support groups could also help expose them to positive peer behaviour specific to their condition (while also helping to ‘normalise’ their condition). However, when using social norms/proof be cognisant of the ‘boomerang effect’, where, if a relatively large percent of people are behaving in an undesired way or if the individual is achieving above average, they may regress towards the norm. Making clear what is the desirable behaviour is key, for example by using smiley faces in user interface’s for feedback on ideal behaviour.

Other potential nudges are pre-commitment strategies and/or to elicit implementation intentions. Pre-commitment leverages people’s tendencies to want to maintain a consistent and positive self-image, [3] avoiding reputational damage and/or cognitive dissonance. Simply getting patients to ‘commit’ (even to a limited number of people i.e. HCP, caregiver, family, etc.) to taking their medication on a long-term basis can help. ‘Public commitment’ can take pre-commitment to an even higher level. Studies for pre-commitment on medication adherence is scant but that is not to say it cannot be explored. With implementation intentions, studies have shown that simply getting people to state their intentions can increase the likelihood of acting on them. A US study [4] demonstrated that by asking participants to write down a date and time they intended to get an influenza vaccination increased vaccinations by 4.2 percentage points (small but statistically significant). Even greater increases have been seen in voting turnout when voters were asked to create a voting plan (i.e. when, where, etc).

Another social influence is that we are heavily affected by who is communicating information. Delivering key messages via an authoritative figure leverages the authority bias, where people tend to attribute greater credence to someone who they see as an expert. Healthcare professionals can play an important role in communicating the importance of adherence whether this is via a consultant, GP, nurse, pharmacist, etc. A recent study in Ireland showed that patients felt talking regularly to their doctor helped their adherence (along with a good understanding of their illness and prescribed medicine). [5] As mentioned in ‘Make it Simple’, telemedicine and telehealth can improve accessibility, enabling more frequent communication. Monitoring apps that can be viewed by doctors also help motivate patients. However, solutions need to consider that doctors may not want to commit to monitoring data but simply knowing that they can access it can motivate patients. Getting doctors to review data in front of the patient during a visit can also encourage adherence. Similarly, messages delivered via a person the target audience can identify with and trust taps into the affinity bias. Both can help build trust. During the Covid 19 pandemic examples can be found in multiple jurisdictions where celebrity experts came to the fore and mainstream celebrities became advocates.

Finally, we can never underestimate the power of family support, getting those who are nearest and dearest (and often caregivers) on-board is hugely powerful. In addition, getting the patient to envision how their non-adherence may impact this broader group can also improve motivation.

4. Leverage Defaults

Inertia or the status quo bias is a powerful behavioural bias that can be tapped into i.e. the inclination for people to take no action. One of the most renowned examples of successful defaults use is auto-enrolling people into organ donation programs rather than requiring them actively sign up; countries who deploy opt-out organ donation policies typically have ≈ 90% enrolment, whereas countries that have opt-in policies typically have ≈ 15%. [6]

For healthcare auto-enrolling patients into programs such as regular screening, vaccinations programs (e.g. Covid 19), check-ups, patient support programs, specialist support groups, specialist apps, etc. can help them engage with their condition and set a ‘default’ expected behaviour for managing it (and perceived risk if they don’t). However, there can be significant gaps between signing up to something and actively engaging with it. Auto-enrolment can expose patients to tools and supports while also creating some friction to actively disengage.

Determining an appropriate point in their healthcare plan to do this can be tricky. It could be combined with some of the previous tactics mentioned e.g. with a pre-commitment or intention statements. It could also be when patients are taking out or receiving benefits from health insurance, getting a prescription (if practical), etc. Many governments are already actively doing this by auto-enrolling target groups into screening programs to tackle health issues that have significant impacts on society but more areas and instances can be explored across conditions and specific patient journeys.

5. Pros and Cons of Incentives

Incentives can be a powerful way of initiating a habit but they need to be carefully thought through or they can backfire. In the short-term patients can be incentivised to adhere to a certain behaviour but this may not create motivation for the actual behaviour, just the reward (the same goes for threats or punishments). If the reward is unsustainable or taken away, so too may the motivation. Fundamentally the primary goal is to create intrinsic as opposed to extrinsic motivation. In fact, shifting the focus to extrinsic rewards may actually sap or ‘crowd out’ intrinsic motivation, potentially decreasing it.

Overuse of incentives should also be avoided, otherwise you may create adverse conditional behaviour i.e. ‘I’ll only do it if I get the reward’. For example, a study on the effects of incentives for weight loss demonstrated that incentivised participants of a 16-week weight loss program lost more weight than the control group (who received no incentives), however, once the program ended (and incentives were removed) they did not keep the weight off. [7]

Weight loss for each incentivised group over time

Weight loss for each incentivised group over time [7]

Another pitfall can be the erosion of trust. Extrinsic incentives may prompt the question as to the motivation of the giver i.e. ‘What’s in it for them’.

However, short term incentives can sometimes lead to developing long-term behavioural change particularly if positive impacts are experienced and benefits recognised, ultimately shifting motivation to the intrinsic. As mentioned previously, present bias is an important consideration, if incentives are pushed out too far into the future they will be discounted and should be delivered relatively quickly to be effective.

6. Framing

How information is presented can have a significant impact on motivation, decision making and subsequent behaviour. The framing effect makes us more compelled to positive rather than negative attributes. For example, stating that something is ‘95% effective’ rather than ‘5% ineffective’ is more compelling primarily due to loss aversion and taking mental shortcuts. However, it needs to be balanced for the particular context. A 1989 study demonstrated that preferences for less effective but less toxic treatment was preferred over a more effective and toxic treatment when the chance of survival dropped below fifty percent. Patients responded to the negative frame where quality of life became more salient than quantity of life. [8]

In addition, presenting data as a (well-designed) graphic can be easier to assimilate. Visual representations of percentages can communicate weighting while also introducing a human element.

Visual representations of percentage rates

Visual representations of percentage rates

To combat misinformation or incorrect perceptions, showing the impact of various factors on breast cancer can help contextualise data on the risks of taking HRT.

Behaviours that impact breast cancer

Behaviours that impact breast cancer

Related to framing, the decoy effect is a tactic often used (or misused) in eCommerce and retail where a particular product/offering is made more attractive when placed beside options that are less attractive. Based on ‘asymmetric domination’, typically three options are provided where one is the ‘target’ (the option the business wants you to pick), one is the ‘competitor’ (the genuine alternative option) and the other is the ‘decoy’. The decoy is typically presented in a way that makes the target look very attractive e.g. Small Coffee $3.50 (competitor), Medium Coffee $4.75 (decoy), Large Coffee $4.95 (target). Decoys can even strengthen decision justification and therefore commitment. In the healthcare settings decoys could be used to sway a patient towards better options (by contrasting them with a more unsavoury ones). However, needless to say, the patient’s best interest is central. For example, for cancer screening three options could be provided: firstly no screening (competitor), secondly at a local clinic five miles away (target), or thirdly at a hospital 15 miles away (decoy).

Example of the Decoy Effect

Example of the Decoy Effect

Decoys can help de-stress the decision-making process but having too many options can do the opposite. The ‘paradox of choice’ can cause paralysis in the decision-making process where people fear they won’t make the optimal choice (loss aversion) and/or may have difficulty processing and prioritising a large number of attributes. Again, we come back to the importance of simplicity.

Conclusion

Tackling the issue of patient non-adherence is complex. It can be a fundamental issue where patients are just not bought into the treatment plan and education and simple messaging plays a strong role. However, depending on education alone is not always sufficient, we need to work with behavioural tendencies and biases to help guide patients in managing their conditions particularly over the long-term. We need to make treatment plans easy and convenient leveraging the power of defaults and framing. We need to recognise that people are more driven by what is immediate and salient and have tendencies to discount impacts in the future. We need to capture the power of social influence and understand the pros and cons of extrinsic incentives to drive behavioural change. And finally, we need information to be clear and simple supporting patients throughout the varied stages of their journey.

Nudges are typically nuanced and can have small or large impacts, but positive impacts regardless of scale, are good. They can be implemented at any stage in the patient journey, by various actors (consultant, other HCPs, pharmacist, pharma companies, government, etc) and across channels and artefacts (apps, patient leaflets, patient support groups & programs, government programs, GPs, hospital care, etc). Because they are typically nuanced and are a component of a much larger/complex context or ecosystem, testing is imperative. Small tweaks can demonstrate significant impacts and you need to be sure these are positive. To create innovative, effective nudges Frontend always develops a detailed understanding of the exact problem area, contexts, patient perceptions, patient journeys, influencing factors/people, etc. Rarely is there a quick and simple answer but neither does the solution need to be complex, it just needs to be well considered.

Finally, the originators of nudge theory, (Nobel Memorial Prize recipient) Richard Thaler and Cass Sunstein, advocate that nudges should always be used to drive behaviour that is in the best interest of the individual (in this case the patient). Thaler subsequently created the phrase ‘sludge’ to describe behavioural interventions that do not. Not only is ‘sludge’ ethically wrong, it can also ultimately degrade brand equity of the offenders. Trust is an important aspect of healthcare, something that should always be safeguarded.

Get In Touch

If you find the ideas we have explored in this article to be interesting and relevant to your corporation then contact Fiona Murphy, our expert on this topic.

Our multidisciplinary healthcare design team is based in our studio in Dublin, Ireland. Unlike most design consultancies, our healthcare research is conducted by professional researchers while our design team draws on their experience in medical devices, industrial design, usability, psychology, computer science, and business process improvement. We engage with patients, doctors, nurses, and other healthcare professionals, understanding their environments and creating solutions that work at every touchpoint. Contact us to collaborate on your upcoming healthcare project.


References

  1. Lemstra M, Blackburn D. Nonadherence to statin therapy: discontinuation after a single fill. Can J Cardiol 2012; 28 (5):567–573 (https://pubmed.ncbi.nlm.nih.gov/22658124/)
  2. https://openknowledge.worldbank.org/handle/10986/24530
  3. Cialdini, 2008
  4. https://www.pnas.org/doi/10.1073/pnas.1103170108
  5. https://www.drugsandalcohol.ie/21614/1/Adherence_Report_Final.pdf
  6. https://sparq.stanford.edu/solutions/opt-out-policies-increase-organ-donation
  7. https://thedecisionlab.com/insights/health/can-money-buy-good-health-rct-of-financial-incentives-for-weight-loss
  8. https://pubmed.ncbi.nlm.nih.gov/2918321/