Bad behaviour: why understanding human behaviour can improve outcomes
Why did I do that? A common question I often ask myself after opening the biscuit packet for the third time in an hour. Only ten minutes before I had a mental argument with myself, which I thought I had won, promising not to eat another one until tomorrow. The process that goes on inside our heads, affecting the good and bad choices we make regarding our health every day, is the focus of health psychology and the growing interest around behavioural change.
Research on the social determinants of health indicates that our behaviour accounts for up to 38% of our health status and that we should be looking to broader aspects of health as medical care represents only 11%. This research also shows the complex system that drives our health outcomes, including the environment, our genetics and our social circumstances.
Our behaviour patterns shape the conscious and unconscious decisions we make about our health and are often an indicator of future health outcomes. Therefore, understanding why we exhibit bad health behaviour is an essential part of planning healthcare interventions, and this is especially true for chronic or long-term diseases.
Human behaviour underpins our actions towards medication adherence, physical activity, tobacco and drug use. It affects our sleep patterns, shopping behaviour, hand washing and the way we monitor ourselves for changes in health or disease indicators.
Outside of direct effects on our health behaviour, it also affects health through other people’s decisions. For health workers, choices change the way we interpret new clinical information and the speed at which we adopt new clinical standards. The behaviour of care workers and their decisions also affects individual care. As the social determinants of health help visualise, behaviours should be viewed as part of a system, and therefore when we attempt to change behaviour our interventions need to address the interplay of factors that underpin current actions.
Great leaps have been made in the improvement of patient outcomes – but there's a growing realisation that further growth will require us to use a deeper understanding of behaviour and how to change it to make these outcome gains more sustainable.
The most recent health strategies aim to build an approach to health based on the Four P’s of disease:
- Prevention: preventing a disease or reversing illness before it has an irreversible effect on health
- Prediction: knowing when a disease will have an impact on health and providing interventions beforehand
- Precision: moving to interventions that target diseases specifically instead of broadly
- Personalisation: creating interventions based on individuals knowing their genetics, biology and psychology as well as their social and geographical environment.
While great progress has been made in diseases like diabetes, where HbA1c can be controlled for the majority of patients, we can still improve health outcomes further by providing better monitoring of disease and through more personalised drug delivery.
Advances in digital tools and medical devices have also enabled better outcomes through better decisions. More recently, work on understanding the drivers of positive health determinants like food choice, smoking cessation, and increased physical activity have started to add to overall health improvements for diabetic patients. Our understanding of the basis of behaviour and the choices we make are moving us away from the reliance on information and education as the prime intervention. More systematic approaches to understanding behaviour and the interventions that support change appear in the literature. In part, this change is fueled by recent research but also from advances in digital tools and the ability to access people’s actions through devices like smartphones.
In a previous article I argued that behavioural science capabilities are a new skill that pharma needs to master. This is not the first time that pharma has tried to go ‘Beyond the Pill’. Ten years ago, a wave of digital health departments started focusing on the capabilities of new digital media. mHealth followed, with the advent of connected systems and the rise of the Internet of Medical Things (IoMT). Recently a more considered approach to digital medicine and digital therapeutics has taken over. Prescription Digital Therapeutics (PDTs) are appearing as both a companion and a replacement to some drugs. Companies like Pear, Omada, Wealthy, Noom, Lovingo and Welldoc all provide solutions to help patients improve health outcomes, most of them having a component of behavioural change.
There are many models of health behaviour that attempt to both explain the origin of current behaviour and plan for interventions to support change in behaviour. A review of the literature shows common approaches include the Trans Theoretical Model, the Theory of Planned Behaviour and COM-B. Each of these and the other theories have their place in helping health providers plan for change.
COM-B is an accessible approach to behaviour change developed by Michie et al. at the Centre for Behavioural Change, UCL in London. It draws from 93 other models to create a unified approach to understanding and changing behaviour. COM-B is an acronym for the drivers of behaviour, with people needing the (C) capability to perform the desired behaviours as well as the (O) opportunity and the (M) motivation. This approach has had successful implementation in many settings, such as smoking cessation, hand washing, medication adherence and others.
Remembering that behaviours occur in systems helps us use tools like COM-B to create health interventions that are more holistic and consider the underlying cause of behaviours that may need to be changed to improve the target outcome. COM-B asks if the person has the capability of performing the behaviour. Enablers of this are both physical and psychological. For example, in physical activity, there may be a physical limitation, through skill, strength or stamina. Psychologically there may be a need to inform or educate to enable the behaviour.
Going back to the physical activity example, we may need to explain to patients what we mean by physical activity to ensure they can execute the behaviour. COM-B provides a validated taxonomy of interventions that may support patients’ capability to perform the behaviour more frequently.
Beyond capability, patients also need the opportunity to perform the planned behaviour. Patients’ opportunity can be viewed as having the right resources and environment to perform the behaviour. There are also social opportunities that arise from those around us that influence our thinking and actions, as well as the cultural norms that affect the way we think.
Finally, we must also understand patients' motivation to perform the desired behaviour. For example, what motivates patients to check blood glucose or to take medication? Our motivation systems are complex, and there is much research in this area. In terms of COM-B, we can think of reflective motivation, which encompasses the plans we make and how we evaluate our choices. How much do we value the task of performing the behaviour? The second system of motivation is our automatic motivation with processes involving emotional reactions, desires (wants and needs), impulses, inhibitions, drive states and reflex responses.
Behavioural change frameworks help teams in pharma, medical device, and digital therapeutic companies create programmes to improve health outcomes. These frameworks create intervention plans that support pharmacotherapy and device use. They are also useful tools for looking at brand plans to understand if the planned tactics can support the type of behavioural change intended.
For many diseases, the next level of health innovation will require advanced chemistry, formulation or delivery (in other words, what pharma companies are good at today) along with insights into behaviour and how to change it, as well as how to deliver behavioural change at scale. Not all our behaviours or choices are bad, but there is room for improvement for all of us, and we need all the behavioural support we can get.
About the author
Mark Lightowler is the CEO of Phorix, a behavioural change design agency. They work with patients, physicians and pharmaceutical companies to improve health outcomes through behaviour change design and are based in Basel and London.