What drives patients to adhere to advice

Dr Caroline Wood

Many healthcare challenges today are social or behavioural in nature rather than purely medical. Understanding how people behave in the real world, rather than how we want them to behave, is key to designing effective healthcare interventions. 

Dr Caroline Wood, head of behavioural insights and research at Bupa, explains how behavioural insights benefit healthcare

Behavioural insights are used to understand how humans make choices, applying thinking from diverse fields including psychology, sociology, behavioural economics and anthropology. 

Research from these areas shows that, as humans, we are irrational thinkers and often behave in ways that are counterintuitive and not always in our best interests. This has big implications for healthcare.

For example, patients can make poor lifestyle choices that negatively impact their overall quality of life or health outcomes – such as smoking, poor diet, lack of exercise – or fail to stick to medication regimens or recommended treatment pathways. 

Understanding the science of why people do what they do can help us to deliver better healthcare and enable us to design more effective products and services that work alongside human psychology.

Incorporating behavioural insights into your practice

We know many diseases can be preventable if patients follow optimal health behaviours. 

Clinicians play an important role in influencing patients’ health behaviours and advising them about how they can make healthier choices. 

Each patient interaction is an opportunity to deliver a brief behavioural intervention to provide advice and motivate patients to make meaningful behaviour changes. 

These touchpoints are important in preventing disease and controlling the burden of non-communicable diseases on society. 

In the UK, this approach to tackling preventable diseases is what’s called ‘making every contact count’ (Health Education England/Public Health England: www.makingeverycontactcount.co.uk).

Having an awareness of what behavioural insight is and how it can support patient care is rapidly becoming a differentiator in the clinician’s toolkit. 

The ability to understand patient motivations and identify barriers in current behaviour enables clinicians to tailor the support they provide more closely to patients and deliver a more personalised, efficient standard of healthcare. 

What a behavioural insights team does

Perhaps the most high-profile behavioural insights team or, ‘nudge unit’ as they are now popularly known, was the team established by David Cameron’s UK government in 2010. 

Since then, many organisations have established their own behavioural insights teams, and have demonstrated how behavioural insights can have a big impact on public health and healthcare systems through making simple changes. 

For example, increasing organ donor consent rates by 38% through changing how consent was framed on a sign-up webpage or reducing the number of missed hospital appointments by 25% through simply sending patients timely reminders by text message.

At Bupa UK, we are on a journey to embed behavioural insights in our products and services, with the aim of supporting our customers and our people to make better choices and lasting lifestyle changes. 

Our behavioural insights team is made up of individuals with a range of backgrounds, including behavioural economics, psychology and public health. 

Interdisciplinary approach

Our evidence-based, interdisciplinary approach enables us to create simple and targeted interventions to improve health and well-being. 

We use this interdisciplinary expertise to understand a range of health-related challenges and create simple and targeted interventions to bring about change. 

We offer insight to a wide range of challenges including how to increase participation in health and well-being initiatives and improve adherence to health programmes through to how to optimise people’s engagement with health information. 

When people aren’t behaving in the way that we expect them to, the tendency is to dive straight into solution mode and try lots of approaches to change their behaviour. 

Some of these might work, some might work well for a while and then lose their impact, some might not work at all. 

The problem with using this ‘kitchen sink’ approach is that there is no roadmap to help you choose your next strategy or help you understand why what you tried didn’t work. 

This approach means you end up wasting time, money and other resources trying to find the solution.   

By taking a behavioural science approach, we first understand why people aren’t behaving as expected before trying to change their behaviour. 

This provides us with a theory-based ‘roadmap’ to help guide our design of a solution. Having this guide means we can bring about change more quickly, streamline our costs and resources, and increase confidence that the solution will directly address the behaviour and barrier unique to the context. 

Supporting our patients

We know that our residents living in Bupa care homes are particularly susceptible to the flu virus, with two-thirds of outbreaks during the winter originating in care homes. 

To help keep both our residents and people safe and well, it is imperative that our people receive the flu jab. 

We interviewed our people working in care homes and reviewed existing literature on flu vaccination to find out the main barriers to uptake. 

We discovered these included common misperceptions, such as the vaccine not being necessary or causing flu itself, which we were then able to address through targeted communications to dispel flu myths and make it easier for people to get their vaccine. 

Making these small changes led to an 11% increase in flu vaccine uptake among our staff. 

Enhancing our clinical practice

Antimicrobial resistance is a top global public health threat facing humanity. In light of this, we have worked closely with our Bupa UK pharmaceutical managers to reduce antibiotic prescribing where prescription of certain drugs was not always necessary. 

Drawing on insights from similar effective interventions designed by the UK behavioural insights team, we sent a behaviourally informed letter to consultants to clearly communicate national guidelines and make it really simple to understand what was required of them. 

Following the intervention, spend on unnecessary prescriptions fell and one hospital group introduced an automated process in its prescribing systems, meaning that the change was maintained over time. 

Upskilling our clinicians

We have also developed two bespoke, interactive training programmes for our front-line clinicians: one for health advisers in our clinics and another targeted at dentists across our global practices.

These provide them with the tools to embed principles from behavioural insights into their practice to enhance the interactions they have with patients. 

Bupa’s health assessments offer a fantastic opportunity for customers to identify and address their own health risks. 

However, the hardest part is often knowing how to best support and motivate customers to make the necessary changes after their health assessment, like increasing physical activity or adopting a healthier diet. 

Knowing how to approach customer conversations like these and what to say at which point enables our health advisers to better support our customers to adopt a healthier lifestyle.  

Working closely with our health advisers and consulting regularly with academic experts at Univ­ersity College London, we have developed bite-size learning videos, interactive quizzes and in-practice examples structured around a framework we call the Bupa 3Bs: behaviour, barriers and behaviour change techniques.  

B1 – Behaviour: It’s important to first identify what behaviour you want to target for change or to support your patient to change. 

Not having a clear target in mind, selecting a change that doesn’t sufficiently motivate or appeal to your patient or trying to make too many changes at once can jeopardise chances of success.  

B2 – Barriers: Taking the time to explore existing barriers to change as well as things that may facilitate the desired behaviour can help you more closely tailor the support you provide. 

The COM-B model is a simple framework which can help you identify barriers from patient conversations. The model proposes that for behaviour change to happen, patients must have the:

Capability – the know-how, ability; 

 Opportunity – resources such as time, a supportive network around them;

 Motivation – the drive to change, wants and needs. 

If one or more of these is missing, then this may prevent change from happening and is where your support would be best focused.  

B3 – Behaviour change techniques (BCTs): BCTs are the ‘ingredients’ of a patient conversation about change and can include techniques such as helping them set a goal, providing information about any consequences if they chose not to make changes, as well as showing them in person how to do the behaviour. 

In the training, we introduce trainees to twelve of the most commonly used, evidence-based BCTs that can be built into patient conversations to build motivation to change, plan and set goals, as well as to support patients to maintain that change. For a full list of techniques, go to www.sbm.org/UserFiles/file/Michie-etal2013BCTV193techniquesAddlFileTaxonomy.pdf.

The twelve techniques are:

  1. Goal setting;
  2. Action planning;
  3. Feedback on behaviour;
  4. Social support;
  5. Restructuring the environment;
  6. Commitment;
  7. Self-monitoring;
  8. Instructions on how to perform behaviour;
  9. Information about health consequences;
  10. Problem solving;
  11. Rewards;
  12. Credible source, e.g. communications from a respected person.


Embedding the 3Bs in your practice

Although sometimes difficult to conceptualise a ‘typical’ patient appointment, there are some common features that most patient-clinician interactions will share. 

Here’s how you could implement the 3Bs into your own practice: 

Before the appointment

Reviewing the patient’s history and medical notes may help you identify any areas to prioritise for change or to explore further with your patient during their time with you.

Gathering insights and selecting a target behaviour

Welcoming your patient into the clinic room and engaging them in conversation provides an opportunity to build rapport and establish strong relationships. 

Not only does developing a good rapport encourage patients to be open with you, it also builds patient confidence and motivation for behaviour change. 

This first part of the appointment is key, as it gives you a great opportunity to find out more about your patient’s lifestyle, including anything that may influence their readiness and motivation for change.

Assessing their health status follows, finding out more about their health behaviour and any problems they might be having. This is where you bring in B1 (behaviour) and B2 (barriers) of the 3Bs. 

It’s where you identify an appropriate target behaviour, consider whether there are any barriers to change and start to
discuss goals with the patient.

Having assessed your patient, you will likely already have a good idea about what they need to do – that is to say, their target behaviour – to improve their health. 

This is the perfect time to find out whether the target behaviour you have in mind would also be a good ‘fit’ for your patient

Exploring barriers

When talking with your patient, listen to see if they mention anything that could be a barrier for change. 

Keeping the simple idea of the COM-B model in your mind as they are speaking can help you identify whether it’s a capability, opportunity or motivation issue and where to focus. 

Setting goals and providing ongoing support 

Building effective behaviour change techniques (B3) into your conversation can help you take your patient from thinking about change, through to setting goals and onto maintaining change after their appointment.

End of the appointment

The end of the appointment typically involves confirming next steps and any goals before bringing the appointment to a close. The final step in the process is to update the patient records as you usually would.