Why do some patients struggle to adhere to life-saving, long-term treatment plans? What stops them from taking the action medical professionals insist will improve their quality of life – and potentially extend their life expectancy?
When asked those questions before a workshop in Amsterdam, physicians outlined a number of common problems they believed prevented patients sticking to long-term treatment plans. These included lack of motivation, lack of information, failing to experience the benefits of the medication, and concerns over the side effects of drugs.
Professor Dan Ariely¸ explained that underlying these problems are nine key behavioral factors that, if addressed, could help more patients stick to their long-term treatment plans. This in turn should decrease healthcare costs and result in better health outcomes.
1. Information alone is not enough to change behaviorWorkshop report: Applying behavioral economics to treatment adherence
Doctors, says Ariely, are trained to focus their efforts in the wrong direction. They are taught to educate their patients about their disease, answering questions patiently and in detail. But a doctor’s training places no emphasis on how to change a patient’s behavior – despite this being so crucial.
Are patients discouraged from making positive change simply through the amount of shame they feel? Ariely says: “In the whole (weight) argument it is calorie in, calorie out – and if you are obese it is your fault, you’re not managing it well.” In framing certain conditions this way, is the healthcare profession building mental barriers that are simply too great for most patients to overcome?
3. Internal versus external disease
Viruses – such as HIV – are acquired externally, while other diseases, such as cardiovascular diseases (CVDs), develop due to a patient’s lifestyle choices, such as a sedentary lifestyle, poor diet, smoking and other bad habits. For those diseases that develop due to a patient’s own choices, the patient must not only battle with the disease itself – but also with changing their own behaviors, and overcoming any feeling of shame for getting themselves into this position.
4. History of disease
Diseases with dramatic histories often startle patients into adopting good chronic care management behaviours. HIV, for example, used to lead to a person’s visible decline and death in a relatively short period of time. Those memories are still present, despite new drugs changing patient outcomes in recent years. Cardiovascular disease, however, makes slow and largely invisible progress – giving patients far fewer visible signs to encourage changes in their behaviour.
5. Hyperbolic discounting
The perspective of time to an event is defined as hyperbolic discounting. It essentially means that we give little importance to events that will happen many years from now. Says Ariely, “Imagine the probability of dying from cigarettes. You’re chipping away at it every time, versus a situation where one in a million cigarettes had a little explosive in it, and if you smoke it you will die on the spot. That would be a very different feeling, even though the probability stays the same.” The challenge is to find a way to bring these long-term effects to the short term to convince people to change their behaviour.
6. Social pressure
Social pressure can help change patient’s behaviours. Consider passive smoking and the negative perception that has forced onto smokers. However, it can also be a barrier to sticking to treatment plans if a patient’s social circle behaves differently.
7. ‘What the Hell’ effect
A patient who experiences the ‘What the Hell’ effect often thinks in all-or-nothing terms. For example, taking pills as prescribed is relatively little effort but following lifestyle recommendations can be harder. If one part of a treatment fails like changing their lifestyles, they might reject all other parts of their treatment plan.
8. The never-ending race
A patient diagnosed with a chronic disease normally needs lifelong treatment. In contrast, surgery, says Ariely, “removes the disease and, therefore, the dependency on pills and the shame that comes with it”. For those facing a lifelong commitment, it can often be difficult for them to experience any feeling of ‘success’ against their condition.
9. Measurement of achievement
How do you give patients a sense of achievement? Readings such as blood pressure levels are often used, but Ariely says: “Being motivated by a long-term goal that fluctuates over time is just not part of the human capacity.”
Tackling these nine barriers is a major challenge facing physicians around the world. But by identifying these hurdles, physicians can take the first step towards understanding their patients’ difficulties and ultimately working towards better treatment adherence.