“A spoonful of sugar makes the medicine go down”, sang Mary Poppins. It is unclear whether this claim has ever been empirically verified (in the song, ‘medicine’ was a metaphor for an unpleasant task – can any chore be more unpleasant than, as a child, having to tidy your room?). Let’s just say that there is little, if any, evidence that sugar can help make sure people take their medication according to the prescription.
This is a pity, since it might have been a simple way of solving a serious problem: it is estimated that only half of patients with long term conditions take their medication as required. In the UK, the annual cost of medicines wasted in this way was estimated at £300M in 2009. In the United States, the cost of medication non-adherence is even more staggering – to the tune of $100-289 billion per year in avoidable healthcare costs.
While many who try to tackle this challenge tend to assume that forgetting is the main problem to be solved, such non-adherence can have many different causes. Some of these are unintentional (e.g., problems with dexterity or memory or mental capacity), others are more intentional (e.g., beliefs, doubts and unmet expectations). Recent research has also identified perceived necessity of the treatment (positive) and concerns about potential adverse effects (negative) as factors in adherence. Can behavioural science help?
To explore this question, it is useful to refer to six behavioural phenotypes that are sometimes used to classify non-adherent patients: (1) those who consider the treatment too complex, (2) those who don’t pay enough attention to their regimen, (3) those who are unaware of the importance to follow prescriptions, (4) those whose beliefs conflict with the treatment, (5) those who doubt the efficacy of the medications, and (6) those who consider the efforts required to adhere outweigh the benefits. The first three categories are more related to non-intentional non-adherence, while the latter three are more intentional behaviour. But these conceal multiple underlying reasons, ranging from unconscious influences (e.g., the patient denies the problem, or wants to avoid being reminded of their condition by taking medication), fear of addiction and mistaken belief that the diseases is cured, to forgetfulness and difficulty accessing or measuring the required dose.
Not one size nudge fits all
This perspective reveals a crucial fact: the heterogeneity of the patient population. It is unlikely that one type of intervention will address this diverse set of reasons for non-adherence. Nevertheless, it makes sense to consider some basic behavioural science insights – none more so than the way Nudge co-author Richard Thaler summarizes nudging: ‘Make it easy’. What can be done to make taking medication easier? Multi-compartment pillboxes exist, but they can – certainly for patients on relatively large numbers of medicines – be a bit baffling. A design that is adapted to the capabilities of the individual may help overcome dexterity-related as well as cognitive barriers; an alternative might be tailored calendar blister packs. It may also be worthwhile to consider altering the dosing frequency, or a different way of administering it (e.g., a pill rather than a liquid) to make it easier to handle from the patient’s perspective.
Of course, if patients intentionally resist following their prescription, such nudges will have little effect. If that is the case, practitioners are better off seeking to understand what is behind the patient’s reluctance: “Ditch the deficit model”, as Caitlyn Finton, a psychologist at Cornell University, writes. An approach that assumes people’s distrust is based on insufficient information (a deficit) and that seeks to fix it by bombarding them with facts and evidence is unlikely to work. Instead, “approach conversations with the other person’s background in mind,” and perhaps even more importantly, “acknowledge their views and feelings” – every patient wants to do what is best for them. Active listening and empathy might help an unwilling patient acknowledge the need, recognize the potential value of the treatment, and weigh up the pros and cons differently. Unfortunately, this is not an easily scalable intervention, which relies heavily on 1:1 interaction with the patient.
For patients who struggle with remembering to take their medication, reminders may help. A randomized controlled trial in the UK followed just over 300 people taking medicines to reduce the risk of cardiovascular disease over six months. In the control group, the proportion of patients who were taking less than 80% of the prescribed drugs was 25%, while in the intervention group, where patients received regular text messages, that proportion was 9%.
Reminders are one of five types of nudges featuring in a systematic review (of 38 studies focusing on diabetes management, with medication adherence as the primary outcome), alongside framing, gamification, social modelling and social influence. The authors found all types of nudges had the potential of significantly influencing patient behaviour, although the efficacy might depend on both the delivery mode of the intervention (ranging from 1:1 counselling and group sessions to email, SMS and via an app), and the patient characteristics (in particular their age).
For patients with long-term conditions that are at the start of their treatment, adopting a habit of taking medication can help maintain good adherence. Common wisdom has it that a habit is formed after 21 days of task completion, but unfortunately this is not supported by evidence. Recent research by Colin Camerer and colleagues found that a hand washing habit in a clinical environment took on average 36 shifts to take root, and developing a habit to visit the gym 198 days. Perhaps more strikingly, the range around these two averages was very large in both cases: the 75th percentile for handwashing was 83 days, and for gym attendance 453 days. Developing a habit is not easy and takes time. Behavioural engineer Nir Eyal suggests starting with a routine (a series of actions that is followed regularly and consciously) before trying to turn it into a habit (a behaviour that requires little or no thought). This involves deliberately scheduling taking the medication, anticipating and getting used to the discomfort that is experienced, and pre-committing.
Yet even these simple steps will be different for different patients, especially for medication that cannot be tied to mealtimes. The context, including the patient characteristics, will influence what is more, and less, likely to help build the adherent behaviour as quickly and robustly as possible. Stuart Mills, a behavioural scientist at the London School of Economics, argued recently that the future of nudging will be personal. Personalized medicine makes us think first of all of tailored treatments – both preventative and curative – for diseases, with doses and even formulations of drugs adapted for individual patients. That is a massive biochemical challenge, but the behavioural challenge of customizing interventions to encourage the right patient behaviour is at least as ambitious.
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