The Science and Application of Behaviour Change in Pharma
At the core of any change within a company is the need for concomitant change in individual and collective behaviour. Internationally, pharma is facing growing pressure from governments, regulatory agencies, payers, and patient advocacy groups to change a variety of behaviours – ranging from how companies interact with doctors and how sales reps sell, to how pharma involves the patient, and much more. In this respect, pharma, physicians, patients, and payers can benefit from a deeper understanding of the science of behaviour change.
Understanding Theories of Behaviour and Change
Several theories of behaviour underlie the ways behavioural change is encouraged by organisations. Attitudes are shaped by both internal and external factors. Social cognitive theory posits that external forces motivate people (Glanz and Bishop, 2010). Based on social cognitive theory, building confidence, offering incentives, and providing social support are useful strategies to foster behavioural change (World Bank, 2010).
In the theory of planned behaviour, individuals behave according to their intent, which is affected by their attitudes and social pressures (World Bank, 2010). Based on planned behaviour theory, information on positive results of change, as well as perceived control, also stimulate behavioural change.
The transtheoretical model (TTM) focuses aspects of leading behaviour change models into the stages of change method, which “involves [gradual] progress through a series of stages: precontemplation, contemplation, preparation, action, maintenance, and termination” (Prochaska, 2008, p. 1). Ideation in the precontemplation and contemplation stages leads to action and maintenance of action (World Bank, 2010). According to the TTM, matching the type of encouragement provided to the stage of the individual is important to achieve change in behaviour. Increasing both awareness and information is important for people in precontemplation and contemplation stages to understand the effects of their behaviour and move forward.
For the contemplation stage, analysing advantages and disadvantages of change and making lists of barriers are tools that can be used to consider potential changes to behaviour. Connecting via an emotional experience, analysing values, inclusion of imagery, use of healthy models, setting specific goals, and establishing ways to achieve objectives are all approaches relevant to the preparation stage of behaviour change. Keeping a diary of behaviour and health accomplishments, affirmative self-talk, and support are suggested techniques for individuals to increase their chances of success during the action stage. This model has been the theory most utilised in healthcare settings (Harvard Medical School, 2007).
Key drivers of behaviour change include threat, fear, response efficacy, and self-efficacy (World Bank, 2010). Increased information on advantages and disadvantages of the behaviour, and the change process can address threat and fear, respectively. Demonstrating that certain responses alleviate threats, communicating the importance of outcome expectations, building confidence, modifying perceptions, and encouraging changes in attitude, help to foster an environment favourable to behaviour change. Altering and maintaining behaviour requires knowledge, learning new skills and opportunities for practising them, receipt of feedback, and reinforcement (Heckleman, 2009).
Adopting Behavioural Change by Pharma and Their Customers
Compliance with evolving regulatory requirements for sales representatives is just one area in which pharma has applied behaviour change through training such as observational learning.
In today’s cost-containment environment, the importance of pharmacoeconomics is demonstrated through the incorporation of health economics and outcomes research (HEOR) data into clinical trials and post-marketing surveillance studies. Pharmacoeconomic data can be used to justify regulatory approval, pricing, and formulary inclusion, as well as improve public perception of pharmaceutical companies.
Some pharma companies already collaborate with behaviour change experts and psychologists, as well as implement this knowledge to expand business and healthcare success. In 2009, GSK adopted an Accelerating Delivery and Performance (ADP) programme that incorporated change management and project management (McGuire, 2014). Core principles included changing oneself, defining desired goals, focusing on key aspects for change, committing to making the changes, and tasking relevant staff with designing solutions that address customer needs. The utilisation of ADP has resulted in successful regulatory approvals of new GSK drugs.
Pharma companies currently utilise patient education, nurse educators, and mobile applications to foster positive patient behaviour change and adherence to therapy for chronic diseases, including diabetes and multiple sclerosis. Healthcare communications companies have evolved from being considered vendors to being considered partners of pharmaceutical companies in order to strengthen disease management programmes and improve treatment compliance and healthcare outcomes. Patients, physicians, other healthcare professionals, and pharma companies integrate through disease management programmes involving mobile applications and in-home care.
Novartis and InVivo Communications developed Helio, a health and lifestyle management mobile application for patients with chronic obstructive pulmonary disease (COPD) (Hill, 2015). The application, which is not specific to use of a Novartis drug, tracks the status of disease and offers a “gamified” rewards programme for positive change in health and lifestyle behaviour, including adherence to medication, appropriate diet, exercise, and cessation of smoking.
Micromass Communications (2016) utilises patient engagement and support techniques, such as motivational interviewing, cognitive behaviour techniques, problem solving, and goal setting via mobile devices and in-home interactions, in addition to traditional patient education. Clients of Micromass include Accountable Care Organisations (ACOs), other healthcare systems, and pharmaceutical companies.
In collaboration with Micromass, Onyx Pharmaceuticals developed Onyx 360, a programme providing oncology nurse advocates for patients with multiple myeloma receiving Kyprolis® (carfilzomib) (Raedler, 2014). The programme comprises treatment support for patients and caregivers, reimbursement/payment support, counselling and emotional support, referrals, and transportation/lodging support. These support services
help patients adapt to and maintain behavioural changes, such as adherence to therapy.
BioLucid has developed virtual reality technology as an empathy tool, so that physicians and patients in the early stages of a progressive disease can understand what patients in a later stage of chronic diseases, such as diabetes, are facing (Lau, 2016). Patients with pre-diabetes are then motivated to change their behaviour, which can lead to improved health outcomes.
According to a recent survey, pharma employees in Europe view patient and public involvement (PPI) in the development of medicines as a positive concept (Parsons et al., 2016). Involving patients and the public in R&D decisions would represent behaviour change for the pharma industry, attitudinal change for the public towards pharma, and potential lifestyle behaviour change for patients. However, the challenges in implementing PPI include insufficient layperson understanding of development issues, perception of lack of industry receptivity, and industry codes of practice (Parsons et al., 2016). Fostering relationships between pharma and the public and thereby achieving more positive media coverage of the pharma industry, may further facilitate the desired changes to create a more patient-centric approach to medicines and health, ultimately resulting in better health outcomes.
Glanz, K. and Bishop, D. B. (2010). The role of behavioral science theory in development and implementation of public health interventions. Annual Reviews in Public Health. 31:399-418.
Harvard Medical School (2007). Why it’s hard to change unhealthy behavior –and why you should keep trying. Harvard Women’s Health Watch. Available at <www.health.harvard.edu/staying-healthy/why-its-hard-to-change-unhealthy-behavior> [Accessed 06 December 2016].
Heckleman, W. (2009). The changing pharmaceutical sales landscape. PharmaceuticalExec.com. Available at <http://www.pharmexec.com/changing-pharmaceutical-sales-landscape [Accessed 06 December 2016].
Hill, A. (2015). The power of apps. Available at <http://social.eyeforpharma.com/commercial/power-apps> [Accessed 06 December 2016].
Lau, V. (2016). Sharecare aims to drive behavior change with VR acquisition. Medical Marketing & Media. Available at < http://www.mmm-online.com/technology/sharecare-aims-to-drive-behavior-change-with-vr-acquisition/article/526107/> [Accessed 06 December 2016].
McGuire, D. (2014). Organizational change management at work in the global pharmaceutical industry. Project Management Institute. Available at
[Accessed 06 December 2016].
Micromass Communications (2016). Patient engagement and support. Available at <www.micromass.com/services/patient-engagement-support/>. [Accessed 06 December 2016].
Parsons S., Starling B., Mullan-Jensen C., Tham S. G., Warner, K., and Wever, K. (2016). What do pharmaceutical industry professionals in Europe believe about involving patients and the public in research and development of medicines? A qualitative interview study. BMJ Open. 6(1): e008928.
Prochaska, J. O. (2008). Decision making in the transtheoretical model of behaviour change. Med Decis Making, 28(6): 845-9. Available at: <http://mdm.sagepub.com/content/28/6/845.full.pdf+html> [Accessed 06 December 2016].
Raedler, L. A. (2014). Overview of Onyx 360 patient assistance program. Oncology Practice Management. Available at <http://oncpracticemanagement.com/issue-archive/supplements/patient-assistance-profiler-december-2014/overview-of-onyx-360-patient-assistance-program/> [Accessed 06 December 2016].
World Bank (2010). Theories of behavior change. Communication for Governance and Accountability Program (CommGAP). Washington, DC: World Bank. Available at <http://documents.worldbank.org/curated/en/456261468164982535/Theories-of-behavior-change> [Accessed 06 December 2016].