Why it takes more than smart reminders and small nudges to prevent medication dropout:

Using behavioral science to address barriers to non-adherence.

By Rune Nørager, Tim L. Leinert, Tereza Keprdova

Non-adherence to medication is a worldwide problem leading to high patient dropout rates, poor health outcomes and increased healthcare costs (1). Statistically, the figures show that nearly one in two patients do not adhere to the treatment prescribed to them, which results in billions of extra dollars spent on hospitalization (2, 3). In order to solve this increasing problem, many companies have turned to mobile technologies to remind and nudge patients to take their medication. These interventions are often based on the assumption that patients simply forget to take their medication, but forgetfulness is only a small part of the picture leading to non-adherence behavior. In this article, we explain why current strategies based on mere forgetfulness fail to solve the problem adequately. The multifactorial approach that we propose is rooted in behavioral psychology and called the Behavioral Mode of Action™ (BMOA™).

Reminders and nudges are good, but are they good enough? 

It is commonsense to believe that patients are aware of the benefits of taking their medication and therefore adhere to their treatment, especially in the case of chronic or life-threatening diseases. It is also reasonable to assume that if they do not stick to their prescribed medication, it is very likely because they have forgotten and need to be reminded. Based on this assumption, companies together with digital agencies have set out to develop intelligent solutions to overcome patient non-adherence behaviors, such as smart-pillboxes and apps for smartphones and smartwatches (4).These solutions are often based on reminders and small nudges. Reminders, it is argued, trigger the behavior of taking the medicine at a specific time and are sometimes coupled to a specific place. The mainstream methodology of nudging is considered to correct non-adherence behavior by sending alerts to friends and HCPs if the patient has not taken the medicine and rewards the adherence behavior with motivational incentives (5). This combination of daily reminders and small nudges is expected to be an effective tool against non-adherence (4).

The problem is that daily reminders and small nudges often don’t work. As a recent study (Volpp et al., 2017) has shown, even when the smart-pillbox reminder is accompanied with nudges (6) such as social support and a motivational incentive like a daily lottery participation, patients still do not stick to their treatment (5). Why is this so? Are daily reminders and small nudges alone not sufficient enough to support behavioral change? 

There are broadly two types of non-adherence but with an indistinct crossover between the two.

To answer these questions, we need to take a more in-depth look at how non-adherence is described in the literature. Non-adherence is defined as two types: 

1. Intentional non-adherence

2. Unintentional non-adherence

Unintentional non-adherence is defined as a passive process, including forgetfulness, carelessness or other uncontrollable circumstances. Intentional non-adherence refers to an active decision to not follow treatment recommendations (7). This means that interventions that only address forgetfulness work to tackle the occasional forgetfulness of absent-minded patients, but they don’t address more substantial barriers leading to situations in which patients cannot or don’t want to take their medications. 

Having worked with many types of patient support programs where we developed support material to enable patients to be successful in their self-management and adherence behavior, we know that patients encounter a broad range of barriers, ranging from the practical and logistical to social and psychological factors. Not all of these barriers are behavioral in nature. A lot has to do with plain and simple usability and human design factors making medical leaflets understandable and designing medical devices so that they are intuitive to use. That is a separate chapter on its own. Here we focus alone on the behavioral barriers of fitting a medical regimen into practical and social daily life.

However, we also know that in addition to such barriers, there are also resources within and around the patient, like existing motivational values, family members and peers, that can be factored into an intervention strategy. Both the barriers and resources need to be identified, understood, and addressed systematically so that companies don’t use significant amounts of their development budgets on only solving a small part of the problem - like forgetfulness. This becomes especially relevant when the recent research is starting to show that the border between the two types of non-adherence behavior might be more blurred than previously assumed, perhaps unintentional non-adherence is not passive at all. Instead, perceived patient forgetfulness might involve more complex barriers, such as a patient’s beliefs about their own disease, concerns about medication, or the interplay of sociodemographic factors (8). This therefore warrants a much broader uncovering both of patients’ barriers and resources. Behavior change is a complicated endeavor. While changing existing behavior is a challenge on its own, the obvious fact often missing is that most medical conditions are accompanied by entirely new behaviors that need to be learned (9). We need to help patients to overcome barriers and to build upon resources in order to integrate adherence-behavior in a meaningful way into their daily life-contexts.

The Behavioral Mode of Action™

To expose the full-set of barriers and resources leading to non-adherence behavior and to carefully target these in patient support programs, the Behavioral Mode of Action™ (BMOA ™) is a systematic analysis and design tool to enable and sustain behavioral change in a specific patient or user group. Just as a medicine has a mode of action that targets a specific biological function, designpsykologi’s BMOA™ targets specific behavioral barriers and resources along the treatment journey. We know that the treatment journey can be a bumpy road for patients and that it consists of many challenges at both contextual and individual levels. By addressing key barriers and resources, patients are guided on their journey and they are supported in developing skills to achieve sustainable treatment values. 

We therefore advocate that instead of focusing only on daily reminders and small nudges, to start with analyzing the patient's barriers and resources regarding adherence behavior. For this, we use the STReBA™ tool that systematically identifies barriers and resources across seven socio-technical dimensions (see the graphic below, step 1). This systematic analysis provides an overview of individual and contextual barriers as challenges and resources as opportunities. Consequently, forgetfulness might only be a small part leading to non-adherence behavior, and it might not even be the most important. 

At the heart of the BMOA™ analysis and design tool, we mitigate the key barriers and recruit key resources with evidence-based intervention techniques rooted in behavioral psychology as well as classic usability design guidelines (see the graphic below, step 2). This results in a design strategy to help companies to reach the full potential of enabling patients to achieve adherence behavior without overwhelming them with too much complex information.

To give a couple of examples, this could involve framing the core story of how patients understand their disease from a story of failure into one of opportunity, perhaps by developing empathic learning materials on how other patients in similar situations have learned to manage their condition. Another example is enabling patients to set realistic expectations and goals towards their treatment journey in order to both counteract early drop-outs and to encourage them to explore how this journey is related to their core values. This can be combined with examples of step-by-step guides on how to build the relevant skills to achieve healthier lifestyles or how to turn setbacks into learning opportunities. 

In the final step, we implement the systematic design strategy through the optimal medium, touchpoint and communication channel (see the graphic above, step 3). This ensures the delivery of interventions that impact patient behavior along the treatment journey in the right context and through the right design solution. Therefore, by working with BMOA™, we provide companies with a strategic analysis and design tool which systematically targets key barriers and resources that go far beyond reminders and small nudges.  

Non-adherence is a complex issue requiring a holistic intervention strategy.

If we want to crack “the non-adherence code” we need to acknowledge that forgetfulness is only a small part of the problem, and that there are many other key barriers and resources leading to non-adherence behavior that need to be systematically identified and addressed. Instead of focusing on daily reminders and small nudges alone, we can develop multifactorial intervention strategies that have a much more meaningful impact on patient non-adherence behavior. In doing so, companies develop patient support programs which enable patients to make sustainable behavioral changes, provide meaningful self-management guidance, align treatment expectations with core values, and, in return, reduce high patient drop-out rates. Otherwise, we can only design for “forgetful” patients - leaving out all patients who can’t or don’t want to take their medication.

Five take-aways: 

•  Reminders and small nudges are good, but not enough

• Forgetfulness is only a small part of non-adherence behavior 

• Change of non-adherence behavior requires a multifactorial intervention strategy

• Patient support programs should not only address barriers towards medication, but also build upon resources such as treatment expectations and long-term core values to make treatment plans more meaningful 

• The Behavioral Mode of Action™ (BMOA™) is a tool that helps companies systematically transform patient insights into sustainable intervention strategies with the purpose of helping patients overcome the multiple barriers that they experience across their patient journeys  

Want to learn more? 

• We are happy to present your team with all our design tools. Contact Rune Nørager: +45 4041 4422, rune@designpsykologi.dk

• Or attend our seminars: uxcamp.us The next seminar "Servicedesign" is on September 11. & 12. You can sign up here. 

References

1.  WHO (2003). Adherence to long-term therapies: Evidence for action. 

2. Cutler, D. & Everett, W. (2010). Thinking outside the pillbox – medication adherence as a priority for health reform. In The England Journal of Medicine, 326;17, pp. 1553-1555.

3. Osterberg, L. & Blaschke, T. (2005). Adherence to medication. In New English Journal of Medicine, 353, pp. 487-497.

4. Health Inc. (2017). 'Smart' pill bottles aren't always enough to help the medicine go down.

5. Volpp et al. (2017). Effect of electronic reminders, financial incentives, and social support on outcomes after myocardial infarction. The HeartStrong randomized clinical trial. In JAMA Internal Medicine, 177 (8), pp. 1093-1101.

6. Note: We do not evaluate here whether these particular implemented nudges are good examples or not.

7. Lehane, E. & McCarthy, G (2007). Intentional and unintentional medication non-adherence: A comprehensive framework for clinical research and practice? A discussion paper. In International Journal of Nursing Studies, 44, pp. 1468–1477.

8. Gadkari & McHorney (2012). Unintentional non-adherence to chronic prescription medications: how unintentional is it really? In BMC Health Services Research, 12:98, pp. 1-12.

9. Note: Herein lies the most fundamental limitation of “nudging” techniques for patient groups. When the required skill-sets and behavioral routines have not been established a person cannot be nudged into that behavior.