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Inside the mind of a diabetic

AQR Prosper Riley-Smith Qualitative Excellence Awards finalists Crawford Hollingworth and Rachel Abbott deliver insights on diabetic patient healthcare.

In the UK alone, 2.9 million people are diagnosed diabetic and it is estimated that 35% of the UK population is pre-diabetic. Taking medication, following a diet, and/or executing lifestyle changes are effective in improving type 2 diabetes patients’ health. However, patient adherence (the extent to which behaviour corresponds with agreed recommendations from a healthcare provider) is estimated at 50% or below.

In the last ten years, our scientific knowledge of why people behave in a certain way has increased exponentially. The Behavioural Sciences have given us frameworks and tools not only to understand behaviour, but also to change it. In ‘A BE-led investigation in Diabetes — Unlocking insight and inspiring behavioural interventions’, we set out to explore the power of these behavioural frameworks and concepts to unlock behavioural understanding and inspire ways to change behaviour within the healthcare sector.

The Behavioural Architects, bringing specialist knowledge of applying behavioural sciences to insight challenges, collaborated with healthcare research specialists Hall & Partners to:

  • Understand triggers and barriers to adherence
  • Identify opportunities to improve adherence and apply behavioural insights to the design of a simple behaviour change intervention
  • Evaluate and understand the impact of the intervention on adherence.

Our methodology was a ‘BE-inspired’ four-stage iterative approach.

Stage 1: Developing person-centred behavioural hypotheses

Given the fundamental principle that the architecture of current behaviour must be understood before it can be changed, our first mission was to develop a set of behavioural hypotheses about barriers to drug adherence and healthier lifestyles.

To achieve this we ran an inter-disciplinary session involving academics, healthcare professionals, behavioural experts and medical researchers. A literature review and depths with diabetes nurses provided rich material to immerse the attendees in the life of the patient. Core behavioural hypotheses were identified and short-listed at this stage of the project.

Stage 2: Examination of hypotheses through a BE lens

Overlaying our hypotheses with BE concepts provided a depth of behavioural understanding as well as inspiration to fuel the creation of behavioural interventions, designed to nudge patients towards healthy lifestyle change and medication adherence. For example:

  • The power of now: Patients have a tendency to discount the future in favour of now. Tomorrow never comes.

  • Commitment bias: There is often a lack of deeper behavioural commitment to change.

  • Status quo bias: With little behavioural feedback people tend to stick with existing behaviour, to stick to the status quo.

  • Finally, there is very little use of powerful visual or verbal primes or methods that leverage system 1 thinking and saliency.

Stage 3: Developing BE-based interventions

Based on these insights a number of behavioural interventions were created, which were then incorporated into the design of a simple poster tracking medication and lifestyle behaviour each day:

BE intervention 1:
Deploy a public commitment device, a ‘promise contract’ signed by the patient and a loved one. This involved setting personalised and realistic goals.

BE intervention 2:
Dial up the saliency of behaviour change through further leveraging the role of a loved one in supporting their condition. The poster included a picture of their loved one from intervention one, along with a pair of watching eyes — a simple but deep behavioural prime.

BE intervention 3:
Present drug adherence and lifestyle challenges as a day-by-day journey, allowing the patient to track progress and give feedback each day. Feedback stickers (happy, neutral, sad faces) were used to depict how the patient felt each day had gone — mentally chunking the challenge and priming/rewarded behaviour — simple yet powerful nudges!

Stage 4: Behavioural monitoring and qualitative deep-dive

We recruited type 2 diabetes patients who were taking oral medication at least twice a day and who showed sub-optimal levels of adherence.

Monitoring pre-intervention engagement with drug adherence and lifestyle choices to identify a base level against which to evaluate changes during the intervention period was critical.

Each day participants used a mobile app to record their behavioural journey using self-assessment measures: one for lifestyle and health, the other for drug adherence. We had a control period of two weeks and then an intervention of two weeks.

After the intervention period, we explored the impact of the poster from the participant’s perspective. Using a combination of open and closed forum activities, we explored experiences, thoughts and feelings around the intervention, and participation in the study overall. The findings were subsequently analysed in the context of behavioural insights and hypotheses previously generated.

Outcome

The study achieved extraordinary behavioural changes: a significant and demonstrable impact on behavioural metrics. In the intervention period vs. Control, recorded frequency of healthy behaviour went up by over 45% and, with 70% of patients showing an increase in drug adherence.

Final thoughts

Although this work is a powerful demonstration of how a combination of BE and qualitative research can unlock understanding and inspire change within healthcare, the learning and methodological approach are relevant across all sectors. This research has been awarded the prestigious EphMRA JH Award and been shared with many leading pharma companies and associated charities.

 

Crawford Hollingworth
Copyright © Association for Qualitative Research, 2015