Could Behavioral Science Crack Non-Adherence?

The industry is looking to the field of psychology to answer one of its most protracted problems

Non-adherence and non-compliance to medicines are well-documented problems which have been the subject of much research over the past 25 years.

There is no definitive solution and it is believed up to 75% of patients do not take their treatments as directed, with up to a third stopping their medicine earlier than recommended.

The implications are far-reaching with estimated costs to international healthcare systems running into hundreds of billions annually.

However, behavioral psychology - a relatively new approach that focuses on people’s actions, emotions and thoughts - is currently being explored by a handful of pharmaceutical companies as a possible way to address the issue.

Tom Kenny, Medical Director and CEO of boutique behavior-change consultancy Spoonful of Sugar (SoS), believes there is huge scope for pharma companies to use behavioural psychology to help close the gap between effective medical treatment and optimum health outcomes.

SoS has created unique behaviour-changing methodologies founded on a deep understanding of why engagement with medicines is often suboptimal and how these behaviours can be changed to improve outcomes for patients and the healthcare system.

Kenny explains that patients’ motivation to start and continue with a prescribed medication is influenced by the way in which they judge their personal need for the medication (necessity beliefs), relative to their concerns about potential adverse effects. This is known as the Necessity Concerns Framework.

“In its simplest form,” explains Kenny, “there are three heuristic questions: how much do I believe I need this treatment, how much can I get away without it and what bad thing might happen to me if I take it?

“People don’t literally ask themselves those questions,” he says, “but we can understand the way people are thinking about their medicines under those headings and wherever concerns outweigh necessity beliefs, people do not generally engage with that healthcare or medicine.”

And if patients don’t take their medicines properly or don’t persist with their medicines once they are on them there are three potential losses, he adds.

“A loss to the patient because they don’t get the benefit of the treatment, a long-term loss to the health system because it has paid for a drug that isn’t being used and a loss to the pharmaceutical company because its drug looks less effective.”

The behavioral psychology approach follows the 3CBC model, or the three Cs of behavioral change – channel, content and context.

“The first thing we do,” explains Kenny, “is to identify the channel we are going to use, who or what we are going to use to support the patient - is it going to be a digital app, a nurse, doctor or community pharmacist for example.

We then look at designing the content based on the necessity beliefs, tailored to the channel through which you want to deliver the message. The context is also really important because there are often cultural differences which dictate the kind of message and who you can give it to and there are also points of high leverage — those moments where you have a real opportunity to change the way someone thinks and believes about something.”

Japanese pharma company Eisai was drawn to the behavioral science approach after noticing that the duration of treatment in patients taking its oral cancer drug lenvatinib, for differentiated thyroid cancer, seemed to be shorter in clinical practice than in clinical trials. It knew the drug was effective, but patients were not getting optimal benefit.

In the past, duration of treatment in patients taking oncology drugs has rarely gone beyond the 12-month mark but, thanks to rapid advances in new oral agents, patients are now taking them for much longer, something clinicians are not used to managing.

The behavioral psychology approach was attractive, says Anne-Marie Lancaster, Senior Brand Director, EMEA, oncology, at Eisai, because it aligned so closely to the company’s human healthcare (hhc) philosophy. “If we are able to help clinicians to support patients to get the very best out of a treatment it is going to benefit them and their families. It is also hugely satisfying to know that we are actually making a difference to those patients.”

In collaboration with SoS, Eisai launched behavioral change programme, Perspective, which aimed to increase adherence to lenvatinib by providing healthcare professionals (HCPs) with tailored support materials to give to their patients.

The project received an overwhelmingly positive response from HCPs and narrowly missed out on an award for most valuable HCP initiative at eyeforpharma’s Barcelona conference in March.

“Typically, when a drug is launched,” explains Lancaster, “a pharma company will develop patient information or some sort of support material for healthcare professionals to give to patients, but this is very much a one-size-fits-all approach.

“We wanted to develop some kind of support for our clinicians which was more tailored and actually aligned with our human healthcare philosophy that not all patients are the same.”

Lancaster says the partnership with SoS gave Eisai the opportunity to gain a deeper knowledge and understanding of why patients do not persist with a treatment based not just on how they are managed by a clinician, but also on how they view the side effects of a medicine, how they understand their illness and how much they accept their diagnosis.

The project involved analysis of existing data, interviews and focus groups with patients and clinicians and insight mapping, which revealed that one of the main reasons patients were not persisting with lenvatinib was largely because of its side effects.

Perhaps one of the most surprising revelations was that even patients with a life-threatening or a terminal illness, such as differentiated thyroid cancer, often do not adhere to their treatment.

There are numerous reasons for this, says Lancaster, ranging from patients burying their head in the sand to those who lack an understanding of their illness and the implications of not taking the treatment.

Based on learnings from the project a suite of bespoke support materials was constructed to help clinicians conduct conversations with their patients about these issues, depending at what point of the treatment journey they were at. Matched materials for patients were also produced.

“What we know from every bit of psychology out there is that people can cope with what they know or expect,” says Kenny. “If you tell someone, before you do a medical procedure, that it is going to hurt, they cope far better than if you don’t tell them even though the perception of the pain is identical.

“People form conceptualizations of their disease or their drug from their life experiences or the experiences of someone they know. So, we must build on that. We start to set out the things they need to look out for, so they can start to link that with the drug and the fact that it is working, and it being the right thing to continue and persist with.

“Priming someone that they may well get side effects and assuring them that they are all manageable is beneficial. Letting them know that they can return to their HCP for support and that they will know when a drug is working at their two-month scan when they see their tumour shrinking is all part of it.”

Although there is not yet any hard data to demonstrate the success of the project, Lancaster says it has been so well-received by clinicians that the company is now embarking on a new project with the same drug that has different indications. She adds that it has also served to raise awareness of Eisai, which is relatively new to the oncology space, in a professional way that is aligned to its patient-centric philosophy.