The Challenge of Influencing Behaviour

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The Challenge of Influencing Behaviour
Bruce Hugman Consultant to the Drug Evaluation
Committee of the Shanghai Institute of
Pharmacology and to the Uppsala Monitoring Centre
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What influenced us all to come here today?

• Academic, professional, intellectual curiosity?
• The wish to learn?
• The boss said we should come?
• Enhancing status?
• Payment/sponsorship?
• Time-off work?
• Seeing old friends?
• Shopping in Shanghai?
• A few days freedom?
• More?

Lots of different reasons!
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The public and the private

• What we will admit to in public
• What we really feel
• Public agreement
• Private neglect
• And why did many people not come here today?

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Why influence medics?

• Irrational prescribing
• Antibiotics
• Antidepressants
• Polypharrnacy
• Patient pressure
• Dangerous prescribing
• Contraindications
• Interactions
• Failure to test
• Power of industry
• Marketing, detailing, advertising, funding
• Reporting
• Low levels of ADR and error reporting

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Why influence patients?

• Involved and knowledgeable patients are healthier
• Treatment for well-informed patients is more
  likely to succeed
• Reduction in irrational behaviour
• Collaboration with healthcare

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Leading research

• Contraindicated use of Cisapride
• Impact of FDA regulatory action
• Walter Smalley et al Journal of the American
  Medical Association, Vol 284 No. 23, December 20
  2000
• Labelling changes and Dear Doctor letters had
  no material effect on contraindicated cisiparide
  use.

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Leading research

• Liver Enzyme Monitoring in Patients Treated With
  Troglitazone
• David J. Graham, MD,MPH Carol R. Drinkard,
  MPH,PhD Deborah Shatin, PhD Yi Tsong, PhD
  Margaret J. Burgess
• JAMA. 2001286831-833.
• In all cohorts, less than 5 received all
  recommended liver enzyme tests by the third month
  of continuous use.

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Leading research

• Adverse drug reactions as cause of admission to
  hospital prospective analysis of 18 820
  patients.Pirmohamed M, James S, Meakin S, Green
  C, Scott AK, Walley TJ, Farrar K, Park BK,
  Breckenridge AM.Department of Pharmacology and
  Therapeutics, University of Liverpool, Liverpool
  L69 3GE. munirp_at_liv.ac.uk
• BMJ. 2004 Jul 3329(7456)15-9.
• ADR prevalence over 6 mortality 0.15

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Needs, desires, rewards

• Everyone seeks to
• meet their basic needs
• For food, shelter, safety
• pursue their desires
• For status, money, security, affection, happiness
• find rewards
• Recognition, reputation, respect

Variable across cultures, regions, age groups,
gender, etc
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Needs, desires, rewards

• Everyone seeks to
• meet their basic needs
• For food, shelter, safety

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Needs, desires, rewards

• Everyone seeks to
• pursue their desires
• For status, money, security, affection, happiness

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Needs, desires, rewards

• Everyone seeks to
• find rewards
• Recognition, reputation, respect

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The secret of influence

• To understand what peoples needs and desires are
  and what rewards they seek
• These are the keys to influencing others
• To offer something which helps them achieve their
  wishes or dreams or threatens the loss of
  satisfaction for non-cooperation

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What do they (possibly) want?

• Professionals
• To be effective
• To be respected
• To be successful
• To save time and money
• OR
• To take the easy way
• To muddle through
• To stagnate

• Patients
• To get well quickly
• To avoid ADRs or complications
• To understand their therapy
• To make decisions
• OR
• To be passive, uncritical recipients

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Failure to change

• Laziness
• Being busy (conflicting motivation)
• Believing all is well (conservatism)
• Not paying attention
• Negative attitude to proposer of change (not
  change itself)
• A stronger, conflicting influence

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Basic needs
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More sophisticated desires
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Options for changing behaviour

• Assertion of authority
• Punishment
• Persuasion and influence
• To offer something which helps people achieve
  their wishes or maintains their satisfaction

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How do we know what people desire?

• Ask them
• But
• They may answer in their public voice (what is
  expected)
• They may shelter or disguise what they personally
  want or are willing to do

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The masters of persuasion
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Influencing means

• Identifying our audience
• Asking and listening
• Discovering what motivates
• Understanding obstacles
• Planning to stimulate motivation
• Making the response, change, easy for the
  audience
• Recognising and rewarding cooperation

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ADRs and Patient Safety

• Investigate, enquire, listen
• Important, heartfelt project
• High priority for everyone at all levels
• Demonstrable benefits for doctors and patients
  and public health
• Simple, minimal effort demanded
• Positive appreciation for participation
• Evident benefits to everyone

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Identifying our audience

• Who are they?
• Where are they?
• What age are they?
• What education level?
• Are they employed/affluent/unemployed/poor?
• How varied are they?

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Asking and listeningDiscovering what motivates

• Ask, ask, ask
• Listen, listen, listen
• What do they want (needs, desires, rewards)?
• How motivated are they?
• What are they willing to do?
• Do they understand and like what were offering?
• What obstacles are there?

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Planning to stimulate motivation

• Tailor the request/offer/product to their tastes,
  preferences and motives
• Anticipate what they dislike and desire
• Deal with obstacles
• Make the response easy
• Make compliance simple and agreeable

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Recognising and rewarding cooperation

• Ensure that responding is a positive experience
• Ensure that the positive effects/feelings last
• Actively reward or appreciate
• Consolidate and follow up

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Follow up

• How are they feeling now?
• Was the experience positive?
• Have the positive feelings lasted?
• Is there a willingness to repeat the action,
  develop the process or relationship?
• If not, why not? What needs to be changed?

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Influencing and changing behaviour

• Understand your audience
• Find out their needs and desires and what rewards
  they seek
• Discover the obstacles to collaboration
• Tailor and target the offer carefully
• Reward collaboration
• Follow up

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Doctors and patients

• Need much better, more effective communications
  and information
• The bureaucratic model doesnt work
• Getting alongside, collaborating
• Providing relevant, clear information at the
  point of use or need
• Constantly experimenting, researching, testing

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