Behavioral science at work: Purohit Navigation	June 2009

Ahnal Purohit, Ph.D. gave Med Ad News several examples of her agency’s behavioral science work in patient compliance.

Recently, we completed a comprehensive patient information kit in the CNS category. The condition is complex where the perception of poor outcomes (the depressing need for a wheelchair) pervades. Behavioral research indicates that while the outlook for the condition is promising, some patients many reject or deny the diagnosis for a variety of reasons. They also do not discuss their concerns with family and friends. In many cases, they avoid discussions with employers and other groups for fear of retribution (denied claims or firing) or being labeled “disabled.” And because this condition affects each person differently, the treatment plan can be complex and differs from patient to patient. 

Our compliance program focused on the first three months of diagnosis and our content emphasized hope and empowerment. Content was written to encourage dialogue between the healthcare team and the patient. We also provided “dialogue starters” for patients when meeting with a new healthcare team member. We touched on the value and importance of building a relationship with a financial planner and provided insights into the payer system. The materials were designed to be gender, race and generation neutral, based on learnings that the condition is no longer relegated to older, Caucasians or to women.

The daily journal was unique because it helped patients pinpoint pain location and write about key emotions. Because of memory lapses, the journal became a valuable document for patients. The patient kit also included a CD, a zip drive, and flash cards. To keep all materials together (so they are easy to find and refer to when needed), we designed the packaging to be easy to carry and unobtrusive.

The information kit is scheduled to expand online because research demonstrated the newly diagnosed patient’s ability to maneuver online. Initially, Purohit Navigation could have developed a patient brochure to accommodate the initial need for information and be done. However, our experience in behavioral science demonstrated that a single brochure would not help improve patient compliance. Instead, the patient information kit encompassed not just disease awareness, but also touched on the multiple social systems that would impact the patient’s ability to accept and control MS.

In another program, we were asked to develop a compliance program for a product that focuses on growth deficiency in pediatric endocrinology. 

We knew that shortly after diagnosis and in the beginning of the treatment plan, parents/caregivers strive to carefully comply with instructions required for a successful outcome. The outcomes are measured not just by filling the prescription but also in the patient’s growth status. But after a certain time period, the parents/caregivers and young patients become lax in following the rigorous twice-daily injections. Marketing research showed that lifestyle and convenience played a factor in compliance. Also, the young patients were initially scared of the shots. But as they became accustomed to the injections, they eventually tire of the shots. The regimen became a constant battle in which the patient sometimes won.

For the patient brochure, we wrote content simply so they could quickly and easily remember key points. The patient brochure also fit easily into the packaging so it could be kept with the medication. When parents/caregivers needed to refer to specific information, they knew where to find it.

To continue the momentum of better compliance, we developed a calendar that the family can use together. Our experience told us that when the treatment plan involves the whole family, adherence increases. Accordingly, the calendar included growth facts and helpful aids such as space to record the time of the required morning and evening injections. Playful stickers were included to keep track of injections. The stickers encourage the young patients to get involved with their treatment plan. The creative approach was playful, imaginative and fun so families felt comfortable displaying the calendar in their home, without concern for its medical intent and content. With a calendar that is easy and fun to follow, parents/caregivers and patients were more likely to remember and follow the injection schedule.

Materials were also given to the specialty sales force to educate the pediatric endocrinologists and nurses with the product and how to reinforce compliance with parents/caregivers.

The client was extremely pleased with results surrounding the adherence program. Parents were filling the prescriptions at appropriate times, which indicated that they were following the twice-daily injections. Of all the patient materials developed, the most widely requested from both parents and physician offices was the calendar, demonstrating positive behavior change. The creative campaign won several international awards for its distinctive and fun design.

Yet another example is a patient compliance/persistence program that we developed in oncology. Research and literature demonstrated that medication compliance with oncology patients in the beginning of the treatment plan is high. However, as patients undergo cancer treatments, compliance decreases because of several factors, including depression, anxiety, fear, side effects and financial concerns.

Patients did not feel comfortable discussing some of these concerns with their healthcare team and were unwilling to “burden” their support systems. Physicians and oncology nurses, in turn, weren’t asking patients key questions that would lead to assessing patient compliance levels. 

To truly understand the behavior behind cancer patients, Purohit Navigation established two advisory boards (one patient, one multidisciplinary) and implemented behavioral research targeting the various support systems. Out of this research came a revelation of the need to develop materials that answer the experiential and psychosocial issues patients require. The result is a cancer companion series designed to achieve the three phases of cancer patients experience — diagnosis, treatment, and future outlook.

We developed several tactics, such as patient brochures, a calendar, a journal, etc. We also incorporated an organizer to help patients record their symptoms, keep test results and insurance interactions. Instead of creating lengthy content, we produced information that physicians would deliver to patients in “bite-size” formats when the information becomes relevant to the patient. For example, physicians would provide information on nausea and side effects when the patients began treatment, instead of at diagnosis. This format allowed the healthcare team to personalize the information to each patient type. Topics that were difficult to discuss were written simply. 

The specialty sales force was given the materials and trained to explain to the healthcare team why this unique approach to patient education was chosen. They were also charged with clarifying how to best present information to patients at specific time frames.

As a testament to its success, the client continues to use the companion program nearly five years later. Additionally, the healthcare team indicated that this approach to communication improved their physician-patient relationship. The cancer companion series also received the endorsement of the Oncology Nursing Society.

What made the cancer companion series unique was that the content, the delivery vehicles and the practitioner who initiated the education were all rooted in the learnings obtained from the behavioral research. It enabled us to create synergy between the managed care initiatives that were being developed to ensure that patients received a well-rounded program.

In summary, because patient compliance is a multifactorial behavior, it requires a multifactorial approach. An effective compliance program should not only concentrate on patient behavior, but also tackle other factors that affect those behaviors, such as the communication with the healthcare providers (e.g., physicians, nurses, pharmacists, etc.) and the relationships with the support systems (such as caregivers and friends).

In many cases, companies that settle for developing a patient brochure and call it a compliance program are missing several pieces of the puzzle. Approaches that take into consideration multifactorial strategies are more effective than unifactorial strategies.