Patient non-adherence is a serious public health concern. But three factors – motivation, recall, and comprehension – have been shown to yield the best results for combatting this issue. To leverage the power of these key influencers, brands should consider utilizing narrative communication methods. Specifically: Strategic, regulatory-compliant, patient-driven storytelling.
Sometimes it’s striking how healthcare topics that have been around for centuries remain current and highly relevant. Think of the Hippocratic Oath and how it encouraged patient centricity millennia ahead of our time. Or think of Molière’s classic 17th century comedy Le malade imaginaire and how it highlights the responsibility of care partners and the balancing act between a patient’s and an HCP’s authority. Of course, there are revolutions in the medical field that do not simply recycle old ideas but are genuinely new: Science and evidence-based medicine was one of those revolutions; the institution of regulatory bodies to oversee the pharmaceutical industry was another one; and public health policies as well as private health insurances have also all played their part in shaping healthcare into what it is today. Yet a lot of things that preoccupy our industry have in some form or other been around for a long time.
One current trend that made me think of that is the shift in who’s sitting in the driver seat on treatment decision-making. Shifts in policies around the globe, due to fiscal restraints and an aging population, force patients to carry a larger share of the cost burden, so naturally patients demand a bigger say about their care. Another factor that gives patients more weight is, of course, the way information is now accessible. The web and social media make it possible for patients to form their own opinions before they meet with an HCP. The negative side of that coin is the difficulty for experts and regulatory bodies to enforce quality standards of that information. So with patients covering more of their own healthcare costs and making up their own minds online, patients and HCPs again enter into a delicate balancing act of competing authority, reminiscent of the one described by Molière, even though, of course, there is no comparison between the expertise and ethics of real-world 21st century doctors and the ones caricatured in the 17th century play.
Double-edged sword of emotions
The fact that patients assert themselves in the doctor’s office has major consequences on how treatment decisions are made: An expert HCP may still be weighing statistical significance, relative risk, absolute benefit, effect size, sample size, and whatever else is available for rational treatment decision-making. But this process is now compounded with a patient or care partner who responds much more strongly to personal experiences and emotionally charged anecdotes. The bad news is: Emotions can undermine medical best practice. Just consider parents who actively choose to expose their children to the risk of serious infections rather than to provide them with the protection of a vaccine.
The good news is: Emotions can just as well be a powerful driver of medically sound decisions. Many HCPs in their everyday practice point to specific anecdotes to illustrate how their proposed prescription has, in concrete cases, helped others with the same condition. People respond to stories, and they like to hear them. We are all storytellers, and we instinctively prefer to receive information in this approachable way over having to analyze intellectually challenging piles of data. Several pieces of research indicate how narrative communication can be a tool for health behavior change., Clearly, here’s a call for the life science industry to support adherence and other positive behaviors through storytelling, to blunt emotionally charged disinformation with emotionally charged information.
The cost of non-adherence
No matter how captivating these stories are though, they are easily dismissed and can even backfire if they lack authenticity. You cannot just tell stories and expect them to have the desired effect. Your stories have to be true, believable, relatable, and vetted for the right messaging. In other words: They should come from people living with the condition concerned who, at some point in their journey, made good decisions for themselves. Even people who had made poor health choices in the past can demonstrate to others just like them that anybody can eventually find a more positive approach to life.
Improving medical treatment adherence is of course of major interest to our industry: $188 billion of lost revenue is attributed to patients not taking their medication as prescribed. That’s just the industry side, but what about all those avoidable hospital readmissions? What about the public and private resources for treatment and prevention going to waste? The man-hours lost from people who can’t work, because their disease has gotten the upper hand? The material loss to the whole of society through non-adherence is estimated to be $300 billion in the United States, and that doesn’t even count the human suffering from preventable pain and death.
Motivation, recall, comprehension
It is often presumed that non-adherent patients willingly reject their prescriptions; that’s why sometimes we still hear the expression “non-compliant” in this context, even though in the UK the terminology has shifted to “non-concordant,” and internationally to “non-adherent,” in order to stop implying disobedience on the patient’s part. The perception of willful non-adherence focuses on patient motivation alone and generously overlooks all of the other factors that play a part in the puzzle. Patients may also simply forget to follow their treatment (patient recall). Or they may have misunderstood their physician’s instructions (patient comprehension). Or it could be external factors, such as medication access, that cause patients to go without the right treatment. To address external factors, some companies have co-pay assistance programs, or they join advocacy groups in their lobbying for improved access.
For patient factors such as motivation, recall, and comprehension, narrative communication has been shown to be the strategy that yields the best results. Specifically: Strategic, regulatory-compliant, patient-driven storytelling. As fMRI studies at the University of Princeton have shown, storytelling can lead to neural coupling, where the brains of listeners essentially mirror activities happening in the brain of the storyteller. This means that if the storyteller shares an authentic, subjective perspective on why he or she adheres to treatment, the audience will likely feel the same way about it. Through neural coupling, a storyteller who shares a personal account of events will get the audience to almost experience the same thing and go through the same emotions and the same rational thoughts. The increased levels of attention and alertness that come with following a story improve intellectual processing of the content. In other words: The audience understands better and will also remember better.
The peer factor
People diagnosed with a life-changing condition and those caring for someone newly diagnosed long for nothing more than to speak to someone just like them. Of course, they want to exchange ideas on how to best cope with their own situation; but more than that, they really want to get hope and inspiration from strong peers who can act as role models, and they want to know they’re not alone with this disease. No doubt: When you’re diagnosed with a life changing, scary disease, you tap into any resource you’ve got. You’ll go online, consult medical books and journals, and seek advice from HCPs, friends, and family. You’re not going to let the dry language of textbooks bore you out of reading them. But being personally affected, you’ll also soon realize how overwhelming all this information is, and how difficult you find it to see the right path for yourself. So stories come in as an additional resource for you, acting as a compass in the vast ocean of information you’ve got. Therefore, an audience of people affected by the disease as patients and care partners will resonate most strongly with stories, just like they’re also most likely to dive into the details and data and seek as much information as they can get.
The most credible messenger for any target group is a peer. Testimonials and personal recommendations by people in our inner circle have always had the strongest influence on our most important life decisions. We trust people who are just like ourselves more than total and utter strangers. That’s why the storyteller should share the background of the target demographic. Especially when it comes to cultural backgrounds, we often find that the patient journey can look markedly different from one population to the other. Hispanic epilepsy patients, for instance, sometimes find it hard to relate to the epilepsy story of a Caucasian, simply because their own experience with friends and family doesn’t match what their Caucasian counterpart is sharing, as certain superstitions surrounding epilepsy are more common in Hispanic communities than in other parts of the population. So it makes sense to choose spokespeople who don’t just speak the language but who can also say to their audience: “Yes, I’ve been through that as well.” When you work on a disease that affects African Americans more than the rest of the population, of course you’re going to make sure you recruit a suitable proportion of African American Patient Ambassadors®. In a specific case my colleagues at Snow Companies worked on, the pharma company involved created targeted info packages, including culturally appropriate multimedia stories. The creation and distribution of this award-winning material didn’t just get the word out to the community but created lasting ties with African American doctors and advocacy groups. So it’s well worth it to give a voice and a platform to vetted patients of the right demographic to talk to their peers.
Engaging the disengaged
This doesn’t mean that the value of a personal story is lost on audiences not directly affected. On the contrary, compared to other outreach efforts, stories are the most likely way to get through to previously unengaged audiences. In other words: If we need to reach, say, at risk populations who should get tested for a disease, it is all but imperative to give a voice to those who have a personal perspective to share that illustrates the need to be proactive. Policymakers, HCPs, and various other stakeholders can also benefit greatly from patient stories in order to make decisions informed from all angles.
Stories are a constant in human communication. They’ve been our way of teaching and learning since the beginning of humankind. And they’re not foreign to healthcare either. Patients and care partners who share their stories have been as universal as Hippocratic patient centricity, or patient-doctor sparring about choosing the right treatment option. What’s new though is that we are now aware of the power of stories. This helps us influence the narrative to improve health outcomes to the benefit of all. It’s worth tapping into this great potential.
 T.K. Houston, J.J. Allison, M. Sussman, W. Horn, C.L. Holt, J. Trobaugh, M. Salas, M. Pisu, Y.L. Cuffee, D. Larkin, S.D. Person, B. Barton, C.I. Kiefe, S. Hullett (2011) Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized Trial. Annals of Internal Medicine, 154, 77-84.
 L.J. Hinyard, M.W. Kreuter (2007) Using Narrative Communication as a Tool for Health Behavior Change: A Conceptual, Theoretical, and Empirical Overview. Health Education & Behavior, 34, 777-792.
 E. Vermeire, H. Hearnshaw, P. Van Royen, J. Denekens (2001) Patient adherence to treatment: three decades of research. A comprehensive review. Journal of Clinical Pharmacy and Therapeutics (2001) 26, 331-342.
 G.J. Stephens, L.J. Silbert, U. Hasson (2010) Speaker-listener neural coupling underlies successful communication. Proceedings of the National Academy of Sciences of the United States of America, 107 (32), 14425-14430.
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