THE SCIENCE OF COMPLIANCE

 

 

Many businesses and consumer environments understand and utilise six universal principles of persuasion to successfully influence their target audiences.

How can these scientifically validated principles of persuasion be applied equally effectively in medicine and healthcare in the pursuit of increasing patient compliance?

 

 

Professor Robert B. Cialdini PhD

Arizona State University

 

Steve J Martin B.Sc., FInstSMM., CMC

Influence at Work

 

 

 

Address correspondence to:

Steve J Martin                                                        

Influence At Work (UK)                          

Dixies Barn A                                         

High Street Ashwell               

Hertfordshire                          

UK SG7 5NQ                                                          

Steve@influenceatwork.co.uk              

 

Dr. Robert Cialdini Ph.D

Dept of Psychology

Arizona State University

Tempe, Arizona

USA 85287-1104

 

               

If only Mary Poppins was right and all it took was a “spoonful of sugar” to help the medicine go down. More likely that the medicine prescribed will, not even find its way out of the bottle or blister pack in which it is contained.

Why is it that people will routinely forget or even decide not to take a medicine that they have been prescribed? Why, when there are obvious and clear benefits to a healthy lifestyle, will individuals ignore the advice of their Doctor or Healthcare Professional regarding their diet and exercise habits?

 

The cost of non-compliance

 

-          In 2002 approximately 444,000[i] prescriptions were written each day by General Practitioners.  As many as 1 in 5 of those prescriptions don’t even reach the pharmacy.

-          In 2001 over £230million of prescribed medicines were returned unused to UK pharmacies[ii] – provoking the question “what is the net worth of medicines that are not consumed and are not returned to pharmacies?”

-          It is estimated that 31% - 45% of patients on long term medication will fail to collect a repeat prescription within the first year of treatment[iii]

-          Non-compliance is not limited to specific medical conditions and ranges in incidence from 30% for arthritis treatments to an amazing 90% in the case of contraception[iv]

-          The impact of medical non-compliance is not even limited to the taking of medicines. It can manifest itself other ways such as;

-          failing to attend appointments

-          failing to accept and carry out medical recommendations that have a beneficial impact on an individuals’ general health and well-being e.g. smoking cessation, regular exercise and intake of a well balanced diet.

 

There can be no question that non-compliance (or non-concordance as it is also termed) to a medical treatment or a piece of healthcare advice can result in some very undesirable outcomes. Whilst the most obvious is the deterioration in an individual’s health there is impact elsewhere too. The cost to the National Health Service and the UK tax payer is huge.  The  lost income to healthcare and pharmaceutical suppliers is substantial, and the potential loss of faith in medicines is damaging.

 

Health professionals and the wider healthcare community consistently deliver large amounts of information to patients and their families.  Why will people often disregard these very important health communications? Why do they fail to comply with their doctors’ recommendations and, as a result, expose themselves to behaving in health damaging ways.

 

Information Overload

 

In our busy society we are bombarded daily by information on a variety of issues including effective diets, recommended cholesterol levels andexercise regimes. Not only is the amount of information overwhelming, the sources of information are also increasing :  healthcare professionals, patient information leaflets, TV / Radio advertising, the Internet and family and friends.  There is simply too much information for people to register it all. As a result, people will use cognitive shortcuts or rules of thumb to help them decide what to make of a communication andwhether to comply with the recommended action[v]. Understanding these shortcuts can provide tools to enhance the likelihood of increasing compliance to the benefit of an individuals’ health.

 

These cognitive shortcuts fall naturally into six categories that describe commonly used principles of social influence[vi] (See Table 1; Cialdini, 2001). The business and consumer professionals seem intuitively to know and understand these principles of social influence and use them very effectively in getting their customers to buy new cars, use a particular brand of washing powder or donate to a worthwhile charitable cause.

 

Can these principles of social influence be used to improve the communication of health information so that people are more likely to behave in ways that protect their health? Social scientific research strongly suggests that the answer to this question is a resounding ‘yes’. This research has identified many of the key factors that can help enhance a medical professional’s attempt at effecting positive behaviour change and increasing patient compliance.

 

PRINCIPLES OF SOCIAL INFLUENCE[vii]

(table 1.0)

 

Principle

Description

Scarcity

People typically overvalue things that are rare, dwindling in availability or difficult to acquire

Authority

People are more easily persuaded by individuals perceived to be legitimate authorities

Social Proof

People often look to the behaviour of similar others for direction about what choices to make

Liking

People prefer to say “yes” to those they like

Reciprocity

People feel obligated to repay, in kind, what has been given to them

Consistency

People feel strong pressure to be consistent within their own words and actions

 

Scarcity

 

The principle of Scarcity suggests that people typically associate greater value with things that are rare, dwindling in availability, or difficult to acquire. There are many examples in our everyday environment that support this claim. As recently as October 2003 the notion of losing something caused thousands of people to block a major motorway to see the final take-off of the Concorde, a familiar daily sight for the last 30 or so years.

 

We are familiar with the concept of our likelihood to be persuaded more by what we stand to lose than what we stand to gain, but can this principle be applied in the medical environment to increase the level of compliance to medical advice and treatment? Well according to social psychologists Beth Meyerowitz and Shelly Chaiken the idea of presenting what a patient stands to lose when delivering a healthcare recommendation is especially effective[viii]. When distributing information leaflets asking women to perform breast self-examination on a regular basis they found that those who had received a leaflet that contained positive messages about the benefits e.g. women who perform this examination have an increased chance of finding a tumour at a treatable stage, were no more likely to perform the examination than those that were just given instructions on how to conduct the self-examination. Contrast that with the third group who were provided with instructions for carrying out self-examination along with information on the negative consequences of failing to do so (i.e women who fail to perform the examination have a decreased chance of finding a tumour at a treatable stage). Four months after being given this negatively framed information; this group were found to be significantly more likely to carry on performing the breast self-examination. How you present information can often make a significant difference in a real life and death situation. Prompting the use of the mental shortcut of scarcity can motivate positive health behaviour change[ix].

 

Authority

 

Social psychological research indicates that people are more easily persuaded by individuals perceived to be legitimate authorities. Doctors, for example, are afforded substantial authoritative power in our society. Because we tend to view authorities as credible sources of information, they are particularly effective as agents of behaviour change. Indeed, research suggests that nurses who wear stethoscopes, an emblem symbolising a physician’s expertise, are viewed as more authoritative than those who do not[x].

 

To maximise patient compliance, it is crucial that health professionals make the most of their authority. Whenever possible, doctors should communicate instructions to their patients, rather than passing them indirectly through people who may be viewed as less credible in the eyes of the patient (e.g. a nurse, receptionist, practice manager, etc.). This may not always be possible but doctors can emphasise to their patients, the training and expertise of their colleagues so that they are also viewed as credible sources of information. In turn, these healthcare professionals can increase their credibility by prominently displaying their professional training, awards, and certifications[xi].

 

Social proof

 

Suppose that you decide to take some more exercise and to lose weight. How do you choose the best way to achieve your goal? Most likely, you’ll look to others around you for at least part of the answer.  The principle of social proof says that when we are uncertain and we are attempting to make the right decisions about our health, we will often look to the behaviour of others around us for direction about what choices to make. This is compounded when those around us are similar to us in terms of age, education, social standing and experience. Compliance can be improved by highlighting the benefit other patients with a similar medical condition found when taking their medicine as prescribed. 

 

It is important that the healthcare professional does not use the principles of social proof to reinforce an unwanted behaviour. An interesting study[xii] on road safety has important implications for surgeries trying to reduce the number of missed appointments. We are familiar with signs displaying the number of other drivers who have been caught travelling in excess of the legal speed limit. What is fascinating is that a sign declaring, “347 drivers were caught speeding on this road last month” can have the effect of increasing the number of speeding drivers in subsequent months. Why would this be so? Well drivers could be forgiven for thinking that “lots of other people in a similar position to me are speeding so it must be OK”.

 

A familiar sight in Surgeries and Health Centres up and down the country is the poster on the waiting room wall stating that “34 people failed to turn up for their appointment last month.” The road safety study would suggest that it is not surprising that the poster has little effect decreasing the number of no-shows. Better to use power of social proof to reinforce the change one desires by pointing out that “over 95% of patients who are unable to make their appointment with the doctor telephone the surgery the day before to inform us.”

 

Liking

 

Put simply, the principle of liking says that people prefer to say “yes” to and comply with the requests of those they like.

 

Social scientists point towards three specific amplifiers of liking: Similarity, Praise and Co-operation. 

 

Firstly, people tend to like others who are similar to them[xiii], For example  a dietician might point out areas of similarity she shares with her patients (e.g. she was once not in the best physical shape; but, like them, she wanted a healthy, well-rounded lifestyle).

 

Secondly, people will tend to like those, and therefore be more persuaded by those, who pay them compliments and give them praise[xiv]. There is strong evidence to suggest that people are extremely receptive to the requests of others immediately after they have received a compliment. A doctor or healthcare professional who wishes patients to continue to comply with their medicine regimewould do well to first compliment them on the progress they have made so far before making the request that “they continue taking their medicine regularly”.

 

Thirdly, we like people who co-operate with us towards mutual goals.[xv].  As this evidence suggests, understanding patient’s treatment goals and working together to make a jointly owned plan of care will enhance co-operation so that when a suggestion is made by the doctor or healthcare professional then it is done in the context of working together.

 

Reciprocity

 

Imagine that a volunteer from the National Blood Service approaches and asks if you would be willing to participate in a long-term blood donor initiative by donating a unit of blood every 60 days for the next three years. Thinking of the time this would require (and of the pile of work waiting for you on your desk) you decline. The volunteer responds, “I understand. In that case, would you be willing to help us with a one-time donation sometime this week?” With some hesitation you agree to this more reasonable request.

               

Interestingly, Cialdini & Ascani (1976)[xvi] presented this very scenario in a scientifically controlled experiment: Those people who declined to participate in the long-term donor initiative (as nearly all did) subsequently agreed to the one-time donation substantially more often than people who were simply asked to offer a one-time donation straightaway (49.2% vs. 31.7%). This study exemplifies our 5th principle of persuasion - reciprocity. The principle of reciprocity states that people feel obligated to repay, in kind, what has been given to them.  In this case, the volunteer granted the potential donor a concession – retreating from the larger request to the smaller request. In turn, donors felt obligated to repay the volunteer with a reciprocal concession, agreeing to the smaller one-time donation. The power of reciprocity is far reaching– not only did those people who reciprocated agree to the smaller donation more often than those who were only presented with the smaller request, when those people arrived at the blood donation centre they were also more likely to volunteer for future donations[xvii].

 

In another version of the reciprocal concessions technique, a doctor might advise patients to engage in the most beneficial (likely also to be the most difficult) regime appropriate for their medical condition[xviii]. If the patients fail to comply, she might then suggest, as a concession, a somewhat easier regime. In using this approach, there is the chance for two kinds of successes: Some patients will comply with the most beneficial regimen, which is to everyone’s advantage; but, those who don’t should be more likely to comply with the moderate (but still effective) plan than if the doctor had suggested it alone.   

 

There are two caveats to the principle of reciprocity – firstly for it to be effective, people must be able to view the gift or favour given as valuable to them personally; if they see it simply as an attempt to persuade them, the strategy can backfire.  Secondly, the gift must be seen as a gift and not as a reward for a particular behaviour. The principle of reciprocity is clear. When seeking compliance from a patient, it is important that the healthcare professional is the first to give. Information, advice, compliments and attention will all serve to make subsequent requests you make more likely to be actioned and adhered to[xix].

 

Consistency

 

A ubiquitous part of human nature is that people strive to feel good about themselves. This includes behaving in accordance with one’s important values and beliefs – when our behaviour is consistent with who we are and what we value, it makes us feel good[xx].

 

Imagine that you are a medical receptionist. A patient is waiting to book a follow-up appointment. Should you fill out the patient’s reminder card or produce a computerised appointment letter? Or might it be better to give the patient a blank appointment card and a pen and ask them to fill out the card themselves? Our principles of social scientific research suggest the reason why the latter procedure should be used: People feel strong pressure to be consistent within their own words and actions[xxi]. Making a commitment ties a person’s sense of self to a particular course of action. Asking the patient to fill out her own form establishes a basis for consistency – failing to return for her scheduled appointment would be inconsistent with her earlier commitment[xxii].

 

There are several conditions in which consistency tends to have maximum impact and increase compliance. Firstly, the person’s commitment should contain an effortful action[xxiii]. Indeed, in the aforementioned example, having the patient fill out the card herself, should enhance her sense of commitment. And in general, the greater the effort - the greater the resulting sense of commitment will be. Secondly, the commitment should be made public[xxiv]. Watching the patient fill out her reminder card should increase the probability of her return, whereas simply handing her the card and allowing her to fill it out by herself is likely to be much less effective. Indeed, one of the linchpins of the consistency principle is that people don’t like to appear inconsistent to others. Thirdly, the commitment should be (or at least appear to be) freely chosen and owned[xxv]. Commanding the patient to fill out her own card would not be nearly as effective (since the commitment would not be internally motivated). The more effective receptionist would merely politely suggest to the patient that she write her own reminder, giving her the sense that her action was freely chosen.

 

Conclusion

 

We have sought to provide interesting and scientifically validated evidence of how healthcare professionals can increase the likelihood of compliance with their recommendations and prescribed treatments but also some practical applications for the use of these principles.[xxvi]

 

There are some additional points we would like to make regarding the use of the principles we have described. Firstly, although these principles are conceptually distinct, the communications are likely to be most effective at fostering compliance and concordance when using several at once. For example, consider a doctor who is prescribing a medicine to a newly diagnosed diabetic patient.  The doctor could point out how a number of her other diabetic patients, who happen to be of a similar age and in similar circumstances, have achieved good blood glucose control by taking the medicine twice daily and keeping a diet diary.  The doctor may then go on to compliment the patient on his or her past with medical treatments. By doing this, the doctor creates a powerful communication to the patient that, utilises three of the social influence principles we have presented namely, Social Proof, Consistency and Liking. 

 

Secondly, it is important to realise that people use these shortcuts because, they tend to steer them in the right direction. It’s not the case that people are making mistakes when they use these mental heuristics. They are often simply overwhelmed with information and know subconsciously that these shortcuts have served them well in the past.

 

Thirdly, the principles we have discussed are not an alternative to providing people with substantive health information but more a vehicle for ensuring those important messages are communicated in an impactful and persuasive way that makes compliance most likely.

 

Our final point concerns influencing the influencers themselves. Clearly the healthcare professional needs support to utilise effectively the vast body of social psychological research on which this report is based. Appropriate education and training will provide those healthcare professionals with the ability to improve compliance and concordance rates with a robust and scientifically validated set of tools. The relative cost-effectiveness of training and education of this kind is a very attractive proposition when one considers the obvious improved health outcomes to the patient, the huge savings to be made to the Health Service and the increased profitability to the healthcare and pharmaceutical providers. 


 

 

THE PRINCIPLES OF SOCIAL INFLUENCE AND THEIR

APPLICATION IN IMPROVING PATIENT COMPLIANCE

 

(Table 2.0)

Principle

Definition

Application

Scarcity

People typically overvalue things that are rare, dwindling in availability or difficult to acquire

Highlight what could be lost or potentially lost if an individual fails to take appropriate health protective behaviour or act on the advice of the healthcare professional

 

Authority

People are more easily persuaded by individuals perceived to be legitimate authorities

Make visible the credentials of those who deliver health care advice including displaying certificates, diplomas and training

 

Social Proof

People often look to the behaviour of similar others for direction about what choices to make

Point out how other patients in similar circumstances have achieved favourable health outcomes by following the advised course of treatment or action

Liking

People prefer to say “yes” to those they like

Point out areas of similarity and give genuine compliments to patients. Demonstrate the healthcare professionals desire to work with the patient and co-operate with the advised course of treatment

Reciprocity

People feel obligated to repay, in kind, what has been given to them

Use concessions to engage the patient in behaviour changes that are recommended. Give attention, compliments, advice and information first. Use gifts and not rewards as a motivator of future compliance

Consistency

People feel strong pressure to be consistent within their own words and actions

Have people make active, public commitments to their health, preferably in writing.