Do behaviour-change techniques actually work in healthcare?

Have you ever wondered how behaviour-change techniques work? Monash healthcare quality researcher Associate Professor Peter Bragge has worked on changing behaviour of patients – and GPs – for years.  

But any effort to change behaviour to improve quality has to begin with analysing your own assumptions, BehaviourWorks’ Associate Professor Bragge told newsGP.
 
‘If you just go in and tell GPs this is what they need to do, it’s very unlikely to work,’ he said. ‘The thing that most frustrates healthcare professionals is being told something they already know.
 
‘Often the reason healthcare quality improvement doesn’t work is we haven’t analysed our assumptions about why things are the way they are.’
 
Associate Professor Bragge gave the example of efforts to reduce high rates of lumbar spine X-rays for routine back pain.
 
‘When researchers sat and spoke to GPs about why they order X-rays [for this issue], they found the problem they had was they were unable to negotiate with patients who expected an X-ray,’ he said.
 
‘The assumption was there was a knowledge gap.
 
‘But here GPs were saying it was easier to get them an X-ray because they had a full waiting room.’
 
This, Associate Professor Bragge said, helps explain why earlier efforts to reduce X-rays for back pain had failed.
 
‘What actually worked was training for GPs with actors simulating patients and practising the skill of negotiating [with patients], saying X-rays only show bones, not soft tissue, there’s no need for this, and you’re exposed to radiation,’ he said.
 
‘GPs are frank – they’ll say they know the guidelines but just don’t have time, or there’s a skill I need to do the right thing.’
 
Associate Professor Bragge said there are three key things to think about for GPs interested in continuous quality improvement.
 
‘First, what’s the standard we’re talking about? Most quality improvement starts with a standard – what we need to do under these circumstances.
 
‘Second, what’s happening in practice? Are we adhering to the standard?
 
‘Third, why are people doing things the way they’re doing them? And who needs to do what differently?
 
‘Say you find you’re not seeing your chronic diabetes patients more than once a year – why might that be the case? You could build this into a practice meeting and ask if there were systems to identify people with diabetes and send them a reminder for a check-up.’ 
 
Another challenge for healthcare quality improvement is an ever-growing body of medical literature.
 
‘In healthcare, there’s almost always a gap between recommended practise and actual practise,’ Associate Professor Bragge. ‘But with the sheer volume of evidence coming out – more than 2000 studies a day – it’s not surprising healthcare professionals find it hard to keep up.’
 
To counter the deluge of studies, Associate Professor Bragge recommended the systematic reviews published by Health Systems Evidence and by the Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) group.
 
He said patients represent a ‘huge untapped resource’ in behaviour change, with examples of effective multifactor interventions, such as reminder letters being sent to both GPs and patients after an emergency department presentation for a wrist fracture.
 
Personalised text messages could also be effective, with the Southeast Melbourne PHN’s innovative use of a text system encouraging patient self-care.
 
‘Patients are a key behaviour-change target, and a much larger population than healthcare practitioners,’ Associate Professor Bragge said. 
 
Associate Professor Bragge said behaviour-change techniques could be effectively applied to patients to reduce antibiotic overuse and increase vaccine uptake.
 
His unit, BehaviourWorks, was recently funded to successfully trial techniques to boost the human papillomavirus (HPV) vaccination rate in Victoria using techniques such as sending SMS reminders to parents of teenagers who had consented to receiving the vaccine or sending letters to school comparing their rates of consent card returns to other schools.

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