University of the West of Scotland
As heath professionals, a large part of our time seems to be spent telling other people what they should be doing, often with good reason.
The evidence-based nature of healthcare means that training we go through as health professionals fills up eager clinicians with volumes and volumes of important information, just waiting to be transferred from their heads into those of patients. Eat healthy! Exercise often! Remember to take your medication! Come to the clinic! These are just some of the messages we try to impart to patients.
The most common sense answer to the question, “Why don’t people do what is good for them?” is simple – they don’t know the how to. If this is the case, the way to get people to behave in a healthy way is also simple – give them the information. If someone knows they should take medication each day, and how important it is to their own health, they’ll take it. Right?
However, a quick moment of introspection will swiftly show that a lack of information is not always the problem. Most the audience reading this will be aware of the health messages surrounding health eating. How many pieces of fruit and/or vegetables are you and I currently told we should be eating? Now, do you do it? How about exercise? Calorie intake? If know the answer to these questions, you are in the majority of health care professionals. If your answer to the question “do you do it?” for each of these is also an emphatic “yes”, then you are in the minority. Being aware of how we ‘should’ behave is not always the same thing as actually putting these ideas into action. This seems to hold both for behaviours we would wish to limit (over-eating, excessive alcohol use, smoking) and those we would wish to promote (healthy eating, exercise, and medication adherence). We can think about the use of technological innovations that aid our health in the same way that we think about these other behaviours. With the emergence of new text-based services like Flo, it is interesting to think about what factors, other than knowledge of it’s existence and effectiveness, will play a part in whether patients choose to use the system or not, and whether its use will be effective also.
There are many different factors that research has shown play a role in our decision making. One theory that encapsulates some of these factors is Ajzen’s Theory of Planned Behaviour (or, TPB). It says there are 3 things that effect our intention to perform a behaviour or otherwise. These three things are: Attitudes, Perceived Social Norm, and Perceived Control. We’ll take a look at how each of these three factors could (in theory at least) effect whether a patient uses Flo or not. Our attitude towards something is made up of various factors. What are the expected outcomes of the behaviour? For using a system like Flo, these might be things like, will the system consistently work, will I feel guilty for ignoring the texts, will I get negative feedback if I have gained weight, etc. Also included in attitudes is our evaluation of the expected outcomes of the behaviour. We may be pretty sure of what the outcomes will be, but we how we think these outcomes effect us is also part of our attitude. For example, we may not care about receiving negative feedback, and not see this as a bad thing, even though we may expect it as an outcome.
Perceived Social Norms refers to how ‘normal’ we believe any behaviour is amongst those who we think of as our peers, that is, our “normative beliefs”. In general, the more normal we think it is, the more likely we are to do it. One of the reasons that females in their 80s rarely drive in excess of 120 mph down a motorway in a Vauxhall Corsa with lowered suspension and alloy wheels is that this is not perceived as the ‘norm’ for those categorised as such. There’s very little social pressure to do so. However, those who define themselves in a certain way may feel peer-pressure to comply with the norm. This is true of both pro-social as well as anti-social behaviour. Seatbelt wearing is very much seen as the norm, and this plays a big part in whether you or I choose to buckle up each time we take to the road. Who the reference group are for any particular behaviour will alter what we think of as norm also. There is a correlation between some social groupings and unfamiliarity with technology, meaning that those belonging to these groups may be reluctant to use technology because it’s “not the done thing”, or because “people like me find these things difficult”. For example, take a patient who is a 67-year-old retired male who was a charter accountant, with a history of prostate cancer, and now a diagnosis of Type-II Diabetes. We may wish this patient to use Flo to monitor his own insulin, weight, etc. Typically, those over 60 find it harder to adapt to new technology than younger groups. However, “over 60” is not the only social category that this man falls into. He comes from a professional background and is highly educated – both factors that make him more likely to use technology.If we can shift his frame of reference from “over 60” to “highly educated professional” we may stand a better chance of him adopting the technology in the long-term.
As well as normative beliefs, another aspect of how the social norm impacts our behaviour is our own motivation to comply with the norm. There was a time when I was a student in the late 90s and early 00s when the vast majority of students were starting to become inseparable from their mobile phones – myself included (does anyone else remember fondly the game ‘snake’ on the Nokia 3210). I remember a few late adopters from that time who refused to take the plunge and purchase a mobile, not because of a fear of the technology, or a lack of funding, but because of something else. Often, these were individuals with low motivation to comply. Perhaps some of them saw mobile use as too mainstream, or as an imposed new norm from society that they didn’t want to comply with. For these individuals, the fact of something being the norm was actually a disincentive to adopt the new behaviour. In such cases, these are the factors that any clinician wishing a patient to use Flo would have to face.
The last aspect of Ajzen’s TPB model that can affect intention to perform any behaviour is “Perceived Behavioural Control”. Does an individual believe that they have control over whether or not they use Flo? Their attitude and perceived social norm may point in the direction of adopting the technology, but this will count for nothing if they believe they can’t do it – “I’d really like to use that but I can’t because…” These reasons (or control factors) are as numerous as there are clients. Perhaps the client feels they don’t have the technological know how. They may live in an area with very poor phone reception. They may be busy during the day, and feel they will not be able to respond to the requests of Flo in a timely manner. Perhaps they feel they lack the skills in taking the required measurements. In this situation, it is the job of the clinician to elevate the clients’ level of perceived power over the control factors.
Overall, we can see how knowledge of something (and why that something is good for us or not) is not the only piece of information we need to consider when thinking about why our patients do or do not choose to behave in the way we would like them to, as caring professionals. Even if an individual is aware of the benefits of using a system like Flo, the removal of other psychological barriers may be a useful way of making the use of the system more likely to stick.