Treatment Chronic-al : understanding patient behavior in chronic diseases

Iti Seth
Iti Seth
Apr 16, 2019 · 7 min read
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Illustration by Mudita Agarwal

In India, the ’80s were simpler. Economic growth was the mega solution that was supposed to address a wide breadth of social problems, from population to health to unemployment. 2019 seems a bit more complex. The economic growth happened but without the magic wand it was supposed to have come with. We are better off in a lot of development sectors like infrastructure, agriculture, education, employment and in some areas like health, the progress has been multifaceted with some facets being future-facing while some are not.

There have been commendable improvements in nutritional status, fertility and mortality rates and access to healthcare which have led to a shift in the disease profile of the country. Though communicable diseases still contribute significantly to the overall disease-load, there has been a steady (even accelerated) rise in the prevalence of chronic non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease, cancers, and mental health disorders.

The non-communicable diseases, NCDs, are commonly and quite aptly referred to as lifestyle diseases and their determinants are wide spread over other non health sectors like agriculture, urbanisation, education, industrialization, and culture at large.

Accentuated by increase in the aging population, physical inactivity and unhealthy eating patterns, the share of NCDs in total mortality has catapulted from 40% in 1990 to around 67% today. This poses a significant challenge to the healthcare system in India. The treatment cycles for NCDs are usually long drawn, multi-phased, often extensive, financially exhausting and are further complicated by low patient adherence.

The healthcare system and pharma services need to constantly adapt to address this complex network of cause and effect. Attempts are being made to dwell in the patient-space to understand their journey, address gaps and realign the role of various stakeholders to create a treatment experience that enables adoption. The approach needs to find the fine balance between empathizing with the patient’s belief systems and nudging them towards a behavior change that will lead to a resolution. Insights into this journey open up new ways of engagement for healthcare entities.

The prevalence of Doctor Shopping: moving through the circle of trust

Through regular exposure and experience, a community develops it’s own references of a normal behavior. The same is true for medical interventions. Our research helped reflect how communities or sections of people will harbour a notion of what is an effective treatment and will be biased to look for it to feel better. For most of rural and semi-urban India, drug delivery through injections and drips is perceived to be more effective than oral drugs and hence patients do not build a trust relationship with treatment cycles involving only oral drugs, irrespective of their actual efficacy. When in need of treatment, the patients would further try to find a medical practitioner (or even a quack) who is able to play along with their bias and administer the treatment that the patients think is effective. This leads to the phenomenon of Doctor Shopping.

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Illustration by Mudita Agarwal

When symptoms appear, patients try their own remedies. After the initial prognosis, the patients tend to move from a stage of trusting their self medication ability to trying out therapies suggested by trusted family members.

The next stage is consulting a professional who has been referred by either a family member or others in the known circle. This is usually a Registered Medical Practitioner (RMP) in case of rural and semi urban environs or a General Practitioner, GP, in urban locales.

When symptoms aggravate, the patients then move further out in this circle of trust to access specialised Doctors often one after the other because they do not have a trust relationship with the Doctor and therefore with the diagnosis. They are also looking for a Doctor to tell them what they want to hear regarding their illness and treatment v/s what the Doctor feels is correct.

This continual shift delays the adoption of a focused treatment cycle, aggravating the symptoms and advancing the disease. The loss of engagement between the patient and the treatment process also translates into a lost opportunity for the pharma and healthcare players involved. Any intervention to resolve this issue has to respect the circle of trust and leverage the bonds that the patient has developed.

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Illustration by Mudita Agarwal

One approach to address it, is by empowering the RMP to connect the patient to the right Doctor and guide the patient accordingly, creating more stickiness for the Doctor and prompting more patients to seek formal treatment and adhere to a treatment cycle.

The RMP can also evolve into being a confidant (to the patient) with an overview of the disease and act as an anchor (for Pharma companies) for long-drawn treatment cycles.

The inertia of the new normal

Autoimmune diseases like Rheumatoid Arthritis or type 1 Diabetes have a slow and prolonged progression phase spread over years, sometimes decades. The treatment cycles are also multi phased and time intensive.

After a certain advancement of the disease as the symptoms worsen, they start to restrict optimal lifestyle of the affected, curtailing their daily activities. The patients have an inherent need to feel normal so they tend to accept the present state of unwellness, adapting their mindset to treat is as the norm(al). They make behavior changes to live with these symptoms and consider this restricted lifestyle as normal. This is the inertia of the new-normal. The patient will not seek treatment till he/she is able to overcome this inertia.

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Illustration by Mudita Agarwal

It takes an assisted shift or trigger to bring the patient out of this inertia and adopt a new treatment cycle or revive an existing one. If left unmonitored, the patient is likely to slip into the inertia again. The shift to move out of the inertia could be triggered by someone in the innermost circle of trust. Another trigger could be an event that communicates the decline in health and the aggravated symptoms. The event could be a sudden health-scare or the alarming results of a monitoring test or a social activity that the patient is excluded from due to the aggravated symptoms.

To ensure that patients manage their disease and adhere to a treatment cycle it is important to identify the markers of inertia and initiate steps to help the patients overcome this self-resistance.

The interventions need to help reconfigure the understanding of what is normal to the patient.

Reconfiguring the new normal — an approach to services in chronic disease management and prevention

In chronic ailments and lifestyle diseases, this new understanding of what is normal can also pave the way for a shift in mindsets. The determinants of these diseases lie in multiple sectors ranging from food habits, work culture, social lifestyle, to environment etc. Therefore management and prevention of these diseases needs a behavioral change. A new definition of what is normal could enable the potential patient to become a Health Conscious Individual.

The preventive healthcare space in India is growing and is slated to be USD 100 billion by 2022 with over 130 million HCIs — Health Conscious Individuals actively taking preventive measures to ensure a healthy living. Unlike the treatment space for chronic diseases, where the trigger is eventual mortality; preventive healthcare is driven by nuanced factors of overall wellness. This space therefore needs a connected deck of services that go beyond the diagnostic services, to identify and address the Health Net Worth of this consumer group.

The opportunity is immense, the work extensive, the future promising.

Iti is a design strategist who loves to plug in her understanding of macro trends and business viability with gut instinct to find new opportunities for design to make a difference. Her exploration into the nuances of user behavior and experience has led to over 15 US patents and she continues her probe as the business & strategy Principal at Treemouse. She can go on talking about traditional foodgrains, wellness and the latest Seth Godin podcasts but you talk about a new perspective and she is all ears. Reach out to her here —

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