Primary healthcare is so important to deliver on the promise of the informed health consumer.

If the goal of primary care is to address healthcare issues as early as possible, perhaps even before they originate, then inducing health seeking behaviour in consumers must be a critical target for intervention. Imagine a world in which 7 billion people are trained, informed, empowered and given the tools to lead a healthy lifestyle. Giving them the resources to identify and seek early intervention could dramatically alter the healthcare delivery experience in our future. The proactive, informed, health conscious citizen is more likely to identify disease and seek early intervention for it.


Healthcare workers, doctors of different specialties and nurses, themselves have different levels of expertise and understanding of medical science. Naturally, demystifying medical science to reasonably inform consumers that have disparate levels of understanding is a huge and uphill task. However, nudging consumers with behaviour change information will form a critical piece of the puzzle to address healthcare issues in the future. Primary care workers,  tied as they will be into communities, will have the opportunity and responsibility to influence healthier community habits. This article looks at several approaches that indicate how the future of primary healthcare is inextricably linked to consumer focused preventive health and demand generation efforts.

Patient education to ensure healthier lifestyles has been around a long time. A chinese physician around 2000 B.C. advocated “cereals for energy, fruits for accessory, animals for benefit, vegetables for supplement.” In the 1800s in the US, doctors and nurses were educating patient families on how to prevent disease, including sanitary precautions.  A 1971 publication, “The need for Patient Education” wrote about the need for specific, individualized patient education. Patient education as a right and expectation of quality healthcare was specified in the 1976 edition of the Joint Commission on Accreditation of Hospitals. One of India’s leading socials reformers, Raghunath Karve was a leading proponent of family planning and birth control for the masses as far back as in 1921. Most of these initiatives were attempts from forward thinking healthcare leaders to educate the masses. However, attempts by doctors and health providers to educate patients on healthy lifestyles has always been a challenge. Plato noted the difficulty and frustration encountered by physicians when they tried to influence what people do in their daily lives as a means of favorably influencing health. My GP, after years of evangelizing healthy lifestyles has taken the pragmatic view that he has limited influence over information sources of his patients.

People consume health information from multiple sources today, accelerated by the exploding consumption of healthcare information of the internet. Suddenly, anyone could be citing “scientific research linking tea to piles” (or whatever) and they’d be competing for the health consumer’s mindshare with thousands of other self-proclaimed wellness thinkers. The cacophony has amplified the volume of health information, but made it increasingly difficult for credible information to get through to consumers. Not only does this defeat the purpose of patient education, but also threatens to worsen the lot of health consumers by nudging them towards wrong behaviours. There is an urgent need to partner with health consumers, so they have access to reliable and actionable information that activates the desired behaviour change.

Other industries offer interesting templates to co-opt the consumer in the service journey. Airlines have started allowing travelers to book their seats, print their boarding cards, choose their seats and meals. The installation of ATMs and digital banking have transformed the experience for the average banking customer. I have never ever stepped into my bank in Mumbai over the last 17 years. These changes required the industry to place the consumer at the center of the experience. The business drivers varied, in some cases it was operational efficiency and cost reduction, in others it was a response to new emerging technologies. Regardless of the driver, consumers have pushed their providers to innovate, faster and frequently. While there are many differences between healthcare and other industries, engaging and influencing consumer demand early in their journey is an important lesson to be learnt.

In engaging patients to generate demand, three buckets of consumer-focused activities come to mind. One approach penalizes unhealthy behaviours, the second one incentivizes healthier lifestyles and the third one creates incentives for early diagnosis, prevention and intervention.

The curbs on cigarette smoking in countries around the world is a clear example of consumer focused efforts to penalize unhealthy behaviors. A combination of regulations, high taxes (and high consumer prices) and sustained patient education has led to a dramatic fall in cigarette smoking over the last 50 years. In the US, current per capita consumption levels are close to those a hundred years back. India too, despite being a high growth market, has seen a 10% drop in prevalence of smoking between 1980-2012.

 

 

Other recent examples of penalties for unhealthy behaviors include smoke-free laws for worksites, restaurants and bars in the US, India and other countries, that have undoubtedly aided efforts to curb smoking. The disincentives for smoking as a behaviour over the last 50 years have been so strong as to threaten the existence of the tobacco industry. In a crackdown on rising obesity, France earlier this year made it illegal for restaurants to offer unlimited sugary drinks, 5 years after slapping a tax on these drinks. The government of Maharashtra (of which Mumbai is the capital city) earlier this year banned the sale of chips and soft drinks in school canteens. No surprise that many of these industries are now pursuing growth through alternative businesses.  Sodas, chips and cigarettes are examples of consumer behavior with well-established deleterious effects on health of the individual and the community. Actively penalizing consumers from their use has successfully helped move millions away from the adverse health consequences of these behaviours.

A second set of consumer education approaches have incentivized healthier lifestyles. Many corporate offices now have fitness centres with very active employee wellness programs that encourage healthy lifestyles. Many business leaders are often seen promoting fitness behaviors, providing not so subtle nudges for employees to make time to hit the gym. A big part of the digital health industry over the last few years has been focused on fitness. The over 100 million smartwatches and fitness trackers sold in 2016 and the 32% increase in marathon events in the US since 1980 are a pointer to more conversation around fitness. More restaurants are now displaying calorie counts against listed food items hoping patrons will make healthier choices. In 2015, the Cleveland Clinic shut down a Mcdonald’s branch in its cafeteria to promote a culture of wellness. Many urban planners, especially in Europe, are incorporating walking and cycling options to promote healthier commutes. These examples illustrate the use of positive messaging to nudge consumers towards making healthier choices. It’s too early to tell if these efforts have been successful. In the long run though, promoting a culture of healthier choices will be integral to helping consumers make the right decisions for their health. As Steve Downs writes in this great series, using technology to make help consumer make healthier choices will be integral to our health in the future.

A third set of efforts focus on early diagnosis, prevention and intervention for disease. The extensive use of mammograms and the prostate specific antigen testing for screening breast and prostate cancers over the last few decades are examples of large-scale consumer education for prevention and early diagnosis of diseases with significant healthcare and financial toll. The Indian government recently announced a mandatory screening program for oral, breast and cervical cancer in 100 districts, before expanding to other districts. Several large-scale programs (Aponjon, MomConnect, mMitra and Kilkari) reach pregnant women and new mothers with vital health information with the objective of generating and driving demand towards specific health services. Omada Health, a San Francisco based digital health company has made a business model out of managing and preventing diabetes in high-risk populations. CareMore, a California based provider for seniors has demonstrated a significant reduction on costs and improvement in health outcomes with interventions crucial for managing chronic conditions.  The data on effectiveness of many of these interventions is yet inconclusive. While there is no question many lives have been saved by early screening and behavioural prevention, the cost-effectiveness of many of these programs over the long term needs more evidence. This does not detract from their need, it simply bolsters the case to generate high quality efficacy and cost-effectiveness data to refine the interventions, if needed.

The role of our neighbourhood primary healthcare physicians in influencing consumer behaviour and demand has been largely reactive as it is quite likely that they don’t see themselves as a primary driver of consumer demands. That must change! Primary care doctors have the roots and the credibility in the community to help cut through the cacophony of health information. They offer resources to navigate the conversation on healthier lifestyles in the community . To do so effectively, they must be better educated and given the tools to drive behaviour change and early diagnostic conversations with communities. Activating demand is most likely to increase pressure on their practices so giving them the resources to deal with the demand is critical. These additional resources can be healthcare coaches trained in patient communication. Most importantly, primary care physicians today make money when they see patients, driving demand may increase their costs while not providing an increase in revenue for their practices. We must experiment with alternative business models that incentivize these physicians with demand activation approaches. We’ll know we are on the right track when primary care workers are incentivized not as much to treat patients, but to improve community health by driving demand generation and wellness focused approaches.

While the evidence on effectiveness of demand activation remains limited thus far, there cannot be any question about its importance. The burgeoning health information industry (mostly unregulated) and the health fitness industry (almost entirely unregulated) have irretrievably placed the health conversation in the hands of the consumers. That is a shift to be celebrated! People are making healthcare choices today based on what they read and hear, choices that will influence the health and wellness of their communities in the years to come. The only way to ensure health consumers are constructively playing a role in their health experience is to provide them with credible behaviour change information.

Primary healthcare workers are best positioned to deliver on the promise of the informed, engaged health consumer.

 

Dr Aakash Ganju is a healthcare consultant and entrepreneur, focused on increasing transparency, access, and convenience to health providers and consumers. He is the Co-founder of Avegen and lives in Mumbai, India.

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