All healthcare requires collaboration between providers and patients, but chronic disease management demands particularly high levels of patient engagement over an extended period of time. And that often means changes in lifestyle and routine to incorporate regular exercise, nutritious diet, medication, progress tracking, and check-ins with providers.
But our research into consumer purchase decisions indicates that even where people are highly motivated to make a change in their lives, they still face barriers to adoption of new solutions, whether a product, like a different brand of mattress, or a new behavior, like a novel approach to time management. In fact, people confront two types of forces when considering adoption of a new solution: those compelling adoption, and those opposing it.
The forces compelling adoption include the magnitude of the problem a person wants to solve, and the attractiveness of the new solution purporting to solve it. The forces opposing adoption include present habits, as well as anxieties about adopting new solutions, such as cost, learning requirements and disconcerting unfamiliarity. Opposing forces also include practical challenges associated with making a change, such as disposing of an old mattress after purchasing a new one.
In the case of health solutions like a chronic care regime, forces compelling adoption usually include concern about the life-limiting implications of a disease, and the promise of precluding them. Those opposing adoption may include factors like a habit of driving everywhere instead of walking even the shortest distances, a demanding work schedule that thwarts efforts to shop for and prepare healthy meals, and anxiety about medication side effects.
Addressing such barriers is well outside the scope of our traditional healthcare delivery system, which is rather designed to deliver clinical solutions for clinical problems. But providers recognizing the health and economic benefits of tackling them are exploring innovative means of doing so, such as those employed in a Cedars-Sinai Medical Center pilot program designed to help African-American men control their blood pressure.
According to the Centers for Disease Control, hypertension contributed to over 1,100 deaths per day in America in 2014. It is a known risk factor for heart disease and stroke, and the American Heart Association estimates that collectively these three conditions drive medical and indirect costs of $365 billion each year. Hypertension affects African American men at higher rates than other segments of the population, due to a range of factors including stress related to racism, poor understanding of hypertension, mistrust of the healthcare system, and lack of access to healthcare and medication.
In the Cedars-Sinai pilot, 52 barbershops across Los Angeles, representing 319 hypertensive patrons who chose to participate, were divided into test and “active control” groups. In test locations, barbers encouraged hypertensive patrons to meet with a specially-trained pharmacist, who visited the barbershop weekly to prescribe blood pressure medication (with involvement of patrons’ doctors), check patrons’ progress with the drug regime, and adjust it as needed to suit their personal circumstances. In control locations, barbers simply encouraged health behavior change and doctor check-ups.
The test intervention results, recently published in the New England Journal of Medicine, were remarkably positive. After six months, patrons who had received health promotion and encouragement from their barbers coupled with pharmacist-led drug therapy were more likely to have achieved and maintained a drop in blood pressure than those who had received health promotion and encouragement alone.
While it might be tempting to conclude that free medication was the primary success factor, closer analysis reveals how the pilot adeptly addressed a number of barriers patrons faced in accessing the medication, and incorporating the full care regime into their lives. The intervention took place at a location where patrons already had “business” to do on a weekly basis, so it didn’t require squeezing a trip to the doctor into existing routines. And, patrons received accurate information about hypertension, the risks it poses, and its treatment, so they could effectively weigh the pros and cons of treatment according to their own values and goals.
But as designers of the pilot suggested in a recent Kaiser Health News article, perhaps the most formidable potential barrier it addressed was mistrust of the healthcare system. How? By creating a respectful care process, and involving people and places the patrons already trusted. The intervention took place in a setting that was familiar and meaningful to the participating patrons. Information and encouragement came from the barber—someone they knew, and with whom they may already have been in the habit of discussing personal matters. And the pharmacists addressed patrons’ concerns about the motives of, and funding for, the pilot, while helping them deal with challenges in sticking with the medication.
Our healthcare system has a long way to go in helping people prevent and better manage chronic disease. But the barbershop pilot illustrates just how much can be achieved when providers fully understand the forces influencing people’s ability to effectively engage in healthcare and self-care, and create programs and processes that address them.
For more on innovation in chronic disease management, see: