Why are behavioural and implementation sciences gaining traction now in health?

Healthcare is wasting an awful lot of money delivering less-than-optimal care. We know that half of patients do not receive recommended care and that 30% of medical spending is on unnecessary interventions. No healthcare system, no matter how well funded, should be on this path.

The problem isn’t lack of knowledge. We’re drowning in research, guidelines and meta-analyses that show us what actually works. The trouble is we take forever to translate research into routine care delivery, a problem we call the ‘implementation gap’. In healthcare, some people have estimated the length of the gap to be around 17 years. We need to be faster and we need to be consistent.

Implementation science draws on the disciplines of medicine and social and behavioural sciences to try and close the implementation gap. Instead of compiling clinical effectiveness data, giving it to clinicians and saying “Use this, good luck”, we test the impact of different levels of implementation support, such as regular coaching from a clinician champion. It’s critical because when recommended care is used consistently, patient outcomes will be better.

 

How can behavioural and implementation sciences close the implementation gap?

Implementation science studies methods to promote the uptake of research into routine healthcare whether in clinical, organisational or policy settings. We try to describe – qualitatively and quantitatively – how implementation works, when it works and for whom. We use what we know about human behaviour and the local context to nudge, influence and shift individuals, healthcare providers and healthcare systems towards the adoption of evidenced practices.

People often ask for the two or three best things they can do to impact behaviour. The answer is, let me understand what you’re trying to do. I may not have anything off the shelf to recommend; but our options are multiplying. One priority as the implementation science field matures is to develop a better and more accurate library of the effectiveness of different implementation strategies. For instance, we know that auditing performance and providing feedback tends to produce behaviour change in clinicians. Today, we spend a lot of time researching implementation because we don't have a good understanding of how a particular strategy might work in a certain context. A larger and more mature library will enable us to pick and choose strategies better depending on the circumstances of an intervention.

 

What are the common barriers as to why recommended care isn’t put into practice?

You need three ingredients to shift habits: people need to be capable, they need to be motivated, and they need opportunity to enact a behaviour. Behaviour won’t change when one of these is missing.

Take the Surgical Safety Checklist developed by the World Health Organization in 2008 to reduce complications and mortality from surgery. It’s a 19-item checklist – what could be simpler than a piece of paper? It was designed by clinicians so you’d think it would be widely used. But large implementation studies across countries and regions found people were not complying. Why? In interviews, clinicians said, “The checklist just appeared. There was no discussion about it,” or “Our chief executive said ‘You will do this’”.  So it’s not only about the simplicity or complexity of an intervention, it’s also about the implementation journey. Studies and clinical trials I’ve been involved in have uncovered evidence as to why the checklist wasn’t more widely used, and we’ve provided advice to boost its uptake.

One of the keynotes at our inaugural EIS 2023 Singapore Symposium was so refreshing because it was all about why programmes fail. If something doesn't work on a programmatic level, it's really helpful because it’s an opportunity to learn how to do things differently and also what not to do and why.

  

What are BISI’s goals in Singapore?

We have four focus areas: research, capacity-building, network-building and supporting real-world implementation in Singapore.

As a research centre, we want to produce excellent research. We’re interested in studying adaptation processes, what works in Southeast Asia, and novel methodologies for implementation-effectiveness trials. On the capacity side, BISI offers an array of continued education training for healthcare professionals, to enhance their skills; our Masters programme in behavioural and implementation sciences in health and PhD programme will both be available in 2024. We also want to build a network of clinicians, service providers and academics so that skills and talent combine to tackle some of the major population health challenges and healthcare delivery issues in Singapore and the region.

Finally, we will support on-the-ground implementation of public health and clinical programmes across Singapore – not least by using approaches that include all stakeholders from clinicians to managers and patients. One important stakeholder is the “seldom heard” – the people whose voices never make it to the table, such as minorities, people with low digital literacy, or those from lower income backgrounds. We need to prioritize these communities so that interventions reach everybody, not only a small, well-informed minority. This is one of the big challenges in the coming years.

 

What has been your own research journey?

I’m a psychologist by training. After spending ten years designing and evaluating healthcare interventions, I shifted my attention to why on earth we have so many interventions that seem to work in a research environment and yet daily life for most of my clinical colleagues and their patients remained pretty much the same. Since then, I’ve spent a lot of time studying perioperative care, care in long-term conditions such as cancer and diabetes and, more recently, the interface of mental and physical health.

When people think of behaviour change, they often cite the book Nudge, by Richard Thaler and Cass Sunstein. The book has been important in bringing the field to popular attention and showing there is a whole science behind behaviour change. Nudge is just a tiny part of the theory but it’s a way to start a conversation. That’s important because it’s our duty, when we engage with people who are not scientists, to explain what we do and how we do it in a way that's relevant to them. Part of translating evidence into practice is being able to speak different “languages” to different audiences.