How might we help people with cardiovascular disease adhere to their treatment after a cardiovascular incident?
IED BARCELONA team, 2020 - Proposal

 

THE 'WHY'

There is a lot of data indicating the rising prevalence of cardiovascular diseases across Europe. In Spain, which is our current location for this project, a study from 2015 stated that CVD-related deaths outperform cancer and respiratory diseases (1). More specifically, there are an estimated 924,000 patients in a situation of secondary prevention after a cardiovascular event, where secondary prevention refers to helping the patient manage the disease after an incident.

Also, while the healthcare costs in Spain had been around 6 billion euros (2) due to premature death, nowadays the mortality rate from cardiovascular diseases is decreasing in most EU countries. Thus more people live with disability and chronicity caused by CVDs, leading to more costs upon the healthcare system.

 

One of the challenges that weights heavy consequences on both the patient and the healthcare system, resulted from our desk research and expert interviews, was adherence to treatment for patients. It seems that “In Spain, the health care and economic cost of failing to adhere was shown in a recent study that indicated that, by adding just one percentage point to the completion of therapy for the secondary prevention of cardiovascular diseases, would involve an avoidable cost of 10,900,627 euros to public health care. Furthermore, an increase of 10 percentage points in improving adherence would prevent 8,700 deaths and 7,650 episodes caused by CVD, with an avoidable cost of 75 million euros to the health care system.” [emphasis added] (3)

 

Furthermore, a health expert from Barcelona’s eHealthCenter confirmed that adherence to treatment is an important and difficult challenge faced by the healthcare system. He indicated that many people received information about how to manage their health, but very few are capable (know how) to act upon this information. Defying adherence more clearly, according to the World Health Organization, it is described as the extent to which a person's behavior—taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider(4).

 

From the literature, we know that adherence involves a complex behavioral process that requires: “the active, voluntary, and collaborative involvement of the patient in a course of behavior to produce a therapeutic result.” Also, poor adherence to a treatment seems to be a significant barrier in the secondary prevention of cardiovascular disease (CVD) and, as a result, in being able to reach certain levels of health care excellence (5). The reasons for abandoning the treatment could be the patient’s lack of perception of his or her vulnerability, the patient’s lack of information on the treatment and the lack of precise instructions from health care professionals. (6)

 

EXPLORING THE LOCAL CONTEXT - SPAIN

Around the topic of cardiovascular health, in Spain, and Barcelona in particular, we have found several actors that are active in this area, ranging from hospitals to patient associations, professional cooking workshops for cardiovascular patients, social media groups, academic research institutes, health apps (example 1, example 2), and even local initiatives.

Also, a recent survey (7) across the country discovers that :

• the health care professionals (especially doctors) are the main source of information for the patients, followed by internet searches, patient association, health institutions, and other people with cardiovascular conditions;

• people find it hard to respect a diet for cardiovascular disease (37% always, 37% sometimes, 26% never);

• many people (61%) look for information related symptoms and consequences of disease, followed by lifestyle information (54%), other treatments available, (36%), techniques to quit smoking (%).

This type of study gives us an overview on how people with CVD behave, and although we don’t have a clear picture of their personal motives, circumstances of why they behave as such, we can assume that the reasons for non-adherence are related to not knowing how to bridge the intention-action gap (8), meaning how to act upon the information they receive from the doctors.

Also the presence of different actors in the Spanish context shows great initiatives, and the data from above indicates growing initiatives in Spain and Barcelona in particular for CVD. However, the actors and their activities are fragmented, there is a lack of clear information and instructions form the medical side to the patient but also vice-versa, meaning a passive role from the patient in his health care, indicated the eHealthCenter expert on behavioral health.

 

WHO ARE WE DESIGNING FOR?

The common group of people who suffers an cardiovascular incident in Spain is: men, around 66 years old, with primary studies, retired, living with a partner (7).

Influenced by this piece of data, our target group is related to people:

• who have recently or in the last 2 years suffered a cardio-vascular incident (being heart attack, stroke)
• probably retired
• with primary and secondary studies
• who do not have the resources to support themselves or are not even aware of possible methods to improve their lifestyle after a cardiovascular incident.

 

 

HOW WE INTEND TO SOLVE THE CHALLENGE?

For a long time, healthcare professionals have focused on information-giving interventions, hoping that their patients might change and respect their treatment, including changing their lifestyles. However, looking at recents developments in behavioral sciences (the why)(8), structured frameworks to help people change their behavior are starting to appear (see 9). Solutions in behavioral sciences (especially behavior design, see 9,10, 11) demonstrate the effectiveness of interventions using behavioral science insights in healthcare.

Example:

In Barcelona, behavioral change is starting to appear at a very theoretical level in centers like the eHealthCenter. One way we could approach this challenge is to use techniques from behavioral science in order to design an intervention for people who just had a cardiovascular incident, aimed at the patient (after understanding more his context, support system, habits and behaviors), with an impact on the surrounding family. We are striving to use evidence-based techniques that help people make lifestyles changes, that are not based on the idea of motivating people or just giving them information. We know, from psychological studies, that this does not work. These techniques could imply different ways of solving the problem of non-adherence. For example, in Spain there is a big culture of people buying tickets for lottery. As we have seen in the study above by Volpp et al. (2008), these kind of interventions can significantly improve adherence. We can connect with institutions like the eHealthCenter, banks, design firms who can help us design for adherence, in a scientific, human and empowering way.