[Quick disclaimer: I'm using "compliance" and "adherence" a bit interchangeably in this post. I know they're different, but I'm going to spare a big debate. Just go with it. Thanks.]

I’ve been involved in a few discussions lately about how pharma can  improve compliance to their medications. Of course, this isn’t the first time I’ve had these discussions and, likely, it won’t be the last. Part of my last job at AstraZeneca was managing our compliance program for their breast cancer products. If you’re in pharma, you know that this debate has been going on for years. Within the last five years or so, interest has really picked up in this area likely because someone really started crunching the numbers. As pharma sales growth has slowed, they’ve needed to look at different ways to sell more of their products. A seemingly obvious place to start is compliance. If you do some quick math, you figure out that if you can get people to stay on treatment, you can put hundreds of millions, if not billions, of dollars to the company bottom line. Seems simple enough…

Somewhere around a third to a half (or more) of patients don’t take their medications as prescribed. If you want to see a ton of stats about this covering a bunch of different diseases, check out the ultimate in compliance resources, AlignMap. Oh, and by the way, maybe you’re thinking that those patients who are non-compliant are those with less serious diseases. You’re wrong. From AlignMap citing multiple sources…

• Approximately half of the patients who chose to undergo the pain, risk, and emotional trauma of a kidney transplant do not adequately follow their medication regimen prescribed to prevent rejection, and 25% regularly miss doses of prescribed medications.
• In one study, 58% of patients with glaucoma who were told that failure to use their medication would result in blindness were noncompliant; 42% of patients who had already lost sight in one eye after they failed to comply with their medications persisted in their noncompliance.
• Another study estimated that half of those surveyed had missed doses in the two weeks prior to the survey, although they believed the medication to be effective and potentially life-saving.

That’s a problem.

It’s a problem we’ve tried to fix for a long, long time. And, we’ve tried a lot. Here’s a list of the most common compliance interventions out there (again, credit to AlignMap, take the hint and check it out):

• One on one counseling
• Educational videos, brochures, and tapes
• Court mandated and monitored treatment
• Promotions of self-reliance and self-efficacy
• Improved patient-clinician communications
• Directly observed therapy
• Mechanical or electronic reminders
• Adherence programs provided by a pharmaceutical manufacturer
• Automated or personal phone calls or email
• Disease management programs
• Celebrity endorsements
• Public Service Announcements
• Simplification or alteration of regimes
• Assistance to increase accessibility

So, how many of these have you tried at your company? How many have made a big impact? The reality is that very few interventions make a significant difference in compliance rates. We haven’t figured out the magic bullet. If we had, we wouldn’t still be having this conversation. For my part, I believe the reason we haven’t made an impact is because we test and use one intervention at a time. That is, you create a text message reminder program to improve compliance. But what if I don’t use text messages? What we need to offer is a wide choice of different compliance programs with each individual enrolled in the programs that are going to impact them. Of course, this might not be completely practical, as it would require you to create twenty (or more) different compliance programs (see the above list) so that each person had enough choice. That could get pricey. Sorry to say, but likely that’s what’s going to be the thing that significantly impacts compliance when the first company decides to take the plunge and create a comprehensive platform like this.

In the meantime, let’s look at something different. Let’s try something not on the list…something that hasn’t been done before. It’s called fun.

Perhaps you’ve heard of it (from Merriam-Webster).

FUN, Pronunciation: \ˈfən\, Function: noun

Etymology: English dial. fun to hoax, perhaps alteration of Middle English fonnen, from fonne dupe

1 : what provides amusement or enjoyment; specifically : playful often boisterous action or speech <full of fun>

Okay, glad I could remind you. Fun. You like fun, right? Not much from that list above appears to be fun. So, what does fun have to do with drug compliance?

Maybe everything.

Watch what fun can do…

Now, if the pharma industry (myself included perhaps) was asked to increase the number of people who chose the stairs, we’d probably do it a little differently. Likely, we’d put up some signs that show the benefits of exercise on cardiovascular disease (and you know we’d use the word “cardiovascular” a lot). We’d also probably tell you about the risk of not getting enough exercise. Maybe we’d even get a celebrity that we could put on the signs (or make cutouts)…I’m thinking one of those trainers from “The Biggest Loser” would be great. And, we’d probably put in some sort of flashing light to call attention to the people who decided not to take the stairs.

Ho hum. All of those things have one thing in common…they aren’t very fun.

I was recently at a great meeting (in Iceland) where I met people from many different industries. One of the people I spent a lot of time with was Toby Barnes who is Managing Director for a company called Mudlark. This company does a lot, but in the end, they’re a company that makes games. Toby has incredible passion about gaming, but he’s not the guy who sits in front of the XBOX all day. He simply believes in the power of games to change behavior. Toby really just wants to create fun. One of the many things he told me that stuck with me was really simple. I’m going to paraphrase, but the gist was this: humans learn by playing. From the moment we’re born, through our most important developmental years, we learn by playing. The roles we play in life, how things work, what’s good and bad behavior, and how to communicate with others…all from playing. Somewhere along the way though, we stop playing and stop learning.

So, what is playing? Well, first, playing is supposed to be fun. Without that, the rest doesn’t matter much since no one will play with something that isn’t fun.

Let’s go back to the Volkswagon video. They created something fun, something people played with. People saw that taking the stairs could not only be fun, but also that it wouldn’t kill them to do so from time to time. We all know that we should take the stairs more often. It’s a simple way to improve our health that’s available to almost everyone no matter where they are. But, just like our medications, we don’t do what we’re supposed to do. By simply changing the way we encourage people to change their behavior, we can create something different, something that might just work.

Digital technology makes it really simple to create fun and engaging games–games that can teach us to change our behavior while we’re doing something we enjoy. When I mentioned earlier that I had an idea that wasn’t on the list above and hadn’t been tried before, I wasn’t being totally honest. You see, someone has taken this approach in healthcare…and it worked. I actually wrote about this a long time ago in a post called Gaming To Save Healthcare Marketing.

The greatest example of fun leading to a behavior change in healthcare is Re-Mission. This game was created to help kids fighting various cancers. It’s essentially a first-person shooter-type game, but you’re battling the disease.

Well, isn’t that nice. They created a game for kids fighting cancer to help them pass the time during treatment. Right? No. This game was designed to improve outcomes. In fact, the company behind this game, Hope Lab, conducted a randomized trial to test the game’s effectiveness. Half played Re-Mission and half another video game. The results were published in the journal Pediatrics. Here are some high points:

• “Self-efficacy and knowledge were significantly improved in the intervention group compared with the control group.”
• “Adherence to at-home medication (trimethoprim-sulfamethoxazole and 6 mercaptopuring) was significantly improved in the intervention group compared with the control group.”

Yes, you read that right: “Adherence to at-home medication was significantly improved.” How did Re-Mission manage to do this? The game is fun and, if we follow Toby’s logic, we learn by playing. That’s just what happened here. These kids learned about their disease and its treatment by playing. Not only that, they learned by playing something they enjoyed.

Perhaps this is the real key to improving compliance. It’s not about creating fear-laced predictions. Not about creating nagging reminders. Not about creating tedious tracking tools. And not about spying on people. These are the things we do in most of our compliance programs today. They aren’t working like we need them to, so isn’t it time to find something different?

PS: There are a couple more experiments beyond the stairs that Volkswagon tried. All with the idea of fun, check out what else they managed to do: