Monday, March 12, 2012

"Benevolent" Social Engineering for Behavior Change!

The health care industry is heavily regulated and health care workers need to be aware of these rules and regulations that relate to personal and patient safety, security of data, etc.

The big question is whether the training leads to changes in behavior.  Of course, being aware of the information is necessary; no one would dispute that.  But education alone is in most cases a weak intervention for behavior change unless it is accompanied by something I call "benevolent social engineering".  The phrase social engineering has evil connotations and thus the modifier "benevolent".  

What do I mean by this?  Lets take the story of recycling.  
Say, someone crawls out from under a rock and sees a blue recycle bin somewhere.  He would have no clue what to do with it.  He would benefit from a brief training on importance of recycling and how to do it.  Suppose after the training, he decides he wants to recycle his can of soda   If the nearest recycle bin is 250 meters away, but there are 3 trash cans within 10 meters, he is  somewhat unlikely to recycle the can.  On the other hand if there were recycle bins within easier reach, a fewer trash cans, we could change behavior relatively easily.
What implications does this have for health care?  
The IDSA and ATS guidelines for community acquired pneumonia recommend either a fluoroquinolone or macrolide+beta lactam for inpatient cases.  For some hypothetical reason (like local susceptibility patterns), your institution guideline is to not use fluoroquinolone alone for community acquired pneumonia (CAP).  What if you notice that the residents in your hospital are using inappropriate antibiotics to treat patients admitted CAP.  You educate them about the guidelines, formulary, costs and susceptibility patterns and advise them to use azithromycin + ceftriaxone unless there are contraindications like allergies.  You study the effect of your intervention and notice no change in behavior.  You do a focus group of residents to see why they still use a fluoroquinolone alone.  It is possible that you may find that there is an order set in the electronic health record that makes it easier to order a fluoroquinolone rather than the preferred combination.  You change the order set and it is quite possible that you will see a big change in behavior.

Besides making things easier or more convenient, benevolent social engineering sends a message that something is more important.  Otherwise the hidden curriculum of the education intervention is, "We are just paying lip service to this.  Keep doing whatever you were doing."  Seeing the old order set for fluoroquinolone sends the same message as the multiple trash cans - "We don't think recycling is important".  When an institution backs up its educational efforts with the measures that make action easier, it tells the health care worker that it is a priority!  Its like putting your money where your mouth is!