Letters to Healthcare Professionals
Effectiveness of personal letters to healthcare professionals in changing clinical practice behaviours
Letters to healthcare professionals
Aikaterini Grimani, Louis Goffe, Mei Yee Tang, Fiona Beyer, Falko Sniehotta, Ivo Vlaev
03/2020 – 04/2021
Project Outline / Summary
The aim of this research is to investigate whether personal letters sent from healthcare organisations are effective in altering the clinical behaviour (e.g., reduce rates of inappropriate antibiotic prescribing) of healthcare professionals. The study attempts to identify the strategies (Behaviour Change Techniques (BCTs)) within the letters that have the potential to optimise the effect on the behaviour of healthcare professionals.
Letters are regularly sent by healthcare organisations (e.g., Managed Care Organisations, Departments of Public Health, Chief Medical Officers) to healthcare professionals (e.g., primary care physicians) to encourage them to take action, change practice or implement guidance (e.g., adherence to guidelines, reduction in antibiotic prescribing, raise performance of mental health clinicians, reduction in sedative hypnotic medications prescribing). Letters are inexpensive, usually personalised and have wide reach. Common definitions define letters as “a written, typed, or printed communication, sent in an envelope by post or messenger”, “a written message from one person to another, usually put in an envelope and sent by post”, “a direct or personal written or printed message addressed to a person or organization”. In addition, emails are usually defined as “written messages distributed by electronic means via a network”.
Letters are promising in delivering behaviour change and that the utilisation of particular behaviour change techniques boost the effects. For example, Hallsworth (2017) found that a letter containing a social norm message sent to General Practitioners (GPs) to notify them that their practice is prescribing antibiotics at a higher rate than 80% of the practices in their local area reduced the prescribing rate compared to GPs who did not receive a letter. This study also revealed that a message from a high-profile sender (known as messenger effect) substantially reduced antibiotic prescribing. However, there has not been a comprehensive review to assess letters potential more broadly in the role of population health.
Design and methods
This study includes eighteen published (in scientific journals) and unpublished trials of letters interventions targeting healthcare professional clinical practice. These studies have been included after a comprehensive literature search in electronic databases. The overall aim of this systematic review is to evaluate the effectiveness of letters interventions. Our work seeks to identify what behaviour change techniques are particularly effective in altering healthcare professional behaviour and whether the effectiveness of letters vary by the characteristics of the sender(s), the receiver(s) and/ or the target behaviour; the mode of message (email vs. letter); additional content (e.g., added leaflet); additional communications (e.g. follow-up calls, tests, reminder letters); other characteristics (e.g. adding signature).
The results will be used to develop a guide to help staff of healthcare organizations optimize communications with healthcare professionals. Reaching people with a message is one thing, influencing and changing their behaviour is quite another. This guide will include a checklist that details step by step instructions on how to design, develop and test behaviourally informed communications. It will include, tips, techniques and examples of how the methods outlined have been used successfully around the globe in recent years. We will try to keep the guide as simple and accessible as possible. It should help to quickly learn about the theory, steps and techniques that can be applied to design more effective communications. Whether we want our recipients to start, stop or change a behaviour, following the checklist will help influencers to get the response they want. In particular, the review will inform the development of the multi-step checklist which will include sections such as Receiver, Action, Sender, Channel, Techniques. For example:
Receiver: Who is the target audience? This step includes also finding opportunities for segmenting the target audience – i.e. grouping healthcare professionals together by tendencies and characteristics so one can tailor the message to suit the characteristics of each different group.
Action: What is the desired response? This step involves clearly defining the behavioural response required by the recipient(s) of the communication.
Sender: Who is the sender of the letter? The receiver may respond differently depending on who is the messenger (e.g. central government, local authority, senior manager, regulator, clinical/professional body, nongovernmental organization, private company, etc.).
Channel: What is the best mode of letter delivery (e.g. post, email, sms, in person) to maximise engagement for the selected Recipient and Effect?
Techniques: Which behaviour change techniques can be used to design the communications for the selected Recipient, Effect, and Channel? Whilst techniques come in many different forms, we will list the ones that have proven to be particularly effective and useful when designing communications. For example, people are more likely to respond when they feel they are being addressed as individuals and not just a ‘number’. Also, does the letter grab and hold the reader’s attention? Is the language simple, clear and easy to understand? Is there a clear call to action (i.e. can the reader understand what is being asked of them and by when within the first few lines of the document)? Does it use the right tone of voice?
Project Recommendations and Outcomes
There is growing evidence that behavioural change techniques can positively influence decisions in a range of clinical situations. However, it remains unclear what behaviour change techniques have been most effective and how physicians experienced intervention letters (e.g. as helpful feedback or as a scare tactic). Ultimately, this kind of multicomponent intervention may have been the most effective approach considering that the low cost of the letter means that even a relatively small effect size could be cost-effective. These are important insights for policymakers, health insurers, and health systems as they jointly pursue efforts to design policy communications and improve the value of care.