Guest Column | May 14, 2025

Going With The Group: Improve Recruitment With Social Psychology And Behavioral Science, Part 2

By Tatty Scott, patient engagement and recruitment professional

Seamless repetative brain pattern-GettyImages-1265660414

In part one of this two-part series, we looked at targeting System 1 of a patient’s dual process model, modulating environments to make patients more likely to join or remain on a clinical trial.1

In this second part, we’ll explore what social psychology tells us about the magnetic pull of groups on individuals’ behavior and how outreach group engagement activities can maximize behavior change to improve recruitment. Together, we’ll then take an imaginative leap from concerted group engagement toward the establishment of trial-literate cities. (Trial-literate cities also include towns, villages, and hamlets. I chose cities to distinguish between the trial-literate communities already being created by community based participatory research (CBPR) work.)

The Vacant Lot

What happens before a clinical trial begins? I mean out there, in the real world. How are we preparing our customer base for our innovation?

And what is happening between one trial phase ending and the next beginning — when we suddenly go full steam ahead as if recruitment was an 11th-hour surprise? I call this chasm before and between trials the vacant lot; there’s just… air.

What if we developed this vacant lot into something useful? What if we built structures to normalize trial participation among the general public or patient populations? That way, when a trial starts, when they get the invite, they don’t find the concept of participation novel or scary because they are primed and informed.

You may say I’m a dreamer, but I am not the only one. And also, I’ve seen the green shoots. So come with me on this group tour — or this tour of groups, in fact — with science as our guide.

“To Make Change, Start With A Crowd”

The power of a group to change individual behavior is highlighted in a Stanford SPARQ article, “To Make Change, Start with a Crowd”. 2

In the 1940s, during World War II, the U.S. was sending its best cuts of meat to its armed forces. The government wanted people to switch to eating offal, or organ meats, but it was unpopular and seen as something for the poor.

So, Cornell University social psychologist Kurt Lewin researched how to change people’s eating habits. As women generally did the food shopping, he recruited 85 women and assigned them to either a lecture environment or a group environment.3,4 At the lectures, women learned from a nutritionist how to include offal in their family’s diet. In the group environment, women received similar information from a nutritionist, but they also actively discussed with one another how to change eating habits and manage family meals during wartime.

In the week following the sessions, 52% of women from the groups had served offal compared to just 10% of those in the lectures.

Lewin worked on numerous dietary change studies and concluded that it was easier to change people’s behaviors when they were in a group than changing their behaviors as individuals. In the meat example, an individual is more likely to eat offal if they’ve attended a group that has placed a strong, positive value, or valence, on it because, collectively, members of the group have concluded that “Offal is for people like us.”

Changes Already Made To Clinical Trial Perceptions, By Starting With A Crowd

Leap forward 70 years and across town, CBPR is successfully addressing issues of trust and lack of awareness of clinical research in culturally diverse communities.5,6,7,8 Mirroring Lewin’s dietary studies, CBPR’s winning formula is the active participation and discussion in a group, led by an informed and trusted facilitator, to identify issues, goals, and behaviors relating to health and research.

An exceptional CBPR example is the Research Ambassador Program (RAP).9 Held in southern California between 2017 and 2020, the RAP comprised 65 interactive educational workshops delivered by trained Latina community Promotoras de Salud. They were initially held for Latino participants, but they were then modified to include Black participants. The workshops lasted 90 minutes, and discussions ranged from clinical research and types of studies to misconceptions.

Of the 819 participants, 49% enrolled in a clinical trial research registry. The RAP enabled attendees to understand why they had placed a negative value on clinical trials and then helped them problem-solve their own resistance.

Diving back into System 1 of our dual process model for a moment, in part one, you may recall the foot-in-the-door effect. This advertising tactic encourages customers to sign up for a mailing list, and in doing so, they’re then more likely to commit to a future purchase.10 This works because signing up for something small triggers our System 1 urge to act consistently. The RAP’s clinical trial registry will work in the same way; those on the registry are now more likely to consider a clinical trial in the future.

Turning Mountains Into Molehills

Lewin’s research and the RAP show us that, in a group setting, social norms (the unwritten standards of behavior considered “normal”) can be revisited, and our social narratives, the explanations of those norms, can be rewritten.

It’s important to note that we are strongly and unconsciously influenced by the behavior of others around us. Social norms and adhering to them help form our identity and help us navigate society. For good or ill, the expectations of social norms can have profound effects on our behavior.

In the film 12 Angry Men, Henry Fonda’s character manages to change the minds of his fellow jurors. It is slow work, and it is hard tackling their prejudices and norms, but one by one, they change their minds. It is the facility of group discussion in the jury room that makes change possible; without it, the defendant would have been convicted. 

Let’s think about a patient hearing devastating news in their doctor’s office today. Imagine they’re offered standard of care or the option of a clinical trial. What will they say?

Well, what are their norms? Chances are, they don’t know very much about clinical trials. Maybe their System 1 perceives clinical research as a lab-based wild west. Perhaps their social norms tell them that because they don’t know anyone who’s taken part in a trial, participation isn’t for people like them.

There’s a mountain in front of them. In addition, what are the chances that the doctor has time to unpack, understand, and challenge those norms?

But what if the patient had previously attended a group where they talked about clinical trials? Maybe the group shared similar misconceptions, which were then challenged and unpacked. Perhaps, like the RAP, they’d been one of the group members signing a registry, concluding that actually, “Clinical trials are for people like us.” In this instance, the mountain has become a molehill.

Developing The Vacant Lot

Where my starting point in part one was behavioral science and the individual, my focus in this article has been behavioral science and groups. We’ve seen from the examples of Lewin and the RAP that social norms can be revisited and social narratives rewritten, thanks to facilitated groups. The recent success of the RAP, with 49% of participants signing the clinical research registry, demonstrates what can be achieved.

As an industry, our customer base is technically 8.2 billion, i.e., the world’s population. And 49% of that is a lot. So why aren’t we developing the vacant lot into something to engage this enormous customer base, to get our foot-in-the-door?

We know clinical trials are getting longer and more complex,11,12 and it’s becoming imperative that we change our own norms and behaviors and rethink how we manage patient recruitment.

Group engagement works, and coordinating outreach across communities works. They reliably change people’s behavior. Imagine what might happen if we mapped existing groups across a town or city and conducted facilitated clinical trial discussions. Imagine if we organized ad-hoc groups across the same areas, delivering the same sessions.

If we can put a man on the moon and land a probe on a comet, I have complete confidence that we can coordinate and deliver the kind of outreach required to create trial-literate cities.

The biggest question is who pays for it — pharma and sponsors, health services, or public services? Each benefits, so why not a collective approach? Now there’s a group discussion I want to be a part of.

Who Was Kurt Lewin?

Full disclosure: I love Lewin. While this may, in part, relate to daddy issues I stubbornly refuse to address, it is much more attributable to his humanity and smarts.

Lewin had been a professor of psychology at the University of Berlin, working on the periphery of the Gestalt movement, before he fled Nazi Germany for the U.S. as a Jewish émigré in 1933. His first post was at Cornell University before he moved to Iowa University and then MIT, where he established the Research Center for Group Dynamics.

In spite of losing family in the concentration camps, Lewin was a champion for equality and raising the esteem of minority groups. In Action Research and Minority Problems (1946)13, he quotes the prayer from the musical Oklahoma: “Dear God, make me see that I am not better than my fellow men… but that I am every darn bit as good as he.” After he died in 1947 at just 56 years old, he was remembered as “a humanitarian who believed that only by resolving social conflict, whether it be religious, racial, marital or industrial, could the human condition be improved.”14

Lewin’s achievements during his short life were prodigious. He created field theory, invented sensitivity training (described by Carl Rogers as the “most significant social invention” of the 20th century15), and coined the terms “group dynamics” and “action research.” 16 He was seen in the same league as Freud17 and is considered by some academics as the father of social psychology18,19, the father of planned change,20,21 and the founding father of change management.22

And What Was Kurt Lewin’s Field Theory & Group Dynamics?

We can trace a line from Lewin’s early work on field theory right through to the current practice of CBPR.

Lewin argued that our behavior is shaped by ourselves and everything around us, what he called “our field.” He created a formula for behavior to illustrate this: B = F(P, E) showing behavior (B) to be a Function (F) of the Person (P) and their Environment (E).23

Within the field, there are two forces. The first is a driving force that propels us emotionally, cognitively, or physically toward a positive valence (a need or goal, something that appeals) or away from a negative valence (something we do not like or want).

The second force in the field is a restraining force. It doesn’t cause us to move but instead decreases driving forces. As an example, Person A hates their job (negative valence), and although the salary is low, they need the money (positive valence). Their desire to quit (a driving force) is held in place by their financial situation (a restraining force).

To Lewin, group life is a social field with its own driving and restraining forces.24 Groups place cultural value on issues, such as, for example, distrust in the medical profession due to historic and current prejudice; the higher the cultural value, the harder it is for an individual to deviate or disagree. In such a way, groups emit a restraining force on their members.

To achieve change — to rewrite the social narrative — Lewin asserted that we have to first understand a group’s story and values, and that comes through facilitated group discussion.

References:

  1. Kahneman, D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux; 2011.
  2. Stanford SPARQ, To Make Change, Start With A Crowd, Available at: https://sparq.stanford.edu/solutions/make-change-start-crowd; Accessed 28 April, 2025
  3. Lewin, K. ‘Group decision and social change’, in T.M. Newcomb and E.L. Hartley (eds.), Readings in Social Psychology (New York: Holt): 1947 pp. 330-344.
  4. Lewin, K. Forces behind food habits and methods of change. Bulletin of the National Research Council, 1943 108, 35-65.
  5. George, S., Duran, N., and Norris, K. A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders', American Journal of Public Health, 2014 104(2), pp. e16-e31
  6. Shea, L., et al. Improving diversity in study participation: Patient perspectives on barriers, racial differences and the role of communities, Health Expectations, 2022 25(4), pp. 1979-1987
  7. Cunningham-Erves, J. et al. A community-informed recruitment plan template to increase recruitment of racial and ethnic groups historically excluded and underrepresented in clinical research, Contemporary Clinical Trials, 2023 125, pp. 107064-107064.
  8. McFarlane, J.S., et al. Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review, Health Communication, 37(9), 2022 pp. 1075-1092
  9. Wolfe, N., et al. Research Ambassador Program: An Innovative Educational Approach to Addressing Underrepresentation of Minority Populations in Clinical Research, Journal of clinical and translational science, 6(1), 2022 pp. e129-e129
  10. Burger, J.M., The foot-in-the-door compliance procedure: A multiple-process analysis and review. Personality and social psychology review. 1999 Nov;3(4):303-25.
  11. Hardman TC, Aitchison R, Scaife R, Edwards J, Slater G. The future of clinical trials and drug development: 2050. Drugs Context. 2023 Jun 8;12:2023-2-2. doi: 10.7573/dic.2023-2-2. PMID: 37313038; PMCID: PMC10259497.
  12. Tufts CSDD: New Insights on The Clinical Trial Industry, 2024 March 19 Available at: https://www.clinicaltrialvanguard.com/conference-coverage/tufts-csdd-new-insights-on-the-clinical-trial-industry/ Accessed: 28 April 2025
  13. Lewin, K. Action research and minority problems, in Lewin, G. W. (Ed.), Resolving Social Conflict, London: Harper & Row, 1946
  14. Allport, G. W. The Genius of Kurt Lewin, Journal of Social Issues, 1948 4(1 S), pp. 14-21
  15. Rogers, C. Interpersonal relationships, Journal of Applied Behavioral Science, 1968 4, 3-19
  16. Adelman, C. Kurt Lewin and the Origins of Action Research, Educational Action Research, 1993 1(1), pp. 7-24
  17. Tolman, cited in Marrow, A.J. (1969) The Practical Theorist the life and work of Kurt Lewin. New York: Basic Books 1947
  18. Coghlan, D. and Brannick, T.  Kurt Lewin: The "Practical Theorist" for the 21st Century, The Irish journal of management, 2003 24(2), pp. 31
  19. Wheeler, L. Kurt Lewin, Social and personality psychology compass, 2008 2(4), pp. 1638-1650
  20. Schein, E.H. Kurt Lewin's change theory in the field and in the classroom: Notes toward a model of managed learning. Systems Practice 1996 9, 27–47
  21. Bakari, H. How Does Authentic Leadership Influence Planned Organizational Change? The Role of Employees’ Perceptions: Integration of Theory of Planned Behavior and Lewin’s Three Step Model, Journal of Change Management, 2017 DOI: 10.1080/14697017.2017.1299370
  22. Cummings, T. G. and Worley, C. G. Organization Development and Change, 6th edition. Cincinnati, OH: South-Western College Publishing 1997
  23. Lewin, K. Principles of Topological Psychology. New York: McGraw Hill. 1936
  24. Lewin, K. Frontiers in group dynamics, Concept, Method and Reality in Social Science; Social Equilibria and Social Change, Human Relations, 1947(a), 1, 5–41

About The Author:

Tatty Scott is a patient engagement and recruitment professional based in Scotland. She worked as a journalist, focusing on health, and in diverse community engagement for 20 years before joining clinical trial engagement in 2015. Her favorite food is oranges, and she has a cocker spaniel named Piglet.