A Nudge A Day Keeps The Doctor Away

Most people understand what constitutes a “good choice” in the context of health behaviors. To stay healthy, one should care for herself, follow her doctor’s recommendations, take treatments when prescribed, eat healthy, etc. The problem arises both from incomplete information as well as from our cognitive biases, which make adhering to these behaviors quite difficult. Moreover, we also suffer from bounded rationality. That is, even when we have all of the relevant information, we still fail to act optimally.

Fortunately, as we learn more about human behavior, these insights can be applied to the domain of healthcare. Employing simple nudges, medical centers can improve their patients’ outcomes by simplifying forms or sending text message reminders for treatments, among a number of similar, low-cost interventions. As these nudges improve individual health outcomes, they also improve social welfare as a whole. Thus, we hope that by using behavioral tools, patients will be nudged to make better health decisions and, therefore, increase their quality of life.

One of the first applications of behavioral insights to health policy was the case of the organ donation default. For those immersed in the behavioral literature, this example will be familiar. Essentially, the problem was that the rate of organ donation in many countries fell well short of the reported rate of desire to donate one’s organs: i.e., many people self-reported a desire to donate their organs, but did not enroll to be organ donors. The reason was that many forms on which people decide whether to donate were designed with an opt-in default (i.e., unless an action was taken to change it, one would not be an organ donor). By employing the insights of choice architecture, policymakers changed this to an opt-out default (i.e., you are an organ donor unless you actively decide not to be). This simple tweak in the design of a form had a tremendous effect on the number of organ donors — and as a result, not only saved lives, but also better aligned peoples’ actions with their own stated preferences.

With that in mind, I present the following list of cost-effective innovations through which health centers can employ choice architecture to better enable patients to accomplish their health goals, and medical practitioners to deliver more efficient treatments:

• Reducing antibiotics using social norms. In 2014, Hallsworth and colleagues decided to run a trial to reduce over-prescription of antibiotics in England. To accomplish this, they wrote letters to general practitioners (GPs) in the top 20 percent of the prescribing-distribution, informing them of their rates of prescription relative to the lower 80 percent of GPs. They found an effect that was sustained for at least 6 months, substantially reducing antibiotic prescribing at a national scale. This low-cost program reduced unnecessary prescriptions of antibiotics, which contribute to antimicrobial resistance.
• In many cases, operating rooms implement critical processes of care by memory, increasing the likelihood of complications because of missing steps. That’s why, in 2009, Haynes and other researchers developed a nineteen-item checklist, applicable globally, to reduce the rate of preventable surgical complications. They tested the efficacy of this checklist in eight hospitals, and found that the rate of death for patients undergoing surgery fell from 1.6% to 0.8% by following the instruction of their checklist.
• Text message reminders on adherence to treatment. Low rates of adherence to artemisinin-based combination therapy (ACT) increase the risk of treatment failure and may lead to drug resistance. In 2011, Raifman and coauthors implemented a randomized controlled trial (RCT) that took place in Ghana, where the intervention consisted of text-messaging individuals receiving malaria treatment, with (i) a short reminder message “Please take your MALARIA drugs!” or (ii) a long reminder with encouragement component “Please take your MALARIA drugs! Even if you feel better you must take all the tablets to kill all the malaria”. The results showed that just sending the simple message significantly increased the odds of adherence by 1.45 times compared to the control group (no message sent).
• Implementation intention to increase influenza vaccination. A team of researchers let by Wharton’s Katherine Milkman evaluated a field experiment designed to measure the effect of prompts on changing health behaviors of employees in a large firm. In this case, the behavior of interest was whether employees received the free flu vaccination provided by the firm. Employees were randomly assigned to categories, and those in the treatment groups were mailed a reminder with (i) the date the employee planned to be vaccinated or (ii) the date and time the employee planned to be vaccinated. In both cases, the vaccination rates increased relative to the control group — and those employees who received the more specific prompt to write down both date and time saw the biggest increase in vaccination rates (4.2 percentage points higher).

We all make complex decisions everyday, many of which impact our lives or those of our peers. While there are always ethical considerations when attempting to influence people’s behavior, in the domain of health care, these interventions can quite literally be the difference between life and death. In situations where both individual and societal welfare can be improved through simple, low-cost nudges, the question becomes: should we let patients and GPs suffer from their own inherent biases, or intervene and improve their health outcomes?

Recognizing this need is critical to improving health system. By taking advantage of these insights into how people behave, and translating it into policy interventions, we can take another step toward improving health and health care.