Human behaviour in Health

Approaches to improving health outcomes
Health Economics Applications and Policy
Health Economics Applications and Policy
How to change Behaviour? Insights from Behavioural Economics
Many unhealthy behaviours do not result in negative outcomes in
every instance
• Each cigarette, drink, and bag of drugs is probabilistically related
to negative outcomes, not certain negative outcomes.
• Every unprotected sex, poor medicine compliance, delayed
cancer screenings are not going to kill with certainty
If a person is willing to accept the risk of negative outcomes for
greater reward, their “cost-benefit” ratio is acceptable.
To effectively change behaviour, you need…
• Recognition that behaviour change is needed / desirable
• Motivation to make change
• Belief that change can occur and be maintained (perceived selfefficacy)
• Triggers/cues to initiate change
• Perceived benefits of that change
Is health behaviour change hard to achieve…?
For patients:
 Treatment non-adherence ranges from 30-60%
 Prophylactic treatment adherence only 30-35%
 Protective health behaviour 10-30%
For healthcare professionals (HCPs):
 Literature indicates HCPs do not follow clinical procedures they know
should be implemented: Physician performance ranges between 48-
72% of professional standard (Peterson et al., 1980)
 Nurses deviate from infection control rules (Raven & Harley, 1982)
 Dentists fail to adequately shield patients during x-rays (Green &
Neistat, 1983), 20% error rate in care procedures in old people’s
homes (Kayne & Cheung, 1973). etc…
So what do we do to change health behaviour?
Behavioural Economics can offer some valuable insights.
There has been an enormous proliferation of interest in
behavioural economics in the last decade among policy
Both the UK and Australian Governments have developed
insights teams dedicated to finding new ways to ‘nudge’
citizens to be healthier, greener and more civic-minded.
But…on average we would like people to make the ‘right’ health
decisions – from a societal point of view.
The Behavioural Economics approach to this problem is – NUDGE
Nudge – what is it?
NUDGE: Principals and Procedures
 evidence-based
 testing of interventions in
 randomised control trials
Philosophy of libertarian
• Simplification and
framing of information
• Changes to the
physical environment
• Changes to the default
• Use of (descriptive)
social norms
NUDGE could be appropriate for healthy behaviour
Nudges are
appropriate when:
• choices have
delayed effects,
• when they are
complex or
infrequent and
thus learning is
not possible,
• when feedback
is not available,
• when the
Perceived complexity LOW
Perceived complexity HIGH
NUDGE in a nutshell
“… any aspect of the choice architecture* that alters people’s behaviour in a
predictable way without forbidding any options or significantly changing their
economic incentives…. Putting the fruit at eye level counts as a nudge. Banning
junk food does not”.
Thaler, RH & Sunstein CR (2008) Nudge: Improving decisions about health, wealth, and happiness, New Haven, CT., Yale
University Press.
*aspect of the social/physical environment that makes a particular option more attractive, preferred
or even the default choice
Some individual NUDGES are quite effective
95-99% of customers stay with the “green electricity default”
Duplex printing default ~ 30%
Smaller plates -> 20% less food waste
NUDGE (alone) may not change health behaviour
Because making it part of policy and
practice will take a long time and
require some heavy legislation.
One of the most effective nudges
(other than defaults) is 50% drop in
Pringles crisps consumption after
adding 10% red Pringles.
It is people and stricter policies that will resist the obesogenic
environment. Nudge can help by offering policy makers and
citizens better tools.
Nudge in practice: Food and Drug Administration, 2014
Nudge in practice: Food and Drug Administration – New
Nudge in practice: Food and Drug Administration, 2014
• In 2014, the Food and Drug Administration (FDA) proposed to
revise its “nutrition facts” panel, which can be found on almost
all food packages. The FDA stated that the new label could
“assist consumers by making the long-term health
consequences of consumer food choices more salient and by
providing contextual cues of food consumption.”
• The FDA added that the “behavioural economics literature
suggests that distortions internal to consumers (or internalities)
due to time-inconsistent preferences, myopia or present-biased
preferences, visceral factors (e.g., hunger), or lack of selfcontrol,
can also create the potential for policy intervention to
improve consumer welfare.”
Nudge in practice: Old Fuel Efficiency Information
Nudge in practice: New Fuel Efficiency Information
What is the
Karjalainen, S. (2009) Thermal comfort and use of thermostats in Finnish homes and offices
Building and Environment 44 (6), 1237-1245
It doesn’t need to be expensive
A low-cost NUDGE
A NUDGE that went wrong…
Insights from Behavioural Economics
• Strategies developed by behavioural economists include:
o Framing and nudging towards desired behaviours;
o Providing salient information on more immediate benefits
of healthy behaviour and immediate risks of obesity;
o Use of social-network to develop and promote inclusive
and positive group-based norms
• Such strategies hold promise for improving health behaviours
and disease control, but most have not been studied in medical
settings. The effectiveness of these approaches should be
evaluated for their potential as tools for medical professionals.
Some commonly observed behavioural attributes
• Delay discounting: Individuals often overweigh costs and benefits
incurred today (i.e. the present) relative to the costs and benefits
incurred tomorrow (i.e. the future). This type of bias can lead
individuals to forgo healthy behaviours.
o For example, the decision to skip the gym overweighs the cost of
going to the gym today in terms of time and fatigue, while discounting
future health benefits heavily. As a result, individuals buy expensive
monthly gym memberships but go so infrequently that paying per
visit would cost less (DellaVigna & Malmendier 2006).
o Present bias can explain why individuals procrastinate about eating
healthy, quitting smoking, or getting a health check-up done.
o The results of a field experiment by Sarkar et al. (2020) show that
parents who discount the future more heavily tend to exhibit poor
engagement with health programs that benefit their child. Low
discounting parents tend to stick with the program longer.
Some commonly observed behavioural attributes
• Salience: Although more information makes more informed choices,
people are often unable to process information when faced with a
large number of choices. As a result, they tend to pay attention to
information when it is highly visible or can be recognized easily at the
time a choice is made.
o For example, because the adverse complications of diabetes
(i.e., the health costs) are often not felt until late stages of the
disease, the risk of these complications is often not salient to a
decision maker at the time they are considering consumption
of a carbohydrate or sugar-rich food or deciding whether or
not to engage in physical activity. As such, people tend to
underestimate the real costs of diabetes and other chronic
diseases prior to experiencing them.
Some commonly observed behavioural attributes
• Probability discounting: People tend to overestimate the probability
of unlikely events (such as winning the lottery) and underestimate the
probability of likely events, such as being diagnosed with diabetes if
they are obese (Kahneman & Tversky, 1979).
• Framing: The choices people make are influenced not only by the
underlying incentives or signals, but also by the way those incentives
or signals are presented or ‘framed’. For example, a message that is
framed as a loss has different impact on behaviors than a message
that is framed as a gain (Rothman & Salovey, 1997).
Some commonly observed behavioural attributes
• Loss aversion: Many people display loss aversion by which they do
not value losses and gains of equal magnitude equally. Gains, such as
a reward, tend to be valued less than losses, such as a penalty, of
equal magnitude.
• Social preferences: People often display social preferences, whereby
their utility is defined not solely based on their own interests, but
motivated by other-regarding preferences such as, altruism,
reciprocity, cooperation, inequity aversion, or ethical commitments
that induce people to help others (Fehr & Falk, 2002, Goldfarb et al.,
Examples of Behavioural Intervention Programs

  1. Regret Lottery
    • This intervention is based on loss aversion; as well as the fact that
    individuals do not like to regret (called regret aversion).
    • Lotteries can take advantage of the fact that individuals overweight
    small probability events. For example, providing a 1% chance of
    winning $100 might motivate people more substantially than offering
    them $1 directly, even though the two have the same expected value.
    Regret lotteries have successfully influenced behaviour in a variety of
    health domains.
    o For instance, subjects lost significantly more weight when provided
    with a regret lottery that paid out an expected $3 per day (in the form
    of a 20% chance of winning $10 plus a 1% chance of winning $100) if
    the subject is on track to his or her weight loss goal (Volpp et al.
    Examples of Behavioural Intervention Programs
  2. Commitment Devices
    • Another way to leverage loss aversion with monetary incentives is to
    provide individuals the opportunity to make commitment contracts
    (also called deposit contracts) in which they put up their own money.
    This money is then forfeited if they fail to achieve a certain goal, such
    as reaching a weight loss target or attending the gym a specified
    number of times in a week or month.
    • This strategy allows individuals to create monetary incentives for
    themselves and leverage loss aversion simultaneously. A commitment
    contract in which the committed funds were matched 1-to-1 by
    researchers was effective at achieving weight loss by study
    participants (Volpp et al. 2008a).
    Examples of Behavioural Intervention Programs
  3. Peer Mentoring
    • There is growing evidence that social forces have a powerful effect on
    individuals’ health behaviour.
    • In a randomised controlled trial on teen smoking across 59 schools
    and 10,730 students aged 12-13 in Wales (Campbell et al. 2008),
    control schools received the standard smoking education while a
    special program was implemented in treated schools that included
    peer mentors: students who were trained to have informal
    conversations with their peers to discourage smoking.
    • Treated schools showed lower likelihood that students would smoke
    one to two years later.
    Physician Behaviour
    It is often notoriously difficult to change physician behaviour, even when their
    behaviour is deemed inappropriate (e.g., over-prescribing antibiotics, underprescribing
    cholesterol pills). Physicians are strong-willed people, with lots of
    things competing for their attention and with many well ingrained habits.
    • Many physicians prescribe antibiotics, even for common cold. Often
    these prescriptions do more harm than good. They expose patients to
    unnecessary expense and potentially hazardous side effects. And they
    expose the general public to the dangers of antibiotic-resistant
    • How do we get doctors to reduce prescription of unnecessary
    Physician behaviour change – approach 1
    • This JAMA (2016) study showed that
    we can reduce inappropriate antibiotic
    prescriptions using two approaches.
  4. Accountable justification: At the time of
    antibiotic prescriptions, a pop-up screen
    asked the doctors to type in a reason for
    the prescription. The idea behind this
    approach is simple, but powerful. A
    physician might know deep down that an
    antibiotic is unnecessary, but may
    prescribe one anyway to avoid
    confrontation with a demanding patient,
    or just to feel like she did something. If
    physicians like this are forced to slow down
    and think, and provide reasons for their
    actions, they might overcome unjustifiable
    influences that promote inappropriate
    The Figure shows that this slowing
    down/justification intervention
    worked. It led to a significantly
    steeper decline in the use of
    antibiotics, compared to the control
    Physician behaviour change – approach 2
  5. Peer Comparison: The researchers gave
    physicians monthly feedback on whether
    they were a “Top Performer,” one of the
    10% of physicians giving out the smallest
    proportion of inappropriate antibiotic
    prescriptions. The other 90% of physicians
    received a reminder that they were “Not a
    Top Performer.” This intervention appeals
    not only to physician competitiveness
    (who are often very competitive), but also
    to the power of social norms. When
    reminded that some people are able to,
    say, overcome the temptation to prescribe
    antibiotics, physicians may feel more
    empowered to follow suit.
    Again, the intervention worked. Although
    the intervention only took place once a
    month (rather than with each antibiotic
    prescription), the feedback was enough to
    change behaviour. Finding out they were
    not doing as well as their peers was
    effective in reducing inappropriate
    antibiotic prescription.
    Physician behaviour change – approach 3
    • This study published in JAMA (2015) showed that financial incentives informed by
    insights from behavioral economics increased the likelihood of getting patients’
    cholesterol under control.
    • Here is a picture showing that giving financial rewards to both patients and physicians
    increases the odds that patients will take their cholesterol pills as prescribed–will
    “adhere” to their medications.
    Summary: Behavioural Intervention Programs
    • Many interventions rely on other behavioural tools, such as
    Information and Salience (e.g., nutrition labelling leading to
    decreased calorie intake), Context and Framing (changing the default
    of health coverage in insurance plan, changing from opt-in to opt-out
    rules in consent for organ donation), etc.
    • Overall, while the behavioural economics approaches have often
    proven to be cost-effective, so far scientific evidence mostly point to
    short-term effectiveness of behavioural interventions.
    • More research is needed to understand its effects on long-term
    behaviour change, which may help design public health strategies
    that reach segments of the population hitherto impervious to existing
    public health strategies.
    • The rapid rise of obesity and associated chronic diseases
    worldwide has inspired policy responses in many countries.
    o New York City voted to ban the trans-fat in restaurants in 2006.
    o Japan started charging higher premiums for citizens with
    waistlines above a maximum threshold in 2008.
    o Denmark instituted a tax on all products with saturated fat in