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Leveraging Behavioral InsightsTo Improve Public Health
Craig R. Fox
UCLA mHealth Training InstituteAugust 10, 2016
Gérard Dubois
Neoclassical vs. Behavioral Policy
• Homo Economicus
• Three Primary Tools:
1) Information/Education
2) Monetary Incentives
3) Regulation
• Homer Economicus
• Expanded Toolset:
1) Framing, Format, Frequency
2) Behavioral, Social Incentives
3) Nudges
Three Behavioral Approaches
I. Information
II. Incentives
III. Regulation (nudges)
I. Information
Rational agents have unbiased expectations, process information thoroughly and consistently,and are sensitive to content rather than format.
Behavioral agents have biased expectations, Limited memory and information processing capacity,and are sensitive to format of information.
Behavioral Information Guidelines
Make all relevant information available
• Simplify
• Proper Metrics
• Timely Reminders & Feedback
Old USDA Food Pyramid
Simplify:New USDA Food Plate
14 MPG
Murcielago - Lamborghini 612 Scaglietti - Ferrari16 MPG
Focus - Ford35 MPG
Civic Hybrid - Honda45 MPG
89 G/10K M
63 G/10K M
Gas Consumption as a Function of MPG
0100200300400500600700800900
10001100
10 15 20 25 30 35 40 45 50 55
Miles Per Gallon
Gallons Per 10,000 Miles
Old Fuel Economy Label
Proper Metrics:New EPA window stickers for 2013 models
What Kind of Metrics?
• N = 610 Passersby recruited to mobile research lab in shopping area were offered free snack for completing a short survey.
• Random assignment to 1 of 12 calorie labeling conditions.
Downs, Wisdom & Loewenstein (2015).
Menus
• Control (no information)Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Menus
• Control (no information)
• Numerical Values:– Calorie Info Only
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Calories
230
280
140
40
340
130
470
Nutrition experts recommend that men should eat about 2,400 calories per day, and women should eat about 2,000 calories per day.
Menus
• Control (no information)
• Numerical Values:– Calorie Info Only
– Calorie Info + Daily Intake Reference
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Calories
230
280
140
40
340
130
470
Menus
• Control (no information)
• Numerical Values:– Calorie Info Only
– Calorie Info + Daily Intake Reference
– Calorie Info + Daily Snack Intake Reference
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Calories
230
280
140
40
340
130
470
Nutrition experts recommend 200 calories per day for snacks or dessert (10% of a 2,000 calorie per day diet).
Menus
• Control (no information)
• Numerical Values:– Calorie Info Only
– Calorie Info + Daily Intake Reference
– Calorie Info + Daily Snack Intake Reference
– % of Daily Calories
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
% Daily Calories*
12%
14%
7%
2%
17%
7%
24%
*Based on nutrition experts’ recommendation a 2,000 calorie per day diet.
Menus
• Control (no information)
• Numerical Values:– Calorie Info Only
– Calorie Info + Daily Intake Reference
– Calorie Info + Daily Snack Intake Reference
– % of Daily Calories
– % of Daily Snack Calories
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
% Daily Snack
Calories*
115%
140%
70%
20%
170%
65%
235%
*Based on nutrition experts’ recommendation of 200 calories per day for snacks or dessert (10% of a 2,000 calorie per day diet).
*To burn the calories in the snack (this assumes you burn 10 calories per minute).
Min. on Treadmill*
23
28
14
4
34
13
47
Menus
• Control (no information)
• Numerical Values:– Calorie Info Only
– Calorie Info + Daily Intake Reference
– Calorie Info + Daily Snack Intake Reference
– % of Daily Calories
– % of Daily Snack Calories
– Minutes on a Treadmill
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Nutrition Grade*
C
C
B
A
D
B
F
Menus
• Heuristic Cues– Nutrition Grade
*Based on nutrition experts’ recommendation of 200 calories per day for snacks or dessert (10% of a 2,000 calorie per day diet)
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
*For someone who eats this snack routinely over time, based on nutrition experts’ recommendation of 200 calories per day for snacks
or dessert (10% of a 2,000 calorie per day diet)
Menus
• Heuristic Cues– Nutrition Grade
– Expected Body Size
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Expected Body Size*
TrafficLight
Rating*
Menus
• Heuristic Cues– Nutrition Grade
– Expected Body Size
– Traffic Light Rating
*Based on nutrition experts’ recommendation of 200 calories per day for snacks or dessert (10% of a 2,000 calorie per day diet)
Item
Lays Classic Potato Chips
Snickers candy bar
York Peppermint Pattie
Apple Crisps
Choc. Chip Cookie 2 pack
Lays Baked Potato Chips
Hostess apple pie
Only best numerical format (% daily snack calories) did as well as heuristic cues…
Traffic lights seem especially promising.
Reminders: Checklists
Reminders to Buckle Up
Valets at a hotel remind drivers to wear their seat belts• Control: No reminder to wear seat belt• Delayed Reminder: Reminded when valet ticket turned in
(~5.5 min delay)• Immediate Reminder: Reminded as enter car (~30 sec.)
Austin, Sigurdsson & Rubin, 2006
Reminders Must Be Timely
Austin, Sigurdsson & Rubin, 2006
55% 58%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Control Delayedreminder
Immediatereminder
% drivers fastened seat belts before car
in motion
Feedback
Feedback protocols matter!We often miss opportunities to learn from “near misses”
that are encoded as “non-events”
II. Incentives
Rational agents act to maximize their own self-interest. Self-interest is defined by expected utility of benefits minus costs of acting.
Behavioral agents are overly sensitive to losses relative to gains and low-probability events. They are also seek belonging and approval from relevant social groups.
Behavioral Incentives
Make all relevant information available
• Lotteries & Loss Aversion
• Goals as Reference Points
• Timely reminders & Feedback
Descriptive Perspective: Prospect Theory
Behavioral Incentives
• Probabilistic Incentives (Lotteries)
• Loss aversion
• Pre-commitment
• Social Incentives
Warfarin adherence using lotteries Volpp et al. (2008)
Teachers & student math scores Fryer et al. (2013)
Examples of Prospect Theory Inventives
--overweighting low probabilities--loss aversion
Bonus for high math scores given after results (gain) vs. before (loss) gain frame improves scores 1.3%
loss frame improves scores 6.9% (>1 SD)
Coke Vending Machines: A Good Idea?
Present Bias
b) Choose between:
$50 right now $55 one week from today
a) Choose between:
$50 in 52 weeks $55 in 53 weeks
Precommitment: Stickk.com
Clocky ®The patented alarm clock that runs away and hides to get you out of bed. Clocky gives you one chance to get up. But if you snooze, Clocky will jump off your nightstand and wheel around your room looking for a place to hide, beeping all the while. You'll have to get out of bed to silence his alarm.
Precommitment: Clocky
Social Incentives
We are strongly motivated by social concerns:
• Belonging to a group by following its norms
• To secure approval of others
• To maintain a pro-social identity
Social Norms
Descriptive Social Norms = how group members actually behave
Injunctive Social Norms = how group members should behave
How do we reduce energy usage?
Schultz et al, 2007
Your neighbors use less energy
than you! (You use a
lot!)
Your neighbors use less energy
than you! (You use a
lot!)
Your neighbors use more energy
than you! (You use
less!)
Your neighbors use more energy
than you! (You use
less!)
Energy Use and Norms
Schultz et al, 2007
Your neighbors use less energy
than you! (You use a
lot!)
Your neighbors use more energy
than you! (You use
less!)
Your neighbors use more energy
than you! (You use
less!)
Your neighbors use less energy
than you! (You use a
lot!)
-2
-1
0
1
2
Change in Daily Energy Usage
(kWh)
Social Accountability
Social Incentives: Peer Comparison
Source: Meeker, Linder, Fox, Friedberg, Persell, Goldstein, Knight, Hay & Doctor(2016)
0%
5%
10%
15%
20%
25%
30%
Control PeerComparison
Baseline
Intervention
You [are/are not] a top performer
Your rate: X%Top rate: 0%
Inappropriate Rx
Accountability: Justification Note
Source: Meeker, Linder, Fox, Friedberg, Persell, Goldstein, Knight, Hay & Doctor(2016)
0%
5%
10%
15%
20%
25%
Baseline Intervention
Inappropriate Rx
III. Regulation
Rational agents are responsive only to information, financial incentives, and regulation that has (positive or negative) incentives attached.
Behavioral agents are responsive to nudges that facilitate a desired behavior without prohibiting other options or significantly altering important information or economic incentives.
Choice Fatigue: Parole Decisions
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Prop
ortio
n fa
vora
ble d
ecis
ions
Ordinal position
Danziger, Levav & Avaim-Pesso (2011) Source: Linder et al (2014)
Nudging
• Channel Factors
• Selective Exposure
• Smart Defaults
• Ordering & Partitioning
• Commitments & Plans
(Simplified) form is
10 pages
H&R Block Ohio, CharlotteHHs <$45k / year + 17 yo – 30 yo without
bachelors degree3 conditions
1. Control2. Information + auto-fill FAFSA3. (Information)
Bettinger, Long, Oreopoulos & Sanbonmatsu, 2012
FAFSA-Completion Channel
FAFSA-Completion Channel
0%
2%
4%
6%
8%
10%
12%
14%
16%
Submit FAFSA Matriculate Complete 2years
Impact of auto-fill
relative to control
Bettinger, Long, Oreopoulos & Sanbonmatsu, 2012
Impact on Dependents
Nudging
• Channel Factors
• Selective Exposure
• Smart Defaults
• Ordering & Partitioning
• Commitments & Plans
Selective Exposure: The Case of Eating
Nudging
• Channel Factors
• Selective Exposure
• Smart Defaults
• Ordering & Partitioning
• Commitments & Plans
Defaults & Organ Donation
Source: Johnson & Goldstein (2003)
40% 96% generics
Source: Malhotra et al (2016, JAIMIA)
Defaults & Generic Drugs
Nudging
• Channel Factors
• Selective Exposure
• Smart Defaults
• Ordering & Partitioning
• Commitments & Plans
Ballot order: 1 to 3 pp for being firstMiller and Krosnick, 1998
Bigger in Primaries than GeneralsHo and Imai, 2008
Order Effects
A 27-year-old woman with no known underlying lung disease presents with a 10-day history of cough that is productive of yellow nonbloody sputum. Her symptoms began with nasal congestion and a sore throat, but these initial symptoms resolved after a few days. Her remaining symptom is the cough which is less productive than it was several days ago. She denies any known sick contacts. Her cough does not occur in long fits, and there is no post-tussive emesis. On physical examination she is not in respiratory distress, afebrile, and has normal vital signs. Lung exam is normal.
Of the drug choices below, please indicate which drugs you would choose in treating this patient:
☐ cough lozenge
☐ cough spray
☐ cough syrup
Prescription drugs:☐ albuterol inhaler ☐ an antibiotic of your choice ☐ robitussin with codeine ☐ tessalon perles
Of the drug choices below, please indicate which drugs you would choose in treating this patient:
☐ albuterol inhaler
☐ an antibiotic of your choice
☐ robitussin with codeine
☐ tessalon perles
Nonprescription drugs:☐ cough lozenge ☐ cough spray ☐ cough syrup
Grouping Effects
Overall, 27% decrease in aggressive treatment when grouped
Nudging
• Channel Factors
• Selective Exposure
• Smart Defaults
• Ordering & Partitioning
• Commitments & Plans
Turnout Results
-0.2%
2.0%
4.1%
-2.0%-1.0%0.0%1.0%2.0%3.0%4.0%5.0%6.0%
Turnout Effect
Plan-MakingReminder Intention
Nickerson and Rogers, 2010
Planning Prompts and Flu Vaccination
Milkman, Beshears, Choi, Laibson, and Madrian, 2011
Control
Planning prompt
Impact on Flu Vaccination
25%
27%
29%
31%
33%
35%
37%
39%
Control Planning prompt
Vaccination Rate
Milkman, Beshears, Choi, Laibson, and Madrian, 2011
4 percentage
point increase is a
12% increase!
Neoclassical vs. Behavioral Policy
• Homo Economicus
• Three Primary Tools:
1) Information/Education
2) Monetary Incentives
3) Regulation
• Homer Economicus
• Expanded Toolset:
1) Framing, Format, Frequency
2) Behavioral, Social Incentives
3) Nudges
Leveraging Behavioral InsightsTo Improve Public Health
Craig R. Fox
UCLA mHealth Training InstituteAugust 10, 2016
Gérard Dubois