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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