By Benjamin Voyer
Out of all the areas of public life that can benefit from the applications of behavioural economics (BE) principles, healthcare is probably the one where it can make the biggest societal contribution. There are two main reasons why the healthcare industry should welcome (more!) BE insights. The first reason is that many of the traditional ways in which marketing and economics principles have been applied to health are starting to show their limits (e.g. ‘rational’ prevention campaigns or ‘shock-advertising’ commercials used to reduce road accidents or smoking). The second is that BE allows for more efficient policies and reduced costs, which is much welcomed in a healthcare industry facing financial and budgetary challenges. In this post, I highlight ways in which some of the key principles of BE have been – or could be – applied in a healthcare context.
Johnson and Goldstein’s (2003) seminal study on organ donations is probably the most ‘classic’ example of BE applied to public health. They showed how simple interventions, such as registering individuals by default on the organ donation register (people have to opt out if they do not wish to be a donor), could significantly increase organ donations. Governments have also encouraged (and in some cases required) companies to sign up employees to pension schemes by default in order to increase pension savings. The same principles can be applied to other areas of public health if taking out medical cover or insurance is made a default.
Another principle of BE which has interesting and relevant applications in healthcare is that of temporal discounting – the fact that individuals value more what is available immediately rather than what might come in a distant future. This principle has consequences for the management of chronic diseases, for instance, when patients struggle to appreciate the benefits of small behaviours with incremental effects that can avoid long-term costly consequences. Focusing on smaller, short-term goals – e.g. loosing 2 lbs per month, in the case of weight-loss – can be more beneficial than putting forward a long-term ambitious achievement (e.g. 24 lbs of weight loss in one year).
Patient-related decisions often involve a certain amount of risk, an understanding of which can benefit from BE. Given the difficulties in assessing risks in healthcare, and patients’ aversion to risks, doctors can help patients make more informed decisions by offering clear comparison – e.g. in the form of a summary table – between risks and benefits. For instance, choices between surgery and drug-based alternatives can be made easier by listing advantages and disadvantages of each alternative (i.e. immediate, short and medium, long term benefits, and associated side-effects). Choices could also be presented in a way that allows patients to understand what their implicit preferences are. For instance, this may involve a survey of patients that uses forced-choice options, asking them to choose between what they value most (e.g. being fully mobile vs. pain-free, when considering hip-replacement surgery).
Finally, behavioural principles related to the social aspects of decision-making can be successfully applied to healthcare.
Giving patients some feedback on how they are doing in relation to their treatment and progress, possibly compared to another group or age cohort, can motivate people to improve their behaviours and stick to treatments, or effectively trigger a desire to change behaviour and improve to do better than average. This has been used, for instance, to convince patients to quit smoking, by giving them feedback on the ‘age’ of their lungs, compared with a cohort of non-smoking individuals (Parkes, Greenhalgh, Griffin, & Dent, 2008).
These same ideas can also be applied by hospital management to improve staff behaviour within hospitals and clinics. Hospital managers can improve healthcare services by monitoring and giving feedback about services’ relative performance. For instance, Armellino and colleagues (2011) showed that using real-time video monitoring and feedback of hand sanitizing in a critical-care unit could increase usage by more than 800%. The more cohesive a team is, the more they will be motivated by changing their behaviour to perform better than other teams or services. Messages that incorporate social norms can also help to reduce the number of missed appointments among patients. Martin, Bassi, Dunbar-Rees (2012) found that, when patients were exposed to norms expressed as the number of patients who turned up for their appointments – instead of past reference to missed appointments – this resulted in a 32% reduction of non-compliance. Making feedback as precise and targeted as possible can maximize the effects (e.g. ‘80% of patients arrive on time. Be one of them!’ will be more efficient than a message ‘most patients arrive on time’).
Another message aimed at patients in hospital settings encourages them to respect staff (e.g. ‘treat our doctors and nurses the way you would like to be treated’). This follows the principle of reciprocity, inciting people to reciprocate an actual or hypothetical behaviour, which can result in behavioural change. Organ donations, for example, can be increased when the message ‘if you needed an organ, would you take one?’ is used in a communication campaign. For organ recipients, some scholars have even suggested that patients who are themselves registered on the donors’ list should have preferential status. Individuals would thus be encouraged to register on the donor’s list as a matter of reciprocity — they would be given preference over someone not registered if they needed an organ donation at a later time.
Overall, BE principles can be used and benefit healthcare in many ways. A promising area for research and applications of BE in healthcare is through gamification of e-health. Games can be designed to incorporate many BE principles, such as framing decisions, giving feedback on norms and behaviours, setting small and realistic short-term objectives, etc. E-health ensures accurate, personal, and real-time feedback, which can reinforce the efficiency of the messages. Studies have shown that health-monitoring devices (e.g. Fitbit or Apple Watch) can provide useful real-time feedback on health metrics. The real-time aspect of the data can be combined with real-time feedback as parts of games or challenges (e.g. take at least 10,000 steps per day; converting exercise data into points or ‘lives’ for games), to increase individual motivation and agency, thereby triggering behavioural change.
While advances in behavioural science provide a promising avenue to achieve behaviour change, it is becoming increasingly clear that the application of BE principles does not always guarantee results, and other forms of incentives can work equally well if not better (e.g. taxation or financial rewards). Healthcare has long relied on the use of randomized controlled trials (RCTs) to test the efficacy of interventions, and it can continue to lead the way forward in this area of applied behavioural science. RCTs can be used to test and validate programs designed to achieve positive behaviour change. However, some have questioned the ethicality of applying BE principles in the form of ‘nudging’, and RCTs may be controversial if they are applied to serious healthcare issues, especially those involving life or death matters. In addition, there is an increasing awareness that the effects achieved by behavioural interventions may wear off over time. For this reason, the design of RCTs may have to become more ambitious by also measuring effects in the medium or long term.
For more on this topic, please read:
Voyer, B.G. (2015) ‘Nudging’ behaviours in healthcare management: Insights from Behavioural Economics, British Journal of Healthcare Management, Volume 21 (3), Pages: 130-135, special issue ‘innovation in healthcare’
Sola, D., & Couturier, J., Voyer, B.G. (2015), Unlocking patient activation: Coupling e-health solutions coupled with gamification, British Journal of Healthcare Management, 21 (5), pp 223-228
Benjamin Voyer