A Nudge A Day Keeps The Doctor Away

A great number of diseases result from unhealthy behaviors. Even individuals who are fully aware of the risks associated with certain behaviors and have the intention to make good choices struggle to do so. This can cause us to feel anxiety when making choices, and regret about not doing the right thing. The main reason is that many of the decisions we face on a daily basis are made automatically. Conversely, even deliberate decisions related to health behaviors are often sub-optimal. Thoughts such as “If today I’m feeling good, why continue taking the pills?” (which in behavioral slang should be called present bias), or “I remember the last time it hurt me a lot, so I won’t do the screening test again” (availability heuristic), bedevil our efforts to stay healthy. What is more, health care system sometimes creates complex environments for patients, in the sense that completing forms are very extensive; prescriptions don’t follow recommendations of medicine based on evidence, and even general practitioners (GP) can suffer from decision fatigue, decreasing the quality of service and attempting against patient’s health.

In the light of these realities, a new hope has emerged that might improve public health: applying choice architecture to medical centers. In this domain, where consumers have difficulty comprehending and doctors have difficulty communicating information for critical choices involving health, and where bad decisions can lead to enormous negative consequences, medical centers can serve a crucial role in enabling citizens to make better choices in health.

So, what exactly is choice architecture? Thaler, Sunstein and Balz, three well-known thinkers in behavioral science, define it as the “careful design of environments in which people make decisions.”[1] In that regard, the key role for medical centers should be to simplify the decision processes of their patients or general practitioners in order to select the option that will make them better off.

Did I forget to take the pill? New solutions for problems of public health

 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.

Key takeaways for health centers

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.

The Tale of Positive Psychology and Behavioral Economics

With the recent rise and popularisation of behavioral economics, there has been a proliferation of research on the applications of psychological principles in influencing decision making. The primary tools used by behavioral economists are nudges, which are methods of influencing behavior by employing the very biases and barriers that prevent us from carrying out a desirable behavior.

While social psychology and cognitive neuroscience have shared the limelight with behavioral economics in designing nudges, there has been little mention of the connection with positive psychology, and its contributions to the field. This article seeks to make salient the impact of positive psychology on behavioral economics for practitioners and students alike. We will do this by examining existing research and constructs from both fields, with relevance to education, healthcare, and everyday optimal living.

The Zeitgeist of Contemporary Psychology

Around the same time as behavioral economics was gaining ground within scientific circles, psychology witnessed the emergence of a new subfield — positive psychology. Pioneers Seligman and Csikszentmihalyi (2000) defined positive psychology as “the scientific study of positive human functioning and flourishing on multiple levels that include the biological, personal, relational, institutional, cultural, and global dimensions of life.” Early detractors criticised the field’s presumed sole focus on the positive side of the spectrum of emotions and behavior, which positive psychologists disproved by studying concepts such as grief, conflict, and grit, and incorporating them into theories of learned helplessness, resilience, and flow.

The last decade has seen several ideas derived from positive psychology frameworks applied to behavioral economics experiments. Alex Linley, a prominent positive psychologist, partially credited positive psychology with influencing the shift towards behavioral economics (Jarden, 2012). He also emphasised the opportunities for mutual learning and collaboration that exist between the two. This is particularly relevant in areas of education, health, charity, and habit formation, where we can observe real world economic impacts.

How Positive Psychology Contributes to Learning

The Behavioral Insights Team, UK, has run a number of studies examining the effectiveness of different interventions in advancing student success. Personal engagement, flow, grit, and social support are fostered through some of these intervention designs.

In a study that sought to improve student achievement, the team devised exercises to cultivate grit: the passion and persistence to attain a long term goal (Duckworth, Peterson, Matthews, & Kelly, 2007). This involved deep practice and skills to overcome frustration [1]. Deep practice is one of the steps necessary for achieving Flow, a state in which we are intensely involved in a task, which in itself becomes a reward. Students who received the training exhibited an almost 10% boost in attendance relative to those who did not receive the intervention, suggesting that they might have been more motivated to learn.

In a current ongoing study, aptly named Project College Success (Groot & Sanders, 2017), students can nominate a study supporter, who will receive scheduled text messages with conversational prompts about school work. These prompts guide the development of a supportive relationship dynamic. Positive relationships, an element of Seligman’s (2011) PERMA Model (which outlines five pillars of well-being), can be understood as reciprocal, supportive relationships, which reduce stress (Cohen, 2004), and promote development and achievement (Marcon, 1999), to name a few.

Behavioral Insights for Health Promotion

A fundamental roadblock to long term maintenance of healthy actions is present bias – the tendency to value present payoffs more than payoffs in the future. This, when combined with loss aversion (we pay more attention to what we will lose, than to what we will potentially gain), presents a formidable impediment, especially with health behaviors like exercising, weight loss, or smoking cessation, which are not particularly enjoyable at the outset. As we will see, positive psychology can play a role in bypassing these barriers to long-term health promotion.

Several programs have studied the efficacy of providing financial incentives to encourage health behaviors. While this is effective in initiating behavioral change, studies show that financial incentives may be engendering extrinsic motivation, but “crowding out” intrinsic motivation — so when the external goal (money) is removed, the individual no longer feels like continuing the behavior (Lewis & Black, 2015).

Any behavior tends to fizzle out when one is not intrinsically motivated to do it. But the move from extrinsic to intrinsic motivation can occur with the help of positive psychology. When Babcock & Hartman (2009) provided students with financial incentives for gym attendance, they noticed that those with friends who were also in the study tended to perform better than those who didn’t.

In another trial, financial incentives and peer mentorship were compared to usual care in the context of controlling blood glucose levels for diabetic veterans. Normal care included information about haemoglobin A1c (which indicates blood glucose levels) and ideal goal levels of HbA1c. The financial incentive arm involved participants receiving $100 for 1% reduction in blood glucose levels, and $200 for 2% reduction. In the peer mentorship program, participants were paired up with mentors from the same cultural background who had succeeded in bringing their diabetes under control. The strategic pairing of mentors & mentees encouraged comradeship and understanding, resulting in peer mentorship emerging as the most effective intervention. (Long, Jahnle, Richardson, Loewenstein, & Volpp, 2012). Peer support can help us not only stay on the track and be accountable, but it also cultivates optimism, trust, and a community feeling that we’re all in this together.

Habit Formation and Optimal Living

Targeted interventions aside, how can behavioral economics help us in everyday living? Enter Fabulous, an app that was incubated at the Center for Advanced Hindsight at Duke University, with the unique purpose of transforming your life through positive habit formation aided by insights from behavioral economics. Think of it as a gentle guide and an enthusiastic cheerleader rolled into one.

The overarching theme of Fabulous is to harness the power of mindfulness (i.e., paying purposeful attention to the present in a non-judgmental way) to promote rituals involving healthy eating, exercise, productivity, and more. Each ritual begins with a self-made list of reasons why the behavior is important to us, followed by affirmations, and an option to pre-commit to the ritual [2]. When this method was tested for exercise, Fabulous users reported increased frequency of exercise, likelihood to continue exercising, and enjoyment in both the exercise and its preceding ritual. Fabulous is a truly fabulous (pun intended) union of positive psychology and behavioral economics, with the added plus of a beautiful design and UI (no surprise, it won the Google Play Award for Best Use of Material Design last year). Put together, it makes for a great user experience as you’re making your way towards positive living.

Key Takeaway

The aforementioned research illustrates how nudges designed with inputs from positive psychology make for positive, long term behavioral change. In contrast to nudges using merely financial gains or other extrinsic goals, those with elements of positive relationships, grit, mindfulness, and social support seem to show promise in sustaining desirable behavior. It is worth noting that while positive psychology has been used in behavioral nudges in the past, there are unplumbed depths in both disciplines, with lots left to learn and discover. In light of these realities, research with a focus on using positive psychology constructs to design better and more effective behavioral strategies appears to be an area ripe with future opportunities.

Endnotes
[1] “The Behavioural Insights Team’s Update Report: 2015-16”, 2016
[2] “Making Exercise Meaningful,” n.d. — In Center for Advanced Hindsight. Retrieved March 2017, from http://advanced-hindsight.com/case-studies/making-exercise-meaningful/)

Professional Women And Stereotypes: Moving Past Them

Women, especially those pursuing careers in traditionally male-dominated professions, are often the targets of gender-infused stereotypes. At its essence, a stereotype is “a widely held but fixed and oversimplified image of idea of a person or thing.” Of course, women and men have, historically, served different societal functions, and many professions were until very recently reserved for men. As such, even as these roles have begun to evolve, the way women are observed and expected to behave at the work place has not followed suit. Women struggle daily in battling these stereotypes, which often hinders their performance and productivity at work. This article details three of the main stereotypes and generalizations surrounding professional women, which affect the contribution women make at the workplace.

Stereotype #1: Women do not possess the required skills that men inherently possess for certain professions or job titles.

A common misperception is that, while women are skilled in role-specific tasks, they are not fit to manage people, lead, or collaborate. At the same time, an identical male (in qualification, experience, etc.) will be assumed to be able to lead well, delegate responsibly, and effectively communicate with peers. This idea, which leads to an underrepresentation of women in leadership roles, is damaging for a number of reasons. Recent research by Korn Ferry International — one of the largest international consultancy groups for organizational behavior — suggests that women are better at using soft skills, such as demonstrating empathy, adapting to changing work environments, working as part of a team, and managing conflict. Thus, while this stereotype leads to the perception that women are ill-fit for leadership in the workplace, in fact, female leaders are badly needed.

Stereotype #2: Women do not take their career or jobs as seriously as men, and thus are not as dedicated to the work.

The understanding that men are more serious in their endeavors to earn a living is very common, reminiscent of the historical archetype of men as the provider. Conversely, women are often perceived to have other concerns that supersede their interest in the workplace, such as a family. A young professional woman may be independent, confident, and entirely dedicated to her work, yet these factors are overlooked if she also has a family to care for (this relates to our third stereotype). Meanwhile, a single woman is either thought to be just waiting to establish her family in the future, or, if she is older, is subject to a number of other negative stereotypes of single professional women. Meanwhile, men — irrespective of their marital and familial status — are perceived to have unfaltering determination and commitment to their work.

Stereotype #3: Women are primarily responsible for their children and hence will take more breaks from work and inevitably put in less hours as compared to men.

As just mentioned, when a professional woman has a family, it is often assumed that she prioritizes her role as a mother over her career. This is, however, not the case for fathers. As parental roles (like employment) continue to evolve, women and men seem to be sharing more of the responsibilities that were once assumed to be a mother’s job. In this regard, our professional culture should embrace these changing family dynamics, and flexibility should be shown not just to mothers but to parents in general. Such a change will reduce the negative effect that this stereotype has had on women, whose career potentials are often seen to be limited by nature of their motherhood.

These three stereotypic depictions, and no doubt many more, plague women in the professional sphere. Even as formal barriers to entry have come down (i.e., women are now allowed to join professions that were once male-only), these perceptional hurdles have not diminished. Compounded with other racial, ethnic, and socioeconomic barriers, these stereotypes inhibit the contribution of women, particularly minority women, the world over. By discouraging women from participating in the labor force — or segmenting them to specific roles — we hold back the enormous potential for growth and gains to human capital that would result of full-inclusion in the workplace, gender and otherwise. To this end, developing countries are put at an even greater disadvantage.

Allowing women to work, without barriers, will improve outcomes for everyone. The question that falls on use is how do we mold these misperceptions such that we can move past them? Will we ever be able to fully move past them? Success in this endeavor can come only from a collaborative initiative, which aims to ease these burdens so often faced by women, and pushes men to be more forceful advocates and supporters of women’s choices. Most importantly, women need to step up to support women and their choices inside and outside the home.

Are We Happier Than We Think We Are?

Would you like to feel happier?

Shortly before his untimely death, University of Chicago professor Hillel Einhorn weighed in on this issue in a rare interview. His advice: focus less on what you wish for and more on what he referred to as “non-occurrences:” the things you haven’t experienced.

Einhorn’s argument is that feelings of happiness ultimately boil down to one’s “haves” and “wants.”

In our minds, we tend to categorize these into three groups.

The first category consists of the things we have that we want to have. A loving family, a good job, a nice house, and most of our possessions fall into this group. These are around us all the time, they are easy to remember and experience. We feel grateful to have them. They make us happy.

The second category includes the things we have but don’t want. These can be diseases, extra weight, an undesired job, financial difficulties, and some other personal attributes we could do without. Their presence bothers us and makes us miserable.

The third category includes the things we would like to have but don’t. More money, better health, a bigger house, a luxurious car would be in this group. Like the items in the previous category, thinking about these also comes easily and makes us unhappy.

Einhorn suggested that we spend so much time and energy pondering the content of these three categories that we fail to consider the fourth yet crucial category of “non-occurrences:” Things we don’t want and don’t have. Everything that we have not experienced and we really wouldn’t wish to experience.

Consider, for example, the diseases and the physical and psychological challenges we may be fortunate enough not to live with. Or the pains we don’t feel, the problems we don’t need to solve, and the misfortunes we may have the immense luck not to have suffered. The list can go on and on and on…

This fourth category has three important features. First, like the first category, thinking about it would make us happy. Second, it is arguably much larger than the previous three combined. It’s almost infinite for most citizens in a developed country. And third, unlike the other categories, it does not come easily to mind because it does not depend on what we have experienced. It’s about what we haven’t!

Unhappy due to experience

Our personal experience drives much of what we feel and learn. It’s considered a great teacher. In this case, however, it ends up narrowing our perspective and reducing our happiness by making it hard for us to think about these horrible, yet possible non-occurrences in our lives.

Thus by failing to consider the fourth category, people typically judge themselves to be less happy than they actually are. To assess our happiness, we should get better at “counting our blessings” in terms of not only what we have, but what we don’t have as well.

An easy hack to form this habit could be to start making a list of things that belong to the fourth category. Everyone’s list will be different. Yet this exercise would help make these non-occurrences more accessible to one’s experience and intuition.

To the extent that happiness is driven by the correlation between “wants” and “haves,” an accurate assessment needs to consider all four cells of the 2×2 table that Einhorn drew to help himself remember the fourth category.

Looking and thinking about this figure should already make you feel happier than you are at this very moment.