Applying Behavioral Economics to Public Health Policy

Jennifer L. Matjasko, et al in the American Journal of Preventive Medicine: “From the beginning, health has been recognized as a fertile area for applying nudges. The subtitle of the bookNudge is Improving Decisions about Health, Wealth, and Happiness. In their discussion of health behaviors, Thaler and Sunstein propose new nudges in health, such as simplifying decision making in Medicare. In fact, section 1511 of the Affordable Care Act requires large employers to automatically enroll workers into health insurance; similar to the previous example on organ donation, this switched from an opt-in to an opt-out system in order to harness the power of defaults. We will provide examples in which concepts from behavioral economics were applied to public health policy and led to improvements in health attitudes and behaviors. A summary of these applications is provided in Table 1.

Nudges can be effective because people are influenced by stimuli that are visible and new; thus, at least in theory, small changes can lead to behavior modification. Several studies have found that simply prompting (nudging) individuals to make a plan increases the probability of the subject eventually engaging in the prompted health behavior, such as immunizations, healthy eating, and cancer screening. For example, one study found that e-mailing patients appointment times and locations for their next influenza vaccination increased vaccination rates by 36%. Another intervention was even simpler. Rather than assigning a date and time for the patient to be vaccinated, patients were simply mailed a card that asked the patient to write down the day or day and time they planned to get the influenza vaccine (they were also sent the day and time of the free influenza vaccine clinics). Relative to a control condition (people who only received the information about the day and time of the clinics), those prompted to write down the day and time they planned to get the influenza vaccine were 4.2 percentage points (12.7%) more likely to receive the vaccine at those clinics. Those prompted to write down the date but not the time were not significantly more likely to be vaccinated at the clinics. Decision heuristics, such as highlighting consensus, may also help. Highlighting descriptive norms among a group of trusted experts, or priming (e.g., that 90% of doctors agree that vaccines are safe) can significantly reduce public concern about (childhood) vaccines and promote intentions to vaccinate.

The significant influence of framing has been demonstrated in many public health domains, such as messaging about blood transfusion,  smoking cessation, sunscreen use, and mammography utilization. In particular, gains-framed messages (i.e., emphasizing the health gains of a behavior or treatment) were more likely to have a positive impact on the attitudes toward activities targeting prevention (e.g., blood safety, sunscreen use, smoking cessation). Loss-based messages may be more effective at encouraging screening behaviors, such as mammography screening. This points to the importance of testing messages for the uptake of preventive services among varying subgroups, many of which are now covered without cost-sharing as a result of the coverage of preventive services mandated in the Affordable Care Act.

Detailed Illustrative Examples (More)”