2015 Explaining Health Behavior: Insights from Behavioral

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HARVARD SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF SOCIAL & BEHAVIORAL SCIENCES

2015

Explaining Health Behavior: Insights from Behavioral Economics Spring 2: March 23 –May 13, 2015 Monday & Wednesday, 1:30-3:20 pm

Classroom: Kresge G-1

Instructor: Ichiro Kawachi, M.D., Ph.D.

Professor of Social Epidemiology

Chair, Department of Social & Behavioral Sciences

E-mail: [email protected]

Teaching Assistants:

Flora Or

e-mail: [email protected]

Michael Gilbert

e-mail: [email protected]

Course Objectives The course introduces students to the application of theories and constructs from behavioral

sciences (particularly behavioral economics and social psychology) to the field of health

behavior. Individual sessions will cover foundational concepts in behavioral economics,

including: a) bounded rationality and dual process theory; b) heuristics and biases in decision-

making; c) prospect theory, framing effects, and loss aversion, d) choice architecture, asymmetric

paternalism and the use of default options (“nudges”); e) the problem of inter-temporal choice,

self-control, and addiction; and f) the optimal use of incentives vs. commitments to promote

behavior change. Examples of questions posed by the class include: "How can we incorporate

novel insights from behavioral economics to improve the success of behavior change (e.g. to

reduce obesity or promote smoking cessation)?”; “How can incentives be crafted to guide

consumer choice? For example, why is a tax on junk foods more effective than subsidies for

healthy foods?”

What This Course is Not

This course is designed as a non-technical survey of the application of behavioral economics

insights to behavior change. It does not delve into formal theories in behavioral economics

(translation: there are very few equations in my lectures), and hence, the course does not have

mailto:[email protected]



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prerequisites such as prior course-work in economics. Students looking for a course on

behavioral economics taught by a behavioral economist should look to the class taught by

Margaret McConnell, Assistant Professor of Global Health Economics in GHP (“Behavioral

Economics and Global Health”), or classes taught in KSG or FAS (e.g. by Todd Rogers, Sendhil

Mullainathan, David Laibson, and others).

Pre-requisites: None. The course fulfills the theory requirement for Masters level students in

SBS, MPH students in the professional stream, and will be of interest to students taking the

Health Communications Concentration.

Format: Lectures.

Final Course Grade Distribution

Final Course Grades will be distributed as follows:

Mid-term quiz (April 22) 30%

Final Exam (May 13) 70%

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2015 Spring 2 Session

Explaining Health Behavior: Insights from Behavioral Economics Room Kresge G-1 –Monday& Wednesday, 1:30-3:20

Session 1 – March 23 (Monday)

Topics:

Introduction to the course.

Bounded rationality and dual process theory

Instructor: Professor Kawachi

Lesson Objectives:

1. Understand the relevance of behavioral economics for explaining health behavior.

2. Define the classical economics account of “rationality” and contrast it with the behavioral

economics concept of “bounded rationality”.

3. Explain dual process theory and the two systems of cognition.

4. Describe three major heuristics used by System 1: the availability heuristic, the

representativeness heuristic, and the affect heuristic.

Readings:

1. Tversky A & Kahneman D (1974). Judgment under uncertainty: Heuristics and biases.

Science 185: 1124-1131.

2. Kawachi, I (2014). Chapter 13 (pp. 478-511): Applications of behavioral economics to

improve health. In: LF Berkman, I. Kawachi & MM Glymour, eds. Social Epidemiology,

2nd

edition. New York: Oxford University Press.

Session 2 – March 25 (Wednesday)

*LOCATION IN HMS *

Topic: Emotions and the affect heuristic


Learning Objectives:

• Understand how emotions affect judgment and choice via the affect heuristic.

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• Understand the differences between emotion-based and cognition-based judgments in

decision-making.

• Explain the concepts of evaluability and proportion dominance.

Readings:

1. George F. Loewenstein, Elke U. Weber, Christopher K. Hsee & Ned Welch. Risk as

feelings. Psychological Bulletin 2001; 127(2):267-86. Article doi: 10.1037//0033-

2909.127.2.267.

2. Finucane M, Alhakami, Slovic P & Johnson SM (2000). The affect heuristic in judgments

of risks and benefits. Journal of Behavioral Decision Making 13:1-17.

3. Loewenstein G. Hot-cold empathy gaps in medical decision making. Health Psychology

2005;24(4), Suppl: S49-56.

Session 3 – March 30 (Monday)

Topic: Anchors, choice architecture, default options (“nudges”) & asymmetric

paternalism



1. Describe the influence of decoy effects and anchoring bias on decision-making and

choice.

2. Describe the use of default options, “nudges”, and “choice architecture” to guide

behavior.

3. Contrast “asymmetric paternalism” with classical paternalism, as applied to public health

policy.

4. Explain Wansink’s concept of “mindless eating” and the use of portion size control to

curb over-eating.

Readings:

1. Brian Wansink, David R. Just & Collin R. Payne. Mindless eating and healthy heuristics

for the irrational. American Economic Review: Papers & Proceedings 2009;

99(2):165-169. http://www.aerweb.org/articles.php?doi=10.1257/aer.99.2.165.

2. Sue D. Pedersen, Jian Kang & Gregory A. Kline. Portion control plate for weight loss in

http://www.aerweb.org/articles.php?doi=10.1257/aer.99.2.165

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obese patients with type 2 diabetes mellitus. A controlled clinical trial. Arch Intern

Med 2007;167:1277-1283.

3. Julie S. Downs, George Loewenstein & Jessica Wisdom. Strategies for promoting

healthier food choices. American Economic Review: Papers & Proceedings 2009;

99(2):1-10. http://www.aerweb.org/articles.php?doi=10.1257/aer.99.2.1

Session 4 – April 1 (Wednesday)

Topics:

Prospect theory, loss aversion, and endowment effects.

Framing effects



1. Explain concept of loss aversion from prospect theory.

2. Discuss the utility as well as the limitations of the use of loss-framed messages in health

communication.

3. Contrast framing effects in behavioral economics vs. sociology.

Readings:

1. Daniel Kahneman & Amos Tversky. Prospect theory: An analysis of decision under risk.

Econometrica 1979;47:263-291.

2. Alexander J. Rothman, Roger D. Bartels, Jhon Wlaschin & Peter Salovey. The strategic

use of gain- and loss-framed messages to promote healthy behavior: How theory can

inform practice. Journal of Communication 2006;56:S202-S220. [see also dissenting

opinion by -- Daniel O’Keefe & Jakob D. Jensen. The relative persuasiveness of

gain-framed and loss-framed messages for encouraging disease detection behaviors:

A meta-analytic review. Journal of Communication 2009;59:296-316.]

3. Matthew C. Farrelly, Cheryl G. Healton, Kelvin C. Davis, Peter Messeri, James C. Hersey

& Lyndon Haviland. Getting to the Truth: Evaluating national tobacco counter-

marketing campaigns. American Journal of Public Health 2002;92:901-907.

Session 5 –April 6 (Monday)

http://www.aerweb.org/articles.php?doi=10.1257/aer.99.2.1

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Topic: Inter-temporal choice and the problem of self-control



1. Understand the concept of inter-temporal choice as applied to health behavior.

2. Critically analyze the classical discounted utility model (DUM) from classical economics,

and contrast it with hyperbolic discounting from behavioral economics.

3. Discuss approaches by which time preference has been assessed empirically.

4. Understand the health policy implications of the behavioral economics approach to

modeling inter-temporal choice.

Readings:

1. Frederick S, Loewenstein G & O’Donoghue T (2002). Time discounting and time

preference: A critical review. J Econ Lit 40(2):351-401.

2. Rajeev Cherukupalli. A behavioral economics perspective on tobacco taxation.

American Journal of Public Health 2010;100:609-615.

Doi:10.2105/AJPH.2009.160838.

3. McLure SM, Ericson KM, Laibson DI, Loewenstein G & Cohen JD (2007). Time

discounting for primary rewards. J Neurosci 27(21):5796-5804.


Topic: Incentives vs. Commitments



1. Distinguish between the use of incentives vs. commitments to influence behavior.

2. Describe the pros and cons of incentives vs. commitments.

3. Understand the principles of designing optimal incentives and commitments.

4. Describe the behavioral economics principles involved in “super-charging” incentives to

alter behavior.

Readings:

1. Volpp KG et al. Financial incentive-based approaches for weight loss. A randomized

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trial. JAMA 2008;300:2631-7.

2. Volpp KG et al. A randomized controlled trial of financial incentives for smoking

cessation. NEJM 2009; 360:699-709.

3. Xavier Giné, Dean Karlan & Jonathan Zinman. Put your money where your butt is: A

commitment contract for smoking cessation, Journal of Economic Literature, December

2008.

Session 7 – April 13 (Monday)

1.30 – 2.30 pm

Preparation for mid-term quiz (self-directed study)

2.30 – 3.20 pm

Topic: Behavioral economic interventions to promote healthy food choices

Guest Lecturer: Anne Thorndike, Assistant Professor of Medicine, Massachusetts General

Hospital

Readings:

1. Thorndike AN, Riis J, Sonnenberg LM, Levy DE. Traffic-light labels and choice

architecture: promoting healthy food choices. Am J Prev Med. 2014 Feb;46(2):143-9.

doi: 10.1016/j.amepre.2013.10.002.

2. Sonnenberg L, Gelsomin E, Levy DE, Riis J, Barraclough S, Thorndike AN. A traffic

light food labeling intervention increases consumer awareness of health and healthy

choices at the point-of-purchase. Prev Med. 2013 Oct;57(4):253-7. doi:

10.1016/j.ypmed.2013.07.001.

3. Thorndike AN, Sonnenberg L, Riis J, Barraclough S, Levy DE. A 2-phase labeling and

choice architecture intervention to improve healthy food and beverage choices. Am J

Public Health. 2012 Mar;102(3):527-33. doi: 10.2105/AJPH.2011.300391. Epub 2012

Jan 19. Erratum in: Am J Public Health. 2012 Apr;102(4):584.

4. Levy DE, Riis J, Sonnenberg LM, Barraclough SJ, Thorndike AN. Food choices of

minority and low-income employees: a cafeteria intervention. American Journal of

Preventive Medicine. 2012;43:240-248.

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1.30-2.20 pm

Topic: Behavioral approaches to reducing sugar-sweetened beverage consumption.

Guest Lecturer: Jason Block, Assistant Professor of Medicine, Harvard Medical School

Readings:

1. Block JP, Chandra A, McManus KD, Willett WC. Point-of-purchase price and education

intervention to reduce consumption of sugary soft drinks. Am J Public Health. 2010

Aug;100(8):1427-33. doi: 10.2105/AJPH.2009.175687.

2. Block JP, Gillman MW, Linakis SK, Goldman RE. "If it tastes good, I'm drinking it":

qualitative study of beverage consumption among college students. J Adolesc Health.

2013 Jun;52(6):702-6. doi: 10.1016/j.jadohealth.2012.11.017.

3. Block JP, Condon SK, Kleinman K, Mullen J, Linakis S, Rifas-Shiman S, Gillman MW.

Consumers' estimation of calorie content at fast food restaurants: cross sectional

observational study. BMJ. 2013 May 23;346:f2907. doi: 10.1136/bmj.f2907.

4. Block JP. A substantial tax on sugar sweetened drinks could help reduce obesity. BMJ.

2013 Oct 31;347:f5947. doi: 10.1136/bmj.f5947.

2.30-3.20 pm Topic: Can we nudge our way to better food choices?

Guest Lecturer: Christina Roberto, Assistant Professor SBS.

Readings:

1. Chandon P, & Wansink B. Does food marketing need to make us fat? A review and

solutions. Nutrition Reviews, 2012;70: 571-593.

2. Schwartz J, Riis J, Elbel B, Ariely D. Inviting consumers to downsize fast-food portions

significantly reduces calorie consumption. Health Affairs, 2012;31:399-407.

3. Liu P.J., Wisdom, J., Roberto, C.A., Liu, L.J., & Ubel, P.A. (in press). Using behavioral

economics to design more effective food policies to address obesity. Applied Economic

Perspectives and Management.

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April 20 (Monday) Patriot’s Day (Boston Marathon)


1.30-2.20 pm MID-TERM QUIZ – see sample from previous year attached to the syllabus

2.30-3.20 pm

Topic: mHealth for boosting compliance with medical treatment

Guest Lecturer: Dr. Trishan Panch, MD MPH

Chief Medical Officer

Wellframe

Session 10 – April 27 (Monday)

Guest Lecture by BurnsGroup, a New York City-based advertising agency:

Speakers: Joanne McKinney, Alison Earl, Scott Buckley

Topic:

A COMMERCIAL LENS TO DRIVING BEHAVIOR CHANGE

A provocative perspective on target and insight, driving creative thinking at all stages of change

A 2-PART LECTURE:

FIRST HOUR: Exploration of targeting, segmentation and insight in the context of behavior

models and demonstrated through real life advertising examples

SECOND HOUR: Break-out session, to put theory into practice — developing insight, creative

brief and marketing ideas for addressing compliance/adherence in smoking cessation.

PRE-WORK:

In advance of the class, students will be provided insights (actual consumer quotes) from 100

recently relapsed smokers, answering the question as to how they feel about their relapse.

Students will be asked to review the quotes before class, and come with their own ideas on an

overriding and driving insight to the mindset of the failed quitter, gleaned from the quotes. We

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will work in small groups to define insights, craft a creative brief (format provided) and

brainstorm marketing ideas to share with the class in the final 15 minutes.


Topic: Social influence



1. Describe key constructs and measures (reachability, degree & closeness centrality,

betweenness) in sociometric analysis.

2. Describe the “three degrees of influence rule”.

3. Critically analyze the threats to causal inference in empirical studies of social influence

across social networks.

Readings:

1. Thomas W. Valente, Peggy Gallaher & Michele Mouttapa. Using social networks to

understand and prevent substance use: A trans-disciplinary perspective. Substance Use &

Misuse 2004; 39(10-12):1685-1712.

2. Nicholas Christakis & James Fowler, The spread of obesity in a large social network over

32 years. New England Journal of Medicine 2007;357:370-9.

3. Christakis N & Fowler J. The collective dynamics of smoking in a large social network.

NEJM 2008;358:2249-58

4. Lyons R. The spread of evidence-poor medicine via flawed social-network analysis.

Statistics, Politics, and Policy. 2011; 2(1): 1-26.

Session 12 – May 4 (Monday)

Topics:

Social norms

Strategic interactions, social preferences, and behavioral game theory.



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1. Define what is a “norm” – how is it different from customs

2. Explain the rational choice theory account of norms. Critique it.

3. Describe game theoretical accounts of norms (e.g. the norm for fairness and reciprocity).

Readings:

1. James S. Coleman. The Demand for Effective Norms (chapter 10). In: James S. Coleman.

The Foundations of Social Theory, Cambridge, MA: The Belknap Press of Harvard

University, 1990, pp. 241-59.

2. Jon Elster. Coleman on social norms. Revue Française de Sociologie 2003; 44(2):297-

304.

3. Karine Nyborg & Mari Rege. On social norms: the evolution of considerate smoking

behavior. Journal of Economic Behavior & Organization. 2003; 52:323-340.doi:

10.1016/S0167-268(03)00031-3.

Session 13 – May 6 (Wednesday)

Topic: Expectations – and why behavior interventions occasionally misfire



1. Understand how our expectations shape our subsequent experiences.

2. Provide examples of how expectations can be manipulated to influence choice (in either

healthy or unhealthy directions).

3. List and describe situations under which behavioral interventions can misfire –

substitution effects, behavioral compensation, “mere peanuts”, moral licensing and “what

the hell” effects.

Reading:

Roberto, C. & Kawachi I. (2014). Use of Psychology and Behavioral Economics to Promote

Healthy Eating. Am J Prev, Dec;47(6):832-837. doi: 10.1016/j.amepre.2014.08.002.

Session 14 – May 11 (Monday)

Topic: Behavioral economics and health policy – what it adds and does not add.

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1. Critique the potential of applying behavioral economics to health care policy (e.g.

designing employee health incentives).

2. Debate the application of behavioral economics to public health policy (e.g. recent

debates in UK government).

Readings:

1. Volpp KG, Pauly MV, Loewenstein G, Bangsberg D. P4P4P: An agenda for research on

pay-for-performance for patients. Health Affairs 2009; 28: 206-14.

2. Marteau TM et al. Judging nudging: can nudging improve population health? BMJ

2011;342:d228.

Session 15 – May 13 (Wednesday)

FINAL EXAM (2 hour written exam in short-answer format)

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Student Name: _____________________

MID-TERM QUIZ (from 2014) SBS 503 “Explaining Health Behavior”

Instructions

1. Write down your name at the top of this sheet ☺

2. You have 50 minutes (1.30-2.20 pm) to complete this quiz – write down your answers in

the space provided.

Question 1 Fear appeals are commonly used in graphic warning labels on cigarette packs. List the reasons why they can backfire?

Question 2 Anti-smoking campaigns frequently appeal to the emotion of sadness. Explain why this might backfire.

Question 3 Why are health claims (such as “low fat” labels) advantageous for junk food manufacturers, but are often counter-productive from the point of view of encouraging actual healthy food choices?

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Question 4 In order to boost compliance with cancer screening, which is more effective – messages that emphasize the loss in quality of life from delayed diagnosis, or messages that emphasize peace of mind from knowing your result? Why? (justify your answer). Question 5 Subsidies on healthy beverages (e.g. bottled water) are politically more popular than taxes on unhealthy beverages (sugar-sweetened beverages), but they are also less likely to be effective in guiding consumer choice. Why?

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TA resources What Heroin Addiction Tells Us About Changing Bad Habits. January 5, 2015 NPR story about heroin addiction in Vietnam (featuring interviews with Wendy Wood). http://www.npr.org/blogs/health/2015/01/05/371894919/what-heroin-addiction-tells-us-about-changing-bad-habits?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150105

http://www.npr.org/blogs/health/2015/01/05/371894919/what-heroin-addiction-tells-us-about-changing-bad-habits?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150105




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2015 Explaining Health Behavior: Insights from Behavioral