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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

  • 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

    http://www.hrblock.com/index.htmlhttp://www.hrblock.com/index.html

  • 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

    Slide Number 1Slide Number 2Slide Number 3Slide Number 4Slide Number 5Old USDA Food PyramidSimplify:�New USDA Food PlateSlide Number 8Gas Consumption as a Function of MPGOld Fuel Economy LabelSlide Number 11What Kind of Metrics?MenusMenusMenusMenusMenusMenusMenusMenusMenusMenusSlide Number 23Slide Number 24Slide Number 25Reminders to Buckle Up Reminders Must Be TimelyFeedback�Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37Slide Number 38Slide Number 39How do we reduce energy usage?Energy Use and NormsSlide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49FAFSA-Completion ChannelFAFSA-Completion ChannelSlide Number 52Selective Exposure: The Case of EatingSlide Number 54Defaults & Organ DonationDefaults & Generic DrugsSlide Number 57Slide Number 58Slide Number 59Grouping EffectsSlide Number 61Turnout ResultsPlanning Prompts and Flu VaccinationImpact on Flu VaccinationSlide Number 65Slide Number 66