Incorporating behavioral economics in PT Research

Transcription

1 Incorporating behavioral economics in PT Research A How (not) To Daniel Pinto, PT, PhD and Julie Miller, PhD, MPH

2 Plan for today s workshop 1. What is Behavioral Economics (BE)? 2. What are some of the main BE principles and where are they being applied? 3. Test what you have learned so far (with help from friends) 4. Overview of how to use BE in research 5. Group Mapping Activity: Remodel a research study using BE 6. Discussion of the often overlooked limitations of BE and how to avoid some potential pitfalls

3 Traditional assumptions about decision-making Homo Economicus can think like Albert Einstein, store as much memory as IBM s Big Blue, and exercise the willpower of Mahatma Gandhi Traits 1. Hyper-rational 2. Preferences are already formed before entering the marketplace 3. They maximize completely 4. Make purely self interested decisions O Boyle EJ. Stor. Pensiero Econ. 2009

4 Human behavior and health Mokdad et al. JAMA Tencza et al, Demogr Res

5 Ponzo illusion

6 Human decision makers Bounded Rationality (Herbert Simon, 1955, 1956) Strict cognitive limits on memory and processing We use heuristics (short cuts) to handle many decisions People satisfice versus maximize Ecological rationality (Gigerenzer & Goldstein, 1996) Rationality depends on structures in the environment Best possible use of limitations Can lead to near-optimal inferences

7 Dual-Process Theories and Behavior Type 1 Processes Fast, Implicit High capacity Nonconscious Automatic, Associative Independent of Cognitive Ability Evolved Early Biased Responses Experience-based Type 2 Processes Slow Capacity limited Conscious Abstract Rule-Based, Controlled Related to Cognitive Ability Evolved Late Normative Responses Consequential Evans & Stanovich. Perspectives Psychol Sci 2013

8 Dual process theories and behavior System 1 System 2

9 Behavioral Economics A field of study that suggests human decisions are strongly influenced by context, including the way in which choices are presented to us. Behavior varies across time and space, and it is subject to cognitive biases, emotions, and social influences. Decisions are the result of less deliberative, linear, and controlled processes than we would like to believe. Human decision-making departs frequently, significantly and predictably from rational expectations

10 Current Behavioral Strategies and Limitations Mogler et al. J Gen Intern Med. 2013

11 Behavioral Strategies Using BE Mogler et al. J Gen Intern Med. 2013

12 Initiating efforts Factors Knowledge and beliefs Costs and barriers Motivation Considerations Ostrich effect, ambiguity bias, and overconfidence Present bias Social Norms Goal gradient

13 Why education often fails Ostrich effect - people deny and dismiss information that they find frightening. Ambiguity aversion- people stick to what they know

14 Why education often fails Overconfidence Instead of best driver you may be intervening on physician hand washing where clinicians think they have above average immunity. Availability bias I can t remember the last time I got sick from a patient. Grant & Hoffman. Psychol Science 2011

15 Present bias People place an overly high value on the present and an overly low value on the future, even when choices will negatively impact them in the future. Short term Exercise versus relaxing Long term Good health in the future

16 OVERCOMING PRESENT BIAS Commitment devices Committing your future self to follow-through Voluntarily imposed arrangements that restrict future behavior to avoid temptation. Leveraging the influence of existing social network Creating social consequences for failing to achieve goals Disappointing exercise partners Having family members informed when patients do not adhere to medication regimens

17 Commitment lottery your name could be drawn but weekly winners were only eligible for their prize if they attended their gym at least twice that week (the week goal). Short term commitment lottery - 13 weekly lotteries worth 100 each Long term commitment lottery 13 week intervention + After 26 weeks a luxury family-vacation voucher randomly drawn participant. van der Swaluw et al. J Behav Med 2018

18 van der Swaluw et al. J Behav Med 2018

19 Overcoming Present Bias Reward Substitution Immediate rewards which appeal to people s impulsive nature can be used to motivate behaviors that are beneficial in the long run.

20 Holding the Hunger Games Hostage at the Gym: An Evaluation of Temptation Bundling Full intervention audio book access restricted to the gym. Visited the gym 51% more than control. 61% of participants opted to pay to have gym only access to ipods with tempting audio books. Milkman KL, Minson JA, Volpp KG. 2014

21 Social Norms A person s belief about the degree to which other people in a setting engage in a specific behavior. Injunctive norms - what ought to be done, pressures that persons perceive from members of their reference group Descriptive norms - what most people do, behavioral prevalence

22 Physical activity promotion among seniors Exposed to implicit descriptive norm information. They were shown the heading of the news report increasing numbers of exercising older adults in the local community and were asked to choose one of two photos showing older adults engaging in physical activities to include in the news report. Koeneman et al. BMC geriatr 2017

23 Incentives Process and outcomes Faming Altruism Lottery vs deposit contract Team-based

24 Goal gradient People will work harder to achieve a goal as the goal gets closer. May improve self-efficacy, even before full disease control is achieved Coffee purchases were accelerate as progress is made toward reward Kivetz, Urminsky, Zheng. Marketing Research 2006

25 Implementation Intentions Specific plans as to when, where, and/or how an action will be taken. Implementation intentions switch action control from effortful, reflective, topdown control by goals to efficient, automatic, bottom-up control by specified stimuli. Automate action control so that even though the goal was set consciously, subsequent goal striving runs off automatically.

26 Brief Action Plan

27 Thank you Daniel

28 Behavioral Economics in Research

29 Work with human limitations not against them!!!

30 How do you do this? 1.Understand decision making & set the correct context 2.Align incentives properly 3.Set good defaults 4.Give feedback and allow for correction 5.Anticipate failure and continually modify

31 Friction 1. Behavioral Economics as the primary form of intervention Defaults Change Framing or Affect Social norms and incentives

32 Friction 2. Behavioral Economics as a way to increase engagement with the primary intervention Implementation Intentions and Choice Overload Change Framing or Affect Social norms and incentives

33 3. Behavioral Economics to optimize the research process Defaults, Friction, and Cognitive Burden Self-signalling & Endowment Effect Identifiable Victim Social norms and incentives

34 Current BE applications for each of these three research levels/problems Frequency Range of fields Types of behaviors Shifts in field Effectiveness Funding and academic journal interest Other important considerations

35 How to apply BE to research- Part 1 Identify Level: Identify which one of the 3 levels/problems you are interested in addressing (which main problem are you trying to tackle with BE?) Define Target: Specifically define the best target for the BE approach (who is it that you are trying to get to change their behavior) Map Behavior: Map the behavior from the perspective of the target (what are all of the steps that they need to take to complete the desired behavior and what are the barriers) Find Opportunities: Using the map, identify which barriers are psychological in nature or could be overcome with a BE intervention (where are the opportunities for a BE solution, don t pick structural barriers for a BE solution)

36 How to apply BE to research- Part 2 Generate Interventions: Using your Cheat Sheets and knowledge of the biases, brainstorm (both privately and as a group) some possible BE solutions/interventions that you think might work and that you could test Review Literature: Conduct a basic literature review of similar BE solutions and success for your target behavior. (See handout for guidance*) Seek Help: If unclear or complicated, consult with a behavioral scientist!!!!! Iterate or Shift: Make needed adjustments to your proposed BE interventions based on your literature review, feedback from others, and practicality (consider impact on primary intervention if BE is secondary) Implement: Implement your BE intervention as an experiment. Collect data and utilize to determine how to move forward and document success/failure.

37 Some tips! Start small and simple- behaviors and interventions Be as clean as possible Pick interventions/biases that are well-researched (don t reinvent the wheel) Take time to think through the implementation- especially your population Make sure you have a recorded hypothesis and method to collect data Be open to failure and iterations Form partnerships!!!!!!! Be sure to do a literature review of the right types of journals (keywords) When you publish, you can report about both the BE aspects and the PT aspects and have appeal across multiple fields

38 Group Mapping Activity 1. Find your group 2. Review the materials that you have been given (individually and as a group) 3. BE it up! 4. As a group, identify your favorite BE interventions as well as plans to test each. Record on the large papers. 5. Showcase and voting 6. Come back together

39 Group Mapping Activity- BE it up! 1. Brainstorming BE interventions. They can be ridiculous at this point! It is all about quantity. Use your cheat sheets and anything else you need. 2. Generate your ideas in this order: ( about minutes on your own) a. BE as the primary intervention b. BE as a way to boost engagement with the primary intervention c. BE to optimize the research process 3. Talk about one level/problem at a time. As a group, discuss your ideas and cluster similar solutions together. Narrow them down to only interventions that can be implemented and where data can be collected. Make sure all ideas are heard. As a group, select your favorite intervention. 4. Record this idea on your large paper along with predicted outcomes. 5. Move on to the next main problem/level.

40 Group Mapping Activity- Showcase Walk around the room and review all of the proposed interventions. Use the dots to vote. Place dots on your top three solutions. Winners announced and brief recap.

41 When good BE goes bad... Goal: Reduce your time on EPIC by 1 hour a week Take a short walk at lunch instead of working in EPIC You have spent x hours in EPIC this month. Other doctors at Duke spend less time in EPIC than you do.

42 BE is not a silver bullet or golden hammer- TEST! Even the best laid plans... The details matter, a lot

43 Incentives Implicit motivation, explicit motivation, and trait labeling

44 Gamification

45 Some limitations of BE Individual differences (e.g. gender, personality, health status, tech ability) influence the way the interventions work: One size fits MOST Some things have not been studied yet- like repeated or long-term incentives The details matter a LOT- the right behavior, the right time, the right intervention (not as easy as it seems) May complicate research findings if not done well Requires testing and iteration

46 How to avoid common pitfalls Use interventions that are empirically-supported for behaviors and populations that are similar only Don t mix a bunch of BE interventions together Don t use BE interventions that were designed for single-time use repeatedly and expect them to work the same way Consider the characteristics of your sample and staff Listen to feedback, get pilot data when possible Make sure you are targeting the right behavior at the right time!!!!! Collect and use data and iterate when needed, you never know when things could backfire

47 When do you need to get a consult or partner with a behavioral scientist? Consider doing this regardless. It can be mutually beneficial and enhance your work. But, make sure to consult if There are multiple factors influencing a behavior Identifying the key behavior is difficult The literature was mixed You have limited resources It is hard to analyze the data for effectiveness because not enough people did the intervention Recruitment is very slow There is reactance You hit a road block and things are not working the way you think they should

48 How do you find a behavioral scientist? 1. Create a long-term partnership with academic researchers (Center for Advanced Hindsight- Duke, CHIBE- UPenn, Behavioral Insight Group- Harvard, etc.) 2. Work with a non-profit or government group (Behavioral Insights Team- UK, Ideas42, etc.) 3. Use a consulting group (Val Health, TGG group, BE Works) 4. Have no money? That is OK- many behavioral scientists will trade expertise for data that they can write up and get publications. Or- find an intern or students studying BE at one of these places listed above.

49 Thank You and Questions!