Behavioural Economics and The Prevention of Noncommunicable

Transcription

1 ActionSanté - Tuesday November Behavioural Economics and The Prevention of Noncommunicable Diseases What Role and Opportunities for the Private Sector? Prof. Dr. Benjamin G. Voyer BA, MSc, MRes, MSc, MPhil, PhD, DSc (HDR), CPsychol, CSci, MCIM, AFBPsS, FRSA - L OREAL Professor of Creativity & Marketing ESCP Europe Business School Visiting Lecturer Department of Psychological & Behavioural Science London School of Economics & Political Science 1

2 PRESENTATION OUTLINE 1.The Behavioural Economics Revolution 2.BE Principles with applications for promoting dieting & physical activity 3.Case Studies tackling NCDs using Behavioural Economics to Drive Change 4.Recommendations and conclusions 2

3 1. Introduction: The Behavioural Economics Revolution How Behavioural Economics can Help Addressing and Preventing Non-Communicable Diseases 3

4 1. UNHEALTHY BEHAVIOURS ARE PARADOXICAL DECISIONS Decisions are not rational 4

5 2. NOT ALL POPULATIONS UNDERSTAND THE HEALTH RISKS OF THEIR BEHAVIOURS Delayed consequences are difficult to grasp 5

6 3. SOME HEALTHCARE MATTERS QUESTIONS REQUIRE CONSISTENT BEHAVIOURS Consistency is hard to achieve, even for motivated individuals 6

7 BEHAVIOURAL SCIENCES ADDRESS LIMITATIONS OF CURRENT HEALTHCARE PRACTICES Limitations of traditional approaches to healthcare: E.g. rational prevention campaigns E.g. shock advertising Healthcare is facing multiple challenges: From a regulator s point of view: need to get more efficient policies & reducing costs From a private sector point of view: threat to existing markets due to government interventions Behavioural economics: Tackles both cost and efficiency issues Is evidence driven, with a focus on observable & measurable outputs 7

8 W.H.O FACT SHEET ON NONCOMMUNICABLE DISEASES Noncommunicable diseases (NCDs) kill 40 million people each year, equivalent to 70% of all deaths globally. Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 80% of these "premature" deaths occur in low- and middle-income countries. Cardiovascular diseases account for most NCD deaths, or 17.7 million people annually, followed by cancers (8.8 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These 4 groups of diseases account for over 80% of all premature NCD deaths. Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from a NCD. Detection, screening and treatment of NCDs, as well as palliative care, are key components of the response to NCDs. 8

9 2. Behavioural Economics Principles with NCDs Applications Based and adapted from Sunstein s (2014) top 10 Behavioural Economics principles & Human-Centric Health: Behaviour Change and the Prevention of Non-Communicable Diseases 9

10 HYPERBOLIC DISCOUNTING (PRESENT BIAS) Hyperbolic Discounting: now! Rather than later E.g. earning less immediately, rather than earning more in a distant future Studies indicate preferences for short-term rewards Especially relevant for the management of chronic diseases Patients struggle to appreciate the benefits of small behaviours with incremental effects that can avoid long-term costly consequences Focusing on smaller, short-term goals e.g. loosing 1kg per month, in the case of weight-loss can be more beneficial than putting forward a long-term ambitious achievement (e.g. 12kg of weight loss in one year). NOW IN A WEEK 11

11 HYPERBOLIC DISCOUNTING (PRESENT BIAS): APPLICATIONS Offer opportunities for individuals to commit to better behaviour today rather than in the future Used successfully in tobacco cessation programmes / to increase exercise Present choices that bundle a current pleasure with a behaviour that will lead to better health in the future: E.g. giving recognition (e.g. badges) and rewards (gifts or financial) to those who exercise regularly Emphasize the near-term advantages of healthy behaviour rather than the benefits that might be achieved (or the harm that might become apparent) decades later. Making rewards accessible early on, rather than later, to help overcome our natural propensity to procrastinate or make excuses for inaction. 12

12 LOSS AVERSION Loss aversion: we do not like loosing / taking risks, unless there is a big reward E.g. Nobody wants to play games where you have a 50% chance of winning 5 or loosing times the potential loss is what the gain needs to be to convince people to take a risk E.g. People would be prepared to play a game where they either win 12.5 or loose 5 In healthcare: this is used by highlighting the potential losses of: Not receiving treatment Not adhering to treatment Don t forget to also state benefits (i.e. gains!) 13

13 LOSS AVERSION: APPLICATIONS Ways to take advantage of loss aversion to improve personal health: (beyond pricing & taxing) Configure positive incentives so they can be taken away (e.g. receiving a gym membership reduction when weight is kept below target) In (education campaigns) emphasise losses from unhealthy behaviour - and not just future gains from making healthier decisions For instance, point to bad breath and facial wrinkles from cigarette 14

14 FRAMING OPTIONS What are they: Most of the choices we make are relative decisions (i.e. we choose between a limited set of options) rather than absolute ones (i.e. unlimited set of options) The way in which options / alternatives are presented have an effect on how we make decisions: E.g. prices presented by ascending order lead consumers to buy cheaper options E.g. prices presented by descending order lead consumers to buy more expensive options Why this works: we only have limited cognitive resources and will be looking for shortcuts 15

15 FRAMING IN ACTION How options are framed affect the decision made by individuals (Dan Ariely, Predictably irrational) 16

16 FRAMING How this can be used in healthcare: E.g. presenting Gym membership options: Gym membership only (e.g. 60 CHF) Classes only (e.g. 120 CHF) Gym membership + classes (e.g. 120 CHF) 17

17 DEFAULT RULES What are they: making a choice for individuals or giving a default guideline to follow Why this works: Simplifies decision making; people choices made for them People do not like to make the costly effort to change a default option People don t like to disagree How this can be used in healthcare: E.g. 5-a-day E.g. Registering individuals by default on the organ donation register (people have to opt out if they do not wish to be a donor), could significantly increase organ donations. E.g. Governments have also encouraged (and in some cases required) companies to sign up employees to health insurance schemes by default in order to increase pension savings. 18

18 DEFAULT RULES Source: Johnson and Goldstein (2003) 19

19 STORYTELLING & NARRATIVES 21

20 STORYTELLING: FROM FACTS TO COMPELLING STORIES What are they: Tell compelling stories with familiar examples to drive an increase in healthy behaviour Why it works: Data alone is unlikely to drive change - stories, on the hands, especially when reflecting facts accurately, rather than simply instructing people E.g. rather than simply instructing about mortality risk increases for each year of cigarette smoking, show them a picture of a diseased lung How it can be used in healthcare: Use statistics to determine risks on which to focus, but de-emphasize dry, impersonal data when communicating risk. Instead, highlight easyto-remember that-could-happen-to-me facts. E.g. Don t say: Smoking accounts for 30% of all cancer deaths Say: Smoking is associated with 15 different kinds of cancer and your risk of lung cancer is 23 times higher if you smoke. 22

21 No parent should ever have to decide if they can afford to save their child s life J Kimmel Kimmel clips don t usually receive more than 1 million views but this story received more than 14 million in less than 24 hours. 23

22 CREATING SOCIAL NORMS What are they: social refer to commonly accepted and appropriate behaviours and signal what is expected from individuals Why this works: If everyone does it, it must be right Individuals do not want to stand out Simplifies decision making How they can be used in healthcare: Messages that incorporate social norms can help to reduce the number of missed appointments among patients: e.g. "nine out of ten people arrive at their GP appointments in time. Martin, Bassi, Dunbar-Rees (2012): 32% reduction of noncompliance. Share users recommendations (e.g. reviews) to have a consensus emerge 24

23 CREATE SOCIAL NORMS People follow norms (e.g. re-using towels in a hotel), especially when they can identify to it How can you get people to re-use their towels? 25

24 SOCIAL NORMS: IMPLICATIONS FOR DIETING / PHYSICAL ACTIVITY Social norms & dieting: Who is reaching their target weight around you? Compete with friends Compete with your self (e.g. your self 1 year ago) Social norms & sports: Who plays activity around you Compete with yourself Compete with your friends 26

25 CHOICE ARCHITECTURE: EASE & CONVENIENCE What is this: make the desired behaviour easier to engage with than the non-desired behaviour Why this works: Simplifies decision making and action (cognitive and behavioural economy) Affordances: individuals will naturally engage with the easiest option Behaviours are adopted if they are easy to adopt How they can be used in healthcare: E.g. Making healthy food more visible or accessible. E.g. Making it easy to change appointments should enhance appointment compliance, while eliciting implementation intentions (e.g. "Will you please call us if you won't be able to keep your appointment?") is known to increase compliance (Cialdini, 2008). 27

26 CHOICE ARCHITECTURE: EASE & CONVENIENCE HAPPY? 1. Push a button! (1 step) NOT HAPPY? 1. Open your phone 2. Scan a code 3. Download a form 4. Fill in the form 5. Submit it! (5 steps) 28

27 CHOICE ARCHITECTURE: EASE & CONVENIENCE Ways to recognise choice architecture and defaults to improve healthy behaviour: In shops, display healthy food prominently, giving unhealthy items a less favourable position so that buying nutritious items is the easier choice. In cafeterias, offer a healthy meal accompaniment (like an apple) as a default and require extra effort to acquire the less healthy option (such as a cake). In restaurants, offer smaller standard portions with free or lowcost refills, rather than large quantities of food or drink. The default is to eat what is presented, so consumption may decrease when portions shrink and obtaining extra food requires effort. Design buildings so that stairways are open and accessible and lifts require extra steps to reach. Make it easy to walk, and difficult to drive, in a downtown area. 29

28 CHOICE ARCHITECTURE: COMMUNICATION 30

29 CHOICE ARCHITECTURE: COMMUNICATION 31

30 DEPLETION: DESIGN ACHIEVABLE GOALS What is it about: When we have to complete many activities at the same time - or have completed a sequence of demanding activities, our attention and resources become limited and we are depleted Why it works: lack of cognitive resources lead us to use shortcuts in our decision making process How can it be used to improve health decisions: Make sure that the decision to participate in a healthy activity requires no conscious decision at all whenever possible Do not overwhelm people with too many choices E.g. Physicians should not give a dozen new instructions to a patient and expect adherence. Instead, give a small prioritised list and use once-a-day pills that will address multiple conditions. Focus attention on approaches that have the most potential benefit while requiring the least cognitive effort of the target population E.g. For instance, display the apples at the front of the shop and stack the candy at the back. 32

31 PLAY WITH HUMAN OPTIMISM What is this about: Humans are an irrationally optimistic species Evolutionary origins (survival and capacity to take risks) Optimism serves a purpose today as people compete for jobs, love and success. How it works: Examples of optimism in everyday life: Lottery ticket purchasers know the odds are stacked against them, but they feel lucky and buy the weekly ticket thinking it could be the one that makes them rich Optimism makes smokers certain they won t be among the unfortunate many who will suffer from severe lung disease. How it can be used in healthcare: Include a lottery element in health incentives to gain substantial attention for modest cost Emphasise personal accomplishment in achieving healthier behaviour playing to positive self-image. Telling someone, You look great after thinning down, can provide powerful motivation. Not expecting that exhortations of future harm will be highly motivating. Figuring present bias into the equation makes it clear that the decades-away threat of respiratory disease is too weak to motivate an optimistic smoker to quit today. 33

32 USE WARNINGS What are they: visual elements calling for immediate attention Why this works: Evolutionary based, fight or flight decisions Used as a heuristic / shortcut in the decision making process Simplifies the decision making process How they can be used in healthcare 34

33 GIVE FEEDBACK What are they: personalised quantitative and qualitative information on an individual s performance Why this works: Individuals are motivated by doing well Individuals are motivated by consistency / dislike change Individuals can adjust their behaviour if they know where they stand in comparison with a treatment, a cohort, etc Individuals struggle to naturally monitor their performance Feedback makes consequences (of a treatment or bad behaviour) more salients How they can be used in healthcare: Convince patients to quit smoking, by giving them feedback on the age of their lungs, compared with a cohort of non-smoking individuals (Parkes, Greenhalgh, Griffin, & Dent, 2008). 35

34 GIVING FEEDBACK Armellino and colleagues (2011) showed that using real-time video monitoring and feedback of hand sanitising in a critical-care unit could increase usage by more than 800%. 36

35 GIVE FEEDBACK: BREEZE APPLICATION 37

36 PRE-COMITMENT & IMPLEMENTATION INTENTIONS What: asking individuals to commit to specific behaviour ahead of time Why this works: Individuals avoid cognitive dissonance, the unpleasant feeling of having attitudes contradicted by behaviours (or vice versa) How can it be used in healthcare: Example: Committing to certain future actions, such as a smoking cessation program Example: Eliciting questions about future behaviour ( Do you plan to vaccinate your child? ) or calling attention to people's identity ("You are a voter, as your practice suggests ) 38

37 PRE-COMITMENT & IMPLEMENTATION INTENTIONS Contracts may also be used in the form of Ulysses contracts As Dan Ariely has noted, examples of potential Ulysses contracts abound in everyday life For example, one may intentionally avoid buying unhealthy foods, knowing that one s future self will overeat if such items are in the house. 39

38 3. Two Case Studies in Healthcare using Behavioural Economics to Drive Change Adapted from a 2010 discussion paper from the Behavioural Insights Team, Cabinet Office, UK 43

39 3.1. DIET & WEIGHT Six out of ten adults are overweight, costing the UK economy around 7 billion a year (2010 figures) Question: how to encourage individuals to eat more healthily? Traditional Answer: rationale campaigns BE Answer: make it easier to shop for healthy items, set defaults, create visual reminders New Mexico State University study on using visual prompts: Redesigned trolleys including a yellow line and sign in the trolley for fruits and vegetables Including an appealing picture of fresh fruit and vegetables in the trolley to further reinforce the effect Large increase in the amount of fruit and vegetables purchased / no decrease in profitability for the retailer Use 1st person perspective & pleasure (rather than health) to make fruits more appealing (fmri study, Basso, Voyer, Petit, Le Goff, Ouiller, under review) 46

40 3.1. DIET & WEIGHT 47

41 3.2. PHYSICAL ACTIVITY Question: how to improve physical fitness by tackling inactive lifestyles? Traditional Answer: rationale campaigns, compulsory PE classes at school BE Answer: make individuals exercise without them realising and in a fun way Most people are aware of the health benefits of taking the stairs instead of the escalator But when faced with the choice, they usually take the easy option particularly when others are doing the same. The piano stairs was one of the most popular ideas 48

42 3.2. PHYSICAL ACTIVITY 49

43 OVERCOMING BARRIERS TO CHANGE Minimise perceived costs (e.g. by breaking them down) Maximise associated rewards: Using projective techniques Using 1st person images / perspectives Using Storytelling The labeling technique (e.g., Tybout & Yalch, 1980) Assigning a label to an individual and then requesting a favour / behaviour which is consistent with this label. 50

44 4. Recommendations and conclusions Limitations and Challenges of Using BE for the Prevention of Non-communicable Diseases 54

45 BEHAVIOURAL ECONOMICS IS NUDGING NOT MANIPULATING! Behavioural economics focus on tripartite benefits (win-win-win): Consumers Society / Companies Governments The advantages of BE over other methods are: More subtle Longer lasting (formation of new habits) 55

46 BENEFITS OF BEHAVIOURAL ECONOMICS FOR THE PRIVATE SECTOR Improve your understanding of behaviours in your market Acquire better consumer information (more accurate information) Improve return on investment (ROI) measurement 56

47 BEHAVIOURAL ECONOMICS IS NOT ALWAYS A MAGICAL ANSWER TO EVERY PROBLEM 1. Application of BE principles does not always guarantee the highest results 2. Even when it works, effects can be small 3. Other incentives can work equally well (e.g. taxation or financial rewards). 4. Effects achieved by behavioural interventions may wear off over time (behavioural resistance ) 5. Combining BE principles with other forms of interventions can help maximising effects 57

48 FIVE AREAS TO WATCH OUT FOR BEHAVIOURAL ECONOMICS APPLICATIONS IN HEALTHCARE 1. Big data analytics: to identify new biases in decision making 2. Wearable devices: to provide always more comprehensive feedback 3. Gamification: designing sophisticated games to change patients behaviours in the long run 4. Virtual / augmented reality: to study choices made in hypothetical scenarios (VR) or provide instant warning or messages (AR) 5. Chatbots and other artificial intelligence platforms can be programmed to nudge automatically 58

49 FIVE THINGS TO REMEMBER ABOUT BEHAVIOURAL ECONOMICS 1. Small changes or simple nudges can have real effects 2. People can t always explain why they do what they do, or what they want 3. Preferences and choices are not absolute, but relative, social, and contextual 4. People think they are in control of their decisions, but more often than none they are not 5. and most of the time, they will always look for the least effortful way of making a decision (cognitive economy) 59

50 4. QUESTIONS & ANSWERS Q / A 60

51 TO GO FURTHER Dan, A. (2008). Predictably irrational: the hidden forces that shape our decisions. New York. NY, Etats-Unis: HarperCollins Publishers. 61