Nudges that fail

Spillover effects of reminder nudges in complex environments

We present an experiment on the immediate and lasting effects of reminder nudges in a complex environment. In the study, 1,542 subjects face a setting where, within a brief time frame, they have to pay attention to and perform multiple actions in a computer game. The experiment investigates i) the effect of reminders on the reminded actions and their spillovers on nonreminded actions; ii) spillovers between multiple nudges when the number of reminded actions is increased; and iii) intertemporal spillovers from having been exposed to reminders on actions after reminders are withdrawn. Our findings reveal, first, that reminders have a positive effect on the overall number of actions performed. It results from the positive direct effect on the reminded actions dominating the negative spillovers on nonreminded actions. These negative effects are notable in our setting, where reminders could potentially have positive spillovers by freezing attention or by indirectly prompting actions similar to the reminded ones. Second, we observe that reminder nudges are scalable. Increasing the number of reminded actions leads subjects to take more actions overall, albeit with diminishing returns and more pronounced negative spillover effects. Third, after reminders are withdrawn, the positive effect on reminded actions diminishes, while negative spillovers on nonreminded actions persist, thus rendering reminders ineffective in increasing the overall number of actions performed.

Thinking about default enrollment lowers vaccination intentions and public support in G7 countries

Policymakers often face a conundrum between being transparent about policies and ensuring that those policies are effective. This challenge is particularly relevant for behavioral nudges, which are not usually disclosed. Rather than avoiding transparency, we suggest that policymakers encourage citizens to reflect on nudges to help them understand their own views and align those views with their behaviors. Using data from an online survey experiment with 24,303 respondents in G7 countries, we examine the impact of reflection on a hypothetical default nudge policy for COVID-19 booster appointments. Contrary to expectations, participants say they would be less likely to get the booster when automatically enrolled compared with a control condition. Similarly, encouraging citizens to think about the status quo (baseline) policy also reduces intentions for boosters. These interventions have no effect on approval of the policy. Further, encouraging people to think about automatic enrollment decreases approval of the policy and further decreases their intentions to get vaccinated. These findings suggest that reflection on a nudge can increase backlash from a nudge and also elicit policy disapproval, thereby aligning policy support with behavioral intentions.

A Postcard Primer Prior to Mailed Fecal Immunochemical Test Among Veterans: a Randomized Controlled Trial

BACKGROUND

Mailed fecal immunochemical testing (FIT) programs are increasingly utilized for population-based colorectal cancer (CRC) screening. Advanced notifications (primers) are one behavioral designed feature of many mailed FIT programs, but few have tested this feature among Veterans.

OBJECTIVE

To determine if an advanced notification, a primer postcard, increases completion of FIT among Veterans.

DESIGN

This is a prospective, randomized quality improvement trial to evaluate a postcard primer prior to a mailed FIT versus mailed FIT alone.

PARTICIPANTS

A total of 2404 Veterans enrolled for care at a large VA site that were due for average-risk CRC screening.

INTERVENTION

A written postcard sent 2 weeks in advance of a mailed FIT kit that contained information on CRC screening and completing a FIT.

MAIN MEASURES

Our primary outcome was FIT completion at 90 days, and our secondary outcome was FIT completion at 180 days.

KEY RESULTS

Overall, unadjusted mailed FIT return rates were similar among control vs. primer arms at 90 days (27% vs. 29%, p = 0.11). Our adjusted analysis found a primer postcard did not increase FIT completion compared to mailed FIT alone (OR 1.14 (0.94, 1.37)).

CONCLUSIONS

Though primers are often a standard part of mailed FIT programs, we did not find an increase in FIT completion with mailed postcard primers among Veterans. Given the overall low mailed FIT return rates, testing different ways to improve return rates is essential to improving CRC screening.

How do defaults and framing influence food choice? An intervention aimed at promoting plant-based choice in online menus

Nudging consumers towards plant-based foods by making these choices the default option is a promising strategy for effecting sustainable dietary change. In the hypothetical context of online food ordering in a Northern European country, we examined the underlying mechanisms and effectiveness of swapping the default in menus from meat to a plant-based meat alternative. Results showed that pre-selecting a plant-based option in the online setting was not enough to increase choice of plant-based meals alone. Rather, additionally framing the plant-based default as the more sustainable or tasty option was needed to significantly increase choice. While ease was unimportant and held constant in this online setting, endowment and implied endorsement were found to mediate default success such that the positive influence of endowment outweighed the (surprising) negative effect via endorsement. In contrast to general theoretical expectations of default nudges, an endorsement by an online food provider is unlikely to encourage plant-based choices.

The role of attention and health goals in nudging healthy food choice

Introduction

Nudging is a promising intervention technique that supports people in pursuing their healthy eating goals. Recent research suggests that, despite previous assumptions, disclosure of the presence of a nudge does not compromise nudge effectiveness. However, it is unknown whether attention to a nudge affects nudge effects. We assessed the role of attention systematically, by examining explicit and implicit attention to nudges, while also exploring healthy eating goals as a potential moderator.

Methods

Participants were assigned to a nudge (i.e., a shopping basket inlay with pictures of healthy items) or control condition (i.e., a shopping basket inlay with neutral pictures) and chose a snack in an experimental supermarket field study. Explicit and implicit attention (with a mobile eye-tracker) to nudges, healthiness of snack choice, and healthy eating goals were assessed.

Results

Results showed that attention to the nudge did not hamper the nudge's effect. Furthermore, individuals with strong healthy eating goals made healthier food choices in the nudge condition. Individuals with weak to non-existent healthy eating goals were not influenced by the nudge.

Discussion

Findings are in line with the viewpoint that nudging does not by definition work 'in the dark', and suggests that nudges support people in adhering to their healthy eating goal.

The negative impact of vegetarian and vegan labels: Results from randomized controlled experiments with US consumers

Reducing consumption of animal products is a critically important challenge in efforts to mitigate the climate crisis. Despite this, meals containing animal products are often presented as the default versus more environmentally sustainable vegetarian or vegan options. We tested whether vegetarian and vegan labels on menu items negatively impact the likelihood of US consumers choosing these items by using a between-subjects experimental design, where participants chose a preference between two items. Menu items were presented with titles and descriptions typical at restaurants, and a random group saw "vegan" or "vegetarian" labels in the titles of one of the two items. Two field studies were conducted at a US academic institution, where people selected what to eat via event registration forms. The methodology was extended to an online study, where US consumers selected what to hypothetically eat in a series of choice questions. Overall, results showed the menu items were significantly less likely to be chosen when they were labeled, with much larger effects in the field studies, where choice was not hypothetical. In addition, the online study showed male participants had a significantly higher preference for options containing meat versus other participants. Results did not indicate the impact of labels differed by gender. Furthermore, this study did not find that vegetarians and vegans were more likely to choose items with meat when the labels were removed, indicating that removing labels did not negatively impact them. The results suggest removing vegetarian and vegan labels from menus could help guide US consumers towards reduced consumption of animal products.

Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review

OBJECTIVES

To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts.

MATERIALS AND METHODS

We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively.

RESULTS

We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects.

DISCUSSION

Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects.

CONCLUSION

Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.

Activation Versus Change as a Principle Underlying Intervention Strategies to Promote Health Behaviors

BACKGROUND AND PURPOSE

Interventions are effective in promoting health behavior change to the extent that (a) intervention strategies modify targets (i.e., mechanisms of action), and (b) modifying targets leads to changes in behavior. To complement taxonomies that characterize the variety of strategies used in behavioral interventions, we outline a new principle that specifies how strategies modify targets and thereby promote behavior change. We distinguish two dimensions of targets-value (positive vs. negative) and accessibility (activation level)-and show that intervention strategies operate either by altering the value of what people think, feel, or want (target change) or by heightening the accessibility of behavior-related thoughts, feelings, and goals (target activation).

METHODS AND RESULTS

We review strategies designed to promote target activation and find that nudges, cue-reminders, goal priming, the question-behavior effect, and if-then planning are each effective in generating health behavior change, and that their effectiveness accrues from heightened accessibility of relevant targets. We also identify several other strategies that may operate, at least in part, via target activation (e.g., self-monitoring, message framing, anticipated regret inductions, and habits).

CONCLUSIONS

The Activation Vs. Change Principle (AVCP) offers a theoretically grounded and parsimonious means of distinguishing among intervention strategies. By focusing on how strategies modify targets, the AVCP can aid interventionists in deciding which intervention strategies to deploy and how to combine different strategies in behavioral trials. We outline a research agenda that could serve to further enhance the design and delivery of interventions to promote target activation.

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

OBJECTIVES

Antibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall.

METHODS

Medline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group's tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness.

RESULTS

Nineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers.

CONCLUSIONS

Nudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.

Fostering innovation: Experimental evidence on the effectiveness of behavioral interventions

We experimentally investigate an intervention that ought to motivate innovative behavior by changing risk perceptions. Participants run a virtual lemonade stand and face a trade-off between exploiting a known strategy and exploring untested approaches. Innovation through testing new approaches comes along with a risk of failure because participants are compensated based on the profits generated by their virtual business. We test whether we can draw attention away from this risk by implementing a salience mechanism, which ought to focus participants on the input rather than the outcome of the innovative process. However, we find that this intervention is not effective in motivating innovative behavior-rather, it jeopardizes innovation. We discuss potential behavioral channels and encourage further research of risk salience as a tool to foster innovation. Our pre-registered study highlights the importance of evaluating interventions before implementation, as even carefully designed interventions may turn out to be ineffective or even backfire.

Leveraging behavioral economics and implementation science to engage patients at risk for suicide in mental health treatment: a pilot study protocol

BACKGROUND

Primary care is an ideal setting to connect individuals at risk for suicide to follow-up care; however, only half of the patients referred from the primary care attend an initial mental health visit. We aim to develop acceptable, feasible, low-cost, and effective new strategies to increase treatment initiation among at-risk individuals identified in primary care.

METHODS

We will conduct a multi-phase, mixed-methods study. First, we will conduct a chart review study by using administrative data, including medical records, to identify characteristics of primary care patients at risk for suicide who do or do not attend an initial mental health visit following a referral. Second, we will conduct a mixed methods study by using direct observations and qualitative interviews with key stakeholders (N = 65) to understand barriers and facilitators to mental health service initiation among at-risk individuals. Stakeholders will include patients with suicidal ideation referred from primary care who do and do not attend a first mental health visit, primary care and behavioral health providers, and individuals involved in the referral process. We also will collect preliminary self-report and behavioral data regarding potential mechanisms of behavior change (i.e., self-regulation and social support) from patients. Third, we will leverage these findings, relevant frameworks, and the extant literature to conduct a multi-arm, non-randomized feasibility trial. During this trial, we will rapidly prototype and test strategies to support attendance at initial mental health visits. Strategies will be developed with subject matter experts (N = 10) and iteratively pilot tested (~5 patients per strategy) and refined. Research will be completed in the Penn Integrated Care Program (PIC), which includes fourteen primary care clinics in Philadelphia that provide infrastructure for electronic referrals, patient communication, and data access.

DISCUSSION

We will leverage frameworks and methods from behavioral economics and implementation science to develop strategies to increase mental health treatment initiation among individuals at risk for suicide identified in primary care. This project will lead to an evaluation of these strategies in a fully powered randomized trial and contribute to improvements in access to and engagement in mental health services for individuals at risk for suicide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05021224.

Reducing Opioid Analgesic Prescribing in Dentistry Through Prescribing Defaults: A Cluster-Randomized Controlled Trial

OBJECTIVE

To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices.

METHODS

We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation.

RESULTS

Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (-3.3 tablets; CI: -5.9 to -0.7), and lower morphine milligram equivalents (MME) prescribed (-14.1 MME; CI: -27.8 to -0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9).

CONCLUSIONS

Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default.

TRIAL REGISTRATION

ClinicalTrials.org ID: NCT03030469.

Implementation and Evaluation of Two Nudges in a Hospital’s Electronic Prescribing System to Optimise Cost-Effective Prescribing

Providing healthcare workers with cost information about the medications they prescribe can influence their decisions. The current study aimed to analyse the impact of two nudges that presented cost information to prescribers through a hospital’s electronic prescribing system. The nudges were co-created by the research team: four behavioural scientists and the lead hospital pharmacist. The nudges were rolled out sequentially. The first nudge provided simple cost information (percentage cost-difference between two brands of mesalazine: Asacol^® and Octasa^®). The second nudge provided information about the potential annual cost savings if the cheaper medication were selected across the National Health Service. Neither nudge influenced prescribing. Prescribing of Asacol^® and Octasa^® at baseline and during the implementation of the first nudge did not differ (at p ≥ 0.05), nor was there a difference between the first nudge and second (at p ≥ 0.05). Although these nudges were not effective, notable administrative barriers were overcome, which may inform future research. For example, although for legal reasons the cost of medicine cannot be displayed, we were able to present aggregated cost information to the prescribers. Future research could reveal more behavioural factors that facilitate medication optimisation.

Nudging societally relevant behavior by promoting cognitive inferences

Effective behavioral interventions are essential to address urgent societal challenges. Over the past decade, nudging interventions (i.e., arranging the environment to promote adaptive behavioral choices) have surged in popularity. Importantly, effective application of the nudging approach requires clear guiding principles with a firm basis in behavioral science. We present a framework for nudging interventions that builds on evidence about the goal-directed inferential processes underlying behavior (i.e., processes that involve context-dependent inferences about goals and the actions available to achieve these goals). We used this framework to develop nudging interventions that target context-relevant cognitive inferences. We examined the effectiveness of these inference nudging interventions for promoting two important types of societal behavior: pro-environmental actions and adherence to COVID-19 guidelines. As predicted, two online studies revealed that inference nudging interventions successfully increased energy conservation (Study 1) as well as social distancing during the COVID-19 crisis (Study 2). A field experiment found that inference nudging interventions increased hand disinfection in a real-life store during the COVID-19 crisis (Study 3). Our findings highlight the importance of applying state-of-the-art insights about the (inferential) determinants of behavior in behavior change interventions.

A multidisciplinary definition of privacy labels

Purpose

This paper aims to present arguments about how a complex concept of privacy labeling can be a solution to the current state of privacy.

Design/methodology/approach

The authors give a precise definition of Privacy Labeling (PL), painting a panoptic portrait from seven different perspectives: Business, Legal, Regulatory, Usability and Human Factors, Educative, Technological and Multidisciplinary. They describe a common vision, proposing several important “traits of character” of PL as well as identifying “undeveloped potentialities”, i.e. open problems on which the community can focus.

Findings

This position paper identifies the stakeholders of the PL and their needs with regard to privacy, describing how PL should be and look like to address these needs. Main aspects considered are the PL’s educational power to change people’s knowledge of privacy, tools useful for constructing PL and the possible visual appearances of PL. They also identify how the present landscape of privacy certifications could be improved by PL.

Originality/value

The authors adopt a multidisciplinary approach to defining PL as well as give guidelines in the form of goals, characteristics, open problems, starting points and a roadmap for creating the ideal PL.

Tutorial. A Behavioral Analysis of Rationality, Nudging, and Boosting: Implications for Policymaking

As recent trends in policymaking call for increased contributions from behavioral science, nudging and boosting represent two effective and relatively economic approaches for influencing choice behavior. They utilize concepts from behavioral economics to affect agents’ concurrent suboptimal choices: in principle, without applying coercion. However, most choice situations involve some coercive elements. This study features a functional analysis of rationality, nudging, and boosting applied to public policy. The relationship between behavior and environmental variables is termed a “behavioral contingency,” and the analysis can include social and cultural phenomena by applying a selectionist perspective. Principles of behavioral control, whether tight or loose, may be exerted by policymakers or regulators who subscribe to paternalistic principles and may be met with demands of libertarianism among their recipients. This warrants discussion of the legitimacy and likelihood of behavioral control and influence on choices. Cases and examples are provided for extending the unit of analysis of choice behavior to achieve outcomes regulated by policies at the individual and group levels, including health, climate, and education. Further research and intervention comprise the study of macrocontingencies and metacontingencies. Advancing the understanding and application of behavioral science to policymaking may, therefore, benefit from moving from the relatively independent contributions of behavioral economics and behavior analysis to an inclusive selectionist approach for addressing choice behavior and cultural practices.

An integrative framework for transformative social change: a case in global wildlife trade

To achieve a sustainable future, it is imperative to transform human actions collectively and underlying social structures. Decades of research in social sciences have offered complementary insights into how such transformations might occur. However, these insights largely remain disjunct and of limited scope, such that strategies for solving global environmental challenges remain elusive. There is a need to integrate approaches focusing on individuals and social structures to understand how individual actions influence and are in turn influenced by social structures and norms. In this paper, we synthesize a range of insights across different schools of thought and integrate them in a novel framework for transformative social change. Our framework explains the relationships among individual behaviors, collective actions, and social structures and helps change agents guide societal transitions toward environmental sustainability. We apply this framework to the global wildlife trade-which presents several distinct challenges of human actions, especially amidst the Covid-19 pandemic-and identify pathways toward transformative change. One key distinction we make is between different individual actions that comprise the practice itself (e.g., buying wildlife products; private action) and those that push for a broader system change in practice (e.g., signaling (dis)approval for wildlife consumption; social-signaling action, and campaigning for policies that end unsustainable wildlife trade; system-changing action). In general, transformative change will require an integrative approach that includes both structural reforms and all three classes of individual action.

Unstandard Deviation: The Untapped Value of Positive Deviance for Reducing Inequalities

Behavioral science is increasingly used in public policy to understand and address various manifestations of inequalities. Yet evidence from effective population-level interventions is limited. One framework, known as positive deviance, emphasizes individuals from disadvantaged circumstances who have significantly better outcomes than are typical for their group. Studying their behaviors and outcomes helps to understand what might explain their overall success. These insights could also be used to help others from these circumstances experience positive outcomes. Because positive deviance has been markedly understudied, we present a framework for doing so specifically within behavioral science for public policies aimed at reducing inequalities. Using examples from real-world and experimental insights on choices and outcomes of positive deviants, we encourage further study of their choices and trajectories over time to produce valuable insights. We propose that leveraging those findings would inform public policy by introducing interventions that are more ecologically sound and population-relevant and thus have a better chance at benefiting those who start off under adverse circumstances.

Choice Architecture Cueing to Healthier Dietary Choices and Physical Activity at the Workplace: Implementation and Feasibility Evaluation

Redesigning choice environments appears a promising approach to encourage healthier eating and physical activity, but little evidence exists of the feasibility of this approach in real-world settings. The aim of this paper is to portray the implementation and feasibility assessment of a 12-month mixed-methods intervention study, StopDia at Work, targeting the environment of 53 diverse worksites. The intervention was conducted within a type 2 diabetes prevention study, StopDia. We assessed feasibility through the fidelity, facilitators and barriers, and maintenance of implementation, building on implementer interviews (n = 61 informants) and observations of the worksites at six (t1) and twelve months (t2). We analysed quantitative data with Kruskall-Wallis and Mann-Whitney U tests and qualitative data with content analysis. Intervention sites altogether implemented 23 various choice architectural strategies (median 3, range 0-14 strategies/site), employing 21 behaviour change mechanisms. Quantitative analysis found implementation was successful in 66%, imperfect in 25%, and failed in 9% of evaluated cases. These ratings were independent of the ease of implementation of applied strategies and reminders that implementers received. Researchers' assistance in intervention launch (p = 0.02) and direct contact to intervention sites (p < 0.001) predicted higher fidelity at t1, but not at t2. Qualitative content analysis identified facilitators and barriers related to the organisation, intervention, worksite environment, implementer, and user. Contributors of successful implementation included apt implementers, sufficient implementer training, careful planning, integration into worksite values and activities, and management support. After the study, 49% of the worksites intended to maintain the implementation in some form. Overall, the choice architecture approach seems suitable for workplace health promotion, but a range of practicalities warrant consideration while designing real-world implementation.

Towards reduced meat consumption: A systematic literature review of intervention effectiveness, 2001-2019

A reduction of meat consumption and shift to plant-based diets, especially in industrialized countries, is acknowledged as crucial for reaching climate targets, addressing public health problems, and protecting animal welfare. While scholarly research distilled drivers of meat consumption and barriers to its reduction, insights into the effectiveness of measures to initiate such a profound change in consumer behaviour are relatively scarce. This paper presents a systematic literature review on consumption-side interventions in the context of meat consumption across scholarly disciplines. Our analysis confirms that existing research predominantly assessed interventions addressing personal factors of behavioural change such as knowledge and emotions. Whether these interventions are effective depends on whether information (i) is provided on health, animal welfare or environmental effects, (ii) is emotionally or cognitively framed, and (iii) is aligned with consumers' information needs. Moreover, linking meat to living animals or to the humanness of animals activates negative emotions and, thus, reduces meat consumption. Further, increasing the visibility and variety of vegetarian dishes in food environments decreases meat-eating. Also, educational courses on how to shop and cook vegetarian food are effective in reducing meat consumption. There is less evidence on the effectiveness of interventions addressing socio-cultural factors such as social norms. Regarding future research directions, existing research mainly investigated the influence of interventions on attitudes and behavioural intentions. Hence, there is still a need for studies to assess more long-term effects of intervention measures on actual meat consumption and their potential to initiate fundamental changes in dietary habits.

Systematic review of clinician-directed nudges in healthcare contexts

OBJECTIVE

Nudges are interventions that alter the way options are presented, enabling individuals to more easily select the best option. Health systems and researchers have tested nudges to shape clinician decision-making with the aim of improving healthcare service delivery. We aimed to systematically study the use and effectiveness of nudges designed to improve clinicians' decisions in healthcare settings.

DESIGN

A systematic review was conducted to collect and consolidate results from studies testing nudges and to determine whether nudges directed at improving clinical decisions in healthcare settings across clinician types were effective. We systematically searched seven databases (EBSCO MegaFILE, EconLit, Embase, PsycINFO, PubMed, Scopus and Web of Science) and used a snowball sampling technique to identify peer-reviewed published studies available between 1 January 1984 and 22 April 2020. Eligible studies were critically appraised and narratively synthesised. We categorised nudges according to a taxonomy derived from the Nuffield Council on Bioethics. Included studies were appraised using the Cochrane Risk of Bias Assessment Tool.

RESULTS

We screened 3608 studies and 39 studies met our criteria. The majority of the studies (90%) were conducted in the USA and 36% were randomised controlled trials. The most commonly studied nudge intervention (46%) framed information for clinicians, often through peer comparison feedback. Nudges that guided clinical decisions through default options or by enabling choice were also frequently studied (31%). Information framing, default and enabling choice nudges showed promise, whereas the effectiveness of other nudge types was mixed. Given the inclusion of non-experimental designs, only a small portion of studies were at minimal risk of bias (33%) across all Cochrane criteria.

CONCLUSIONS

Nudges that frame information, change default options or enable choice are frequently studied and show promise in improving clinical decision-making. Future work should examine how nudges compare to non-nudge interventions (eg, policy interventions) in improving healthcare.

Proscriptive Injunctions Can Elicit Greater Reactance and Lower Legitimacy Perceptions Than Prescriptive Injunctions

Based on previous research investigating proscriptive injunctions (requesting that one should not do something) versus prescriptive injunctions (requesting that one should do something), we propose that proscription leads to greater reactance than does prescription for a range of actions, and that this effect is associated with lower perceived legitimacy of the injunction. Across five experimental studies, our student and general population samples received proscriptions or prescriptions and reported their reactance. Proscription led to greater reactance than did prescription in all five studies. This effect was accentuated by an authoritative source (Study 2), was mediated by the perceived legitimacy of the request (Study 3 and Study 4), and was attenuated by a self-affirmation intervention (Study 5). We suggest that proscriptions are viewed as more obligatory than prescriptions, limit the scope of behavioral alternatives, restrict perceived autonomy, and elicit greater reactance. The findings have implications for the design of effective persuasive communications.

Eating in the Amazon: Nutritional Status of the Riverine Populations and Possible Nudge Interventions

The Amazon is the largest tropical forest in the world and a source of healthy food, such as fruits and fish. Surprisingly, the Amazonian riverine population present an increased prevalence (as high as 58%) of non-communicable diseases, such as hypertension and insulin resistance, even higher than that described for the urban population of the Amazon. Therefore, this work aimed to analyze the nutritional status and associated risk of the riverine population. Body mass index, waist circumference (WC), waist-to-hip ratio, and neck circumference (NC) were evaluated, and risk analysis was assayed. Furthermore, data about occupation and the prevalence of consumers of the different groups of food were analyzed. All anthropometric parameters revealed high proportions of individuals at risk, WC and NC being the factors that had more high-risk women and men, respectively. Our data confirmed the characteristic profile of the riverine communities with a high number of fish consumers, but also observed different patterns probably associated to a phenomenon of nutrition transition. Based on our data, some nudge interventions that take into account the principles of behavior analysis are discussed and proposed for these populations, aiming to improve the nutritional status and avoid the long-term consequences of the results showed by this work.

[Towards healthy pathways: Effect of nutrition labels on eating behaviours in a university canteen]

Objetivo

Evaluar la efectividad de incluir información nutricional y de propiedades de los alimentos en un comedor universitario de Salamanca (España), para promover las conductas alimentarias saludables.

Diseño

Estudio experimental y correlacional transversal.

Emplazamiento

Comedor universitario de Salamanca (España).

Participantes

En el experimento se recogió información de la elección de 1.122 menús por parte de estudiantes universitarios. El cuestionario fue respondido por 48 estudiantes universitarios que participaron en el experimento.

Medidores principales

Metodología mixta (experimento de campo y cuestionario en línea). La variable independiente fue la inclusión o no de información nutricional de los menús. Con el cuestionario se evaluó la actitud de los estudiantes sobre este tipo de herramientas.

Resultados

El experimento muestra una mejora en la dieta de los estudiantes universitarios con la inclusión de elementos informativos que apelan a la elección más saludable, aumentando su consumo de fruta, verduras, legumbres, pescado y carne blanca.

Los encuestados mostraron un alto grado de receptividad de estas herramientas para la promoción de la salud. A pesar de esto, su autopercepción de mejoría de la dieta era más optimista que lo cuantificado en el experimento. Los estudiantes universitarios muestran un grado de aprobación muy alto frente a otras herramientas de promoción de alimentación saludable, especialmente aquellas de carácter educativo e informativo. Se comprobó que una preocupación mayor por la dieta estaba asociada con un mayor apoyo de estas herramientas.

Conclusión

Existe una mejora en la alimentación de los estudiantes universitarios y una actitud positiva frente a herramientas de promoción de la salud, especialmente por parte de quienes tienen una autopercepción más saludable. Es necesario emplear nuevas herramientas basadas en las ciencias conductuales en la promoción de la salud, por parte de la industria privada y las entidades públicas.

Norm-focused nudges influence pro-environmental choices and moderate post-choice emotional responses

In this paper, we use choice architecture techniques to activate both social and personal norms, seeking to increase pro-environmental choices and to better understand the effect of such norm types on post-choice emotional responses. In four experiments, we make different social or personal norms salient by aligning choice environments with psychosocial mechanisms that activate different types of norms. We use different choice architecture techniques to change information, alter product sets, and generate the social consequences of choices. The target behavior, purchasing a recycled paper notebook, is captured through direct purchase behaviors or willingness to pay commitments. We find that choice architecture activates personal but not social norms, and that associated positive and negative emotions (guilt, shame, regret and pride) are elicited by choices but not by willingness to pay. Moreover, manipulating choice environment moderates the relationship between choice and norm-related emotions, such that positive emotional responses seem to be stronger than negative ones. The results suggest that choice architecture interventions can activate individual level beliefs about sustainability and help reduce the attitude-behavior gap.

Nudging freelance professionals to increase their retirement pension fund contributions

People do not save enough for retirement and this can have serious repercussions on their well-being. We tested an intervention in a large field study (N = 20,507) with the goal of nudging a population of freelance workers to save more for the future. First, we changed the default from the earlier contribution rate of 10% to a contribution rate of 20%, but left people free to choose how much they wanted to contribute. Second, those who reduced their contribution were reminded that they would receive a lower pension as a result. Third, we informed people about how much tax they would save as a result of their contribution. This nudging intervention proved to be a cost-effective, yet powerful way to remind people about the long-term implications of their savings decisions. It was also successful at counteracting the temptation to keep as much money as possible for present consumption while losing out on the long run. Overall, we were able to increase cash flow to the fund by more than eight million Euros (in addition to the roughly 50 million collected in the previous year), with an almost seven-fold increase in the number of people who chose to contribute more than the minimum.

What Is Slowing Us Down? Six Challenges to Accelerating Advances in Health Behavior Change

BACKGROUND

Accelerating advances in health behavior change requires releasing the brake, as well as applying the throttle. This paper discusses six challenges or "brakes" that have slowed progress.

PURPOSE/METHODS/RESULTS

We engage with six issues that limit investigators' ability to delineate and test the strategy-target and target-behavior relations that underlie effective interventions according to the experimental medicine approach. We discuss the need for guidance on how to identify the relevant mechanism of action (target) in an intervention and whether a periodic table of health behavior constructs might aid investigators. Experimental and correlational analyses (prospective surveys and behavior change techniques) have been used to test the validity of targets, and we present evidence that there is little agreement among the findings from different research designs. Whereas target engagement is typically analyzed in terms of increasing scores on constructs that impel behavior change, we discuss the role of impeding targets and the benefits of adopting a broader construal of potential targets and approaches to engagement. There is presently a paucity of competitive tests regarding which strategies best engage targets and we discuss empirical criteria and conceptual developments that could enhance the evidence base. Finally, we highlight the need to take "context" or conditional intervention effects more seriously by leveraging the interplay between questions about why interventions work and questions about when and for whom they work.

CONCLUSION

Candid appraisal of the challenges facing research on health behavior change can generate new opportunities for theoretical development and offer direction and cumulative impetus for empirical work.

Learning from Behavioural Changes That Fail

Behavioural change techniques are currently used by many global organisations and public institutions. The amassing evidence base is used to answer practical and scientific questions regarding what cognitive, affective, and environment factors lead to successful behavioural change in the laboratory and in the field. In this piece we show that there is also value to examining interventions that inadvertently fail in achieving their desired behavioural change (e.g., backfiring effects). We identify the underlying causal pathways that characterise different types of failure, and show how a taxonomy of causal interactions that result in failure exposes new insights that can advance theory and practice.

A Field Experiment on Reducing Drinking Straw Consumption by Default

Against the background of the pollution of the environment through plastic waste, we conducted a field experiment (N = 195) to test the effectiveness of a default nudge intervention that aimed at reducing the consumption of plastic drinking straws. We assumed that separating straws from cups by default leads to an overall decrease in straw consumption. We hypothesized that individuals would consume straws less frequently when they had to pick straws actively out of a separate straw box for their drink compared to when they could choose between cups already containing and not containing straws. Results of a logistic regression revealed a significant difference between both conditions concerning the use of drinking straws [B = 1.129 (SE = 0.30), p < 001 with an odds ratio of OR = 0.32]. Confirming our hypothesis, results underline that minor and subtle interventions addressing waste reduction might have marked effects. More research is needed to improve current and future interventions to significantly reduce the amount of plastic consumption and consequently reduce the waste in the environment.

Nudging in Animal Disease Control and Surveillance: A Qualitative Approach to Identify Strategies Used to Improve Compliance With Animal Health Policies

Professionals from seven European countries were interviewed to identify strategies used in the surveillance and control of animal infections to influence behaviors such as program enrollment, adoption of biosecurity measures, and engagement in surveillance. To find strategies that were well-designed from a theoretical perspective, three frameworks from nudge theory were applied to the strategies: the Nuffield ladder to determine the strength of the interventions, EAST to identify attributes of the strategies, and MINDSPACE to identify the psychological mechanisms involved. We found that almost two thirds (91/120) of the strategies were designed in a manner likely to trigger multiple psychological mechanisms, which is in line with the existing recommendations for successful effect, i.e., achieving a desired behavior. This was despite that the design of the strategies was based on professionals' empirical understanding of the requirements to achieve anticipated outcomes rather than the systematic use of methods from the behavioral sciences and psychology. The most commonly used strategy was provision of information, and the least used mechanism was making a desired behavior easy to perform. The findings in this study, with all the examples of strategies used, can serve as inspiration for others. The theoretical frameworks may also be beneficial to apply as a complement in future design of new strategies. This study did not include evaluation of how efficient different strategies have been, which would be an interesting area for future studies.

Increasing the Proportion of Plant-Based Foods Available to Shift Social Consumption Norms and Food Choice among Non-Vegetarians

Increasing the relative availability of plant-based (versus animal source) foods seems promising in shifting consumption, but it remains unknown how and under what circumstances this happens. We performed two availability manipulations including different foods. The impact on food choice, social norm perceptions about what others do (descriptive) or approve of (injunctive), and salience was assessed. Non-vegetarian participants were visually (Study 1, n = 184) or physically (Study 2, n = 276) exposed to (a) four plant-based and two animal source foods or (b) vice versa. Participants chose one food item, either hypothetically (Study 1) or actually (Study 2), and reported the perceived social norms and salience of plant-based and animal source foods. The results showed no direct effects on food choice, injunctive norms, or salience. An increased proportion of plant-based (versus animal source) foods was interpreted in Study 1 as plant-based foods being less often chosen by others, whereas in Study 2, these foods were interpreted as being more often chosen (marginally significant), while animal source foods were interpreted as being less often chosen. The results suggest that a higher availability of plant-based foods influences descriptive norms, but future research should examine aspects potentially contributing to the contradictory normative interpretations (e.g., norm salience).

When in Doubt, Follow the Crowd? Responsiveness to Social Proof Nudges in the Absence of Clear Preferences

Nudges have gained popularity as a behavioral change tool that aims to facilitate the selection of the sensible choice option by altering the way choice options are presented. Although nudges are designed to facilitate these choices without interfering with people’s prior preferences, both the relation between individuals’ prior preferences and nudge effectiveness, as well as the notion that nudges ‘facilitate’ decision-making have received little empirical scrutiny. Two studies examine the hypothesis that a social proof nudge is particularly effective when people have no clear prior preference, either because people are indifferent (in a color-categorization task; Study 1, N = 255) or because people experience a choice conflict (making shopping decisions about meat products; Study 2, N = 97). Both studies employed a social proof nudge to steer participants’ choices. The potential facilitating effect of the nudge was tested using a mouse-tracker paradigm that implicitly assessed experienced uncertainty during decision-making. Results showed that the nudge was effective in steering participants’ decisions; the facilitation effect (i.e., reduced uncertainty regarding the decision) was only observed for conflicting preferences, but not under indifference. A better understanding of when and how nudges can influence individuals’ behavior may help in deciding whether nudges are an appropriate policy tool for changing particular undesirable behavior.

Overstepping the boundaries of free choice: Folk beliefs on free will and determinism in real world contexts

We know little about the commonality of folk beliefs around applications of psychological research on the unconscious control of behaviours. To address this, in Experiment 1 (N = 399) participants volunteered examples of where research on the unconscious has been applied to influence their behaviours. A subset of these were presented in Experiment 2 (N = 198) and Experiment 3 (N = 100). Participants rated the extent to which the behaviour being influenced in these contexts was: (1) via the unconscious, (2) free, (3) the result of prior conscious intentions, (4) under conscious control. Relative to judgements about the extent to which behaviour was influenced via the unconscious, the remaining judgements regarding conscious control of behaviours were either higher (e.g., political contexts) or lower (e.g., therapy). This study is the first to show, using ecologically valid examples, the folk beliefs people share on psychological constructs concerning free will and determinism.

Models of Cognition and Their Applications in Behavioral Economics: A Conceptual Framework for Nudging Derived From Behavior Analysis and Relational Frame Theory

This paper puts forward a rounder conceptual model for interpreting short- and long-term effects of choice behavior. As a further development of dual-process theory, Kahneman (2003) distinguished between intuition and reasoning, which served as the respective precursors of the cognitive processing systems 1 and 2. We maintain that they reflect the more rigorous distinction between brief and immediate and extended and elaborated relational responding, which may be reinterpreted through an analysis of their functional properties. Repertoires of relational responding are offered by the multi-dimensional multi-level model. Specifically, we provide a conceptual account of how nudging, or the manipulation of environmental contingencies, works on the creation and modification of relational framing. Educative nudges, or boosts, are a subset of nudges that may more easily maintain target choice behavior in the future. The central role of verbal behavior is essential toward formulating rules, which inform and guide choice behavior over time. Although nudges are traditionally regarded as System 1-steered aspects, they are herein regarded as cues for responding to relational frames, which may induce System 2-steered aspects. We suggest adopting the implicit relational assessment procedure (IRAP) to inform how coherent and immediate responding to novel relational responding may occur in the presence of choice behavior. Several examples are included to support the claim of encompassing relational responding and choice behavior. We address the instances of consumer behavior, stereotypy and prejudices, eating behavior, and overcoming cognitive biases. The conclusions depict a promising way forward for the study of choice: an improved model for interpreting and overcoming human errors, due to changes in the contingencies of behavior.

Examining the Efficacy of a 'Feasible' Nudge Intervention to Increase the Purchase of Vegetables by First Year University Students (17-19 Years of Age) in British Columbia: A Pilot Study

In the transition from high school to university, vegetable consumption tends to deteriorate, potentially influencing immediate and longer-term health outcomes. Nudges, manipulation of the environment to influence choice, have emerged as important to behavior change goals. This quasi-experimental pilot study examined the impact of a contextually feasible evidence-informed nudge intervention on food purchasing behavior of older adolescents (1st year students) in a university residence cafeteria in British Columbia, Canada. A co-design process with students and staff identified a student relevant and operationally feasible nudge intervention; a placement nudge, fresh vegetables at the hot food table, combined with a sensory and cognitive nudge, signage encouraging vegetable purchase). Using a 12-week single-case A-B-A-B design, observations of the proportion of vegetables purchased were used to assess intervention efficacy. Data analysis included visual trend inspection, central tendency measures, data overlap, variability and latency. Visual trend inspection showed a positive trend when nudges were in place, which was more apparent with female purchases and during the first intervention (B) phase. However, further analysis showed lack of baseline stability, high variability across phases and overlapping data, limiting efficacy conclusions. Menu choices, staff encouragement, term timing and student finances are other potential influences. Further 'real world' nudge research is needed.

Good job, good pension? The influence of the workplace on saving for retirement

Most private-sector employees in the United Kingdom (UK) are automatically enrolled into individualised defined contribution (DC) pension accounts. In a DC environment, income adequacy in retirement is highly dependent on the decisions that individuals make earlier in their lives. The ease with which they move into employment, and the pension support that they then receive from their employer, can be critical in determining outcomes. This paper discusses how employees respond to workplace pension schemes and the circumstances under which they assess the suitability of their contributions. The findings are based on an embedded case study comprising qualitative interviews with 25 employees of a large UK utility company. Participants were selected on the basis of socio-economic similarity. The research concluded that fixed-term employment negatively impacted on saving for retirement, both with respect to scheme membership and to the level of saving. Furthermore, it was found that the employment context had an influence upon retirement savings behaviour. The proactive approach of the employer in providing retirement benefits, and the trust that employees had in their employer, positively influenced membership and contribution levels. In addition to employer endorsement effects, both the encouragement of older work colleagues and workplace norms had a role to play in influencing how successfully individuals prepared for retirement.