Default neglect in attempts at social influence

Assessing the Impact of Behavioral Sciences Interventions on Chronic Disease Prevention and Management: A Systematic Review of Randomized Controlled Trials

Studies have highlighted the importance of applying Behavioral Sciences interventions to develop equity in the prevention of chronic diseases in the public health domain. Our study aims to assess the evidence of this influence. We undertook a systematic review study using the electronic databases PubMed, Web of Science, Scopus and Cochrane, searching for work published between 2013 and 2023. The research analyzed the influence of Behavioral Sciences intervention studies on public health. This review was registered and published in PROSPERO, registration number CRD42023412377. The systematic search identified 2951 articles. The review analyzed 26 studies. The quality assessment of the articles showed an overall average of 74%, with the majority of studies being of high quality. The interventions with the best evidence for chronic diseases used framing messages, nudges and vouchers. Messages with incentives also showed satisfactory evidence. The most prevalent outcomes were related to screening tests and patient adherence to treatment. The current state of decision-making remains mainly at the patient level, with potential for further exploration of the roles of healthcare professionals and decision-makers in future research efforts. Limitations relate to the heterogeneity of the study sample, which hinders a more precise analysis of specific interventions and outcomes in chronic diseases.

Framing the Default

A key finding within nudging research is the default effect, where individuals are inclined to stay with a default option when faced with a decision, rather than exploring alternatives (e.g., a preselected job opportunity among two alternatives). Similarly, the study of framing effects delves into how the presentation and context of decisions influence choices (e.g., choosing vs. rejecting a job opportunity among two alternatives). Specifically, previous literature examining choosing versus rejecting decision frames in various situations has found that these frames do not invariably complement each other; therefore, individuals' preferences vary based on the task frame. Yet, simultaneous testing of multiple nudges remains relatively unexplored in the literature. In the current study involving 1,072 participants, we examined how framing and default effects can influence decision-making in hypothetical scenarios. The decision scenarios involved two different domains-work and health. We found that framing had a strong effect on decision-making in both work and health domains, whereas default setting contributed only to a limited extent in the work domain and no effect was found in the health domain, mirroring related recent research findings. We argue for a more careful design of nudge interventions when multiple overlapping nudges are used and for a contextual approach to applying behavioral science to citizens.

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 joint effect of framing and defaults on choice behavior

The framing effect leads people to prefer a sure alternative over a risky one (risk aversion) when alternatives are described as potential gains compared to a context-dependent reference point. The reverse (risk propensity) happens when the same alternatives are described as potential losses. The default effect is the tendency to prefer a preselected alternative over other non-preselected given options, without facilitating nor incentivizing the choice. These two effects have mainly been studied separately. Here we provided novel empirical evidence of additive effects due to the application of both framing and default within the same decision problem in a large sample size (N = 960). In the baseline condition, where no default was provided, we measured the proportion of risky choices in life-or-death and financial decisions both presented in terms of potential gains or losses following the structure of the Asian disease problem. In the sure default condition, the same layout was proposed with a flag on the sure option, whereas in the risky default condition, the flag was on the risky option. In both default conditions, we asked participants whether they wanted to change the preselected option. Overall, the comparison between these conditions revealed three distinct main effects: (i) a classic framing effect, (ii) a larger risk propensity in the life-or-death scenario than in the financial one, and (iii) a larger default effect when the flag was on the risky, rather than on the sure, option. Therefore, we conclude that default options can enhance risk propensity. Finally, individual beliefs about the source of the default significantly moderated the strength of the effect. Underlying mechanisms and practical implications are discussed considering prominent theories in this field.

Rational Choice in Context

Human decisions are context dependent in ways that violate classical norms of rational choice. However, these norms implicitly depend on idealized descriptive assumptions that are often unrealistic. We focus on one such assumption: that information is constant across contexts. Choice contexts often supply subtle cues—which may be embedded in frames, procedures, or menus—to which human decision makers can be highly sensitive. We review recent evidence that some important context effects reflect dynamically coherent belief and preference updating, in response to ecologically valid cues. This evidence paints a more nuanced picture of human rationality in natural choice environments and opens up prospects for nonpaternalistic forms of choice architecture.

Meta-nudging honesty: Past, present, and future of the research frontier

Achieving successful and long-lasting behavior change via nudging comes with challenges. This is particularly true when choice architects attempt to change behavior that is collectively harmful but individually beneficial, such as dishonesty. Here, we introduce the concept of "meta-nudging" and illustrate its potential benefits in the context of promoting honesty. The meta-nudging approach implies that instead of nudging end-users directly, one would nudge them indirectly via "social influencers." That is, one can arguably achieve better success by changing the behavior of those who have the ability to enforce other's behavior and norm adherence. We argue that this represents a promising new behavior change approach that helps overcome some of the challenges that the classical nudging approach has faced. We use the case of nudging honesty to develop the theoretical foundation of meta-nudging and discuss avenues for future work.

Antecedents and outcomes of ICTs adoption by mompreneurs: Empirical evidence from Brazil

Information and Communication Technologies (ICTs) have been an ally of women wishing to engage in entrepreneurial activity, especially of the mompreneurs. Within this context, this study aims to investigate the antecedents and outcomes of the use of ICTs by mompreneurs. The data were collected in Brazil through an online questionnaire and were analyzed using structural equation modeling. The results indicated that perceived usefulness, social influence, and trust are antecedent factors of the use of ICTs by these women. Moreover, the use of ICTs has a positive impact on the perception of mompreneurs regarding the financial performance of their ventures in relation to competitors. The results also show that more than 97% of the mompreneurs use smartphones and WhatsApp to manage their business, suggesting that social media and mobile devices have assumed a predominant role in female ventures, especially during the COVID-19 pandemic, period in which the data were collected.

Willpower is a form of, but not synonymous with, self-control

We build on Ainslie's discussion of willpower by highlighting another common misconception in the literature: the conflation of self-control and willpower. In our commentary, we identify this issue and discuss the importance of recognizing willpower not as synonymous with self-control, but rather as a subset of self-control. We describe a set of upstream strategies as more effective alternatives to willpower.

Choice architecture in physician-patient communication: a mixed-methods assessments of physicians' competency

BACKGROUND

Clinicians' use of choice architecture, or how they present options, systematically influences the choices made by patients and their surrogate decision makers. However, clinicians may incompletely understand this influence.

OBJECTIVE

To assess physicians' abilities to predict how common choice frames influence people's choices.

METHODS

We conducted a prospective mixed-methods study using a scenario-based competency questionnaire and semistructured interviews. Participants were senior resident physicians from a large health system. Of 160 eligible participants, 93 (58.1%) completed the scenario-based questionnaire and 15 completed the semistructured interview. The primary outcome was choice architecture competency, defined as the number of correct answers on the eight-item scenario-based choice architecture competency questionnaire. We generated the scenarios based on existing decision science literature and validated them using an online sample of lay participants. We then assessed senior resident physicians' choice architecture competency using the questionnaire. We interviewed a subset of participating physicians to explore how they approached the scenario-based questions and their views on choice architecture in clinical medicine and medical education.

RESULTS

Physicians' mean correct score was 4.85 (95% CI 4.59 to 5.11) out of 8 scenario-based questions. Regression models identified no associations between choice architecture competency and measured physician characteristics. Physicians found choice architecture highly relevant to clinical practice. They viewed the intentional use of choice architecture as acceptable and ethical, but felt they lacked sufficient training in the principles to do so.

CONCLUSION

Clinicians assume the role of choice architect whether they realise it or not. Our results suggest that the majority of physicians have inadequate choice architecture competency. The uninformed use of choice architecture by clinicians may influence patients and family members in ways clinicians may not anticipate nor intend.

Default sensitivity in attempts at social influence

While past research has demonstrated the power of defaults to nudge decision makers toward desired outcomes, few studies have examined whether people understand how to strategically set defaults to influence others' choices. A recent paper (Zlatev et al. Proceedings of the National Academy of Sciences, 114, 13643-13648, 2017) found that participants exhibited "default neglect," or the failure to set optimal defaults at better than chance levels. However, we show that this poor performance is specific to the complex and potentially confusing paradigms they used, and does not reflect a general lack of understanding regarding defaults. Using simple scenarios, Experiments 1A and 1B provide clear evidence that people can optimally set defaults given their goals. In Experiment 2, we conducted a direct and conceptual replication of one of Zlatev et al.'s original studies, which found that participants selected the optimal default significantly less than chance. While our direct replication found results similar to those in the original study, our conceptual replication, which simplified the task, instead found the opposite. Experiment 3 manipulated the framing of the option attributes, which were confounded with the default in the original study, and found that the original framing led to below-chance performance while the alternate framing led to above-chance performance. Together, our results cast doubt on the prevalence and generalizability of default neglect, and instead suggest that people are capable of setting optimal defaults in attempts at social influence.

Exploiting asymmetric signals from choices through default selection

Setting defaults is an effective nudge, but few studies have examined situations where individuals can select their own default settings. Past research suggests that even when the final outcome is identical, observers perceive stronger signals from choices that switch from, rather than stay with, the default. In five experiments using hypothetical scenarios and an incentivized economic game, we test whether decision-makers driven by image concerns could strategically exploit that asymmetric signal. We found that in the presence of observers, participants were more likely to self-select into defaults that require them to switch to enhance a positive signal and into defaults that require them to stay to attenuate a negative signal. Our results support the framework of choice architecture as an implicit social interaction, and have potential implications for behavioral interventions in real-world settings.

Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians

OBJECTIVE

To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures.

DATA SOURCES AND STUDY SETTING

The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness.

STUDY DESIGN

In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist.

DATA COLLECTION

Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims.

PRINCIPAL FINDINGS

We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default.

CONCLUSIONS

Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.

When and why defaults influence decisions: a meta-analysis of default effects

When people make decisions with a pre-selected choice option – a ‘default’ – they are more likely to select that option. Because defaults are easy to implement, they constitute one of the most widely employed tools in the choice architecture toolbox. However, to decide when defaults should be used instead of other choice architecture tools, policy-makers must know how effective defaults are and when and why their effectiveness varies. To answer these questions, we conduct a literature search and meta-analysis of the 58 default studies (pooled n = 73,675) that fit our criteria. While our analysis reveals a considerable influence of defaults (d = 0.68, 95% confidence interval = 0.53–0.83), we also discover substantial variation: the majority of default studies find positive effects, but several do not find a significant effect, and two even demonstrate negative effects. To explain this variability, we draw on existing theoretical frameworks to examine the drivers of disparity in effectiveness. Our analysis reveals two factors that partially account for the variability in defaults’ effectiveness. First, we find that defaults in consumer domains are more effective and in environmental domains are less effective. Second, we find that defaults are more effective when they operate through endorsement (defaults that are seen as conveying what the choice architect thinks the decision-maker should do) or endowment (defaults that are seen as reflecting the status quo). We end with a discussion of possible directions for a future research program on defaults, including potential additional moderators, and implications for policy-makers interested in the implementation and evaluation of defaults.

People use less information than they think to make up their minds

A world where information is abundant promises unprecedented opportunities for information exchange. Seven studies suggest these opportunities work better in theory than in practice: People fail to anticipate how quickly minds change, believing that they and others will evaluate more evidence before making up their minds than they and others actually do. From evaluating peers, marriage prospects, and political candidates to evaluating novel foods, goods, and services, people consume far less information than expected before deeming things good or bad. Accordingly, people acquire and share too much information in impression-formation contexts: People overvalue long-term trials, overpay for decision aids, and overwork to impress others, neglecting the speed at which conclusions will form. In today's information age, people may intuitively believe that exchanging ever-more information will foster better-informed opinions and perspectives-but much of this information may be lost on minds long made up.

Some Middle School Students Want Behavior Commitment Devices (but Take-Up Does Not Affect Their Behavior)

Commitment devices impose costs on one's future self for failing to follow through on one's intentions, offer no additional benefit to one's future self for following through on the intention, and people voluntarily enroll in them. Enrollment in commitment devices reflects self-awareness that one may lack sufficient self-control to fulfill one's intentions. There is little experimental research on whether school-age children possess the self-awareness necessary to enroll in a commitment device, despite evidence that children and young adolescents have many positive intentions that they fail to live up to, such as demonstrating improved school conduct or eating healthier. We report the first field experiment examining the demand for, and impact of, commitment devices among middle school students. We offered students a commitment device that imposed future costs for failing to improve in-school conduct. When presented with the opportunity to actively opt-in (default not enrolled), over one-third of students elected to enroll. When presented with the opportunity to actively opt-out (default enrolled), more than half elected to remain enrolled, showing that changing default options can increase commitment device enrollment. Despite demand for the self-control strategy, taking-up the commitment device did not affect student behavior. These findings have implications for youth-based behavioral interventions broadly, as well as those focused on eating behaviors.