Nudge: Concept, Effectiveness, and Ethics

Nudging Public Health Behaviors to Prevent COVID-19: A Systematic Review

Many countries have implemented strict preventive measures and mandatory policies to curb virus transmission during the COVID-19 pandemic. Some have adopted softer approaches, such as nudge-based intervention, to influence public health behavior. This systematic review, conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines, aims to determine if the nudge-based intervention can effectively influence people's preventive behavior during the early period of the COVID-19 pandemic. The review indicated an overall positive outcome, but results were mixed as nudge-based interventions substantially depended on the situational context. While the review found that the nudging technique that presents and conveys decision-related information was essential to nudging people, a secondary nudge would often applied to deliver the interventions. In addition, there was no indication of an ideal nudge technique that would be effective in most situations. Conversely, our findings indicate that the nudge would likely suffer from habituation after repeated intervention or backfire due to inappropriate use of nudges. Also, the ceiling effect would inhibit any nudge influences regardless of the technique(s) used. In sum, the results and the applicability of nudge-based interventions were mixed, highlighting the need for further research to advance the theory and practical developments.

Targeted nudging for speeding behavior: The influence of interpersonal characteristics on responses to in-vehicle road nudges

Road carnage is one of the most fatal and expensive global issues today. Many solutions have been implemented to minimize it, but most are costly and unreliable. Therefore, in this study, nudges were used as a reliable and inexpensive tool to affect safe driving behavior which, in turn, may reduce road fatalities. To optimize the use of nudges, we suggested that responses to nudges - in a similar manner to responses to other stimuli - may vary by interpersonal characteristics, so that different nudges may lead to more accurate and reliable reactions in different sub-populations in a predictable manner. To test these assertions, we collected a sample of 200 participants, both men and women, ages 17.5 to 83 years. We measured different interpersonal characteristics that included both demographic information (e.g., age, gender, years with a driver's license) and different personality traits. We then assessed responses to nudges using a simulator that was specially designed for this study, in which participants are asked to adjust their speed as they see fit while they watched a video shot from a driver's perspective of the forward roadway. Over the course of the video, a different nudge was displayed for each subject and their response latency and speeds were recorded for further analysis. We were able to observe several interesting phenomena: responses to a reminder nudge and a negative reinforcement nudge were faster than responses to a social norm nudge. However, the latter showed a longer-term impact. The responses to the social norm interventions were also more variable, demonstrating that high neuroticism is linked to decreased response to social norm nudges, a picture that is repeated in men compared to women. Contrarily, conscientiousness was linked to a faster and more reliable response to the social norm nudge, and the gender effect was eliminated for men with high conscientiousness. Moreover, parenthood was found to increase the response to all nudges and was protective against the effects of high sensation-seeking, which led to more road violations. These findings may be tested using modern technology, which can facilitate the measurements of personal traits and verify the reliability of responses to nudges. Therefore, the current study suggests nudge personalization may be beneficial in improving the use of nudges on the road.

Nudge-based misinformation interventions are effective in information environments with low misinformation prevalence

Nudge-based misinformation interventions are presented as cheap and effective ways to reduce the spread of misinformation online. However, despite online information environments typically containing relatively low volumes of misinformation, most studies testing the effectiveness of nudge interventions present equal proportions of true and false information. As the effectiveness of nudges can be highly context-dependent, it is imperative to validate the effectiveness of nudge-based interventions in environments with more realistic proportions of misinformation. The current study (N = 1387) assessed the effectiveness of a combined accuracy and social-norm nudge in simulated social-media environments with varying proportions of misinformation (50%, 20%, and 12.5%) relative to true and non-news-based (i.e., "social") information. The nudge intervention was effective at improving sharing discernment in conditions with lower proportions of misinformation, providing ecologically valid support for the use of nudge-based interventions to counter misinformation propagation on social media.

It's not you (well, it is a bit you), it's me: Self- versus social image in warm-glow giving

Attempts by charities to motivate giving tend to focus on potential donors' altruistic tendencies. However, prior research suggests that approximately 50% of individuals are to some extent motivated by warm glow, the satisfaction received from the act of giving. The satisfaction derives from looking good to themselves (self-image) and/or to others (social image). We conduct an online experiment on MTurk participants (n = 960) with a more realistic simulation of being watched to determine the importance of self- and social image to warm-glow giving. We find evidence that suggests that social image concerns do not increase the likelihood that someone will give but they do increase the amount given; average giving is significantly higher in the treatments when feelings of being watched are stimulated. Our results suggest that charities looking to increase their donor bases might effectively do so by focusing on self-image concerns. Charities wishing to increase the amount donated might effectively do so by focusing on the social image concerns of the donor.

Effect of chair placement on physicians' behavior and patients' satisfaction: randomized deception trial

OBJECTIVE

To evaluate the effect of chair placement on length of time physicians sit during a bedside consultation and patients' satisfaction.

DESIGN

Single center, double blind, randomized controlled deception trial.

SETTING

County hospital in Texas, USA.

PARTICIPANTS

51 hospitalist physicians providing direct care services, and 125 observed encounters of patients who could answer four orientation questions correctly before study entry, April 2022 to February 2023.

INTERVENTION

Each patient encounter was randomized to either chair placement (≤3 feet (0.9 m) of patient's bedside and facing the bed) or usual chair location (control).

MAIN OUTCOME MEASURES

The primary outcome was the binary decision of the physician to sit or not sit at any point during a patient encounter. Secondary outcomes included patient satisfaction, as assessed with the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, time in the room, and both physicians' and patients' perception of time in the room.

RESULTS

125 patient encounters were randomized (60 to chair placement and 65 to control). 38 of the 60 physicians in the chair placement group sat during the patient encounter compared with five of the 65 physicians in the control group (odds ratio 20.7, 95% confidence interval 7.2 to 59.4; P<0.001). The absolute risk difference between the intervention and control groups was 0.55 (95% confidence interval 0.42 to 0.69). Overall, 1.8 chairs needed to be placed for a physician to sit. Intervention was associated with 3.9% greater TAISCH scores (effect estimate 3.9, 95% confidence interval 0.9 to 7.0; P=0.01) and 5.1 greater odds of complete scores on HCAHPS (95% confidence interval 1.06 to 24.9, P=0.04). Chair placement was not associated with time spent in the room (10.6 minutes v control 10.6 minutes) nor perception of time in the room for physicians (9.4 minutes v 9.8 minutes) or patients (13.1 minutes v 13.5 minutes).

CONCLUSION

Chair placement is a simple, no cost, low tech intervention that increases a physician's likelihood of sitting during a bedside consultation and resulted in higher patients' scores for both satisfaction and communication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05250778.

How can we implement targeted policies of rumor governance? An empirical study based on survey experiment of COVID-19

Since early 2020, COVID-19 has been a major public security crisis that has had an enormous impact on the world. With the spread of the epidemic, rumors occur, some of which have even caused public panic. They have greatly affected the government’s efforts of epidemic prevention and thus urgently need to be evaluated. This study aimed to examine how to make flexible use of different policy tools to govern rumors based on their different characteristics. From the perspective of behavioral public policy, this study observes the effectiveness of various behavioral policy tools in rumor governance, hoping to explore the optimal solution of rumor governance from the perspective of micro public psychology. The survey experiment shows that individual behavior-related rumors (hereafter referred to as IBRs) are easier to be governed than epidemic progress-related rumors (hereafter referred to as EPRs) are, and that quick response is more effective than non-quick response. Through interaction analysis, it is known that in the governance of IBRs, nudge is more effective in rapid response, while in the context of non-quick response, boost outperforms nudge in rumor governance. A similar phenomenon can be seen in the scenario of EPR governance, despite a tinier difference in effectiveness compared with that of IBRs. The study enlightens us that rumor refutation requires not only people’s disbelief in and restraint on rumors, but also the implementation of science-based targeted policies. Based on the conclusion, this study puts forward suggestions on implementing targeted policies of rumor governance.

Mental Integrity in the Attention Economy: in Search of the Right to Attention

Is it wrong to distract? Is it wrong to direct others’ attention in ways they otherwise would not choose? If so, what are the grounds of this wrong – and, in expounding them, do we have to at once condemn large chunks of contemporary digital commerce (also known as the attention economy)? In what follows, I attempt to cast light on these questions. Specifically, I argue – following the pioneering work of Jasper Tran and Anuj Puri – that there is a right to attention, and that its existence underlies some of our claims regarding the wrongness of distractions. However, I depart from both these authors in two respects: first, I present a new way of deriving the right to attention, grounding it in the more fundamental right to mental integrity. Second, I remain agnostic on whether the contemporary business practices of capturing attention in exchange for a variety of digital products and services are plagued by routine violations of the right.

The Impact of Communication Information on the Perceived Threat of COVID-19 and Stockpiling Intention

This article investigates the role of diverse nudging communication strategies on perceived threat and stockpiling intention. Across three studies, the authors examined the various effects of “nudging” on consumer behavior. Study 1 demonstrates that a commonly used picture has a stronger impact on perceived threat than a less frequently exposed picture regardless of its accuracy. Study 2 shows that the perceived threat of COVID-19, in terms of severe health consequences, is lower when using an indirect (vs. direct) explanation of the virus, as well as when reducing the amount of information about the virus. Study 3 investigates the impact of salient negative information and childhood socioeconomic status (SES). Findings reveal that negative information about deaths associated with the virus increases the level of perceived threat and stockpiling intention, especially among people of low childhood SES.

The COVID-19 Pandemic Changes the Nudging Effect of Social Information on Individuals' Blood Donation Intention

The positive effect of social information on nudging prosocial behavior is context dependent. Understanding how sensitive intervention outcomes are to changes in the choice context is essential for policy design, especially in times of great uncertainty, such as the current COVID-19 pandemic. The present paper explores the effectiveness of social information in changing voluntary blood donation intention in two contexts: before and after the peak of the COVID-19 pandemic in China. In addition to the dimension of context, information content and its source are also important. Using a survey administered to 1,116 participants, we conducted an intertemporal randomized-controlled experiment to systematically analyze how information can effectively nudge the intention to donate blood. Compared with content featuring blood donors' commendation information, blood users' demand information is found to have a stronger nudging effect. An official information source has a greater influence on participants' donation intention than an unofficial source. Furthermore, our analysis of two waves of experimental data (i.e., before and after the peak of the COVID-19 pandemic) shows that the COVID-19 pandemic has further enhanced the nudging effect of blood users' demand information and official information sources. These findings provide a theoretical basis and policy recommendations for relevant institutions to develop effective blood donation campaign strategies.

Committing to Keep Clean: Nudging Complements Standard Policy Measures to Reduce Illegal Urban Garbage Disposal in a Neighborhood With High Levels of Social Cohesion

Illegal garbage disposals are a persistent urban problem, resulting in high clean-up costs, and nuisance and decreased satisfaction with the neighborhood among residents. We compared three adjacent city-areas in Rotterdam in the Netherlands which, for 2 weeks, either: (1) no action to decrease illegal garbage disposals was taken; (2) standard door-to-door canvassing was carried out; or (3) door-to-door canvassing was enriched with several nudges, most importantly a commitment-nudge. The nudge treatment proved highly effective, reducing illegal disposals at post-test and follow-up (2 months later) with two-thirds, resulting in a very large effect size (d = 2.60). At post-test, standard door-to-door canvassing did not differ from the control treatment, but at follow-up results were comparable to the nudging-treatment. This could, however, be due to spill-over effects. Using a commitment nudge thus proved highly effective in decreasing illegal garbage disposals, however, effects might be specific to neighborhoods with strong social cohesion.

[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.

Preventative Nudges: Introducing Risk Cues for Supporting Online Self-Disclosure Decisions

Like in the real world, perceptions of risk can influence the behavior and decisions that people make in online platforms. Users of Social Network Sites (SNSs) like Facebook make continuous decisions about their privacy since these are spaces designed to share private information with large and diverse audiences. In particular, deciding whether or not to disclose such information will depend largely on each individual’s ability to assess the corresponding privacy risks. However, SNSs often lack awareness instruments that inform users about the consequences of unrestrained self-disclosure practices. Such an absence of risk information can lead to poor assessments and, consequently, undermine users’ privacy behavior. This work elaborates on the use of risk scenarios as a strategy for promoting safer privacy decisions in SNSs. In particular, we investigate, through an online survey, the effects of communicating those risks associated with online self-disclosure. Furthermore, we analyze the users’ perceived severity of privacy threats and its importance for the definition of personalized risk awareness mechanisms. Based on our findings, we introduce the design of preventative nudges as an approach for providing individual privacy support and guidance in SNSs.

A systematic review of school meal nudge interventions to improve youth food behaviors

Background

School meal programs have a large reach and thus are ideal environments in which to implement interventions targeting improved youth eating behaviors and reduced food waste. This systematic review summarizes the evidence on the effectiveness of school meal nudge interventions on influencing children’s eating and waste behaviors.

Methods

Inclusion criteria required studies have participants in primary or secondary school (grades K-12) with interventions that occurred during school lunch or breakfast in the cafeteria and included at least one of the following outcomes: selection, consumption, waste, or school meal participation. Analyses of intervention outcomes were restricted to studies of strong and moderate quality.

Results

Twenty-nine studies were included in the quality assessment. Included interventions fell into three categories: 1) placement/convenience, 2) marketing/promotion, or 3) variety/portions. The 20 strong and moderate quality studies included in outcome analyses generally used strong data collection methods and study designs, but were limited by an overall lack of intervention fidelity checks. Multi-component interventions often did not use methods that allowed for separate analyses of outcomes for different intervention components.

Conclusions

School meal nudge interventions were positively associated with food selection, and had an inconsistent relationship with food consumption. There were few studies evaluating the impact of nudge interventions on meal participation or food waste. The limited evidence available links nudges to improved meal participation, as well as undesirable increases in food waste. Future research in this area should use methods that incorporate implementation metrics, attend to systems factors, and allow the outcomes of individual intervention components to be isolated.

Implementation of a Multi-Component School Lunch Environmental Change Intervention to Improve Child Fruit and Vegetable Intake: A Mixed-Methods Study

Nudge interventions are widely used to promote health in schools, yet implementation metrics are seldom used to understand intervention outcomes. A multi-component intervention consisting of cafeteria decorations, creative names, social norming taste tests, and flavor station components was implemented in three rural elementary school cafeterias by school nutrition services (SNS) and extension staff. Selection and consumption of fruits and vegetables at lunch were measured through monthly plate waste assessments over eight months (n = 1255 trays). Interviews were conducted with SNS staff (n = 3) upon completion of the intervention to assess implementation outcomes using validated acceptability and feasibility metrics. Consumption findings were generally inconsistent across schools and time points, yet fruit consumption increased at School 1 (p < 0.05) during the taste test and flavor station intervention months and School 2 (p < 0.001) during the creative names intervention months compared to baseline. Odds of selecting a vegetable at School 3 were three times higher than baseline during the taste test intervention months (odds ratio (OR), 3.0; 95% confidence interval (CI), 1.3–6.5). Cafeteria decorations and taste tests had higher reported implementation metrics for acceptability and feasibility than other interventions. Thematic analysis underscored the facilitating role of extension support, as well as systems factors, which served as facilitators and barriers across schools and interventions. These findings suggest that nudge interventions are a promising strategy to improve vegetable selection and fruit consumption in school meal programs.

A disruptive cue improves handwashing in school children in Zambia

Behavioral economics hold great promise in changing patterns of behavior that influence human health. Handwashing with soap is one such behavior that is important in reducing exposure to pathogens, and in school-age children, handwashing helps reduce absenteeism through the prevention of respiratory and diarrheal diseases. However, the gap between knowledge on the importance of handwashing and actual handwashing practice, especially with soap, persists. Many traditional behavior change communication approaches have failed in achieving and sustaining improved handwashing practices. Cognitive psychology research on habits as well as nudge theory, a component of behavioral economics predicated on the idea of making a behavior as easy as possible to do, suggests that introducing a disruptive cue into the environment may be able to interrupt current habitual neurological patterns to effect and then sustain behavior change. We used a participatory process to identify and introduce a locally appropriate disruptive cue to improve handwashing behavior in schools in Zambia. We then utilized a school-randomized controlled trial to test the soap-on-a-rope in 50 government schools in Namwala District of Southern Province. Two outcomes were considered among school children; washing hands with water and using soap while washing hands. Following the intervention, soap use was more likely in intervention schools than control schools [Odds ratio = 7.23, 95% confidence interval = (1.76-29.71)], though both intervention and control schools saw an increase in handwashing without soap. This low-cost intervention could be scaled throughout Zambia and may work well in other countries of similar circumstances.

Exploring the early phase of implementation of a vaccine-based clinical decision support system in the community pharmacy

OBJECTIVE

To explore the implementation strategy of a recombinant zoster vaccine (RZV) clinical decision support (CDS) intervention in community pharmacy workflow to increase second-dose vaccination rates.

SETTING

The level of analysis was the unit (e.g., pharmacy). The participants were selected from across approximately 2200 pharmacies in 37 states on the basis of criteria believed to affect implementation success (e.g., size, location) using a sampling matrix.

PRACTICE DESCRIPTION

Large supermarket pharmacy chain.

PRACTICE INNOVATION

Vaccine-based CDS intervention in community pharmacy workflow.

EVALUATION

A mixed-methods contextual inquiry approach explored the implementation of a new RZV CDS workflow intervention. Data collection involved key informant, semistructured interviews and an electronic, Web-based survey. The survey was based on a validated instrument and was made available to all pharmacists nationwide within the study organization to assess views of the implementation's appropriateness, acceptability, and feasibility during early implementation. Afterward, a series of semistructured, in-depth interviews were conducted until a point of saturation was reached. The interview guide was based on selected constructs of the Consolidated Framework for Implementation Research.

RESULTS

A total of 1128 survey responses were collected. Survey respondents agreed or strongly agreed that the implementation was acceptable (78.34%), appropriate (79.92%), and feasible (80.53%). Twelve pharmacist participants were interviewed via telephone. Five themes emerged from the interviews, revealing facilitators and barriers that affected implementation of the intervention: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process.

CONCLUSION

The implementation of the RZV CDS "nudge" intervention was welcomed, suitable, and operable in the community pharmacy setting to meet the needs of the organization, employees, and patients. The contextual factors identified during the implementation process of this CDS intervention in a community pharmacy setting may be used in scaling this and future CDS interventions for public health initiatives aimed at pharmacists in this setting.

‘Better off, as judged by themselves’: do people support nudges as a method to change their own behavior?

In this study, we investigated how people evaluate behavioral interventions (BIs) that are targeted at themselves, aiming to promote their own health and wellbeing. We compared the impact on people's assessments of the acceptability of using BIs to change their own behavior of: the transparency of the BI (transparent or opaque); the designer of the BI (researchers, government policy-makers, advertisers); and three types of arguments regarding their efficacy (positive, positive + negative, negative). Our target BIs were actual interventions that have been used in a range of policy domains (diet, exercise, alcohol consumption, smoking, personal finances). We found that transparent BIs were considered more acceptable than opaque BIs. On average, all BIs were considered acceptable for changing participants’ own behavior, except for the opaque BI in the finance context; there was differential acceptability of BIs across contexts, with finance clearly least acceptable. However, the perceived effectiveness of the BIs was at least as influential a predictor of acceptability ratings as the ease of identification of the behavior change mechanism across the five contexts. Furthermore, effectiveness was partially mediated by desire to change, suggesting that people do think BIs make them better off, ‘as judged by themselves’.

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.

Prominent positioning and food swaps are effective interventions to reduce the saturated fat content of the shopping basket in an experimental online supermarket: a randomized controlled trial

BACKGROUND

Interventions to reduce the saturated fat (SFA) content of food purchases may help reduce SFA consumption and lower cardiovascular risk. This factorial RCT aimed to examine the effect of altering the default order of foods and being offered a swap on the SFA content of food selected during an online shopping experiment.

METHODS

UK adults who were the primary grocery shoppers for their household were recruited online and invited to select items in a custom-made experimental online supermarket using a 10-item shopping list. Participants were randomly allocated to one of four groups (i) to see products within a category ranked in ascending order of SFA content, (ii) receive an offer to swap to a product with less SFA, (iii) a combination of both interventions, or (iv) no intervention. The primary outcome was the difference in percentage energy from SFA in the shopping basket between any of the four groups. The outcome assessors and statistician were blinded to intervention allocation.

RESULTS

Between March and July 2018, 1240 participants were evenly randomised and 1088 who completed the task were analysed (88%). Participants were 65% female and aged 38y (SD 12). Compared with no intervention (n = 275) where the percentage energy from SFA was 25.7% (SD 5.6%), altering the order of foods (n = 261) reduced SFA by [mean difference (95%CI)] -5.0% (- 6.3 to - 3.6) and offering swaps (n = 279) by - 2.0% (- 3.3 to - 0.6). The combined intervention (n = 273) was significantly more effective than swaps alone (- 3.4% (- 4.7 to - 2.1)) but not different than altering the order alone (- 0.4% (- 1.8 to 0.9)), p = 0.04 for interaction.

CONCLUSIONS

Altering the default order to show foods in ascending order of SFA and offering a swap with lower SFA reduced percentage energy from SFA in an experimental online supermarket. Environmental-level interventions, such as altering the default order, may be a more promising way to improve food purchasing than individual-level ones, such as offering swaps.

TRIAL REGISTRATION

ISRCTN13729526 https://doi.org/10.1186/ISRCTN13729526 26th February 2018.