A synthesis of evidence for policy from behavioural science during COVID-19

Scientific evidence regularly guides policy decisions1, with behavioural science increasingly part of this process2. In April 2020, an influential paper3 proposed 19 policy recommendations ('claims') detailing how evidence from behavioural science could contribute to efforts to reduce impacts and end the COVID-19 pandemic. Here we assess 747 pandemic-related research articles that empirically investigated those claims. We report the scale of evidence and whether evidence supports them to indicate applicability for policymaking. Two independent teams, involving 72 reviewers, found evidence for 18 of 19 claims, with both teams finding evidence supporting 16 (89%) of those 18 claims. The strongest evidence supported claims that anticipated culture, polarization and misinformation would be associated with policy effectiveness. Claims suggesting trusted leaders and positive social norms increased adherence to behavioural interventions also had strong empirical support, as did appealing to social consensus or bipartisan agreement. Targeted language in messaging yielded mixed effects and there were no effects for highlighting individual benefits or protecting others. No available evidence existed to assess any distinct differences in effects between using the terms 'physical distancing' and 'social distancing'. Analysis of 463 papers containing data showed generally large samples; 418 involved human participants with a mean of 16,848 (median of 1,699). That statistical power underscored improved suitability of behavioural science research for informing policy decisions. Furthermore, by implementing a standardized approach to evidence selection and synthesis, we amplify broader implications for advancing scientific evidence in policy formulation and prioritization.

Conspiracy theory

Chater & Loewenstein, superb and distinguished social scientists, have misfired. Their complaint is baseless: In the real world of policymaking, behavioral science is mostly being used to reform systems, not to alter individual behavior. Nor is there empirical support for the proposition that interventions aimed at helping individuals make systemic reform less likely.

A "sludge audit" for health system colorectal cancer screening services

OBJECTIVES

"Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services.

STUDY DESIGN

Mixed methods sludge audit.

METHODS

We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes.

RESULTS

Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients.

CONCLUSIONS

Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

Why and When Beliefs Change

Why people do or do not change their beliefs has been a long-standing puzzle. Sometimes people hold onto false beliefs despite ample contradictory evidence; sometimes they change their beliefs without sufficient reason. Here, we propose that the utility of a belief is derived from the potential outcomes associated with holding it. Outcomes can be internal (e.g., positive/negative feelings) or external (e.g., material gain/loss), and only some are dependent on belief accuracy. Belief change can then be understood as an economic transaction in which the multidimensional utility of the old belief is compared against that of the new belief. Change will occur when potential outcomes alter across attributes, for example because of changing environments or when certain outcomes are made more or less salient.

Crowdsourcing interventions to promote uptake of COVID-19 booster vaccines

BACKGROUND

COVID-19 booster vaccine uptake rates are behind the rate of primary vaccination in many countries. Governments and non-governmental institutions rely on a range of interventions aiming to increase booster uptake. Yet, little is known how experts and the general public evaluate these interventions.

METHODS

We applied a novel crowdsourcing approach to provide rapid insights on the most promising interventions to promote uptake of COVID-19 booster vaccines. In the first phase (December 2021), international experts (n = 78 from 17 countries) proposed 46 unique interventions. To reduce noise and potential bias, in the second phase (January 2022), experts (n = 307 from 34 countries) and representative general population samples from the UK (n = 299) and the US (n = 300) rated the proposed interventions on several evaluation criteria, including effectiveness and acceptability, on a 5-point Likert-type scale.

FINDINGS

Sanctions were evaluated as potentially most effective but least accepted. Evaluations by expert and general population samples were considerably aligned. Interventions that received the most positive evaluations regarding both effectiveness and acceptability across evaluation groups were: a day off work after getting vaccinated, financial incentives, tax benefits, promotional campaigns, and mobile vaccination teams.

INTERPRETATION

The results provide useful insights to help governmental and non-governmental institutions in their decisions about which interventions to implement. Additionally, the applied crowdsourcing method may be used in future studies to retrieve rapid insights on the comparative evaluation of (health) policies.

FUNDING

This study received funding from the Austrian Science Fund (SFB F63) and the University of Vienna.

The Modest Effects of Fact Boxes on Cancer Screening

As health care becomes increasingly personalized to the needs and values of individual patients, informational interventions that aim to inform and debias consumer decision-making are likely to become important tools. In a randomized controlled experiment, we explore the effects of providing participants with published fact boxes on the benefits and harms of common cancer screening procedures. Female participants were surveyed about breast cancer screening by mammography, while male participants were surveyed about prostate cancer screening by prostate-specific antigen (PSA) testing. For these screening procedures, we expect consumers to have overly optimistic prior beliefs about the benefits and harms. We find that participants update their beliefs about the net benefits of screening modestly, but we observe little change in their stated preferences to seek screening. Participants who scored higher on a numeracy test updated their beliefs about screening benefits more in response to the fact boxes than did participants who scored lower on the numeracy test.

Ten considerations for effectively managing the COVID-19 transition

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.

How behavioural sciences can promote truth, autonomy and democratic discourse online

Public opinion is shaped in significant part by online content, spread via social media and curated algorithmically. The current online ecosystem has been designed predominantly to capture user attention rather than to promote deliberate cognition and autonomous choice; information overload, finely tuned personalization and distorted social cues, in turn, pave the way for manipulation and the spread of false information. How can transparency and autonomy be promoted instead, thus fostering the positive potential of the web? Effective web governance informed by behavioural research is critically needed to empower individuals online. We identify technologically available yet largely untapped cues that can be harnessed to indicate the epistemic quality of online content, the factors underlying algorithmic decisions and the degree of consensus in online debates. We then map out two classes of behavioural interventions-nudging and boosting- that enlist these cues to redesign online environments for informed and autonomous choice.

Using social and behavioural science to support COVID-19 pandemic response

The COVID-19 pandemic represents a massive global health crisis. Because the crisis requires large-scale behaviour change and places significant psychological burdens on individuals, insights from the social and behavioural sciences can be used to help align human behaviour with the recommendations of epidemiologists and public health experts. Here we discuss evidence from a selection of research topics relevant to pandemics, including work on navigating threats, social and cultural influences on behaviour, science communication, moral decision-making, leadership, and stress and coping. In each section, we note the nature and quality of prior research, including uncertainty and unsettled issues. We identify several insights for effective response to the COVID-19 pandemic and highlight important gaps researchers should move quickly to fill in the coming weeks and months.

Epistemic spillovers: Learning others' political views reduces the ability to assess and use their expertise in nonpolitical domains

On political questions, many people prefer to consult and learn from those whose political views are similar to their own, thus creating a risk of echo chambers or information cocoons. We test whether the tendency to prefer knowledge from the politically like-minded generalizes to domains that have nothing to do with politics, even when evidence indicates that politically like-minded people are less skilled in those domains than people with dissimilar political views. Participants had multiple opportunities to learn about others' (1) political opinions and (2) ability to categorize geometric shapes. They then decided to whom to turn for advice when solving an incentivized shape categorization task. We find that participants falsely concluded that politically like-minded others were better at categorizing shapes and thus chose to hear from them. Participants were also more influenced by politically like-minded others, even when they had good reason not to be. These results replicate in two independent samples. The findings demonstrate that knowing about others' political views interferes with the ability to learn about their competency in unrelated tasks, leading to suboptimal information-seeking decisions and errors in judgement. Our findings have implications for political polarization and social learning in the midst of political divisions.

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers

BACKGROUND

Understanding factors that influence public support for "nudging" policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers' support for requiring pictorial warnings on cigarette packs.

METHODS

In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US.

RESULTS

Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001).

CONCLUSIONS

Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.

Is cost-benefit analysis a foreign language?

Do people think better in a foreign language? In some ways, yes. There is considerable evidence to this effect, at least to the extent that they are less likely to rely on intuitions that can lead to serious errors. This finding reinforces, and makes more plausible, a central claim in regulatory policy, which involves the value of cost-benefit analysis. In a sense, cost-benefit analysis is a foreign language, and it reduces the risk that people will rely on intuitions that cause serious errors.

The intrinsic value of choice: The propensity to under-delegate in the face of potential gains and losses

Human beings are often faced with a pervasive problem: whether to make their own decision or to delegate the decision task to someone else. Here, we test whether people are inclined to forgo monetary rewards in order to retain agency when faced with choices that could lead to losses and gains. In a simple choice task, we show that participants choose to pay in order to control their own payoff more than they should if they were to maximize monetary rewards and minimize monetary losses. This tendency cannot be explained by participants' overconfidence in their own ability, as their perceived ability was elicited and accounted for. Nor can the results be explained by lack of information. Rather, the results seem to reflect an intrinsic value for choice, which emerges in the domain of both gains and of losses. Moreover, our data indicate that participants are aware that they are making suboptimal choices in the normative sense, but do so anyway, presumably for psychological gains.

Should Governments Invest More in Nudging?

Governments are increasingly adopting behavioral science techniques for changing individual behavior in pursuit of policy objectives. The types of “nudge” interventions that governments are now adopting alter people’s decisions without coercion or significant changes to economic incentives. We calculated ratios of impact to cost for nudge interventions and for traditional policy tools, such as tax incentives and other financial inducements, and we found that nudge interventions often compare favorably with traditional interventions. We conclude that nudging is a valuable approach that should be used more often in conjunction with traditional policies, but more calculations are needed to determine the relative effectiveness of nudging.

Hormesis, the precautionary principle, and legal regulation

Many nations have shown mounting interest in a simple idea for the regulation of risk: In case of doubt, follow the precautionary principle (O'Riordan T, Cameron J eds. Interpreting the precautionary principle, 2002). Avoid steps that will create a risk of harm. Until safety is established, be cautious; do not require unambiguous evidence. In a catchphrase: Better safe than sorry.

The Council of Psychological Advisers

Findings in behavioral science, including psychology, have influenced policies and reforms in many nations. Choice architecture can affect outcomes even if material incentives are not involved. In some contexts, default rules, simplification, and social norms have had even larger effects than significant economic incentives. Psychological research is helping to inform initiatives in savings, finance, highway safety, consumer protection, energy, climate change, obesity, education, poverty, development, crime, corruption, health, and the environment. No nation has yet created a council of psychological advisers, but the role of behavioral research in policy domains is likely to grow in the coming years, especially in light of the mounting interest in promoting ease and simplification (“navigability”); in increasing effectiveness, economic growth, and competitiveness; and in providing low-cost, choice-preserving approaches.

Choosing not to choose

Choice can be an extraordinary benefit or an immense burden. In some contexts, people choose not to choose, or would do so if they were asked. In part because of limitations of "bandwidth," and in part because of awareness of their own lack of information and potential biases, people sometimes want other people to choose for them. For example, many people prefer not to make choices about their health or retirement plans; they want to delegate those choices to a private or public institution that they trust (and may well be willing to pay a considerable amount to those who are willing to accept such delegations). This point suggests that however well accepted, the line between active choosing and paternalism is often illusory. When private or public institutions override people's desire not to choose and insist on active choosing, they may well be behaving paternalistically, through a form of choice-requiring paternalism. Active choosing can be seen as a form of libertarian paternalism, and a frequently attractive one, if people are permitted to opt out of choosing in favor of a default (and in that sense permitted not to choose); it is a form of nonlibertarian paternalism insofar as people are required to choose. For both ordinary people and private or public institutions, the ultimate judgment in favor of active choosing, or in favor of choosing not to choose, depends largely on the costs of decisions and the costs of errors.

Due process traditionalism

In important cases, the Supreme Court has limited the scope of "substantive due process" by reference to tradition, but it has yet to explain why it has done so. Due process traditionalism might be defended in several distinctive ways. The most ambitious defense draws on a set of ideas associated with Edmund Burke and Friedrich Hayek, who suggested that traditions have special credentials by virtue of their acceptance by many minds. But this defense runs into three problems. Those who have participated in a tradition may not have accepted any relevant proposition; they might suffer from a systematic bias; and they might have joined a cascade. An alternative defense sees due process traditionalism as a second-best substitute for two preferable alternatives: a purely procedural approach to the Due Process Clause, and an approach that gives legislatures the benefit of every reasonable doubt. But it is not clear that in these domains, the first-best approaches are especially attractive; and even if they are, the second-best may be an unacceptably crude substitute. The most plausible defense of due process traditionalism operates on rule-consequentialist grounds, with the suggestion that even if traditions are not great, they are often good, and judges do best if they defer to traditions rather than attempting to specify the content of "liberty" on their own. But the rule-consequentialist defense depends on controversial and probably false assumptions about the likely goodness of traditions and the institutional incapacities of judges.

moral heuristics

with respect to questions of fact, people use heuristics – mental short-cuts, or rules of thumb, that generally work well, but that also lead to systematic errors. people use moral heuristics too – moral short-cuts, or rules of thumb, that lead to mistaken and even absurd moral judgments. these judgments are highly relevant not only to morality, but to law and politics as well. examples are given from a number of domains, including risk regulation, punishment, reproduction and sexuality, and the act/omission distinction. in all of these contexts, rapid, intuitive judgments make a great deal of sense, but sometimes produce moral mistakes that are replicated in law and policy. one implication is that moral assessments ought not to be made by appealing to intuitions about exotic cases and problems; those intuitions are particularly unlikely to be reliable. another implication is that some deeply held moral judgments are unsound if they are products of moral heuristics. the idea of error-prone heuristics is especially controversial in the moral domain, where agreement on the correct answer may be hard to elicit; but in many contexts, heuristics are at work and they do real damage. moral framing effects, including those in the context of obligations to future generations, are also discussed.

Valuing life: a plea for disaggregation

Each government agency uses a uniform figure to measure the value of a statistical life (VSL). This is a serious mistake. The very theory that underlies current practice calls for far more individuation of the relevant values. According to that theory, VSL should vary across risks. More controversially, VSL should vary across individuals -- even or especially if the result would be to produce a lower number for some people than for others. One practical implication is that a higher value should be given to programs that reduce cancer risks. Another is that government should use a higher VSL for programs that disproportionately benefit the wealthy -- and a lower VSL for programs that disproportionately benefit the poor. But there are two serious complications here. First, bounded rationality raises problems for the use of private willingness to pay, which underlies current calculations of VSL. Second, the beneficiaries of regulation sometimes pay only a fraction or even none of its cost; when this is so, the appropriate VSL for poor people might be higher, on distributional grounds, than market evidence suggests. An understanding of this point has implications for foundational issues about government regulation, including valuation of persons in poor and wealthy nations.

Statistics, not memories: what was the standard of care for administering antenatal steroids to women in preterm labor between 1985 and 2000?

We determined the frequency of antenatal corticosteroid use for mothers with threatened premature delivery in 1985, 1990, 1995, and 2000. We next compared published data to the surveyed recollections of 302 obstetricians who were practicing during these years. Two points emerged. First, published reports reveal that the use of antenatal corticosteroids increased steadily, from 8% in 1985 to 20% in 1990, 52% in 1995, and 75% in 2000 (P <.001). Second, "expert" opinions derived from the recollections of practicing obstetricians consistently overestimated the actual use of antenatal corticosteroids during the year in question-31% versus 8% for 1985, 56% versus 20% for 1990, 78% versus 52% for 1995, and 92% versus 72% for 2000 (all Ps <.001). The use of antenatal corticosteroids by obstetricians in the past 15 years reveals a phenomenon that is widely recognized elsewhere-retrospective memories are often wrong, and when they are wrong they are not randomly wrong. Rather, recollections are systematically skewed toward an outcome that, in hindsight, is considered desirable (the "Monday morning quarterback" phenomenon). We offer a simple proposal. In determining the "standard of medical care," the legal system should rely on statistical data about doctors' performance rather than the recollections of experts about doctors' performance. The fallible memories of isolated experts are a crude second-best, far inferior to the data that they approximate. Widespread adoption of this view by professional physician organizations would dramatically increase the rationality of expert testimony in medical malpractice tort law.

Privacy and medicine: a comment

One of the characteristics of a free society should be a strong presumption in favor of full patient control over personal information. The presumption is rebutted when disclosure to others is necessary (1) for good patient care, as in the case of consultations and medical teams; (2) to compile information that will produce scientific or medical progress; (3) to protect third parties from serious risks of harm; and (4) to prevent harm to patients themselves. In all of these cases, identifying information should be removed unless it is necessary. Principles of this sort should be implemented via physician norms, in fact publicly acknowledged physician norms, and (only) if necessary, by more formal regulations, private and public.

Is tobacco a drug? Administrative agencies as common law courts

Professor Cass Sunstein argues that the FDA has the authority to regulate tobacco products. He considers the text of the Federal Food, Drug, and Cosmetic Act, which supports the FDA assertion, and the context of its enactment, which argues against the FDA. He resolves the tension between text and context in favor of FDA jurisdiction by turning to the emerging role of administrative agencies. In modern government, he contends, administrative agencies have become America's common law courts, with the power to adapt statutory regimes to new facts and new values when the underlying statute is ambiguous. Professor Sunstein's Article, like the other pieces in this volume, was written after the United States District Court for the Middle District of North Carolina decided Coyne Beahm v. FDA, but before a three judge panel of the United States Court of Appeals for the Fourth Circuit reversed that decision in Brown & Williamson Tobacco Corp. v. FDA. In Coyne Beahm, the District Court held that the Federal Food, Drug, and Cosmetic Act authorized the FDA to regulate tobacco products, but not tobacco advertising. The Fourth Circuit rejected the District Court's jurisdictional ruling and invalidated the FDA's regulations in their entirety. The Clinton Administration has since requested an en banc rehearing before the Fourth Circuit.