When it comes to sedentary behaviour modification, should people be told what to do? A randomized comparison trial among home-based office workers living in Ontario, Canada

The effects of adding choice architecture to a theory-based (Health Action Process Approach; HAPA) sedentary intervention remain unknown. To investigate whether choice architecture enhances a theory-based sedentary behaviour reduction intervention in home-based office workers. A 4-week HAPA-based intervention was conducted in London, Canada. Choice architecture was tested as an enhancement via a two (group: 'Choice of Intervention' vs. 'No Choice Intervention') by two (time: Baseline vs. Week 4) factorial repeated measure randomized comparison design. Sedentary behaviour reduction strategies focussed on obtaining a sedentary break frequency (BF) of every 30-45 min with break durations (BD) of 2-3 min. BF, BD, sitting, standing, and moving time were objectively measured (activPAL4™) at both time points. Participants (n = 148) were 44.9 ± 11.4 years old and 72.3% female. BF and total sitting time showed a time effect (P < .001), where both groups improved over the 4 weeks; there were no significant differences between groups across time. BD, standing, and moving time had a significant group by time effect where the 'No Choice' group showed significant increases in BD (P < .001), standing (P = .006), and moving time (P < .001) over the 4 weeks. Augmenting a theory-based intervention with choice architecture resulted in change in some sedentary behaviours in at home office workers. Specifically, while BF increased for all participants, the 'No Choice' group exhibited greater changes for BD, standing, and moving time compared with the 'Choice' group. Overall, these changes exceeded the intervention BF and BD goals.

Rapid appearance of negative emotion during oral fentanyl self-administration in male and female rats

Opioid use disorder has become an epidemic in the United States, fuelled by the widespread availability of fentanyl, which produces rapid and intense euphoria followed by severe withdrawal and emotional distress. We developed a new preclinical model of fentanyl seeking in outbred male and female rats using volitional oral self-administration (SA) that can be readily applied in labs without intravascular access. Using a traditional two-lever operant procedure, rats learned to take oral fentanyl vigorously, escalated intake across sessions, and readily reinstated responding to conditioned cues after extinction. Oral SA also revealed individual and sex differences that are essential to studying substance use risk propensity. During a behavioural economics task, rats displayed inelastic demand curves and maintained stable intake across a wide range of fentanyl concentrations. Oral SA was also neatly patterned, with distinct 'loading' and 'maintenance' phases of responding within each session. Using our software DeepSqueak, we analysed ultrasonic vocalizations (USVs), which are innate expressions of current emotional state in rats. Rats produced 50 kHz USVs during loading then shifted quickly to 22 kHz calls despite ongoing maintenance of oral fentanyl taking, reflecting a transition to negative reinforcement. Using fibre photometry, we found that the lateral habenula differentially processed drug cues and drug consumption depending on affective state, with potentiated modulation by drug cues and consumption during the negative affective maintenance phase. Together, these results indicate a rapid progression from positive to negative reinforcement occurs even within an active drug taking session, revealing a within-session opponent process.

Applying behavioural economics principles to increase demand for free HIV testing services at private doctor-led clinics in Johannesburg, South Africa: A randomised controlled trial

Background

Expanding free HIV testing service (HTS) access to include private clinics could increase testing rates. A donor funded programme, GP Care Cell, offered free HIV testing at selected private doctor-led clinics but uptake was low. We investigated whether HTS demand creation materials that used behavioural economics principles could increase demand for HIV testing at these clinics.

Methods

We conducted a randomised controlled trial in Johannesburg, South Africa (January-April 2022) distributing brochures promoting HTS to adults in five private doctor-led clinic catchment areas. Individuals were randomised to receive three brochure types: (1) "Standard of care" (SOC) advertising a free HIV test and ART; (2) "Healthy lifestyle screening" promoted free low-cost health screenings in addition to HTS; and (3) "Recipient of care voucher" leveraged loss aversion and the endowment effect by highlighting the monetary value of free HTS. The primary outcome was presenting at the clinic following exposure to the brochures. Logistic regression compared outcomes between arms.

Results

Of the 12,129 brochures distributed, 658 were excluded because of errors or duplicates and 11,471 were analysed. About 59% of brochure recipients were male and 50,3% were aged 25-34 years. In total, 448 (3.9%) brochure recipients presented at the private doctor-led clinics of which 50.7% were males. There were no significant differences in clinic presentation between the healthy lifestyle screening and SOC arm (Adjusted Odds Ratio [AOR] 1.02; 95% CI 0.79-1.32), and similarly between the recipient of care voucher and SOC arm (AOR 1.08; 95% CI 0.84-1.39). Individuals were more likely to attend clinics that were centrally located with visible branding for HTS (AOR=5.30; 95% CI: 4.14-6.79).

Conclusion

Brochures that used behavioural insights did not increase demand for HTS at private doctor-led clinics. However, consistent distribution of the brochures may have potential to increase HIV testing uptake at highly visible private doctor-led clinics.

Strengthening HIV and HIV co-morbidity care in low- and middle-income countries: insights from behavioural economics to improve healthcare worker behaviour

INTRODUCTION

Despite advances in HIV and HIV co-morbidity service delivery, substantial challenges remain in translating evidence-based interventions into routine practice to bring optimal care and prevention to all populations. While barriers to successful implementation are often multifactorial, healthcare worker behaviour is critical for on-the-ground and in-clinic service delivery. Implementation science offers a systematic approach to understanding service delivery, including approaches to overcoming delivery gaps. Behavioural economics is a field that seeks to understand when and how behaviour deviates from traditional models of decision-making, deviations which are described as biases. Clinical policies and implementation strategies that incorporate an understanding of behavioural economics can add to implementation science approaches and play an important role in bridging the gap between healthcare worker knowledge and service delivery.

DISCUSSION

In HIV care in low- and middle-income countries (LMICs), potential behavioural economic strategies that may be utilized alone or in conjunction with more traditional approaches include using choice architecture to exploit status quo bias and reduce the effects of cognitive load, overcoming the impact of anchoring and availability bias through tailored clinical training and clinical mentoring, reducing the effects of present bias by changing the cost-benefit calculus of interventions with few short-term benefits and leveraging social norms through peer comparison. As with any implementation strategy, understanding the local context and catalysts of behaviour is crucial for success.

CONCLUSIONS

As the focus of HIV care shifts beyond the goal of initiating patients on antiretroviral therapy to a more general retention in high-quality care to support longevity and quality of life, there is an increasing need for innovation to achieve improved care delivery and management. Clinical policies and implementation strategies that incorporate elements of behavioural economic theory, alongside local testing and adaptation, may increase the delivery of evidence-based interventions and improve health outcomes for people living with HIV in LMIC settings.

Physical activity as an investment or consumption good-a mixed methods approach

Studying individuals' motivation to engage in physical activity raises the question of whether physical activity is a consumption good (enjoyment) or an investment good (a health investment). The aims of the study were: (i) What kind of motivational background is it possible to identify for different forms of physical activity among adults, and (ii) Is there an association between different motivational factors and the form and amount of physical activity among adults. A mixed methods approach was applied using interviews (n = 20) and a questionnaire (n = 156). The qualitative data was analysed using content analysis. The quantitative data were analysed using factor and regression analysis. Among the interviewees, different types of motivation were found: 'enjoyment', 'health reasons' and 'mixed motivations', and from the quantitative data: (i) mixed motivation, a combination of enjoyment and investment, (ii) dislike of physical activity, (iii) social, (iv) goal focused, (v) appearance focused and (vi) exercising only within the comfort zone. Mixed-motivational background, with both enjoyment and investment in health, increased weekly physical activity hours significantly (β = 1.733; p = 0.001). Personal appearance-based motivation increased weekly muscle training (β = 0.540; p = 0.000) and brisk physical activity hours (β = 0651; p = 0.014). Conducting such physical activity which provides enjoyment during the performance of the activity, increased weekly balance-focused exercise hours (β = 0.224; p = 0.034). People have different kind of motivational backgrounds for engaging in physical activity. Mixed motivational background, including enjoyment and investment in health, yielded more physical activity in hours than if the person had only one of these motivations.

The Black Box as a Control for Payoff-Based Learning in Economic Games

The black box method was developed as an "asocial control" to allow for payoff-based learning while eliminating social responses in repeated public goods games. Players are told they must decide how many virtual coins they want to input into a virtual black box that will provide uncertain returns. However, in truth, they are playing with each other in a repeated social game. By "black boxing" the game's social aspects and payoff structure, the method creates a population of self-interested but ignorant or confused individuals that must learn the game's payoffs. This low-information environment, stripped of social concerns, provides an alternative, empirically derived null hypothesis for testing social behaviours, as opposed to the theoretical predictions of rational self-interested agents (Homo economicus). However, a potential problem is that participants can unwittingly affect the learning of other participants. Here, we test a solution to this problem in a range of public goods games by making participants interact, unknowingly, with simulated players ("computerised black box"). We find no significant differences in rates of learning between the original and the computerised black box, therefore either method can be used to investigate learning in games. These results, along with the fact that simulated agents can be programmed to behave in different ways, mean that the computerised black box has great potential for complementing studies of how individuals and groups learn under different environments in social dilemmas.

Self-interested learning is more important than fair-minded conditional cooperation in public-goods games

Why does human cooperation often unravel in economic experiments despite a promising start? Previous studies have interpreted the decline as the reaction of disappointed altruists retaliating in response to non-altruists (Conditional Cooperators hypothesis). This interpretation has been considered evidence of a uniquely human form of cooperation, motivated by an altruistic concern for equality ('fairness') and requiring special evolutionary explanations. However, experiments have typically shown individuals not only information about the decisions of their groupmates (social information) but also information about their own payoffs. Showing both confounds explanations based on conditional cooperation with explanations based on confused individuals learning how to better play the game (Confused Learners hypothesis). Here we experimentally decouple these two forms of information, and thus these two hypotheses, in a repeated public-goods game. Analysing 616 Swiss university participants, we find that payoff information leads to a greater decline, supporting the Confused Learners hypothesis. In contrast, social information has a small or negligible effect, contradicting the Conditional Cooperators hypothesis. We also find widespread evidence of both confusion and selfish motives, suggesting that human cooperation is maybe not so unique after all.

EXPRESS: The Behavioural Economics of Music: Systematic Review and Future Directions

Music-related decision making encompasses a wide range of behaviours including those associated with composition and performance, listening choices, and decisions involving music education and therapy. Although research programmes in psychology and economics have contributed to an improved understanding of music-related behaviour, historically these disciplines have been unconnected. Recently however, researchers have begun to bridge this gap by employing tools from behavioural economics. This paper contributes to the literature by providing a discussion about the benefits of using behavioural economics in music-decision research. We achieve this in two ways. First, through a systematic review, we identify the current state of the literature within four key areas of behavioural economics - heuristics and biases, social decision making, behavioural time preferences, and dual-process theory. Second, taking findings of the literature as a starting point, we demonstrate how behavioural economics can inform future research. Based on this, we propose the Behavioural Economics of Music (BEM), an integrated research programme that aims to break new ground by stimulating interdisciplinary research in the intersection between music, psychology, and economics.

Modelling behaviour in intergroup conflicts: a review of microeconomic approaches

Microeconomic modelling offers a powerful formal toolbox for analysing the complexities of real-world intergroup relations and conflicts. One important class of models scrutinizes individuals' valuations of different group memberships, attitudes towards members of different groups and preferences for resource distribution in group contexts. A second broad class uses game theoretical methods to study strategic interactions within and between groups of individuals in contest and in conflict. After a concise discussion of some essential peculiarities of microeconomic modelling, this review provides an overview of the pertinent literatures in economics, highlights instructive examples of central model types and points out several ways forward. This article is part of the theme issue 'Intergroup conflict across taxa'.

Behavioural barriers and perceived trade-offs to care-seeking for tuberculosis in the Philippines

Effective tuberculosis (TB) treatment has existed for more than 50 years, but TB remains a leading cause of death worldwide and in the Philippines, in part because symptomatic individuals delay or avoid seeking care. Through qualitative interviews in Pampanga, Philippines, we investigated barriers to care-seeking using a behavioural science lens. We found barriers to TB care-seeking to be shaped by: (1) ambiguous symptoms; (2) association of TB risk with lifestyle and habits; (3) expectations of stigma, discrimination, and isolation; (4) short-term costs and long-term financial burden of TB; and (5) visibility of care in public sector facilities. Findings suggest that these barriers are deeply intertwined and that, typically, it is a combination of barriers that holds back a particular symptomatic individual from seeking care, as the barriers influence implicit trade-offs related to health, social, and financial consequences of having TB or another serious illness and of seeking care or not seeking care. The findings suggest avenues for more effectively reaching those with symptoms and their family members to encourage care-seeking by elevating the perceived benefits and putting perceived costs in proper perspective.

Forced choices reveal a trade-off between cognitive effort and physical pain

Cognitive effort is described as aversive, and people will generally avoid it when possible. This aversion to effort is believed to arise from a cost-benefit analysis of the actions available. The comparison of cognitive effort against other primary aversive experiences, however, remains relatively unexplored. Here, we offered participants choices between performing a cognitively demanding task or experiencing thermal pain. We found that cognitive effort can be traded off for physical pain and that people generally avoid exerting high levels of cognitive effort. We also used computational modelling to examine the aversive subjective value of effort and its effects on response behaviours. Applying this model to decision times revealed asymmetric effects of effort and pain, suggesting that cognitive effort may not share the same basic influences on avoidance behaviour as more primary aversive stimuli such as physical pain.

Association of Loss Aversion, Personality Traits, Depressive, Anxious, and Suicidal Symptoms: Systematic Review

OBJECTIVE

Loss aversion is defined as the individual perception of losses with a more significant impact than the gains of the same proportion, where people would be more sensitive to the possibility of losing objects or money than to the possibility of winning, even the same quantities. However, studies relating to loss aversion and psychological factors are still incipient. The aim of the present literature review was to identify and analyze the results of studies that investigated loss aversion regarding personality traits and symptoms of depression, anxiety, and suicidal tendencies.

METHOD

A systematic review was done through PUBMED and Scopus databases. Descriptors were defined according to each database specificities.

RESULTS

At first, 103 articles were encountered. After evaluation of the inclusion and exclusion criteria, there were a total of 14 remaining articles that were group together into six categories related to loss aversion, depression, anxiety, suicidal tendencies, and personality.

CONCLUSIONS

The present study contributes to the literature mapping in the Behavioural Economics field. However, discrepancies were found among the studies, which made it difficult to acquire more conclusive findings.

Fitness-maximizers employ pessimistic probability weighting for decisions under risk

The standard theory of rationality posits that agents order preferences according to average utilities associated with different choices. Expected utility theory has repeatedly failed as a predictive theory, as reflected in a growing literature in behavioural economics. Evolutionary theorists have suggested that seemingly irrational behaviours in contemporary contexts may have once served important functions, but existing work linking fitness and choice has not adequately addressed the challenges of constructing an evolutionary theory of decision making. In particular, fitness itself is not a reasonable metric for decision making since its timescale exceeds the lifespan of the decision-maker. Consequently, organisms use proximate systems that work on appropriate timescales and are amenable to feedback and learning. We develop an evolutionary principal-agent model in which individuals utilize a set of proximal choice variables to account for the non-linear dependence of these variables on consumption. While this is insufficient to maximize fitness in the presence of environmental stochasticity, maximum fitness can be achieved by adopting pessimistic probability weightings compatible with the rank-dependent expected utility family of choice models. In particular, pessimistic probability weighting emerges naturally in an evolutionary framework because of extreme intolerance to zeros in multiplicative growth processes.

Towards a complex model of disaster behaviour

This paper outlines why a move towards a complex adaptive systems model of behaviour is required if the goal is to generate better understanding of how individuals and groups interact with their environment in a disaster setting. To accomplish this objective, a bridge must be built between the broader social sciences and behavioural economics to incorporate discipline-specific insights that are needed to move towards complexity. This is only possible through a deeper understanding of behaviour and how the environment in which they occur can influence actions. It is then that one can counteract the poor behavioural predictions, flawed policies based on myth, inefficient design, and suboptimal outcomes that have flourished in the absence of a complex adaptive systems model. This paper provides a conceptual framework that draws on concepts from across the natural and social sciences, such as behavioural economics, endocrinology, psychology, sociobiology, and sociology in order to build an interactive theory of disaster behaviour.

Public health for paediatricians:How can behavioural economics help to make paediatric practice more effective?

Understanding the principles of behavioural economics is important for paediatricians because behavioural economics offers ideas to help improve the quality of paediatric care. It can also be used to inform health interventions/policy at a population level. This paper summarises key behavioural economic concepts such as bounded rationality, bounded willpower and social influence, explaining how they can be used to shape healthy behaviours in children and adolescents. Case studies of interventions that have used behavioural economics principles (sometimes called 'nudge theory') are provided.

Developmental perspectives on risky and impulsive choice

Epidemiological data suggest that risk taking in the real world increases from childhood into adolescence and declines into adulthood. However, developmental patterns of behaviour in laboratory assays of risk taking and impulsive choice are inconsistent. In this article, we review a growing literature using behavioural economic approaches to understand developmental changes in risk taking and impulsivity. We present findings that have begun to elucidate both the cognitive and neural processes that contribute to risky and impulsive choice, as well as how age-related changes in these neurocognitive processes give rise to shifts in choice behaviour. We highlight how variability in task parameters can be used to identify specific aspects of decision contexts that may differentially influence risky and impulsive choice behaviour across development. This article is part of the theme issue 'Risk taking and impulsive behaviour: fundamental discoveries, theoretical perspectives and clinical implications'.

Reducing the Consumer Attitude⁻Behaviour Gap in Animal Welfare: The Potential Role of 'Nudges'

Simple Summary

Many members of the public express a desire for farm animals to have a good quality of life. Yet, when it comes to purchasing higher welfare products which would support this, many consumers do not ‘walk their talk’. This paper introduces the concept of ‘nudging’ as a means to help consumers align their actions with their intentions and support their desire to engage in pro-animal welfare behaviours. ‘Nudging’ is a collection of behaviour change tools designed to hint to, or suggest, a choice most closely aligned with an individual’s self-interests or intentions. Their purpose is to simplify the decision-making environment by working in concert with the behavioural flaws known to influence human decision-making. Four specific behavioural ‘nudges’ are outlined: self-nudges, choice architecture, social norms and pre-commitments, along with examples of how they can be applied to animal welfare. Inspired by effective applications of ‘nudging’ to close the consumer attitude–behaviour gap in other relevant domains, this paper seeks to highlight how similar initiatives might be applied to better support higher welfare choices amongst consumers and in turn, enhance the lives of farm animals.

Abstract

Citizen concern for the welfare of farm animals is well documented. However, there is a notable gap between people saying they want improved farm animal welfare and how they actually behave as a consumer. This is known as the citizen–consumer attitude–behaviour gap. As improvements in farm animal welfare can be affected by market demand, the choices consumers make become important. This paper introduces the concept of ‘nudging’ and discusses how it could be applied to reduce the attitude–behaviour gap amongst consumers. By designing the choice environment to better reflect the behavioural biases known to impact human decision-making, ‘nudge’ tools function to prompt individuals to make choices that are aligned with their stated intentions. Four ‘nudge’ tools: self-nudges, choice architecture, social norms and pre-commitments are discussed. The behavioural rationales for their use are reviewed and examples of how they might be applied to animal welfare provided. Improved farm animal welfare arguably requires improved pro-welfare consumer behaviour. This paper highlights how this might be encouraged by: self-nudging the salience of an ethical self-image; altering the choice architecture to influence decision-making; articulating social norms to impact behaviour; and using pre-commitment devices to overcome self-control issues.

Nudging people with Type 2 diabetes towards better self-management through personalized risk communication: A pilot randomized controlled trial in primary care

OBJECTIVES

To assess the feasibility in routine primary care consultation and investigate the effect on risk recall and self-management of a new type of risk communication intervention based on behavioural economics ("nudge-based") for people with Type 2 diabetes mellitus (T2DM).

METHODS

Forty adults with poorly controlled T2DM (HbA1c > 7.5%) were randomized to receive a personalized, nudge-based risk communication intervention (n = 20) or standard care (n = 20). Risk recall and self-management were evaluated at baseline and 12 weeks after the intervention.

RESULTS

Both in terms of feasibility and acceptability, this new risk communication intervention was very satisfactory. Study retention rate after 12 weeks was very high (90%) and participants were highly satisfied with the intervention (4.4 out of 5 on the COMRADE scale). Although not powered to identify significant between-group effects, the intervention significantly improved risk recall after 12 weeks and intentions to make lifestyle changes (dietary behaviour) compared to standard care.

CONCLUSIONS

This pilot study provides the first evidence of the feasibility of implementing in primary care a nudge-based risk communication intervention for people with T2DM. Based on the promising results observed, an adequately powered trial to determine the effectiveness of the intervention on long-term self-management is judged feasible. As a result of this feasibility study, some minor adaptations to the intervention and study methods that would help to facilitate a definitive trial are also reported.

Elizabeth Usher Memorial Lecture: How do we change our profession? Using the lens of behavioural economics to improve evidence-based practice in speech-language pathology

Evidence-based practice (EBP) is a well-accepted theoretical framework around which speech-language pathologists strive to build their clinical decisions. The profession's conceptualisation of EBP has been evolving over the last 20 years with the practice of EBP now needing to balance research evidence, clinical data and informed patient choices. However, although EBP is not a new concept, as a profession, we seem to be no closer to closing the gap between research evidence and practice than we were at the start of the movement toward EBP in the late 1990s. This paper examines why speech-language pathologists find it difficult to change our own practice when we are experts in changing the behaviour of others. Using the lens of behavioural economics to examine the heuristics and cognitive processes which facilitate and inhibit change, the paper explores research showing how inconsistency of belief and action, or cognitive dissonance, is inevitable unless we act reflectively instead of automatically. The paper argues that heuristics that prevent us changing our practice toward EBP include the sunk cost fallacy, loss aversion, social desirability bias, choice overload and inertia. These automatic cognitive processes work to inhibit change and may partially account for the slow translation of research into practice. Fortunately, understanding and using other heuristics such as the framing effect, reciprocity, social proof, consistency and commitment may help us to understand our own behaviour as speech-language pathologists and help the profession, and those we work with, move towards EBP.

Use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications

AIM

There is limited evidence on what behavioural economics strategies are effective and can be used to inform non-communicable diseases (NCDs) public health policies designed to reduce overeating, excessive drinking, smoking, and physical inactivity. The aim of the review is to examine the evidence on the use and effectiveness of behavioural economics insights on reducing NCDs lifestyle risk factors.

METHODS

Medline, Embase, PsycINFO, and EconLit were searched for studies published between January 2002 and July 2016 and reporting empirical, non-pharmacological, interventional research focusing on reducing at least one NCDs lifestyle risk factor by employing a behavioural economics perspective.

RESULTS

We included 117 studies in the review; 67 studies had a low risk of bias and were classified as strong or very strong, 37 were moderate, and 13 were weak. We grouped studies by NCDs risk factors and conducted a narrative synthesis. The most frequent behavioural economics precepts used were incentives, framing, and choice architecture. We found inconclusive evidence regarding the success of behavioural economics strategies to reduce alcohol consumption, but we identified several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity.

CONCLUSION

Most studies targeting tobacco consumption, physical activity levels, and eating behaviours from a behavioural economics perspective had promising results with potential impact on NCDs health policies. We recommend future studies to be implemented in real-life settings and on large samples from diverse populations.

Strategic Information Processing from Behavioural Data in Iterated Games

Iterated games are an important framework of economic theory and application, at least since the original work of Axelrod’s computational tournaments of the early 80’s. Recent theoretical results have shown that games (the economic context) and game theory (the decision-making process) are both formally equivalent to computational logic gates. Here these results are extended to behavioural data obtained from an experiment in which rhesus monkeys sequentially played thousands of the “matching pennies” game, an empirical example similar to Axelrod’s tournaments in which algorithms played against one another. The results show that the monkeys exhibit a rich variety of behaviours, both between and within subjects when playing opponents of varying complexity. Despite earlier suggestions, there is no clear evidence that the win-stay, lose-switch strategy is used, however there is evidence of non-linear strategy-based interactions between the predictors of future choices. It is also shown that there is consistent evidence across protocols and across individuals that the monkeys extract non-markovian information, i.e., information from more than just the most recent state of the game. This work shows that the use of information theory in game theory can test important hypotheses that would otherwise be more difficult to extract using traditional statistical methods.

Value-based choice: An integrative, neuroscience-informed model of health goals

OBJECTIVE

Traditional models of health behaviour focus on the roles of cognitive, personality and social-cognitive constructs (e.g. executive function, grit, self-efficacy), and give less attention to the process by which these constructs interact in the moment that a health-relevant choice is made. Health psychology needs a process-focused account of how various factors are integrated to produce the decisions that determine health behaviour.

DESIGN

I present an integrative value-based choice model of health behaviour, which characterises the mechanism by which a variety of factors come together to determine behaviour. This model imports knowledge from research on behavioural economics and neuroscience about how choices are made to the study of health behaviour, and uses that knowledge to generate novel predictions about how to change health behaviour. I describe anomalies in value-based choice that can be exploited for health promotion, and review neuroimaging evidence about the involvement of midline dopamine structures in tracking and integrating value-related information during choice. I highlight how this knowledge can bring insights to health psychology using illustrative case of healthy eating.

CONCLUSION

Value-based choice is a viable model for health behaviour and opens new avenues for mechanism-focused intervention.

Radical framing effects in the ultimatum game: the impact of explicit culturally transmitted frames on economic decision-making

Many studies have documented framing effects in economic games. These studies, however, have tended to use minimal framing cues (e.g. a single sentence labelling the frame), and the frames did not involve unambiguous offer expectations. Results often did not differ substantially from those in the unframed games. Here we test the hypothesis that, in contrast to the modal offer in the unframed ultimatum game (UG) (e.g. 60% to the proposer and 40% to the responder), offers in a UG explicitly framed either as a currency exchange or a windfall will closely conform to expectations for the frame and diverge substantially from the modal offer. Participants recruited from MTurk were randomized into one of two conditions. In the control condition, participants played a standard UG. In the treatment conditions, players were provided a vignette explicitly describing the frame with their roles: some were customers and bankers in a currency exchange, and others were in a windfall scenario. We predicted (i) that modal offers in the currency exchange would involve an asymmetric split where greater than 80% went to customers and less than 20% went to bankers, and (ii) that variation in windfall offers would converge onto a 50-50 split with significantly less variation than the control condition. Our first prediction was confirmed with substantial effect sizes (d = 1.09 and d = -2.04), whereas we found no evidence for our second prediction. The first result provides further evidence that it is difficult to draw firm conclusions about economic decision-making from decontextualized games.

Nudges, shoves and budges: Behavioural economic policy frameworks

Behavioural economics-the study of human decision making and how it sometimes deviates systematically from the assumptions of standard economic theory-has attracted a lot of attention in the health policy discourse over recent years. Many appear to believe that behavioural economic findings can be used only to help inform policies that manipulate the choices made by citizens, ie, the so-called nudge policy. However, these findings can be used to inform several different policy frameworks, from seemingly innocuous liberty-preserving changes to the contexts people operate in, to the outlawing of certain corporate behaviours. This article depicts diagrammatically, with the aid of a "behavioural policy cube" and in relation to smoking cessation interventions, the conceptual parameters of several behavioural economic-informed policy frameworks, which could be easily extended to other areas of health, and indeed broader public, policy.

Failure to CAPTCHA Attention: Null Results from an Honesty Priming Experiment in Guatemala

We report results from a large online randomised tax experiment in Guatemala. The trial involves short messages and choices presented to taxpayers as part of a CAPTCHA pop-up window immediately before they file a tax return, with the aim of priming honest declarations. In total our sample includes 627,242 taxpayers and 3,232,430 tax declarations made over four months. Treatments include: honesty declaration; information about public goods; information about penalties for dishonesty, questions allowing a taxpayer to choose which public good they think tax money should be spent on; or questions allowing a taxpayer to state a view on the penalty for not declaring honestly. We find no impact of any of these treatments on the average amount of tax declared. We discuss potential causes for this null effect and implications for 'online nudges' around honesty priming.

Acute stress alters individual risk taking in a time-dependent manner and leads to anti-social risk

Decision‐making processes can be modulated by stress, and the time elapsed from stress induction seems to be a crucial factor in determining the direction of the effects. Although current approaches consider the first post‐stress hour a uniform period, the dynamic pattern of activation of the physiological stress systems (i.e., the sympathetic nervous system and hypothalamic‐pituitary‐adrenal axis) suggests that its neurobehavioural impact might be heterogeneous. Here, we evaluate economic risk preferences on the gain domain (i.e., risk aversion) at three time points following exposure to psychosocial stress (immediately after, and 20 and 45 min from onset). Using lottery games, we examine decisions at both the individual and social levels. We find that risk aversion shows a time‐dependent change across the first post‐stress hour, evolving from less risk aversion shortly after stress to more risk averse behaviour at the last testing time. When risk implied an antisocial outcome to a third party, stressed individuals showed less regard for this person in their decisions. Participants’ cortisol levels explained their behaviour in the risk, but not the antisocial, game. Our findings reveal differential stress effects in self‐ and other‐regarding decision‐making and highlight the multidimensional nature of the immediate aftermath of stress for cognition.

Lack of efficacy of a salience nudge for substituting selection of lower-calorie for higher-calorie milk in the work place

Obesity is a major burden on healthcare systems. Simple, cost effective interventions that encourage healthier behaviours are required. The present study evaluated the efficacy of a salience nudge for promoting a change in milk selection from full-cream to low-fat (lower-calorie) in the kitchen of a university-based research institute that provided full-cream and low-fat milk free of charge. Milk selection was recorded for 12 weeks (baseline). A sign with the message “Pick me! I am low calorie” was then placed on the low-fat milk and selection was recorded for a further 12 weeks. During baseline, selection of low-fat milk was greater than selection of full-cream milk (p = 0.001) with no significant milk-type × time interaction (p = 0.12). During the intervention period overall milk selection was not different from baseline (p = 0.22), with low-fat milk selection remaining greater than full-cream milk selection (p < 0.001) and no significant milk-type × time interaction (p = 0.41). However, sub-analysis of the first two weeks of the intervention period indicated an increase in selection of both milk types (p = 0.03), but with a greater increase in low-fat milk selection (p = 0.01, milk-type × time interaction). However, milk selection then returned towards baseline during the rest of the intervention period. Thus, in the present setting, salience nudging promoted a transient increase in low-fat milk selection, but also increased selection of full-cream milk, indicating that nudging was not effective in promoting healthier milk choices.

Evaluation of an intervention to reduce tidal volumes in ventilated ICU patients

BACKGROUND

There is considerable evidence that the use of tidal volumes <6 ml kg(-1) predicted body weight (PBW) reduces mortality in mechanically ventilated patients. We evaluated the effectiveness of using a large screen displaying delivered tidal volume in ml kg(-1) (PBW) for reducing tidal volumes.

METHODS

We assessed the intervention in two 6-month periods. A qualitative study was undertaken after the intervention period to examine staff interaction with the intervention. The study was conducted in a mixed medical and surgical intensive care unit at University Hospitals Bristol, UK. Consecutive patients requiring controlled mechanical ventilation for more than 1 h were included. Alerts were triggered when tidal volume breached predetermined targets and these alerts were visible to ICU clinicians in real time.

RESULTS

A total of 199 patients with 7640 h of data were observed during the control time period and 249 patients with 10 656 h of data were observed in the intervention period. Time spent with tidal volumes <6 ml kg(-1) PBW increased from 17.5 to 28.6% of the period of controlled mechanical ventilation. Time spent with a tidal volume <8 ml kg(-1) PBW increased from 60.6 to 73.9%. The screens were acceptable to staff and stimulated an increase in attendance of clinicians at the bedside to adjust ventilators.

CONCLUSIONS

Changing the format of data and displaying it with real-time alerts reduced delivered tidal volumes. Configuring information in a format more likely to result in desired outcomes has the potential to improve the translation of evidence into practice.

Psychological factors in emergency medicine

Human psychology, neuroscience and behavioural economics study the human mind, brain and behaviour. Scientific research has discovered a great deal about the factors that influence human perception, judgment and activity in the real world. In this article, I aim to provide an outline of the relationship between decision-making, cognition, emotion and behaviour. I propose that meta-cognition, or thinking-about-thinking, has the potential to inform how we practice emergency medicine. By accommodating human traits rather than trying to defy them, we can ultimately benefit our patients.

Incentivizing behaviour change to improve diabetes care

Behavioural economics refers to the study of psychological and cognitive factors that relate to decision-making processes. This field is being applied increasingly to health care settings, in which patients receive tangible reinforcers or incentives for meeting objective behavioural criteria consistent with healthy lifestyles. This article reviews the background and efficacy of reinforcement interventions in general, and then as applied to behaviours related to diabetes prevention and management. Specifically, reinforcement interventions have been applied with some notable success towards promoting greater attendance at medical appointments, enhancing weight loss efforts, augmenting exercising regimes, improving medication adherence and increasing blood glucose monitoring. Suggestions for promising areas of future research are provided, keeping in mind the controversial nature of these interventions.

Can a nudge keep you warm? Using nudges to reduce excess winter deaths: insight from the Keeping Warm in Later Life Project (KWILLT)

Nudges are interventions that aim to change people's behaviour through changing the environment in which they choose rather than appealing to their reasoning. Nudges have been proposed as of possible use in relation to health-related behaviour. However, nudges have been criticized as ethically dubious because they bypass peoples reasoning and (anyway) are of little help in relation to affecting ill-health that results from social determinants, such as poverty. Reducing the rate of excess winter deaths (EWDs) is a public health priority; however, EWD seems clearly to be socially determined such that nudges arguably have little role. This article defends two claims: (i) nudges could have a place in tackling even the heavily socially determined problem of EWD. We draw on evidence from an empirical study, the Keeping Warm in Later Life Project (KWILLT), to argue that in some cases the risk of cold is within the person’s control to some extent such that environmental modifications to influence behaviour such as nudges are possible. (ii) Some uses of behavioural insights in the form of nudges are acceptable, including some in the area of EWD. We suggest a question-based framework by which to judge the ethical acceptability of nudges.

Herding, social influence and economic decision-making: socio-psychological and neuroscientific analyses

Typically, modern economics has steered away from the analysis of sociological and psychological factors and has focused on narrow behavioural assumptions in which expectations are formed on the basis of mathematical algorithms. Blending together ideas from the social and behavioural sciences, this paper argues that the behavioural approach adopted in most economic analysis, in its neglect of sociological and psychological forces and its simplistically dichotomous categorization of behaviour as either rational or not rational, is too narrow and stark. Behaviour may reflect an interaction of cognitive and emotional factors and this can be captured more effectively using an approach that focuses on the interplay of different decision-making systems. In understanding the mechanisms affecting economic and financial decision-making, an interdisciplinary approach is needed which incorporates ideas from a range of disciplines including sociology, economic psychology, evolutionary biology and neuroeconomics.