The science of decision making has long been around, in various guises from psychology to game theory, but since the publication of Nudge in 2008, ‘nudging’ and the wider field of Behavioural Economics have been the in-vogue terms. Briefly summarised, it is how you can influence decisions without monetary incentives or limiting options. This is becoming increasingly used in fields other than economics, as demonstrated by the World Bank’s excellent WDR 2015. The extent to which this can benefit health is yet to be established, but this author will advocate for its increased use, as an adjunct to much-needed policies steering the general public away from the behaviours responsible for the staggering rise of Non-Communicable Diseases globally. This abstract will provide some brief examples:
There is growing consensus that at a national strategy level, a shift is needed towards health promotion. A balanced diet is one of the best ways to achieve this, but current food labelling is not conducive to this. ‘2% fat milk’ is a measure by weight and therefore is the same as 2 grams of pure fat being added to 98 millilitres of water. The percentage should instead be the proportion of energy provided. This would change it to 35%, and as such would make it easier for consumers to know what they are choosing. Sugar listed as grams is another example where the information is given in a way that difficult to process. ‘Teaspoons’ of sugar would make it far easier for people to track what they are consuming.
Rather than looking at one large budget, humans tend to ‘mentally account’. We have individualised pots of money for different activities. The classic example is someone who gambles, wins, then puts the original stake back in their pocket and continues to 'gamble with the house's money'. All of the money is theirs, but it is now allocated as OK to lose. Hospitals behave similarly. For example they blame monetary shortfalls for a lack of social services on weekends. This means many, usually elderly, patients spend extra days in an expensive hospital bed, some of whom will then go on to develop hospital acquired pneumonias. The hospital then pays far more (approximately £400/night) for bed space to keep these patients in than it would cost to employ social workers on weekend rates. If they help discharge one patient we would be saving not only money, but bed-space, the risk of further infection, reducing the work load of ward staff and most importantly preventing avoidable deaths. The same is true for employing extra physiotherapists on rehabilitation wards that could get post-operative patients home quicker.
At an individual level, the way that clinicians present options to patients is crucial in determining outcomes. Rather than simply providing options and letting the patients choose, we can establish default options which are known to be hugely influential. It’s subtle, but for example rather than asking if a parent wants their child to be vaccinated, the clinical should take that as the default, which will establish that decision. If the parent is still undecided, then positive framing should be used: vaccinations being 99.99% safe rather than having a 0.01% risk of adverse reaction.
In a field that is dominated by algorhythm-based practice, we advocate for the increased use of creative solutions as an adjunct in tackling the growing burden of behaviourally-driven conditions.