Wednesday, November 02, 2016

Behavioural Economics and Health Psychology Readings

I had promised to send further readings on behavioural economics and health psychology to students I gave a lecture to recently. If people email me with other requests for links, I will add to this post here.

We talked quite a bit about the overlap between behavioural economics and behavioural change strategies coming from health psychology. The article that we discussed previously on the blog here gives a taxonomy of behavioural change interventions emanating from psychology.

A detailed set of readings on the ethical and policy implications of behavioural economics are available here. People interested in various critiques of "nudge" interventions will find many of them expressed in the articles listed there. Also, for those interested in going into the behavioural economics approach in more depth, there are many articles summarising this approach and also several very useful books have started to emerge.

The two documents below summarise the approach of the BIT group (the first one generally and the second specifically to health). The first document gives an accessible summary of the type of influences that might change human behaviour and an agenda for policy.

Dolan, P., Hallsworth, M., Halpern, D., King, K. and Vlaev, I. (2010). Mindspace: Influencingbehavior through public policy. Cabinet Office: Institute for Government.

UK Cabinet Office: ApplyingBehavioural Insights to Health

Below is the House of Lords report that looked into the potential for "nudge-type" interventions to influence behaviour in key public policy domains.

House of Lords Report on Behavioural Change

Below are further readings in this area. I will use this post to develop this further over the next year and hope to organise a workshop in this area.

Allan et al (2015). Snack purchasing is healthier when the cognitive demands of choice are reduced: A randomized controlled trial. Health Psychology, Vol 34(7), Jul 2015, 750-755.

Objective: Individuals with inefficient executive (higher level cognitive) function have a reduced ability to resist dietary temptation. The present study aimed to design and test a theory-based point-of-purchase intervention for coffee shops that reduced the calorie content of customers’ purchases by reducing the need for executive function (EF) at the moment of choice. Methods: Key facets of EF were identified by a multidisciplinary group and used to develop a point-of-purchase intervention (signage). This intervention was evaluated in a randomized controlled trial (RCT) in a public coffee shop on consumer purchases of >20,000 snacks and drinks over 12 weeks. A sample of customers (n = 128) was recruited to complete an embedded cross-sectional study measuring EF strength, dietary intentions, typical purchases, and purchases made after exposure to the intervention. Results: The proportion of snack purchases that were high in calorie reduced significantly (t(10) = 2.34, p = .04) in intervention weeks relative to control. High calorie drink purchases were also lower in intervention than control weeks, however, this difference was not significant (t(10) = 1.56, p = .15). On average, customers purchased items containing 66 calories < usual after exposure to the intervention. The magnitude of the intervention’s positive effect on customer behavior increased as EF strength decreased (β = .24, p = .03). Conclusions: The calorie content of cafe purchases can be lowered by reducing the cognitive demands of healthy food choice at the moment of purchase, especially in those with poor EF. Environmental changes like these have the potential to help achieve population weight control. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Barton (2013). How Tobacco Health Warnings Can Foster Autonomy. Public Health Ethics. doi: 10.1093/phe/pht011

I investigate whether tobacco health warnings’ interference with autonomy is ethically justifiable in order to deter people from smoking. I dissociate first the informational role and the persuasive role of tobacco health warnings and show that both roles enable typical addicted smokers to better rule themselves, fostering their autonomy. The fact that some messages address people’s non-deliberative faculties is therefore compensated by a larger positive influence on their autonomy. However, misleading messages are not ethically justified and should be avoided. Tobacco health warnings’ effect on autonomy highlights an important difference between libertarian paternalism and classical paternalism.

Bern et al (2013). The economic impact of Project MARS (Motivating Adolescents to Reduce Sexual Risk). Health Psychology, Vol 32(9), Sep 2013, 1003-1012.

Objective: The purpose of this study was to economically evaluate Project MARS (Motivating Adolescents to Reduce Sexual Risk; T. J. Callahan, E. A. Montanaro, R. E. Magnan, & A. D. Bryan, 2013, “Project MARS: Design of a multi-behavior intervention trial for justice-involved youth,” Translational Behavioral Medicine, Vol. 3, pp. 122–130), an ongoing, randomized, sexual-risk-reduction intervention for justice-involved youth. We consider the effect of including viral STIs in the economic analysis, and explore the impact of the MARS intervention on the perceived cost of acquiring STIs to justice-involved youth. Method: 206 participants, ages 14 to 18, participated in a sexual-risk-reduction intervention that included screening and treatment for chlamydia and gonorrhea. A Bernoulli probability model was used to estimate averted STIs attributable to the MARS intervention. The economic benefit of averted STIs was monetized using the direct medical cost of treatment. In addition, we used a contingent valuation (willingness-to-pay) model to investigate the impact of the Project MARS on participants’ perceived cost of acquiring an STI. Results: Using the standard outcome domains typically used to evaluate STI interventions, Project MARS resulted in a reduction of $2.08 in direct medical costs for every $1 spent. When viral STIs were added to the economic model, a considerable increase in averted direct medical costs ($2.68 for every $1 spent) was found. Preliminary contingent valuation estimates suggest that participants’ willingness-to-pay for averted STIs significantly increased after receiving the MARS intervention. Conclusion: From an economic perspective, Project MARS is a worthwhile program to adopt. Future attention should be given to the impact of behavioral interventions on viral infections. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Betsch et al (2013). Inviting free-riders or appealing to prosocial behavior? Game-theoretical reflections on communicating herd immunity in vaccine advocacy. Health Psychology, Vol 32(9), Sep 2013, 978-985.

Objective: Vaccination yields a direct effect by reducing infection, but also has the indirect effect of herd immunity: If many individuals are vaccinated, the immune population will protect unvaccinated individuals (social benefit). However, due to a vaccination’s costs and risks, individual incentives to free-ride on others’ protection also increase with the number of individuals who are already vaccinated (individual benefit). The objective was to assess the consequences of communicating the social and/or individual benefits of herd immunity on vaccination intentions. We assume that if social benefits are salient, vaccination intentions increase (prosocial behavior), whereas salience of individual benefits might decrease vaccination intentions (free-riding). Methods: In an online-experiment (N = 342) the definition of herd immunity was provided with one sentence summarizing the gist of the message, either making the individual or social benefit salient or both. A control group received no information about herd immunity. As a moderator, we tested the costs of vaccination (effort in obtaining the vaccine). The dependent measure was intention to vaccinate. Results: When a message emphasized individual benefit, vaccination intentions decreased (free-riding). Communication of social benefit reduced free-riding and increased vaccination intentions when costs to vaccinate were low. Conclusions: Communicating the social benefit of vaccination may prevent free-riding and should thus be explicitly communicated if individual decisions are meant to consider public health benefits. Especially when vaccination is not the individually (but instead collectively) optimal solution, vaccinations should be easily accessible in order to reach high coverage. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Bundorf et al (2013). Are prescription drug insurance choices consistent with expected utility theory? Health Psychology, Vol 32(9), Sep 2013, 986-994.

Objective: To determine the extent to which people make choices inconsistent with expected utility theory when choosing among prescription drug insurance plans and whether tabular or graphical presentation format influences the consistency of their choices. Method: Members of an Internet-enabled panel chose between two Medicare prescription drug plans. The “low variance” plan required higher out-of-pocket payments for the drugs respondents usually took but lower out-of-pocket payments for the drugs they might need if they developed a new health condition than the “high variance” plan. The probability of a change in health varied within subjects and the presentation format (text vs. graphical) and the affective salience of the clinical condition (abstract vs. risk related to specific clinical condition) varied between subjects. Respondents were classified based on whether they consistently chose either the low or high variance plan. Logistic regression models were estimated to examine the relationship between decision outcomes and task characteristics. Results: The majority of respondents consistently chose either the low or high variance plan, consistent with expected utility theory. Half of respondents consistently chose the low variance plan. Respondents were less likely to make discrepant choices when information was presented in graphical format. Conclusions: Many people, although not all, make choices consistent with expected utility theory when they have information on differences among plans in the variance of out-of-pocket spending. Medicare beneficiaries would benefit from information on the extent to which prescription drug plans provide risk protection. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Clayton et al (2013). Maternal depressive symptoms predict adolescent healthcare utilization and charges in youth with Type 1 diabetes (T1D). Health Psychology, Vol 32(9), Sep 2013, 1013-1022.

Objective: To examine whether maternal depressive symptoms predict diabetes-related health care utilization and charges in adolescents with Type 1 diabetes. Method: Mothers of adolescents ages 11–18 with Type 1 diabetes completed the Center for Epidemiological Studies Depression Scale at enrollment and at 12-month follow-up. Demographic and disease-related variables, including HbA1c, were also assessed. Health care utilization data and charges for diabetes-related care (i.e., endocrine clinic visits, emergency room visits, and hospitalizations) for the period of 12 and 24 months following enrollment were assessed. Results: Maternal depressive symptoms at enrollment predicted higher utilization/charges at 12- and 24-month follow-up, after controlling for demographic and disease-related variables and adolescent depressive symptoms. High maternal depressive symptoms at baseline were associated with $8,405 additional charges over the next 2 years. Adolescents of mothers with high depressive symptoms were twice as likely to have an emergency room visit and three times as likely to have a hospitalization. Conclusion: Maternal depressive symptoms are an independent predictor of health care utilization and charges in adolescents with Type 1 diabetes. Interventions aimed at identifying and treating depressive symptoms in mothers could not only enhance caregiver quality of life but could also be economically advantageous for payers and providers. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Feltz & Samayoa (2012). Heuristics and Life-Sustaining Treatments. Journal of Bioethical Inquiry, December 2012, Volume 9, Issue 4, pp 443–455.

Surrogates’ decisions to withhold or withdraw life-sustaining treatments (LSTs) are pervasive. However, the factors influencing surrogates’ decisions to initiate LSTs are relatively unknown. We present evidence from two experiments indicating that some surrogates’ decisions about when to initiate LSTs can be predictably manipulated. Factors that influence surrogate decisions about LSTs include the patient’s cognitive state, the patient’s age, the percentage of doctors not recommending the initiation of LSTs, the percentage of patients in similar situations not wanting LSTs, and default treatment settings. These results suggest that some people may use heuristics when making these important life-and-death decisions. These findings may have important moral implications for improving surrogate decisions about LSTs and reconsidering paternalism.

Ferguson & Starmer (2013). Incentives, expertise, and medical decisions: Testing the robustness of natural frequency framing. Health Psychology, Vol 32(9), Sep 2013, 967-977.

Objectives: The natural frequency effect (NF effect)—whereby framing health risks using information presented as natural frequencies (NFs), instead of conditional probabilities (CPs), results in improved diagnostic problem solving—has led to the recommended use of NFs in clinical practice. This experiment tests, via incentivization of a lab-based decision, the hypothesis that the NF effect reflects differential motivation applied to solving problems that differ in complexity. The study examines if incentive effects are moderated by task complexity and expertise and also explores the extent to which NF frames improve diagnostic understanding. Methods: Three-hundred and 25 participants (235 novices and 90 medical experts) were randomly allocated to a frame (NF vs. CP) by task difficulty (short vs. standard menus) by incentive (present vs. absent) between-subjects design. The task was to calculate the positive predictive value (PPV) of the hemoccult test for colorectal cancer. Effort, self-efficacy, and diagnostic understanding were assessed. Results: Incentives increased correct problem solving and the NF effect was replicated. The NF effect did not vary as a function of incentivization, but was slightly attenuated by task complexity and expertise. There was no evidence that effort mediated the incentive effect. The correct PPV (which is low) was associated with reduced trust in the test’s diagnostic accuracy. For those who committed errors, NF frames increased the likelihood of underestimating the PPV, with underestimation associated with greater trust in the test. Conclusions: The NF effect is robust to incentives supporting the use of NF frames in clinical settings. When errors occur, however, NF frames are linked to underestimation. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Galizzi (2014). What Is Really Behavioral in Behavioral Health Policy? And Does It Work? Appl. Econ. Perspect. Pol. (2014)
doi: 10.1093/aepp/ppt036

Across health systems, there is increasing interest in applying behavioral economics insights to health policy challenges. Policy decision makers have recently discussed a range of diverse health policy interventions that are commonly brought together under a behavioral umbrella. These include randomized controlled trials, comparison portals, information labels, financial incentives, sin taxes, and nudges. A taxonomy is proposed to classify such behavioral interventions. In the context of risky health behavior, each cluster of policies is then scrutinized under two respects: (i) What are its genuinely behavioral insights? (ii) What evidence exists on its practical effectiveness? The discussion highlights the main challenges in drawing a clear mapping between how much each policy is behaviorally inspired and its effectiveness.

Hanks (2013). Slim by Design: Serving Healthy Foods First in Buffet Lines Improves Overall Meal Selection. PLOS ONE.


Each day, tens of millions of restaurant goers, conference attendees, college students, military personnel, and school children serve themselves at buffets – many being all-you-can-eat buffets. Knowing how the food order at a buffet triggers what a person selects could be useful in guiding diners to make healthier selections.


The breakfast food selections of 124 health conference attendees were tallied at two separate seven-item buffet lines (which included cheesy eggs, potatoes, bacon, cinnamon rolls, low-fat granola, low-fat yogurt, and fruit). The food order between the two lines was reversed (least healthy to most healthy, and vise-versa). Participants were randomly assigned to choose their meal from one line or the other, and researchers recorded what participants selected.


With buffet foods, the first ones seen are the ones most selected. Over 75% of diners selected the first food they saw, and the first three foods a person encountered in the buffet comprised 66% of all the foods they took. Serving the less healthy foods first led diners to take 31% more total food items (p<0.001). Indeed, diners in this line more frequently chose less healthy foods in combinations, such as cheesy eggs and bacon (r = 0.47; p<0.001) or cheesy eggs and fried potatoes (r = 0.37; p<0.001). This co-selection of healthier foods was less common.


Three words summarize these results: First foods most. What ends up on a buffet diner’s plate is dramatically determined by the presentation order of food. Rearranging food order from healthiest to least healthy can nudge unknowing or even resistant diners toward a healthier meal, helping make them slim by design. Health-conscious diners, can proactively start at the healthier end of the line, and this same basic principle of “first foods most” may be relevant in other contexts – such as when serving or passing food at family dinners.

Hanoch et al (2013). Health Psychology meets Behavioural Economics: an introduction to the special issue. Health Psychology, Vol 32(9), Sep 2013, 929-931.

Introduces the special issue of Health Psychology, entitled Health PsychologyMeets Behavioral Economics. Psychologists have long been interested in understanding the processes that underlie health behaviors and, based on healthbehavior models that they have developed, have devised a spectrum of effective prevention and treatment programs. More recently, behavioral economists have also provided evidence of effective behavior change strategies through nonprice mechanisms in a variety of contexts, including smoking cessation, weight loss, and illicit drug use. Yet, although all are addressing similar issues, surprisingly little cross-fertilization has taken place between traditional economists, behavioral economists, and psychologists. This special issue is rooted in the assumption that collaboration between economists and psychologists can promote the development of new methodologies and encourage exploration of novel solutions to enduring health problems. The hope is that readers will be intrigued and inspired by the methodologies used in the different articles and will explore whether they might be applicable to the problems they are addressing. Collaborative efforts, although challenging and at times risky, are a promising way to produce more innovative studies, results, and interventions. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Hollands, G. J., Shemilt, I., Marteau, T. M., Jebb, S. A., Kelly, M. P., Nakamura, R., Suhrcke, M., & et al. (2013).Altering choice architecture to change population health behaviour: a large-scale conceptual and empirical scoping review of interventions within micro-environments. Cambridge Behaviour and Health Research Unit Working Paper.

There is considerable public policy interest in choice architecture, an approach that involves altering features of physical or social environments to change behaviour. To date there has been no systematic attempt to clarify the concept and definition or describe the evidence base for such interventions. We conducted a systematic scoping review of empirical evidence, and related conceptual material, to identify the effects of choice architecture interventions in micro-environments on diet-, physical activity-, alcohol- and tobacco-related behaviours.

Hollands et al (2016). Non-conscious processes in changing health-related behaviour: a conceptual analysis and framework. Health Psychology Review.

Much of the global burden of non-communicable disease is caused by unhealthy behaviours that individuals enact even when informed of their health-harming consequences. A key insight is that these behaviours are not predominantly driven by deliberative conscious decisions, but occur directly in response to environmental cues and without necessary representation of their consequences. Consequently, interventions that target non-conscious rather than conscious processes to change health behaviour may have significant potential, but this important premise remains largely untested. This is in part due to the lack of a practicable conceptual framework that can be applied to better describe and assess these interventions. We propose a framework for describing or categorising interventions to change health behaviour by the degree to which their effects may be considered non-conscious. Potential practical issues with applying such a framework are discussed, as are the implications for further research to inform the testing and development of interventions. A pragmatic means of conceptualising interventions targeted at non-conscious processes is a necessary prelude to testing the potency of such interventions. This can ultimately inform the development of interventions with the potential to shape healthier behaviours across populations.

Keane et al (2012). Altruism, reciprocity and health: A social experiment in restaurant choice. Food Policy, Volume 37, Issue 2, April 2012, Pages 143–150.

We used an experimental game to determine whether people imitate restaurant choice, reciprocate food gifts, and thus spread health choices. We randomly paired 138 subjects and recorded their decision to give or keep restaurant vouchers and their choice of restaurant. The majority (83.3%) chose an unhealthy restaurant if their randomly assigned partner chose an unhealthy restaurant. Similarly, 77.8% chose a healthy restaurant if their partner did (p = 0.005). The altruistic were more likely to choose a healthy restaurant (p = 0.017). In sum, restaurant choice is influenced by reciprocity. A cycle of projection, gifting and reciprocation may explain the social dynamics of food choice. We propose policies that capitalize on people’s tendency towards altruism and imitation.

Leslie & Norton (2013). Converging to the lowest common denominator in physical health. Health Psychology, Vol 32(9), Sep 2013, 1023-1028.

Objective: This research examines how access to information on peer healthbehaviors affects one’s own health behavior. Methods: We report the results of a randomized field experiment in a large corporation in which we introduced walkstations (treadmills attached to desks that enable employees to walk while working), provided employees with feedback on their own and their coworkers’ usage, and assessed usage over 6 months. We report how we determined our sample size, and all data exclusions, manipulations, and measures in the study. Results: Walkstation usage declined most when participants were given information on coworkers’ usage levels, due to a tendency to converge to the lowest common denominator—their least-active coworkers. Conclusion: This research demonstrates the impact of the lowest common denominator in physical activity: people’s activity levels tend to converge to the lowest-performing members of their groups. This research adds to our understanding of the factors that determine when the behavior of others impacts our own behavior for the better—and the worse. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Li et al (2013). Nudge to Health: Harnessing Decision Research to Promote Health Behavior Social and PersonalityPsychology Compass. Volume 7, Issue 3, Pages 187–198.

We review selected literature that examines how biases in decision making can be utilized to encourage individual health behavior, such as vaccination, and promote policy decisions, such as resource allocation. These studies use simple interventions to nudge people towards more optimal health decisions without restricting decision-makers’ freedom of choice. Examples include framing effects, defaults, implementation intentions, position effects, social norm, incentives, and emotions. We suggest that nudges are an effective way to promote healthy behavior.

Liu et al (2013). Using Behavioral Economics to Design More Effective Food Policies to Address Obesity. Appl. Econ. Perspect. Pol. (2014) 36 (1): 6-24.

Many policy interventions that address rising obesity levels in the United States have been designed to provide consumers with more nutrition information, with the goal of encouraging consumers to decrease their caloric intake. We discuss existing information-provision measures and suggest that they are likely to have little-to-modest impact on encouraging lower caloric intake, because making use of such information requires understanding and/or motivation, which many consumers lack, as well as self-control, which is a limited resource. We highlight several phenomena from the behavioral economics literature (present-biased preferences, visceral factors, and status quo bias) and explain how awareness of these behavioral phenomena can inform both more effective information-provision policies and additional policies for regulating restaurants and public school cafeterias that move beyond information to nudge people towards healthier food choices.

Jusot & Khlat (2013). The role of time and risk preferences in smoking inequalities: A population-based study. Addictive Behaviors
Volume 38, Issue 5, May 2013, Pages 2167–2173.
Many policy interventions that address rising obesity levels in the United States have been designed to provide consumers with more nutrition information, with the goal of encouraging consumers to decrease their caloric intake. We discuss existing information-provision measures and suggest that they are likely to have little-to-modest impact on encouraging lower caloric intake, because making use of such information requires understanding and/or motivation, which many consumers lack, as well as self-control, which is a limited resource. We highlight several phenomena from the behavioral economics literature (present-biased preferences, visceral factors, and status quo bias) and explain how awareness of these behavioral phenomena can inform both more effective information-provision policies and additional policies for regulating restaurants and public school cafeterias that move beyond information to nudge people towards healthier food choices.

Marteau et al (2011). Judging nudging: can nudgingimprove population health? BMJ, volume 342. 

Moffitt et al (2010). A gradient of childhood self-control predicts health, wealth, and public safety. PNAS.

Policy-makers are considering large-scale programs aimed at self-control to improve citizens’ health and wealth and reduce crime. Experimental and economic studies suggest such programs could reap benefits. Yet, is self-control important for the health, wealth, and public safety of the population? Following a cohort of 1,000 children from birth to the age of 32 y, we show that childhood self-control predicts physical health, substance dependence, personal finances, and criminal offending outcomes, following a gradient of self-control. Effects of children's self-control could be disentangled from their intelligence and social class as well as from mistakes they made as adolescents. In another cohort of 500 sibling-pairs, the sibling with lower self-control had poorer outcomes, despite shared family background. Interventions addressing self-control might reduce a panoply of societal costs, save taxpayers money, and promote prosperity.

Murtaugh et al (2013). Spend today, clean tomorrow: Predicting methamphetamine abstinence in a randomized controlled trial. Health Psychology, Vol 32(9), Sep 2013, 958-966.

Objective: This secondary analysis of data from a randomized controlled trial tested two behavioral economics mechanisms (substitutability and delay discounting) to explain outcomes using contingency management (CM) for methamphetamine dependence. Frequency and purchase type (hedonic/utilitarian and consumable/durable) of CM payments were also examined. Methods: A total of 82 methamphetamine-dependent gay/bisexual men randomly assigned to conditions delivering CM received monetary vouchers in exchange for stimulant-negative urine samples in a 16-week trial requiring thrice weekly visits (Shoptaw et al., 2005). At any visit participants could redeem vouchers for goods. A time-lagged counting process Cox Proportional Hazards model for recurrent event survival analysis examined aspects of the frequency and type of these CM purchases. Results: After controlling for severity of baseline methamphetamine use and accumulated CM wealth, as measured by cumulative successful earning days, participants who redeemed CM earnings at any visit (“spenders”) were significantly more likely to produce stimulant-negative urine samples in the subsequent visit, compared with those who did not redeem (“savers”) 1.011* [1.005, 1.017], Z = 3.43, p < .001. Conclusions: Findings support the economic concept of substitutability of CM purchases and explain trial outcomes as a function of frequency of CM purchases rather than frequency or accumulated total CM earnings. Promotion of frequent purchases in incentive-based programs should facilitate substitution for the perceived value of methamphetamine and improve abstinence outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Niza et al (2013). Incentivizing blood donation: Systematic review and meta-analysis to test Titmuss’ hypotheses. Health Psychology, Vol 32(9), Sep 2013, 941-949.

Objectives: Titmuss hypothesized that paying blood donors would reduce the quality of the blood donated and would be economically inefficient. We report here the first systematic review to test these hypotheses, reporting on both financial and nonfinancial incentives. Method: Studies deemed eligible for inclusion were peer-reviewed, experimental studies that presented data on the quantity (as a proxy for efficiency) and quality of blood donated in at least two groups: those donating blood when offered an incentive, and those donating blood with no offer of an incentive. The following were searched: MEDLINE, EMBASE and PsycINFO using OVID SP, CINAHL via EBSCO and CENTRAL, the Cochrane Library, Econlit via EBSCO, JSTOR Health and General Science Collection, and Google. Results: The initial search yielded 1100 abstracts, which resulted in 89 full papers being assessed for eligibility, of which seven studies, reported in six papers, met the inclusion criteria. The included studies involved 93,328 participants. Incentives had no impact on the likelihood of donation (OR = 1.22 CI 95% 0.91–1.63; p = .19). There was no difference between financial and nonfinancial incentives in the quantity of blood donated. Of the two studies that assessed quality of blood, one found no effect and the other found an adverse effect from the offer of a free cholesterol test (β = 0.011 p < .05). Conclusion: The limited evidence suggests that Titmuss’ hypothesis of the economic inefficiency of incentives is correct. There is insufficient evidence to assess their likely impact on the quality of the blood provided. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Operario et al (2013). Conditional economic incentives for reducing HIV risk behaviors: Integration of psychology and behavioral economics. HealthPsychology, Vol 32(9), Sep 2013, 932-940.

Objective: This article reviews psychology and behavioral economic approaches to HIV prevention, and examines the integration and application of these approaches in conditional economic incentive (CEI) programs for reducing HIV risk behavior. Methods: We discuss the history of HIV prevention approaches, highlighting the important insights and limitations of psychological theories. We provide an overview of the theoretical tenets of behavioral economics that are relevant to HIV prevention, and utilize CEIs as an illustrative example of how traditional psychological theories and behavioral economics can be combined into new approaches for HIV prevention. Results: Behavioral economic interventions can complement psychological frameworks for reducing HIV risk by introducing unique theoretical understandings about the conditions under which risky decisions are amenable to intervention. Findings from illustrative CEI programs show mixed but generally promising effects of economic interventions on HIV and sexually transmitted infection (STI) prevalence, HIV testing, HIV medication adherence, and drug use. Conclusions: CEI programs can complement psychological interventions for HIV prevention and behavioral risk reduction. To maximize program effectiveness, CEI programs must be designed according to contextual and population-specific factors that may determine intervention applicability and success. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Probst et al (2013). The effect of defaults in an electronic health record on laboratory test ordering practices for pediatric patients. Health Psychology, Vol 32(9), Sep 2013, 995-1002.

Objective: Defaults have been shown to impact decision making in a variety of domains. However, no research has applied defaults to medical care decisions utilizing an Electronic Health Record (EHR). This research was designed to examine how providers’ inpatient laboratory ordering practices were influenced by default selections in EHR order sets. Method: Providers were asked to complete inpatient admission orders for six fictitious pediatric patients using three EHR interface designs: opt-in (no laboratory tests preselected), opt-out (all laboratory tests preselected), or recommended (only laboratory tests recommended by pediatric experts preselected). EHR design was manipulated within subjects. Seventy-two providers from a Midwestern pediatric hospital reviewed the six cases and completed admission orders for all cases, entering two cases with each EHR design. Order of the cases and EHR designs were counterbalanced across participants. Results: When all laboratory tests were preselected, providers ordered significantly more tests and increased the cost of admission by more than $70 when compared with the opt-in, p < .01, and recommended EHR designs, p < .01. Furthermore, providers ordered more tests recommended by the pediatric experts when using the recommended design than when using the opt-in design, p = .03, although the total number of tests ordered did not differ significantly, p = .97. Conclusions: This study demonstrated that default selections in an EHR can significantly influence providers’ laboratory test ordering practices and that hospital systems could benefit from adding expert-recommended defaults to EHR order sets. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Promberger & Marteau (2013). When do financial incentives reduce intrinsic motivation? Comparing behaviors studied in psychological and economic literatures. Health Psychology, Vol 32(9), Sep 2013, 950-957.

Objective: To review existing evidence on the potential of incentives to undermine or “crowd out” intrinsic motivation, in order to establish whether and when it predicts financial incentives to crowd out motivation for health-related behaviors. Method: We conducted a conceptual analysis to compare definitions and operationalizations of the effect, and reviewed existing evidence to identify potential moderators of the effect. Results: In the psychological literature, we find strong evidence for an undermining effect of tangible rewards on intrinsic motivation for simple tasks when motivation manifest in behavior is initially high. In the economic literature, evidence for undermining effects exists for a broader variety of behaviors, in settings that involve a conflict of interest between parties. By contrast, for health related behaviors, baseline levels of incentivized behaviors are usually low, and only a subset involve an interpersonal conflict of interest. Correspondingly, we find no evidence for crowding out of incentivized healthbehaviors. Conclusion: The existing evidence does not warrant a priori predictions that an undermining effect would be found for health-related behaviors. Health-related behaviors and incentives schemes differ greatly in moderating characteristics, which should be the focus of future research. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Sniehotta et al (2014). Time to retire the theory of planned behaviour. Health Psychology Review, Volume 8, 2014 - Issue 1.

Volpp et al (2011). Redesigning Employee Health Incentives — Lessons from Behavioral Economics. N Engl J Med 2011; 365:388-390.

Vallgarda (2012). Nudge—A new and better way to improve health?
Health Policy, Volume 104, Issue 2, February 2012, Pages 200–203.

Nudging, or libertarian paternalism, is presented as a new and ethically justified way of improving people's health. It has proved influential and is currently taken up by the governments in the US, the UK and France. One may question the claim that the approach is new, in any case it has many similarities with the idea of “making healthy choices easier”. Whether the approach is better from an ethical perspective depends on the ethical principles one holds. From a paternalistic perspective there could be no objections, but from a libertarian, there are several. Contrary to what the authors state, libertarian paternalism is an oxymoron.

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