Nudging You for Better


Written by Rhiannon White | Edited by Sahng-Ah Yoo

Why is it that rates of joining the organ donor registry are so low, rates of obesity are so high, and one in ten people don’t show up for their hospital appointments? How can these behaviours be changed? 

These are questions that excite and motivate Dr Michael Sanders, Head of Research at the Behavioural Insights Team, to figure out how to promote socially positive behaviours. The team uses insights from behavioural psychology to identify reasons why people make bad choices and then tests small changes in the way choices are presented to “nudge” them into make better decisions.  Nudge Theory, developed by American academics Richard Thaler and Cass R Sunstein, proposes that the designing of choices should be based on the “bounded rationality” of the human mind, often using instinctive and subconscious cues to make decisions, instead of the rational choice theory often espoused in current politics and policies. As Sanders puts it, if you want people to do things, they should be made “easy, attractive, social, and timely.”

Missed Hospital Appointments
The cost to the NHS in time and resources wasted by missed hospital appointments is around £225 million every year; potentially resulting in significant losses to the quality of public healthcare. As well as this financial cost, missed appointments mean that patients are not receiving the treatment they need, therefore incurring personal as well as social costs.

The Behavioural Insights Team theorised that text messages, sent to patients shortly before their appointment, may encourage patients to either attend or cancel the appointment rather than simply not show up, and therefore waste it. To determine the most persuasive message content, they randomly allocated patients at St Bart’s Hospital to different groups, and sent each group a different type of text message shortly before they were due to have an appointment. They then calculated the rates of missed appointments compared to a control group, who received a standard text reminder of their appointment time, and were asked to cancel the appointment if they were not able to attend. They found that texts which simply included the phone number for cancellations led to a significantly lower number of missed appointments. Invoking social norms –by telling patients that nine out of ten people did attend their appointments- did also slightly, but not significantly, lower missed appointment rates. However, the most effective message included the specific cost of missed hospital appointments to the NHS, lowering miss rates from 11% in the control group to only 8.4%. Over a large scale, this has the potential to bring huge savings to the NHS. These measures are now being put into practice in many different hospitals across the country.

Increasing Organ Donation Registrations
Not only is organ donation of great importance, transforming the lives of those who receive an organ transplant, it is potentially an easy target – despite low numbers of organ donation registrations, surveys suggest that a majority of people are already quite willing to be an organ donor but simply never signed up.

The Behavioural Insights Team devised a scheme in which, following online tax disc renewal, an on-screen message was displayed inviting people to join the organ donor resister. To determine what type of message was the most effective, the team compared joining rates for people receiving a range of different messages; from those that stressed doing so could save lives, to those that highlighted the deaths of those who do not receive organ donations, and those that simply saw a logo or request to join. It was found that the reciprocity condition, which asked if individuals would take an organ themselves should they need one, led to the greatest increase in sign up rates: 3.2%, compared to 2.3% who saw the request alone. This has now been brought in as national policy, and has the potential to save around six lives a year, at no additional cost.

Suprisingly, a message in which participants were told that thousands of people had registered, and saw a photograph of different people, led to slightly lower sign up rates compared to the request-only control. This highlights the importance of thoroughly testing the effects of these interventions before they are put into practice, to produce maximized effects.

Reducing Obesity Rates
Although it is common knowledge that obesity is harmful to health, and can be addressed by healthy diet and regular exercise, this advice is increasingly not being followed. The Behavioural Insights Team assessed the response of groups of employees from a large company in the FitBit Challenge: participants wore a device which tracked the number of steps taken in a day, and estimated the number of calories they burned from this. They were sent a weekly email telling them about their team’s rank in comparison to other teams, as well as information such as the best performer in their team and the best performer in other teams, thus invoking a sense of competition.

Upon analysing the data, the team found significant gender differences: while women responded to the sense of competition, this made no difference to men. The impact of the FitBit also depended on the baseline amount of activity of the participants: for those for had been highly active – in the top quartile – before the competition had little effect. However, for the bottom quartile, the intervention increased activity levels by an average of around 40%. As an indication of the importance of this, the additional calories burnt were equivalent to eating around five extra cheeseburgers per week. It is easy to see how such results could have huge implications for national health levels and health care policies.

The Behavioural Insights Team is continuing to research into other diverse areas, and the long term outcomes of these interventions continue to be monitored as more data is obtained. With increasing interest into such applied behavioural sciences work, both nationally and internationally, it is likely that the impact of the Nudge will continue to grow.

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