Sunday, May 4, 2014
Perhaps it’s because reading stories about behavioral economics makes me feel better about the irrational things I do on a regular basis, but it seems that stories and research reports about the potential value of behavioral economics for health policy and public health are appearing with increasing frequency. I don’t claim to be a highly sophisticated consumer of this literature, nor do I claim to have rigorously tracked the frequency of references to behavioral economics in the health literature. (But apparently I have been reading enough empirical scholarship that I know an author is expected to state caveats about her findings.)
In any event, three items that I’ve read recently have me pondering the value of this literature.
In April, a Robert Wood Johnson Foundation-sponsored research program with the long-winded name “Applying Behavioral Economics to Perplexing Health and Health Care Challenges” issued a Progress Report on the results of studies in its initial funding cycle. The program (which explicitly cites to Richard Thaler and Cass Sunstein’s 2008 book Nudge: Improving Decisions about Health, Wealth, and Happiness) looks for solid evidence that behavioral economics techniques can in fact have a positive effect on health-related behaviors. Although RWJF finds behavioral economics approaches sufficiently promising to fund research investigating them, the recent Progress Report was no pep rally. It stated that the results of the Round 1 studies have been mixed, in terms of finding that behavioral economics-inspired interventions can successfully lead to positive changes in health-related behavior. Notwithstanding these mixed results, the program’s director reported being encouraged, since the point of funding this research is to learn what sorts of “choice architecture” interventions actually influence behavior and why.
A recent article in the Washington Post reported on such an intervention – the distribution of grocery store coupons for healthful foods (such as fruits, vegetables, lean meats and seafood) rather than the typical subject of coupons (processed foods and sugary beverages). Linkwell Health (a marketing firm) sent the coupons to a health plan’s enrollees with chronic health conditions, and according to Linkwell, recipients’ purchases of nutritious foods increased by 4.5 percent. The campaign (which might be considered experimental, but probably not research) consciously sought to “nudge” recipients into making healthier food choices, and is akin to programs where physicians write "prescriptions" (to be filled at farmers’ markets rather than pharmacies) for patients to eat fresh produce.
The idea that altering the “choice architecture” in which people make decisions that affect their health – decisions about what to eat, whether to smoke, or how much to sit during a day – suggests some sliver of middle ground in what has become a heated political debate about the most important causes of poor health in the US. Those who view environmental factors and social determinants as the critical factors to address in improving public health could endorse behavioral economics’ recognition that individual choices are shaped and constrained by a person’s environment. And those who insist that increasing personal responsibility is at the heart of improving health may be reassured that “nudging” interventions still place on individuals’ shoulders the ultimate responsibility for responding to the nudges. (Given the general tenor of the political environment, though, we may also see either camp trying to co-opt behavioral findings to advance its own agenda.)
The third article resonated with me the most. In "'Misfearing' -- Culture, Identity, and Our Perceptions" (published in February in the New England Journal of Medicine), cardiologist Lisa Rosenbaum puzzles over why women tend to fear breast cancer most, even if rationally they know that they have a greater chance of dying of heart disease, and why the recent recommendation regarding scaled-back mammography screening for women under 50 produced a firestorm of opposition from women, despite being based on decades’ worth of data. Rosenbaum suggests that cognitive science, particularly evidence that our weighing of data regarding risks may be unconsciously influenced by our sense of affiliation with cultural groups, might help explain such “misfearing” (a term Cass Sunstein coined to describe “the human tendency to fear instinctively rather than factually”).
I am intrigued by how behavioral economics and cognitive science may serve to expand the “mind/body continuum” in ways that offer some promise for improving health. In exploring what makes a difference for our health, not only do we have to remember that humans’ cognitive organ (a.k.a. brain) resides in a body, we also have to remember that our bodies operate in physical environments and live in social communities. Aren’t we fascinating specimens?