Behavioral Economics and Healthy Behaviors

Key Concepts and Current Research

Yaniv Hanoch, Andrew Barnes, Thomas Rice, Yaniv Hanoch, Andrew Barnes, Thomas Rice

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138638204
• eBook ISBN: 9781317269519
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

The field of behavioural economics can tell us a great deal about cognitive bias and unconscious decision-making, challenging the orthodox economic model whereby consumers make rational and informed choices. But it is in the arena of health that it perhaps offers individuals and governments the most value. In this important new book, the most pernicious health issues we face today are examined through a behavioral economic lens. It provides an essential and timely overview of how this growing field of study can reframe and offer solutions to some of the biggest health issues of our age.

The book opens with an overview of the core theoretical concepts, after which each chapter assesses how behavioral economic research and practice can inform public policy across a range of health issues. Including chapters on tobacco, alcohol and drug use, physical activity, dietary intake, cancer screening and sexual health, the book integrates the key insights from the field to both developed and developing nations.

Also asking important ethical questions around paternalism and informed choice, this book will be essential reading for students and researchers across psychology, economics and business and management, as well as public health professionals wishing for a concise overview of the role behavioral economics can potentially play in allowing people to live healthier lives.

PART I
Background material

1
INTRODUCTION

Yaniv Hanoch, Andrew J. Barnes, and Thomas Rice

Tackling poor health behaviors

One of the biggest challenges facing governments around the world is improving people’s health while simultaneously controlling health expenditures that are now responsible for costs amounting to around US$7.2 trillion per year (World Health Organization [WHO], 2014). Multiple factors contribute to poor health, such as the environment, governmental policies, access to health care, and genes. Personal choices or behaviors have been identified as primary contributors to people’s poor health. Indeed, many health care interventions are specifically designed to improve unhealthy behaviors, such as substance abuse, poor diet, and lack of physical activity. According to the Centers for Disease Control and Prevention (Yoon et al., 2014), up to 40% of deaths from the five leading causes are preventable, as they relate to unhealthy behaviors.

Personal behaviors and choices influence a wide range of conditions. Cigarette smoking, one of the leading causes of premature death, is still highly prevalent in countries such as China, where 68% of males are smokers and an estimated 1 million people die annually from tobacco use (Chen et al., 2015). According to the Global Status Report on Alcohol and Health (World Health Organization, 2014b), a similar trend has emerged for alcohol consumption: alcohol misuse is associated with 3.1 million deaths a year. In a recent study, Gowing and colleagues (2015) estimated that just under 5% of the world population can be classified as having an alcohol use disorder. Drug abuse is no different: It is estimated that 27 million adults worldwide are problem drug users, with 0.5% reported using cocaine- and amphetamine-type drugs (Gowing et al., 2015; UNODC, 2012). In 2014, over 34 million people were living with HIV (with about 2 million being newly infected), with over 25 million of them in Africa (World Health Organization, 2016a)—mostly as a result of unprotected sex or intravenous drug use. Another line of research has shown that even health care providers are not immune to making bad health decisions, such as not following recommended medical procedures and guidelines, and prescribing antibiotics to patients with a common cold (Harris et al., 2016).

Obesity rates (body mass index greater than or equal to 30.0) in the United States, likewise, increased from 22.9% during the years from 1984 to 1994, to 36.3% in the period between 2011 and 2014 (Fryar et al., 2014). Across the globe, the trend has been just as alarming: In 2014 more than 1.6 billion people were overweight, and 600 million of them were classified as obese (World Health Organization, 2016b), doubling the rate of obesity since 1980. In response to the growing concern over obesity, the WHO (2000) published a report on preventing and managing the phenomenon. Among its conclusions, one point is especially pertinent to this book: “Obesity is a serious disease, but its development is not inevitable. It is largely preventable through lifestyle changes” (p. 4).

Although the WHO statement referred specifically to obesity, it clearly applies to many health behaviors affecting morbidity and mortality, such as smoking, drug abuse, lack of physical activity, and poor diet. Furthermore, one of the key messages that the WHO report is that many behaviors are amenable to change. Indeed, smoking, taking drugs, not exercising, drinking alcohol, choosing and sticking with low-value health plans, and mis-prescribing drugs are a few examples of behaviors that can be changed to improve health outcomes. The more difficult and fundamental question, however, is how people can be convinced to change behaviors. For example, what can be done to reduce smoking, drug abuse, and alcohol consumption? What can be done to increase exercising rates and duration? How can we improve health care plan choices? And how can we improve physicians’ antibiotic prescriptions?

Economic solutions: traditional and behavioral

It should be clear from the magnitude of the health problems described above that no single antidote will cure all these complex problems. Traditional economic approaches have had some success in modifying behavior. For example, an increase in cigarette and alcohol prices has been associated with reductions in the consumption of these substances, but high smoking rates persist in many countries and across a number of subpopulations in the United States. Providing consumers with information about health insurance plans can aid them in making better choices (Barnes et al., in press), but despite these efforts, the rate of switching to more cost-effective plans has been lower than what economic theory would predict.

The approaches employed in traditional economics to alter behavior, such as pricing and information-based strategies, represent a critically important set of tools for regulators and governments focused on improving health and health care. However, growing literature has pointed out the shortcomings of traditional economic thinking and ideas, as well as their somewhat limited success achieved in changing behavior. For example, the idea of Homo economicus, that is, rational economic man, has been shown to be problematic. Herbert Simon’s (1955, 1956) introduction of the term bounded rationality was one early attempt to highlight the shortcomings of traditional theory and, since then, a host of psychologists and economists have provided empirical evidence that further calls it into question.

Perhaps the most important challenge to the traditional economic theory of individual behavior has been the development of behavioral economics. Incorporating insights from psychology and neuroscience, behavioral economics diverges from traditional economics in that it does not assume that agents are fully rational, or make decisions that always maximize their expected utility. Rather, it works from the assumption that agents are limited in their computational abilities, do not possess full information, lack perfect willpower, make decisions that are often affected by trivial differences in their environment, and frequently make choices that deviate from their best self-interest. Working from within this framework, behavioral economics has already made promising contributions in the domain of health behaviors. Indeed, behavioral economics offers rich and novel insights into a spectrum of old, persistent, and complex health-related problems. Tackling these problems can help reduce costs across the globe, improve people’s health and well-being, and allow people to make better decisions.

The complex nature of changing health behavior, and the high price (both financial and related to personal well-being) associated with poor health, served as a partial motivation to develop this book. The need to advance new methods to tackle these complex behaviors was another. Behavioral economics offers one promising line of reasoning and its insights can supplement existing approaches. In fact, a number of governments have already taken advantage of the insights from behavioral economics in developing and designing policies. The U.K. government, one of the pioneers in the field, established the Behavioral Insight Team (sometimes dubbed the “Nudge Unit”) in 2010 to examine ways that behavioral economics could help tackle a host of policy problems, among them health behaviors. A few years later, the Social and Behavioral Sciences Team (SBST) was inaugurated in the United States. Early SBST projects include improving registration for the Federal Health Insurance Marketplace and increasing flu vaccination rates. The Behavioral Insight Team and the SBST are two examples where behavioral economics has injected a novel perspective.

This book offers a window into the opportunities and challenges that behavioral economics offers to address a wide spectrum of health behaviors. Needless to say, no single book can cover the entire range of health problems that can potentially be addressed with behavioral economics. Furthermore, given the relatively recent development of behavioral economics, its ideas and promises have not been tested in many health-related areas. Thus, the book should serve as an inspiration and a guide to the type of approaches employed thus far.

Organization of the book

The chapters in this book tackle issues on both the individual and government level, and they range from personal behavior to government policies. The book is divided into three broad sections: Part II: Shaping Health Behaviors, Part III: Detecting and Managing Disease, and Part IV: The Role of Providers, Insurers, and Government. Before Part II, however, Chapter 2 provides readers with a brief overview of behavioral economics. A solid understanding and knowledge of the underlying principles governing economics and specifically behavioral economics are essential for making use of the entire book and for those wishing to develop these ideas further.

Part II: Shaping health behaviors

Smoking represents one of the greatest public health problems. In fact, the WHO argued that smoking “is one of the biggest public health threats the world has ever faced,” with over 5 million deaths per year (WHO, 2016c). Reducing tobacco use, hence, has the potential to reduce morbidity and mortality rates worldwide. There is little doubt that using traditional economic approaches, particularly increasing prices (taxes), has led to a reduction in tobacco use. Yet, advances over the past three decades have provided us with additional innovative means to tackle this important public health problem.

In Chapter 3, by Warren K. Bickel, Lara N. Moody, Sarah E. Snider, Alexandra M. Mellis, Jeffrey S. Stein, and Amanda J. Quisenberry, the authors review four behavioral economics techniques—operant self-administration, hypothetical purchase task, naturalistic demand assessment, and experimental tobacco marketplace—that have made a substantial contribution to our knowledge about tobacco use and addiction. In the chapter, the authors argue that while traditional economic tools have been useful in informing us about historical trends, employing behavioral economics tools, both in and outside the lab, can provide more up-to-date evidence. Operant self-administration—a method that allows researchers to examine the effects of price on tobacco self-administration in the lab—has afforded researchers important insights on how price affects tobacco use and thus how it might affect smokers’ purchasing behavior. Hypothetical purchasing measures, where individuals are asked how much tobacco product they would purchase at varying prices, have allowed investigators to capture purchasing behavior using a technique that is cheaper and more efficient to employ than traditional measures. Naturalistic demand assessment builds on hypothetical purchasing measures, but with the important extension of collecting real-world data, both with regard to price change as well as actually giving the tobacco products to participants. Naturalistic demand assessment, thus, can be important in substantiating and validating laboratory findings. Finally, experimental tobacco marketplaces have allowed researchers to develop a rigorous study protocol and carefully manipulate variables of interest (i.e., product, price, brand name, strength, flavor, etc.) to evaluate their possible effects on behavior. Chapter 1, thus, provides policymakers with insights into how different policies might affect tobacco consumption and gives researchers a spectrum of tools to further investigate alternative methods for reducing tobacco use.

According to the WHO (2015), alcohol misuse is responsible for 3.3 million deaths a year worldwide (or 5.9% of all deaths), and illicit drug use accounts for another 200,000 (UNODC, World Drug Report, 2012). With enormous financial, health, and social ramifications, reducing alcohol and drug use has long been of interest to researchers and policymakers alike. Yet, there is still no consensus on the factors associated with drug and alcohol misuse, nor on how best to prevent and treat these disorders. Traditional economics has relied on price elasticity of demand (imposing taxes or setting a minimum price per unit) and market regulation (prohibiting the sale of alcohol to people under 18) as two key approaches to battling misuse of alcohol and illicit drug use. Behavioral economists, on the other hand, have focused on the notion of delay discounting—or the tendency to place a greater value on immediate versus future rewards—in their attempt to address the problem. They have also developed more sophisticated tools that can better capture demand. Chapter 4, by Michael Amlung, Joshua Gray, and James MacKillop, provides an overview of the approaches taken in behavioral economics to gain a better understanding of the mechanisms underlying addictive behavior, and delineates clinical methodologies for preventing and treating addiction. Among the techniques designed to alter delay-discounting rates and engagement with alcohol are episodic future thinking (EFT)—one that requires participants to project themselves into the future in order to pre-experience the event, and substance-free activity sessions (SFAS)—a method designed to increase the salience of the person’s future goals, highlight the potentially negative association between substance use and goal achievement, and increase engagement in substance-free alternative activities.

Along with stopping smoking, and reducing alcohol intake, increasing physical activity is one of the most common pieces of health advice provided by public health authorities. Indeed, according to the Centers for Disease Control and Prevention, physical activity can help reduce the risk of cardiovascular disease, type 2 diabetes, metabolic syndrome, and some cancers. It can also improve mental health, mood and the chances of living longer, enhance the ability to do daily activities, prevent falls, as well as help control weight and strengthen bones and muscles. Despite the host of benefits linked to physical activity, relatively few adults (Troiano et al., 2008) adhere to the recommendations put forth by health authorities (e.g., the American Heart Association recommends 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 minutes). Early interventions focused on the individual level, with the principal idea being that individuals make rational decisions based on the costs and benefits associated with engaging in physical activity. Some researchers have come to realize that a multi-level approach that incorporates the individual, social/cultural, organizational, environmental, and policy levels would be more conducive to improving physical activity levels (Owen et al., 2011; Sallis et al., 2012). Chapter 5, by Tammy Leonard and Kerem Shuval, reviews a host of measures that can be used on both the individual and organizational level to encourage physical activity. These include supporting physical activity routines at work, designing environments that naturally boost physical activity (such as playgrounds), offering incentives based on objective measures (such as the length of time exercised), establishing pre-commitment schemes, and framing physical activity messages in a positive light (rather than emphasizing the negative consequences). While more data is needed to evaluate the merits of behavioral economics in improving (long-term) physical activity rates, early results are promising.

Another health-related behavior that has garnered much attention is diet. The U.S. Department of Health and Human Services and the U.S. Department of Agriculture (2015) dietary guidelines for 2015–2020 contain five overarching recommendations for consumers: follow a healthy eating pattern across the life span; focus on variet...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• About the Editors and Authors
• Part I Background material
• Part II Shaping health behaviors
• Part III Detecting and managing disease
• Part IV The role of providers, insurers, and government
• Index