By Jon Warner, November 2024
Just over 15 years ago now, Richard Thaler and Cass Sunstein, two Professors in the University of Chicago, brought the term ‘nudge theory’ into the lexicon. Nudge theory, as described in their book "Nudge," argues that subtle changes to the environment in which people make decisions ("choice architecture") can influence behavior in predictable ways without restricting options or using coercion. They called this "libertarian paternalism" - "libertarian" because it preserves freedom of choice, and "paternalistic" because it steers people towards choices deemed (by a third party) to be in their ‘best’ interest.
The book provides numerous examples of how nudges can improve outcomes in areas like general health, finance, and the environment. For example, placing healthy food at eye level in a cafeteria is a ‘nudge’ that makes it easier for people to choose those options.
In simple terms, Thaler and Sunstein argued that because people are often irrational and influenced by cognitive biases, nudges are a way to help them make better decisions without unfairly limiting their autonomy. This view that we need to overcome unhelpful biases has deepened considerably over the years, with many researchers and authors weighing in on the topic, which has become the realm of what we now called ‘behavioral economics’, popularized by people such as Daniel Kahneman (among many others) in his wonderful book on the subject “Thinking fast and thinking slow”.
The application of nudge theory and behavioral economics since the early days has been fast and furious in much of everyday life and this is particularly true across many industry sectors, such as retail, banking and finance, automotive, technology, food and beverage supply and many others. However, one sector and perhaps the most important to all of us, is healthcare, that has experienced much lower levels of utilization. In the rest of this brief article therefore we will explore why this is the case and what might change this relatively limited use in the future.
Healthcare is a very large and complex sector, with multiple sub-sectors within it, many of which operate quite independently. However, practically all parts of healthcare have been slow to adopt ‘nudge theory’ in any form and their main reasons for this are as follows:
Complexity: Healthcare involves intricate biological, social, and behavioral factors, making it challenging to design universally effective nudges. What works for one patient, condition, or clinician may not work for another.
Ethical Considerations: Nudging in healthcare raises particular ethical concerns about manipulation and autonomy when we are dealing with illness and ‘life and death’ situations. Striking the right balance between influencing choices for better health outcomes and respecting patient autonomy requires careful consideration.
Implementation Challenges: Implementing nudges in complex healthcare systems with long established workflows or patterns and potential resistance from front line providers can be difficult.
Data Privacy Concerns: Utilizing data for personalized nudges requires navigating strict patient privacy regulations, which can be complex and time-consuming.
While all of the above are valid, at least in part, there are signs that the situation is changing as leaders see the potential for improvement, especially as it relates to better patient outcomes by deploying it. An example of this is in the broad area of patient non-adherence.
Patient non-adherence to prescribed medical care plans is a widespread problem that negatively impacts health outcomes and wastes healthcare resources. While education and counseling seek to build intrinsic motivation for adherence, an alternative approach, grounded in behavioral economics/science, may provide complementary benefits - applying insights from "nudge theory" to guide patients towards healthier choices through subtle environmental cues rather than coercion.
When applied to healthcare, nudges could help address some of the common barriers to care plan adherence like forgetfulness, lack of motivation, difficulty establishing new habits, and perceived effort of adherence tasks. For example, simple reminders (via emails and text messaging, for example) have been shown to significantly improve medication and appointment adherence just by reducing the cognitive effort required. More advanced digital solutions now allow automated, personalized reminders via smartphone apps that can be tailored based on individual schedules and needs.
Beyond reminders, leveraging social motivations could also boost adherence through nudges. Public commitments, either to care teams or social networks, have been found to increase follow-through due to consistency motives - people strive to behave in line with their commitments for the sake of appearance. Digital tools enabling patients to publicly track progress meeting care goals may appeal to these social drivers.
A sub-set of nudge theory is often called ‘gamification’. Gamification represents another avenue for nudging through positive reinforcement. This may involve awarding virtual badges or points for achieving adherence milestones to help turn the process into a game, activating reward pathways in the brain (an area in which better mental health is seen to be very promising in the future). Early research shows gamified health apps can significantly increase physical activity levels and medication adherence, for example, compared to standard programs. Simply put, by reframing adherence as an enjoyable challenge rather than an onerous chore, gamification nudges improved behaviors.
Of course, nudges alone, however well they may have been designed, may have limited effectiveness for complex, long-term conditions requiring major lifestyle changes and ongoing self-management. A more comprehensive approach would integrate nudges with traditional education and counseling methods. For instance, care teams could first use motivational interviewing to build intrinsic motivation for a new regimen, then employ nudges post-counseling to reinforce learning and help turn intentions into sustained habits. Digital tools also create opportunities for just-in-time adaptive interventions, delivering nudges when patients show signs of disengaging from their care plan.
To deploy nudges ethically and avoid unintended consequences, an evidence-based framework is needed. The MINDSPACE model developed by the UK's Behavioral Insights Team offers a systematic way to consider how environmental and social factors influence individual decision-making. Its nine categories - Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, Ego - can be used to audit a care plan from a behavioral perspective and identify optimal leverage points for nudges. Oversight is also important to ensure vulnerable groups are not manipulated or disadvantaged.
In summary then, when carefully designed and applied as one part of a multimodal adherence strategy with healthcare, nudges hold promise as a gentle way to guide patients towards healthier choices without compromising autonomy. By making desired behaviors easier through subtle contextual cues, nudges could help address some of the cognitive and motivational barriers preventing many from optimally managing their care at home, or when they are no in a formal care setting. As digital solutions continue advancing, new opportunities will emerge to deploy personalized, evidence-based nudges at scale across many healthcare stakeholders to complement education and counseling in improving long-term care plan adherence. In this way healthcare may well catch up with other sectors in the economy and reap significant benefits in doing so
This article was written by Jon Warner, Executive Chair of Citizen Health Strategies (CHS). Citizen Health Strategies (CHS) specializes in building innovative products and solutions where and when health citizens need - eliminating care gaps and bottlenecks to create operational efficiencies and outcome effectiveness.
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