Public Views on Policies Involving Nudges

When and Why Do People Accept Public-Policy Interventions? An Integrative Public-Policy-Acceptance Framework

The successful introduction of public policies to prompt behavior change hinges on the degree to which citizens endorse the proposed policies. Although there is a large body of research on psychological determinants of public policy acceptance, these determinants have not yet been synthesized into an integrative framework that proposes hypotheses about their interplay. In this article, we develop a review-based, integrative public-policy-acceptance framework that introduces the desire for governmental support as a motivational foundation in public-policy acceptance. The framework traces the route from problem awareness to policy acceptance and, ultimately, policy compliance. We propose this relationship to be mediated by a desire for governmental support. We integrate numerous key variables assumed to qualify the relationship between problem awareness and the desire for governmental support, such as control attributions, trust, and value fit, as well as the relationship between the desire for governmental support and policy acceptance, such as perceived policy effectiveness, intrusiveness, and fairness. We exemplify the use of the proposed framework by applying it to climate policies.

An experimental investigation into whether choice architecture interventions are considered ethical

Despite their increasing use, choice architecture interventions have faced criticism for being possibly manipulative and unethical. We empirically explore how an intervention's acceptability differs by the type of intervention used, by the domain, and by the way in which its implementation and benefits are explained. We employ a 5 × 5 × 5 factorial design with three fully crossed predictor variables: domain, type of intervention, and explanation. We measure participants' acceptance of the proposed intervention, perceived threat to autonomy and freedom of choice, and belief that the intervention will be successful. We hypothesized that acceptability of the intervention and perceived threat to autonomy will change as a function of the type of intervention used, the domain in which it is implemented, and the rationale for which its use is presented. We find that acceptability of the intervention, perceived threat to autonomy, and belief that the intervention will be successful differ by the type of intervention used and by the domain in which it is implemented. The rationale for the use of the intervention appears to change acceptability of the intervention depending on the type of intervention that is being used, and the domain in which it is implemented. Exploratory analyses were conducted to investigate differences between specific levels within factors, and interactions between factors. Given the variation in acceptability across the three factors, we believe that the discourse about the ethics of choice architecture should avoid generalizations and should instead be at the level of individual interventions in a specific situation. We conclude with a discussion about areas for future research. PROTOCOL REGISTRATION: The stage 1 protocol for this Registered Report was accepted in principle on 14 October 2022. The protocol, as accepted by the journal, can be found at: https://doi.org/10.6084/m9.figshare.21758666 .

Campus food service users' support for nudge strategies for fruit and vegetable-rich items: findings from a large Canadian national sample

Although customer support is critical to the wider uptake of nudging strategies to promote fruits and vegetables (FV) in institutional food service (FS) settings, empirical research is sparse and typically based on small convenience samples. An online survey was conducted to assess support, perceived effectiveness and intrusiveness of nine nudge types drawn from Münscher et al.'s Taxonomy of Choice Architecture. We focused on the setting of campus FSs across Canada. A national sample of post-secondary students regularly using campus FSs was used (N 1057). Support for changing the range of options (B3) was the highest, closely followed by changing option-related effort (B2) and changing option-related consequences (B4). Facilitating commitment (C2), changing default (B1) and providing a social reference point (A3) received lowest support. Furthermore, we extracted three clusters of respondents based on perceived effectiveness and intrusiveness of nudge types. Characterised by a relatively low level of perceived effectiveness and moderately high level of intrusiveness, Cluster 1 (61⋅7 % of the sample) reported the lowest support for nudges. Cluster 2 (26⋅6 %), characterised by intermediate effectiveness and low intrusiveness of nudging, reported a high level of support for nudges. Lastly, Cluster 3 (11⋅7 %), characterised by high perceived effectiveness of as well as high perceived intrusiveness, reported the highest level of support for nudges. Findings confirm overall support for FV nudging, with significant differences across nudge types. Differences in customers' acceptance and perception across nudge types offer campus FS operators initial priors in selecting nudges to promote FV.

Let the Chips Fall! Public Nudging Arrangements, Coercion, and the Role of Independent Shopkeepers

Nudging, according to its inventors and defenders, is supposed to provide a non-coercive way of changing human behavior for the better-a freedom-respecting form of "libertarian paternalism." Its original point was to complement coercive modes of influence without any need of justification in liberal frameworks. This article shows, using the example of food-product placement in grocery stores, how this image is deceptive. Although nudging practices may not restrict the freedom of consumers, nudging arrangements by public health authorities do restrict the freedom of shopkeepers in standard liberal senses. Libertarianism cannot justify this coercion, and the creed is best left out of the equation as the ideological ruse that it, in this discussion, is. Other liberal theories can justify the coercion, but on grounds that can also be applied to other methods of public health promotion by subsidies and regulation. This result reaffirms that nudging should be seen to complement, not to replace, those other methods.

The effects of default nudges on promoting approval of welfare cuts: An exploration during COVID-19

The global COVID-19 pandemic has created significant financial and operational challenges for some businesses. As a result, temporary welfare benefit reduction may be a tough but future-oriented choice for both employers and employees. The present study examined whether default nudges can be used to promote employees' approval of welfare-cutting policy while avoiding negative attitudes. Two online surveys were conducted during the first pandemic wave in China (February 2020). In the first study (N = 310), the participants were presented with a hypothetical welfare-cutting policy that used either an opt-in approach or an opt-out approach. We aimed to investigate how their approval and attitudes were different between two conditions. The results showed that the employees in the opt-out condition were more likely to accept the welfare-cutting policy than those in the opt-in condition, while participants' attitudes toward the policy employing opt-out approach were as negative as that employing opt-in approach. Study 2 (N = 1,519) involved a replication of Study 1 with two additional improved opt-out approaches (opt-out education and opt-out transparency). Compared with the opt-in approach and standard opt-out approach, the opt-out education approach both increased policy support and improved attitudes toward the welfare-cutting policy. The theoretical and practical implications of these findings are discussed.

Using nudges to promote clinical decision making of healthcare professionals: A scoping review

Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.

Healthcare workers' acceptability of influenza vaccination nudges: Evaluation of a real-world intervention

Nudges have been proposed as an effective tool to stimulate influenza vaccination uptake in healthcare workers. However, the success of such nudges in practice is heavily reliant on their acceptance by the intended healthcare worker population, which has not been thoroughly examined to date. This study investigated healthcare workers’ acceptability of diverse influenza vaccination nudges implemented in a real-world vaccination campaign and explored the relationship between nudge acceptability and vaccination uptake. A cross-sectional study was conducted among 244 Dutch hospital employees, following a hospital-wide influenza vaccination nudging intervention. A survey assessed healthcare workers’ perceived acceptability of ten distinct influenza vaccination nudges, along with their vaccination status and relevant covariates (e.g., general perceptions regarding influenza vaccination of healthcare workers). Influenza vaccination nudges in general were deemed acceptable, with reward-based nudges being the least accepted, while digital vaccination forms, a mobile vaccination post, peer vaccination, and digital vaccination reminders were most appreciated. A higher overall acceptance of these nudges was associated with a greater likelihood of being vaccinated, particularly in healthcare workers with favorable perceptions of influenza vaccination usefulness. Our findings suggest that influenza vaccination nudges are an accepted means to systematically promote immunization of healthcare workers, and thus present a viable strategy for public health policies aimed at this group.

Soft Economic Incentives and Soft Behavioral Interventions on the Public's Green Purchasing Behaviour - The Evidence from China

Purpose

To explore the effects of "soft" behavioral intervention policies (eg, green emotions, social norms) and "soft" economic incentive policies (eg, high-intensity subsidies, low-intensity subsidies) and their combinations on the public's green product purchasing behavior.

Participants and Methods

An online questionnaire experiment was conducted on Chinese users using Credamo online questionnaire platform to explore the effects of different "soft" intervention policies on consumers' green purchasing behavior, and the sample data were examined using multiple regression. In Study 1, a total of 460 valid samples were collected to explore the differences in the effects of single intervention policies; in Study 2, a total of 556 valid samples were collected to explore the effects of a combination of soft policies.

Results

In the area of green product purchasing, both behavioral interventions and economic incentives alone can promote green consumption behavior; economic incentives have a more positive impact on guiding consumers to green consumption; the combination of "soft" behavioral interventions and "soft" economic incentives has a positive impact on green consumption. The combination of "soft" behavioral intervention policies and "soft" economic incentive policies is more effective than the individual policies.

Conclusion

The experimental results of Study 1 show that the policy effects of both behavioral intervention policies and economic incentive intervention policies are evident for goods with different value attributes. Meanwhile, comparing the two types of soft intervention policies, we find that the effect of economic incentive intervention policies is stronger than that of soft behavioral intervention policies. In Study 2, the empirical analysis of the policy mix shows that the policy mix is more effective. The combination of "soft" economic incentive policies and "soft" behavioral intervention policies can effectively increase the salience of policy instruments, and the effect of policy combinations is greater than that of single policies.

Acceptance of healthy lifestyle nudges in the general population of Singapore

Background

In recent years, behaviourally driven policies such as nudges have been increasingly implemented to steer desired outcomes in public health. This study examines the different nudges and the socio-demographic characteristics and lifestyle behaviours that are associated with public acceptance of lifestyle nudges.

Methods

The study used data from the nationwide Knowledge, Attitudes and Practices study (KAP) on diabetes in Singapore. Three types of nudges arranged in increasing order of intrusiveness were examined: (1) information government campaigns, (2) government mandated information and (3) default rules and choice architecture. Acceptance was assessed based upon how much respondents ‘agreed’ with related statements describing heathy lifestyle nudges. Multivariable linear regressions were performed with socio-demographics and lifestyle behaviours using scores calculated for each nudge.

Results

The percentage of respondents who agreed to all statements related to each nudge were: 75.9% (information government campaigns), 73.0% (government mandated information), and 33.4% (default rules and choice architecture). Respondents of Malay/Others ethnicity (vs. Chinese) were more likely to accept information government campaigns. Respondents who were 18 – 34 years old (vs 65 years and above), female, of Malay/Indian ethnicity (vs Chinese), were sufficiently physically active, and with a healthier diet based on the DASH (Dietary Approach to Stop Hypertension) score were more likely to accept nudges related to government mandated information. Respondents of Malay/Indian ethnicity (vs Chinese), and who had a healthier diet were more likely to accept default rules and choice architecture.

Conclusion

Individuals prefer less intrusive approaches for promoting healthy lifestyle. Ethnicity and lifestyle behaviours are associated with acceptance of nudges and should be taken into consideration during the formulation and implementation of behaviourally informed health policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13668-x.

Taking a Closer Look at the Bayesian Truth Serum

Abstract. Over the past few decades, psychology and its cognate disciplines have undergone substantial scientific reform, ranging from advances in statistical methodology to significant changes in academic norms. One aspect of experimental design that has received comparatively little attention is incentivization, i.e., the way that participants are rewarded and incentivized monetarily for their participation in experiments and surveys. While incentive-compatible designs are the norm in disciplines like economics, the majority of studies in psychology and experimental philosophy are constructed such that individuals’ incentives to maximize their payoffs in many cases stand opposed to their incentives to state their true preferences honestly. This is in part because the subject matter is often self-report data about subjective topics, and the sample is drawn from online platforms like Prolific or MTurk where many participants are out to make a quick buck. One mechanism that allows for the introduction of an incentive-compatible design in such circumstances is the Bayesian Truth Serum (BTS; Prelec, 2004 ), which rewards participants based on how surprisingly common their answers are. Recently, Schoenegger (2021) applied this mechanism in the context of Likert-scale self-reports, finding that the introduction of this mechanism significantly altered response behavior. In this registered report, we further investigate this mechanism by (1) attempting to directly replicate the previous result and (2) analyzing if the Bayesian Truth Serum’s effect is distinct from the effects of its constituent parts (increase in expected earnings and addition of prediction tasks). We fail to find significant differences in response behavior between participants who were simply paid for completing the study and participants who were incentivized with the BTS. Per our pre-registration, we regard this as evidence in favor of a null effect of up to V = .1 and a failure to replicate but reserve judgment as to whether the BTS mechanism should be adopted in social science fields that rely heavily on Likert-scale items reporting subjective data, seeing that smaller effect sizes might still be of practical interest and results may differ for items different from the ones we studied. Further, we provide weak evidence that the prediction task itself influences response distributions and that this task’s effect is distinct from an increase in expected earnings, suggesting a complex interaction between the BTS’ constituent parts and its truth-telling instructions.

Nudging societally relevant behavior by promoting cognitive inferences

Effective behavioral interventions are essential to address urgent societal challenges. Over the past decade, nudging interventions (i.e., arranging the environment to promote adaptive behavioral choices) have surged in popularity. Importantly, effective application of the nudging approach requires clear guiding principles with a firm basis in behavioral science. We present a framework for nudging interventions that builds on evidence about the goal-directed inferential processes underlying behavior (i.e., processes that involve context-dependent inferences about goals and the actions available to achieve these goals). We used this framework to develop nudging interventions that target context-relevant cognitive inferences. We examined the effectiveness of these inference nudging interventions for promoting two important types of societal behavior: pro-environmental actions and adherence to COVID-19 guidelines. As predicted, two online studies revealed that inference nudging interventions successfully increased energy conservation (Study 1) as well as social distancing during the COVID-19 crisis (Study 2). A field experiment found that inference nudging interventions increased hand disinfection in a real-life store during the COVID-19 crisis (Study 3). Our findings highlight the importance of applying state-of-the-art insights about the (inferential) determinants of behavior in behavior change interventions.

Customer support for nudge strategies to promote fruit and vegetable intake in a university food service

Background

Diverse nudges, also known as choice architectural techniques, have been found to increase fruit and vegetable (FV) selection in both lab and field studies. Such strategies are unlikely to be adopted in mass eating settings without clear evidence of customer support; confirmation in specific contexts is needed. Inspired by the Taxonomy of Choice Architecture, we assessed support for eight types of nudging to increase the choice of FV-rich foods in a university food service. We also explored whether and to what extent nudge support was associated with perceived effectiveness and intrusiveness.

Methods

An online survey was conducted with students who used on-campus cafeterias. Multiple recruitment methods were used. Participants were given 20 specific scenarios for increasing FV selection and asked about their personal support for each nudge, as well as perceived intrusiveness and effectiveness. General beliefs about healthy eating and nudging were also measured. Results were assessed by repeated measures ANOVA for the 8 nudge types.

Results

All nudge scenarios achieved overall favourable ratings, with significant differences among different types of nudging by the 298 respondents. Changing range of options (type B3) and changing option-related consequences (type B4) received the highest support, followed by changing option-related effort (type B2) and making information visible (type A2). Translating information (type A1), changing defaults (type B1) and providing reminders or facilitating commitment (type C) were less popular types of nudging. Providing social reference points (type A3) was least supported. Support for nudge types was positively associated with the belief that food services have a role in promoting healthy eating, perceived importance of FV intake, trustworthiness of the choice architect and female gender. Lastly, support for all types of nudges was positively predicted by perceived effectiveness of each nudge and negatively predicted by perceived intrusiveness above and beyond the contribution of general beliefs about healthy eating and nudging.

Conclusions

Findings from the current study indicate significant differences in support for nudge techniques intended to increase FV selection among university cafeteria users. These findings offer practical implications for food service operators as well as public health researchers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13054-7.

Who accepts nudges? nudge acceptability from a self-regulation perspective

BACKGROUND

Public acceptability of nudging is receiving increasingly more attention, but studies remain limited to evaluations of aspects of the nudge itself or (inferred intentions) of the nudger. Yet, it is important to investigate which individuals are likely to accept nudges, as those who are supposed to benefit from the implementation should not oppose it. The main objective of this study was to integrate research on self-regulation and nudging, and to examine acceptability of nudges as a function of self-regulation capacity and motivation.

METHOD

Participants (N = 301) filled in questionnaires about several components of self-regulation capacity (self-control, proactive coping competence, self-efficacy, perceived control and perceived difficulty) and motivation (autonomous motivation and controlled motivation). To evaluate nudge acceptability, we used three vignettes describing three types of nudges (default, portion size, and rearrangement) that stimulated either a pro-self behavior (healthy eating) or pro-social behavior (sustainable eating) and asked participants to rate the nudges on (aspects of) acceptability.

RESULTS

Results revealed that there were substantial differences in acceptability between the three types of nudges, such that the default nudge was seen as less acceptable and the rearrangement nudge as most acceptable. The behavior that was stimulated did not affect acceptability, even though the nudges that targeted healthy eating were seen as more pro-self than the nudges targeting sustainable eating. From all self-regulation components, autonomous motivation was the only measure that was consistently associated with nudge acceptability across the three nudges. For self-regulatory capacity, only some elements were occasionally related to acceptability for some nudges.

CONCLUSION

The current study thus shows that people are more inclined to accept nudges that target behaviors that they are autonomously motivated for, while people do not meaningfully base their judgments of acceptability on self-regulatory capacity.

Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment

Background

Nudging, a strategy that uses subtle stimuli to direct people’s behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion.

Methods

A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations.

Results

This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience.

Conclusion

Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of ‘what works’ and ‘how it works’. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC.

Behavior is at the core of neglected tropical disease (NTD) prevention and control, certainly within low-, and middle- income countries (LMIC) where resources are often limited. Therefore, strategies to promote behavior change should be included and investigated in future efforts. Nudging, a low-cost strategy that subtly directs people towards positive behavioral choices, has recently gained attention in global health promotion. Nudge strategies have been applied to a wide range of health-promoting behaviors such as handwashing. To understand which strategies were used, where and how these were applied, and whether these were ethically informed and implemented, we undertook a comprehensive review of the available sources. This resulted in 33 included studies, with a total of 67 nudge strategies for behavior-based prevention and control of NTDs in LMIC. Only two studies targeted NTDs in particular, the other 31 included studies were focused on more general health promoting behaviors, with the majority targeting handwashing with soap. The most common nudge strategies were those targeting decision assistance, such as fostering commitment and reminder actions. In general, the ethical assessment presented favorable results. We identified the need for robust study designs to better understand how nudges can be implemented in the future.

Wearable devices for seizure detection: Practical experiences and recommendations from the Wearables for Epilepsy And Research (WEAR) International Study Group

The Wearables for Epilepsy And Research (WEAR) International Study Group identified a set of methodology standards to guide research on wearable devices for seizure detection. We formed an international consortium of experts from clinical research, engineering, computer science, and data analytics at the beginning of 2020. The study protocols and practical experience acquired during the development of wearable research studies were discussed and analyzed during bi-weekly virtual meetings to highlight commonalities, strengths, and weaknesses, and to formulate recommendations. Seven major essential components of the experimental design were identified, and recommendations were formulated about: (1) description of study aims, (2) policies and agreements, (3) study population, (4) data collection and technical infrastructure, (5) devices, (6) reporting results, and (7) data sharing. Introducing a framework of methodology standards promotes optimal, accurate, and consistent data collection. It also guarantees that studies are generalizable and comparable, and that results can be replicated, validated, and shared.

Nudging in the time of coronavirus? Comparing public support for soft and hard preventive measures, highlighting the role of risk perception and experience

The importance of researching public support for preventive policies have been amplified by the COVID-19 pandemic. Using a representative sample of the Hungarian population, we investigated the support for commonly used preventive measures (social distancing, hand hygiene and wearing masks) comparing two different policy tools (nudges and regulations). Because of the high risk and unfamiliarity of the pandemic, the respondents' risk perception and experience with the disease was also assessed. All preventive measures were generally supported and, contrary to the findings of previous nudge research, there was no clear pattern whether regulations or nudges are preferred. People with higher level of risk perception supported both types of policies more but slightly favoured the regulations. Those who had contact with the disease (either themselves or a close friend or family member contracting COVID-19) reported a higher level of risk perception. When the person themselves was afflicted, this higher levels of risk perception did not translate to a higher level of support, moreover, it even decreased support for the regulations according to regression analysis. In case of a loved one contracting the disease, there was an increased support for both types of measures, but that is explained by the higher risk perception.

Nudging health care workers towards a flu shot: reminders are accepted but not necessarily effective. A randomized controlled study among residents in general practice in France

BACKGROUND

A nudge corresponds to any procedure that influences choice architecture, without using persuasion or financial incentives. Nudges are effective in increasing vaccination with heterogeneous levels of acceptability.

OBJECTIVE

To evaluate the effectiveness and acceptability of a nudge promoting influenza vaccination for general practice trainees, also called residents.

METHODS

The hypothesis was that a reminder would be efficient and accepted and that prior exposure to a nudge increases its acceptability. Residents were randomly divided into three parallel experimental arms: a nudge group, a no-nudge group and a control group in order to evaluate the Hawthorne effect. The nudge consisted of providing a paper form for the free delivery of the vaccine and contacts for occupational health services.

RESULTS

The analysis included 161 residents. There was a strong consensus among the residents that it is very acceptable to nudge their peers and patients. Acceptability was better with residents exposed to the nudge and with residents included in step 1 (Hawthorne effect). The nudge did not increase vaccination coverage.

CONCLUSION

The failure of this nudge highlights the importance of matching an intervention to the population's needs. The experimental approach is innovative in this context and deserves further attention.

CLINICALTRIALS.GOV PRE-REGISTRATION

NCT03768596.

Lessons From the UK's Lockdown: Discourse on Behavioural Science in Times of COVID-19

In recent years behavioural science has quickly become embedded in national level governance. As the contributions of behavioural science to the UK's COVID-19 response policies in early 2020 became apparent, a debate emerged in the British media about its involvement. This served as a unique opportunity to capture public discourse and representation of behavioural science in a fast-track, high-stake context. We aimed at identifying elements which foster and detract from trust and credibility in emergent scientific contributions to policy making. With this in mind, in Study 1 we use corpus linguistics and network analysis to map the narrative around the key behavioural science actors and concepts which were discussed in the 647 news articles extracted from the 15 most read British newspapers over the 12-week period surrounding the first hard UK lockdown of 2020. We report and discuss (1) the salience of key concepts and actors as the debate unfolded, (2) quantified changes in the polarity of the sentiment expressed toward them and their policy application contexts, and (3) patterns of co-occurrence via network analyses. To establish public discourse surrounding identified themes, in Study 2 we investigate how salience and sentiment of key themes and relations to policy were discussed in original Twitter chatter (N = 2,187). In Study 3, we complement these findings with a qualitative analysis of the subset of news articles which contained the most extreme sentiments (N = 111), providing an in-depth perspective of sentiments and discourse developed around keywords, as either promoting or undermining their credibility in, and trust toward behaviourally informed policy. We discuss our findings in light of the integration of behavioural science in national policy making under emergency constraints.

Nudging healthcare professionals in clinical settings: a scoping review of the literature

BACKGROUND

Healthcare organisations are in constant need of improvement and change. Nudging has been proposed as a strategy to affect people's choices and has been used to affect patients' behaviour in healthcare settings. However, little is known about how nudging is being interpreted and applied to change the behaviour of healthcare professionals (HCPs). The objective of this review is to identify interventions using nudge theory to affect the behaviour of HCPs in clinical settings.

METHODS

A scoping review. We searched PubMed and PsycINFO for articles published from 2010 to September 2019, including terms related to "nudging" in the title or abstract. Two reviewers screened articles for inclusion based on whether the articles described an intervention to change the behaviour of HCPs. Two reviewers extracted key information and categorized included articles. Descriptive analyses were performed on the data.

RESULTS

Search results yielded 997 unique articles, of which 25 articles satisfied the inclusion criteria. Five additional articles were selected from the reference lists of the included articles. We identified 11 nudging strategies: accountable justification, goal setting, suggested alternatives, feedback, information transparency, peer comparison, active choice, alerts and reminders, environmental cueing/priming, defaults/pre-orders, and education. These strategies were employed to affect the following 4 target behaviours: vaccination of staff, hand hygiene, clinical procedures, prescriptions and orders. To compare approaches across so many areas, we introduced two independent dimensions to describe nudging strategies: synchronous/asynchronous, and active/passive.

CONCLUSION

There are relatively few studies published referring to nudge theory aimed at changing HCP behaviour in clinical settings. These studies reflect a diverse set of objectives and implement nudging strategies in a variety of ways. We suggest distinguishing active from passive nudging strategies. Passive nudging strategies may achieve the desired outcome but go unnoticed by the clinician thereby not really changing a behaviour and raising ethical concerns. Our review indicates that there are successful active strategies that engage with clinicians in a more deliberate way. However, more research is needed on how different nudging strategies impact HCP behaviour in the short and long term to improve clinical decision making.

What do Germans really think about health-nudges?

BACKGROUND

In recent years, policymakers have increasingly used behaviourally informed policies, including 'nudges'. They have been implemented to produce desirable social outcomes such as healthier eating and physical activity. In Germany, a small research team at the Federal Chancellery acts as the central unit to promote the introduction of nudges in the design of public life. Despite this, the nudging concept itself as well as the understanding around it has not spread widely among German citizens. When reporting about the concept, German media is often very critical of the concept.

METHODS

Using a for age, sex and educational level nationally representative online survey with 1000 participants, we investigate whether German citizens know about the concept of nudging. We also explore if they approve of the theoretical concept as well as a list of seven specific interventions regarding healthy eating and physical activity. A particular focus is placed on whether the level of approval is dependent on the target group of the intervention, as well as different intervention-initiators.

RESULTS

We find that nearly 80% of the respondents have never heard of nudging. However when being provided with a definition, we find that a strong majority (90%) supports the concept of nudging as well as all the specific interventions. Acceptance rates are higher if interventions are targeted at the general population compared to only children. All initiators - statutory health insurers, the government, private companies, and independent experts - are accepted as nudge initiators.

CONCLUSION

Amongst Germans nudges are an accepted method to promote health behaviours. Policy makers from various fields in Germany should take that into account to improve future health policy.

‘Better off, as judged by themselves’: do people support nudges as a method to change their own behavior?

In this study, we investigated how people evaluate behavioral interventions (BIs) that are targeted at themselves, aiming to promote their own health and wellbeing. We compared the impact on people's assessments of the acceptability of using BIs to change their own behavior of: the transparency of the BI (transparent or opaque); the designer of the BI (researchers, government policy-makers, advertisers); and three types of arguments regarding their efficacy (positive, positive + negative, negative). Our target BIs were actual interventions that have been used in a range of policy domains (diet, exercise, alcohol consumption, smoking, personal finances). We found that transparent BIs were considered more acceptable than opaque BIs. On average, all BIs were considered acceptable for changing participants’ own behavior, except for the opaque BI in the finance context; there was differential acceptability of BIs across contexts, with finance clearly least acceptable. However, the perceived effectiveness of the BIs was at least as influential a predictor of acceptability ratings as the ease of identification of the behavior change mechanism across the five contexts. Furthermore, effectiveness was partially mediated by desire to change, suggesting that people do think BIs make them better off, ‘as judged by themselves’.

Informed consent within a learning health system: A scoping review

INTRODUCTION

A major consideration for the implementation of a learning health system (LHS) is consent from participants to the use of their data for research purposes. The main objective of this paper was to identify in the literature which types of consent have been proposed for participation in research observational activities in a LHS. We were particularly interested in understanding which approaches were seen as most feasible and acceptable and in which context, in order to inform the development of a Quebec-based LHS.

METHODS

Using a scoping review methodology, we searched scientific and legal databases as well as the gray literature using specific terms. Full-text articles were reviewed independently by two authors on the basis of the following concepts: (a) LHS and (b) approach to consent. The selected papers were imported in NVivo software for analysis in the light of a conceptual framework that distinguishes various, largely independent dimensions of consent.

RESULTS

A total of 93 publications were analysed for this review. Several studies reach opposing conclusions concerning the best approach to consent within a LHS. However, in the light of the conceptual framework we developed, we found that many of these results are distorted by the conflation between various characteristics of consent. Thus, when these characteristics are distinguished, the results mainly suggest the prime importance of the communication process, by contrast to the scope of consent or the kind of action required by participants (opt-in/opt-out). We identified two models of consent that were especially relevant for our purpose: metaconsent and dynamic consent.

CONCLUSIONS

Our review shows the importance of distinguishing carefully the various features of the consent process. It also suggests that the metaconsent model is a valuable model within a LHS, as it addresses many of the issues raised with regards to feasibility and acceptability. We propose to complement this model by adding the modalities of the information process to the dimensions relevant in the metaconsent process.

Nutrition Policy and Individual Struggle to Eat Healthily: The Question of Public Support

The evidence for the effectiveness of nutrition policy interventions is growing. For the implementation of such interventions, social acceptability is crucial. Therefore, this study provides insight into public support for nutrition policy measures such as labelling and taxation. Further it analyses the level of acceptance in a quantitative segmentation approach. A new element to our approach is the comparison of different policy instruments, focusing on the interaction between policy acceptance and the perceived individual struggle to eat healthily. The survey was conducted in November 2017 and a total of 1035 German consumers are included in the data. The results indicate that the majority of German citizens accept nutrition policy interventions. Based on a cluster analysis, five different target groups according to the general acceptance of policy interventions and their own struggle to eat healthily are derived. The five-cluster solution reveals that both consumers who tend to eat a healthy diet as well as those who have problems with their diet support nutritional interventions. This shows that the perceived own struggle to eat healthily does not predict whether consumers accept nutrition policy interventions.

Nudging physical activity in offices

Purpose

This paper aims to investigate whether and why nudging interventions in an office environment are effective to stimulate stair use of employees.

Design/methodology/approach

This paper is based on a pre-test/post-test case study design at the headquarters of a Dutch online retailer. Observations were conducted to test the impact of two nudge interventions, being footprints and posters, on employees’ stair use in two consecutive pre-test/post-test weeks. An online survey questionnaire was used to assess employees’ overall experience with the nudging interventions after the fifth and again neutral week.

Findings

A total of 14,357 observations were recorded during five weeks. This research shows that footprints as nudging intervention significantly increase stair use of employees, and after removal, significantly decrease stair use again. Moreover, footprints were more effective than posters, of which the latter did not impact stair use significantly. Results from the survey questionnaire, completed by 46.2 per cent of the employees, showed that, in terms of degree of perception, footprints (91.4 per cent) were more noticeable than posters (46.3 per cent).

Originality/value

This paper contributes to the non-conclusive research regarding the effectiveness of nudging interventions on stair use in office environments. It clearly shows that perceptibility in combination with a positive attitude towards the nudge leads to a higher degree of initial behavioural change, yet not to a change of mind.

Ethical Criteria for Health-Promoting Nudges: A Case-by-Case Analysis

Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google's rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most-but not all-nudges in most-but not all-circumstances.

Nudging in the clinic: the ethical implications of differences in doctors' and patients' point of view

There is an extensive ethical debate regarding the justifiability of doctors nudging towards healthy behaviour and better health-related choices. One line of argument in favour of nudging is based on empirical findings, according to which a healthy majority among the public support nudges. In this paper, we show, based on an experiment we conducted, that, in health-related choices, people's ethical attitudes to nudging are strongly affected by the point of view from which the nudge is considered. Significant differences have been found between doctors' ethical attitude to clinical nudging and that of patients. We show how these differences weaken the argument for nudging from public support. Moreover, our findings raise concerns regarding doctors' ability to nudge ethically according to their own standards, as they may underestimate the degree of harm medical nudges can cause to informed consent, doctor-patient trust and other important ethically relevant features of health-related choices.

Improving acceptability of nudges: Learning from attitudes towards opt-in and opt-out policies

Policy makers should understand people’s attitudes towards opt-out nudges to smoothly promote and implement the policies. Our research compares people’s perceptions of opt-in and three improved versions of opt-out (transparency, emphasis on the low-cost opt-out option, education) in pro-social and pro-self policy domains, e.g., organ donation (N=610), carbon emission offset (N=613), and retirement saving (N=602). We found that people acknowledged more practical and societal benefits of opt-out than opt-in in organ donation and retirement saving but less so in carbon emission offset. Improved opt-out policies failed to address ethical concerns and most emotional discomfort concerns in organ donation whereas opt-out transparency and emphasis on low-cost opt-out were more successful than education at addressing concerns in retirement saving and carbon emission offset. Nonetheless, transparency and education may raise consciousness of policies’ aims. The results suggest that 1) acceptability of opt-out approaches may be more difficult to enhance in some domains than others; 2) policy makers should ensure the public understands that opt-out is a convenient choice and may consider combining all forms of improvement to increase people’s acceptance of opt-out nudges.

Do minorities like nudges? The role of group norms in attitudes towards behavioral policy

Attitudes of public groups towards behavioral policy interventions (or nudges) can be important for both the policy makers who design and deploy nudges, and to researchers who try to understand when and why some nudges are supported while others are not. Until now, research on public attitudes towards nudges has focused on either state- or country-level comparisons, or on correlations with individual-level traits, and has neglected to study how different social groups (such as minorities) might view nudges. Using a large and representative sample, we tested the attitudes of two distinct minority groups in Israel (Israeli Arabs and Ultra-Orthodox Jews), and discovered that nudges that operated against a minority group’s held social norms, promoting a more general societal goal not aligned with the group’s norms, were often less supported by minorities. Contrary to expectations, these differences could not be explained by differences in trust in the government applying these nudges. We discuss implications for public policy and for the research and applications of behavioral interventions.

Welfare effects of nudges: The emotional tax of calorie menu labeling

Traditionally, information has been assumed to never harm consumers, a notion recently challenged. Salience nudges have been argued to evoke negative emotions, therefore acting as “emotional taxes”. I design a hypothetical restaurant meal experiment to analyze the emotional and short-term consumer welfare impact of a calorie salience nudge (calorie menu labeling) – a policy implemented nationwide in the U.S. in 2018. I find that a calorie salience nudge may act as an emotional tax, but only for some – there is considerable heterogeneity in the emotional response to the nudge. In particular, the nudge emotionally taxes people with low eating self-control, while it emotionally subsidizes those with higher levels of eating self-control. It therefore emotionally taxes the “right” people. However, people with lower levels of self-control may experience fewer benefits from the nudge – the nudge causes them to adjust their high calorie meal consumption by less than do those with higher self-control. It is therefore unsurprising that consumers with lower self-control attach a lower (a negative) value to the calorie salience nudge. Overall, the calorie salience nudge positively affects consumer welfare, although heterogeneity over consumers is substantial – the consumer value ranges from positive to negative. I find no distributional effects over income from the calorie salience nudge.

Reducing the Consumer Attitude⁻Behaviour Gap in Animal Welfare: The Potential Role of 'Nudges'

Simple Summary

Many members of the public express a desire for farm animals to have a good quality of life. Yet, when it comes to purchasing higher welfare products which would support this, many consumers do not ‘walk their talk’. This paper introduces the concept of ‘nudging’ as a means to help consumers align their actions with their intentions and support their desire to engage in pro-animal welfare behaviours. ‘Nudging’ is a collection of behaviour change tools designed to hint to, or suggest, a choice most closely aligned with an individual’s self-interests or intentions. Their purpose is to simplify the decision-making environment by working in concert with the behavioural flaws known to influence human decision-making. Four specific behavioural ‘nudges’ are outlined: self-nudges, choice architecture, social norms and pre-commitments, along with examples of how they can be applied to animal welfare. Inspired by effective applications of ‘nudging’ to close the consumer attitude–behaviour gap in other relevant domains, this paper seeks to highlight how similar initiatives might be applied to better support higher welfare choices amongst consumers and in turn, enhance the lives of farm animals.

Abstract

Citizen concern for the welfare of farm animals is well documented. However, there is a notable gap between people saying they want improved farm animal welfare and how they actually behave as a consumer. This is known as the citizen–consumer attitude–behaviour gap. As improvements in farm animal welfare can be affected by market demand, the choices consumers make become important. This paper introduces the concept of ‘nudging’ and discusses how it could be applied to reduce the attitude–behaviour gap amongst consumers. By designing the choice environment to better reflect the behavioural biases known to impact human decision-making, ‘nudge’ tools function to prompt individuals to make choices that are aligned with their stated intentions. Four ‘nudge’ tools: self-nudges, choice architecture, social norms and pre-commitments are discussed. The behavioural rationales for their use are reviewed and examples of how they might be applied to animal welfare provided. Improved farm animal welfare arguably requires improved pro-welfare consumer behaviour. This paper highlights how this might be encouraged by: self-nudging the salience of an ethical self-image; altering the choice architecture to influence decision-making; articulating social norms to impact behaviour; and using pre-commitment devices to overcome self-control issues.

Using nudges to reduce waste? The case of Toronto's plastic bag levy

The overuse of disposable plastic bags is a major environmental problem across the globe. In recent years, numerous jurisdictions have sought to curb disposable bag use by implementing a levy or fee at the point of purchase. These levies are typically small and symbolic (around $0.05 per bag), but serve as a highly-visible and continuous reminder to consumers. As such, they are consistent with nudging policies that seek to encourage broad changes in behaviour through small, non-coercive measures that influence people's thinking about an issue. While existing empirical evidence suggests that nudges are highly effective in reducing disposable bag use, we argue that many of these studies are flawed because they lack adequate temporal and geographic controls. We use longitudinal data from four waves of a major Canadian survey to analyze the effect of a disposable bag levy in the City of Toronto. Controlling for demographics and changes in social norms over time, we find that the levy increased the use of reusable shopping bags by 3.4 percentage points. Moreover, we find that the impact of the policy was highly variable across behavioural and demographic groups. The levy was highly effective in encouraging people who already used reusable bags to use them more frequently, while having no effect on infrequent users. We also find that the effects are limited to households with high socio-economic status (as measured by income, educational attainment, and housing situation). This suggests important limitations for nudging policy more generally, as people with lower socio-economic status appear to have been unaffected by this behavioural prompt.

Do Europeans like nudges?

In recent years, many governments have shown a keen interest in “nudges” — approaches to law and policy that maintain freedom of choice, but that steer people in certain directions. Yet to date, there has been little evidence on whether citizens of various societies support nudges and nudging. We report the results of nationally representative surveys in six European nations: Denmark, France, Germany, Hungary, Italy, and the United Kingdom. We find strong majority support for nudges of the sort that have been adopted, or under serious consideration, in democratic nations. Despite the general European consensus, we find markedly lower levels of support for nudges in two nations: Hungary and Denmark. We are not, in general, able to connect support for nudges with distinct party affiliations.

American attitudes toward nudges

To successfully select and implement nudges, policy makers need a psychological understanding of who opposes nudges, how they are perceived, and when alternative methods (e.g., forced choice) might work better. Using two representative samples, we examined four factors that influence U.S. attitudes toward nudges – types of nudges, individual dispositions, nudge perceptions, and nudge frames. Most nudges were supported, although opt-out defaults for organ donations were opposed in both samples. “System 1” nudges (e.g., defaults and sequential orderings) were viewed less favorably than “System 2” nudges (e.g., educational opportunities or reminders). System 1 nudges were perceived as more autonomy threatening, whereas System 2 nudges were viewed as more effective for better decision making and more necessary for changing behavior. People with greater empathetic concern tended to support both types of nudges and viewed them as the “right” kind of goals to have. Individualists opposed both types of nudges, and conservatives tended to oppose both types. Reactant people and those with a strong desire for control opposed System 1 nudges. To see whether framing could influence attitudes, we varied the description of the nudge in terms of the target (Personal vs. Societal) and the reference point for the nudge (Costs vs. Benefits). Empathetic people were more supportive when framing highlighted societal costs or benefits, and reactant people were more opposed to nudges when frames highlighted the personal costs of rejection.