A manifesto for applying behavioural science

Nudges for people who think

The naiveté of the dominant 'cognitive-miser' metaphor of human thinking hampers theoretical progress in understanding how and why subtle behavioural interventions-'nudges'-could work. We propose a reconceptualization that places the balance in agency between, and the alignment of representations held by, people and choice architects as central to determining the prospect of observing behaviour change. We argue that two aspects of representational (mis)alignment are relevant: cognitive (how people construe the factual structure of a decision environment) and motivational (the importance of a choice to an individual). Nudging thinkers via the alignment of representations provides a framework that offers theoretical and practical advances and avoids disparaging people's cognitive capacities.

The MINDSPACE Expanded Framework (MINDSPACE X): Behavioral insights to improve adherence to psychiatric medications

The MINDSPACE framework has made it easier to incorporate insights from behavioral science into policy, including health policy, but lacks granularity. Difficult policy problems such as adherence to psychiatric medication can benefit from judicious selection of nudges. We present a MINDSPACE Expanded Framework including 34 insights from behavioral science in the 9 MINDSPACE principles to support a more detailed integration of behavioral science into policy. We illustrate the framework with examples relating to adherence to psychiatric mediation.

Integrating Systems Thinking and Behavioural Science

Traditional approaches to changing health behaviours have primarily focused on education and raising awareness, assuming that increased knowledge leads to better decisions. However, evidence suggests these methods often fail to result in sustained behavioural change. The dual-process theory of decision-making highlights that much of our behaviour is driven by automatic, intuitive processes, which educational interventions typically overlook. Compounding this challenge, behavioural research is often conducted on small groups, making it difficult to scale insights into broader societal issues, where behaviour is influenced by complex, interconnected factors. This review advocates for integrating behavioural science with systems approaches (including systems thinking and approaches to complex adaptive systems) as a more effective approach to resolving complex societal issues, such as public health, sustainability, and social equity. Behavioural science provides insights into individual decision-making, while systems approaches offer ways of understanding, and working with, the dynamic interactions and feedback loops within complex systems. The review explores the commonalities and differences between these two approaches, highlighting areas where they complement one another. Design thinking is identified as a useful structure for bridging behavioural science and systems thinking, enabling a more holistic approach to problem-solving. Though some ideological challenges remain, the potential for creating more effective, scalable solutions is significant. By leveraging the strengths of both behavioural science and systems thinking, one can create more comprehensive strategies to address the "wicked problems" that shape societal health and well-being.

Boosting: Empowering Citizens with Behavioral Science

Behavioral public policy came to the fore with the introduction of nudging, which aims to steer behavior while maintaining freedom of choice. Responding to critiques of nudging (e.g., that it does not promote agency and relies on benevolent choice architects), other behavioral policy approaches focus on empowering citizens. Here we review boosting, a behavioral policy approach that aims to foster people's agency, self-control, and ability to make informed decisions. It is grounded in evidence from behavioral science showing that human decision making is not as notoriously flawed as the nudging approach assumes. We argue that addressing the challenges of our time-such as climate change, pandemics, and the threats to liberal democracies and human autonomy posed by digital technologies and choice architectures-calls for fostering capable and engaged citizens as a first line of response to complement slower, systemic approaches.

Maize-fusarium interactions: Tunisian insights into mycotoxin ecology

Maize is a worldwide crop yet can be associated with mycotoxigenic fungi, much investigated in humid tropical and cooler, wet temperate regions. However, in hot, arid/semi-arid regions data on their occurrence are poor. In this paper, we focused on interactions between maize and Fusarium fungal species in Tunisia, which has a Mediterranean climate, with hot, dry summers and milder, damper winters. Maize kernels, stalks, and roots were sampled from 19 agricultural fields and 56, 72, and 88 % of samples, respectively, yielded Fusarium isolates. Based on molecular identifications, these were mainly F. verticillioides (67 %), and other species of Fusarium fujikuroi species complex and members of Fusarium incarnatum-equiseti-, oxysporum-, burgessii-, solani- and concolor species complexes. In addition, five isolates were identified as Clonostachys rosea. Fusarium verticilloides and Fusarium proliferatum, that produce fumonisins, suspected carcinogenic compounds, were isolated from all kinds of samples, whereas the other species were isolated only from root and stems. Fumonisin B1 was higher in kernels than in silage, while deoxynivalenol, potent protein synthesis inhibiting compound, was detected (at low levels) in grains and silage. A subset of selected strains, representative of all species identified, was also used to evaluate their ability to produce mycotoxins.Fusarium verticillioides, Fusariumproliferatum and Fusarium nygamai produced high levels of fumonisin B1in vitro, as well as beauvericin and enniatins. These findings confirm that, even in hot arid regions, which generally do not favour fungal growth, mycotoxin-producing fungi can be reason of concern for human and animal health.

Can nudges be leveraged to enhance diversity in organizations? A systematic review

In this article, we review and summarize key findings from a growing literature exploring how nudges can facilitate efforts to diversify organizations. Nudges are psychologically-informed interventions that change behavior without restricting choice or altering incentives. We focus on two types of nudges to enhance organizational diversity: (1) nudges that target organizational processes directly or the decision makers who oversee them to increase the diversity of those hired and promoted and (2) nudges that target the underrepresented candidates themselves to increase the diversity of those applying for organizational roles. We categorize nudges designed to enhance organizational diversity, both by their target and based on the psychology they leverage to improve outcomes for women and racial minorities.

The BSSO Foundry: A community of practice for ontologies in the behavioural and social sciences

There has been a rapid expansion in the quantity and complexity of data, information and knowledge created in the behavioural and social sciences, yet the field is not advancing understanding, practice or policy to the extent that the insights warrant. One challenge is that research often progresses in disciplinary silos and is reported using inconsistent and ambiguous terminology. This makes it difficult to integrate and aggregate findings to produce cumulative bodies of knowledge that can be translated to applied settings. Ontologies can address these challenges; their development and use have the potential to accelerate the behavioural and social sciences. Ontologies can facilitate communication through precise specification and dissemination of terms, and enable efficient data integration, sharing, comparison and analysis. The widespread use of ontologies in the biomedical and biological sciences has led to multiple successes. It is time now for the behavioural and social sciences to follow that lead. In recent years, a number of ontologies have been developed within the behavioural and social sciences; however, efforts have tended to be isolated, with limited resources to support developers and those who work (or would like to work) with and use ontologies. There is a need for coordination and exchange to reduce duplication of work and leverage the value of a community to support the interoperability of these ontologies (linking of entities across domains and datasets). We have therefore initiated the Behavioural and Social Sciences Ontology (BSSO) Foundry, a community of practice and online repository for the development, adoption and use of ontologies in the behavioural and social sciences. The BSSO Foundry aligns with and builds upon the model provided by the Open Biological and Biomedical Ontology Foundry. We describe this new initiative and how to join and contribute to the community of interoperable ontologies for the behavioural and social sciences.

The HIV prevention decision-making cascade: Integrating behavioural insights into HIV prevention efforts

The syndemic of HIV, sexually transmitted infections (STIs), and early pregnancy remain a key challenge to global public health. Decision-making around sexual and reproductive health (SRH) behaviours is critical to ensuring the uptake of biomedical technologies. Drawing from behavioural science theories, we propose a novel conceptual framework-the Decision Cascade-to describe the decision-making process that a user will go through as they navigate these decisions. Analogous to the HIV prevention and treatment cascade, this model describes key steps individuals go through when deciding to use HIV prevention technologies. Each step (being cued/triggered to act, reacting to the behaviour, evaluating the behaviour, assessing the feasibility of acting and the timing and final execution of the action), is influenced by a myriad of individual and socio-cultural factors, shaping the ultimate decision and behaviour outcome in a continual cycle. This framework has applications beyond HIV prevention, extending to other SRH technologies and treatments. By prioritizing human-centered design and understanding user decision-making intricacies, interventions can enhance effectiveness and address the complexities of SRH service uptake across diverse populations. The Decision Cascade framework offers a comprehensive lens to inform intervention design, emphasizing the need for nuanced approaches that resonate with the realities of decision-makers. Adopting such approaches is essential to achieving meaningful impact in HIV prevention and broader SRH initiatives.

Understanding healthcare professionals' responses to patient complaints in secondary and tertiary care in the UK: A systematic review and behavioural analysis using the Theoretical Domains Framework

BACKGROUND

The path of a complaint and patient satisfaction with complaint resolution is often dependent on the responses of healthcare professionals (HCPs). It is therefore important to understand the influences shaping HCP behaviour. This systematic review aimed to (1) identify the key actors, behaviours and factors influencing HCPs' responses to complaints, and (2) apply behavioural science frameworks to classify these influences and provide recommendations for more effective complaints handling behaviours.

METHODS

A systematic literature review of UK published and unpublished (so-called grey literature) studies was conducted (PROSPERO registration: CRD42022301980). Five electronic databases [Scopus, MEDLINE/Ovid, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Health Management Information Consortium (HMIC)] were searched up to September 2021. Eligibility criteria included studies reporting primary data, conducted in secondary and tertiary care, written in English and published between 2001 and 2021 (studies from primary care, mental health, forensic, paediatric or dental care services were excluded). Extracted data included study characteristics, participant quotations from qualitative studies, results from questionnaire and survey studies, case studies reported in commentaries and descriptions, and summaries of results from reports. Data were synthesized narratively using inductive thematic analysis, followed by deductive mapping to the Theoretical Domains Framework (TDF).

RESULTS

In all, 22 articles and three reports met the inclusion criteria. A total of 8 actors, 22 behaviours and 24 influences on behaviour were found. Key factors influencing effective handling of complaints included HCPs' knowledge of procedures, communication skills and training, available time and resources, inherent contradictions within the role, role authority, HCPs' beliefs about their ability to handle complaints, beliefs about the value of complaints, managerial and peer support and organizational culture and emotions. Themes mapped onto nine TDF domains: knowledge, skills, environmental context and resources, social/professional role and identity, social influences, beliefs about capability, intentions and beliefs about consequences and emotions. Recommendations were generated using the Behaviour Change Wheel approach.

CONCLUSIONS

Through the application of behavioural science, we identified a wide range of individual, social/organizational and environmental influences on complaints handling. Our behavioural analysis informed recommendations for future intervention strategies, with particular emphasis on reframing and building on the positive aspects of complaints as an underutilized source of feedback at an individual and organizational level.

Taking the Big Leap | understanding, accessing and improving behavioural science interventions

Applied behaviour science's focus on individual-level behaviours has led to overestimation of and reliance on biases and heuristics in understanding behaviour and behaviour change. Behaviour-change interventions experience difficulties such as effect sizes, validity, scale-up, and long-term sustainability. One such area where we need to re-examine underlying assumptions for behavioural interventions in Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) prevention, which seek population-level benefits and sustained, measurable impact. This requires taking a "Big Leap." In our view, taking the big leap refers to using a behavioural science-informed approach to overcome the chasms due to misaligned assumptions, tunnel focus, and overweighting immediate benefits, which can limit the effectiveness and efficiency of public health programmes and interventions. Crossing these chasms means that decision-makers should develop a system of interventions, promote end-user agency, build choice infrastructure, embrace heterogeneity, recognise social and temporal dynamics, and champion sustainability. Taking the big leap toward a more holistic approach means that policymakers, programme planners, and funding bodies should "Ask" pertinent questions to evaluate interventions to ensure they are well informed and designed.

The NUDGE Framework: Application to Address Behavioral Barriers to Antiretroviral Therapy in Adolescents Living With HIV in Eswatini

Behavioral economics offers a unique opportunity to understand the social, cognitive, and psychological nuances that may influence health behavior. The purpose of this article is to demonstrate the application of NUDGE, a novel behavioral economics and design thinking framework, to address barriers to antiretroviral therapy adherence among adolescents living with HIV in eSwatini. NUDGE comprises five steps: (1) Narrow the focus to a specific target behavior, (2) Understand the context of the behavior through inquiry, (3) Discover behavioral insights related to the target behavior, (4) Generate intervention design features to address behavioral barriers to the target behavior, and (5) Evaluate the design features through iterative pilot testing. This article demonstrates the application of the Discover and Generate steps using qualitative data. In showing the utility of the NUDGE framework, we provide a practical tool for creating interventions informed by behavioral insights.

Behavioral science should start by assuming people are reasonable

Should policymaking assume humans are irrational? Using empirical, theoretical, and philosophical arguments, we suggest a more useful frame is that human behavior is reasonable. Through identifying goals and systemic factors shaping behavior, we suggest that assuming people are reasonable enables behavioral science to be more effective in shaping public policy.

How do behavioral public policy experts see the role of complex systems perspectives? An expert interview study

Amidst the global momentum of behavioral insights (BI), there has been a shift from mostly nudge-based BI applications to systemic approaches. This is particularly pressing in public health, where interacting issues regularly produce unanticipated consequences. Regardless, little is known about adopting complex systems approaches in behavioral public policy. This study aims to capture current practices of international BI experts on the definition, application, drivers, and hindering factors in adopting complex systems approaches in public policy. Semi-structured individual expert interviews (n = 12) of international BI experts with extensive experience in educating, cooperating with, and/or advising public servants were analyzed with inductive content analysis. While the working definition of BI aligned with published definitions, experts varied in their descriptions of complex systems approaches and its significance for public policy, including socioecological aspects, systematic BI use across policy stages, recognizing intertwined behavior, and lack of ready-made solutions. They emphasized the importance of systems approaches, identifying drivers (e.g. need for a broader focus) and hindrances (e.g. pressure for quick results). Embracing complex systems in behavioral public policy provides a holistic perspective, extending beyond simple nudges, sometimes presumed as universally applicable. While complexity perspectives would align with policymakers' worldview, applications require more work to tailor to local situations and to evaluate. Recognizing that, given their distinct expertise content, BI expertise can be quite different from complex systems expertise. The field would benefit from clear descriptions and specialized training for effective integration and advocacy for these approaches.

Meeting statement: Call to action for step-change in health behaviours

Background

Enabling, supporting and promoting positive health-related behaviours is critical in addressing the major public health challenges of our time, and the multifaceted nature of behaviours requires an evidence-based approach. This statement seeks to suggest how a much-needed enhanced use of behavioural and cultural science and insights for health could be advanced.

Study design and methods

and methods: Public health authorities of Europe and Central Asia and international partner organizations in September 2023 met in Copenhagen, Denmark, to discuss the way forward. Drawing on 1) country reporting to WHO, 2) interview study with public health authorities and 3) the meeting deliberations, this meeting statement was developed.

Results

The meeting statement presents a joint call for step-change accelerated use of evidence-based approaches for health behaviours. Actionable next steps for public health authorities and international and regional development partners in health are presented.

Conclusions

The way forward involves increased resource allocation, integration of behavioural insights into health strategies, advocacy through case and cost-effectiveness examples and capacity building.

Field testing the transferability of behavioural science knowledge on promoting vaccinations

As behavioural science is increasingly adopted by organizations, there is a growing need to assess the robustness and transferability of empirical findings. Here, we investigate the transferability of insights from various sources of behavioural science knowledge to field settings. Across three pre-registered randomized controlled trials (RCTs, N = 314,824) involving a critical policy domain-COVID-19 booster uptake-we field tested text-based interventions that either increased vaccinations in prior field work (RCT1, NCT05586204), elevated vaccination intentions in an online study (RCT2, NCT05586178) or were favoured by scientists and non-experts (RCT3, NCT05586165). Despite repeated exposure to COVID-19 vaccination messaging in our population, reminders and psychological ownership language increased booster uptake, replicating prior findings. However, strategies deemed effective by prediction or intention surveys, such as encouraging the bundling of COVID-19 boosters and flu shots or addressing misconceptions, yielded no detectable benefits over simple reminders. These findings underscore the importance of testing interventions' transferability to real-world settings.

How can a behavioral economics lens contribute to implementation science?

BACKGROUND

Implementation science in health is an interdisciplinary field with an emphasis on supporting behavior change required when clinicians and other actors implement evidence-based practices within organizational constraints. Behavioral economics has emerged in parallel and works towards developing realistic models of how humans behave and categorizes a wide range of features of choices that can influence behavior. We argue that implementation science can be enhanced by the incorporation of approaches from behavioral economics. Main body First, we provide a general overview of implementation science and ways in which implementation science has been limited to date. Second, we review principles of behavioral economics and describe how concepts from BE have been successfully applied to healthcare including nudges deployed in the electronic health record. For example, de-implementation of low-value prescribing has been supported by changing the default in the electronic health record. We then describe what a behavioral economics lens offers to existing implementation science theories, models and frameworks, including rich and realistic models of human behavior, additional research methods such as pre-mortems and behavioral design, and low-cost and scalable implementation strategies. We argue that insights from behavioral economics can guide the design of implementation strategies and the interpretation of implementation studies. Key objections to incorporating behavioral economics are addressed, including concerns about sustainment and at what level the strategies work.

CONCLUSION

Scholars should consider augmenting implementation science theories, models, and frameworks with relevant insights from behavioral economics. By drawing on these additional insights, implementation scientists have the potential to boost efforts to expand the provision and availability of high quality care.

One size doesn't fit all: methodological reflections in conducting community-based behavioural science research to tailor COVID-19 vaccination initiatives for public health priority populations

BACKGROUND

Promoting the uptake of vaccination for infectious diseases such as COVID-19 remains a global challenge, necessitating collaborative efforts between public health units (PHUs) and communities. Applied behavioural science can play a crucial role in supporting PHUs' response by providing insights into human behaviour and informing tailored strategies to enhance vaccination uptake. Community engagement can help broaden the reach of behavioural science research by involving a more diverse range of populations and ensuring that strategies better represent the needs of specific communities. We developed and applied an approach to conducting community-based behavioural science research with ethnically and socioeconomically diverse populations to guide PHUs in tailoring their strategies to promote COVID-19 vaccination. This paper presents the community engagement methodology and the lessons learned in applying the methodology.

METHODS

The community engagement methodology was developed based on integrated knowledge translation (iKT) and community-based participatory research (CBPR) principles. The study involved collaboration with PHUs and local communities in Ontario, Canada to identify priority groups for COVID-19 vaccination, understand factors influencing vaccine uptake and co-design strategies tailored to each community to promote vaccination. Community engagement was conducted across three large urban regions with individuals from Eastern European communities, African, Black, and Caribbean communities and low socioeconomic neighbourhoods.

RESULTS

We developed and applied a seven-step methodology for conducting community-based behavioural science research: (1) aligning goals with system-level partners; (2) engaging with PHUs to understand priorities; (3) understanding community strengths and dynamics; (4) building relationships with each community; (5) establishing partnerships (community advisory groups); (6) involving community members in the research process; and (7) feeding back and interpreting research findings. Research partnerships were successfully established with members of prioritized communities, enabling recruitment of participants for theory-informed behavioural science interviews, interpretation of findings, and co-design of targeted recommendations for each PHU to improve COVID-19 vaccination uptake. Lessons learned include the importance of cultural sensitivity and awareness of sociopolitical context in tailoring community engagement, being agile to address the diverse and evolving priorities of PHUs, and building trust to achieve effective community engagement.

CONCLUSION

Effective community engagement in behavioural science research can lead to more inclusive and representative research. The community engagement approach developed and applied in this study acknowledges the diversity of communities, recognizes the central role of PHUs, and can help in addressing complex public health challenges.

Exploring open science practices in behavioural public policy research

In their book 'Nudge: Improving Decisions About Health, Wealth and Happiness', Thaler & Sunstein (2009) argue that choice architectures are promising public policy interventions. This research programme motivated the creation of 'nudge units', government agencies which aim to apply insights from behavioural science to improve public policy. We closely examine a meta-analysis of the evidence gathered by two of the largest and most influential nudge units (DellaVigna & Linos (2022 Econometrica 90, 81-116 (doi:10.3982/ECTA18709))) and use statistical techniques to detect reporting biases. Our analysis shows evidence suggestive of selective reporting. We additionally evaluate the public pre-analysis plans from one of the two nudge units (Office of Evaluation Sciences). We identify several instances of excellent practice; however, we also find that the analysis plans and reporting often lack sufficient detail to evaluate (unintentional) reporting biases. We highlight several improvements that would enhance the effectiveness of the pre-analysis plans and reports as a means to combat reporting biases. Our findings and suggestions can further improve the evidence base for policy decisions.