Seeking better health care outcomes: the ethics of using the "nudge"

The unit size effect on chocolate consumption: How to make consumers eat less? (The unit size effect on chocolate consumption)

Understanding the impact of environmental stimuli, such as nudges, on consumption behavior is crucial for developing effective dietary interventions. This study investigates the unit size effect, a behaviourally-oriented nudge, on chocolate consumption. In particular, it examines how different unit sizes and the presence or absence of packaging influence the quantity of chocolate consumed and the perceived energy intake in grams and calories. The research contributes to the theoretical framework of nudge theory, particularly the concept of unit bias, which suggests that larger units lead to higher consumption volumes. The novelty of this paper lies in its exploration of the combined effects of unit size and packaging and healthy lifestyle on consumption behavior, a relatively under-researched area. The methodology involved an experiment with four focus groups, differentiated by health-consciousness, who were provided with chocolate in varying unit sizes and packaging conditions. The data from the experiments were subjected to a three-way repeated measures ANOVA (RM-ANOVA) model. The results indicated that larger unit sizes significantly increase consumption compared to smaller units, regardless of packaging. This demonstrates that unit size has a greater impact on consumption than packaging, reinforcing the power of unit bias. The health-conscious participants consumed a markedly lower quantity of packed chocolates and exhibited a tendency to significantly overestimate the amount consumed, suggesting that those who are health-conscious may be more conscious of their diet. The findings support the effectiveness of behaviourally-oriented nudge marketing tools in influencing consumption behavior without altering consumer knowledge or emotions.

When should doctors nudge? Nudging and preference-sensitive care

When should doctors nudge their patients towards the treatments they think are best? If the nudge is compatible with the patient giving informed consent, then the nudge could be permissible. To be compatible with informed consent, the nudge must, at minimum: (1) not make the patient's understanding worse and (2) not make it hard for the patient to resist consenting. Arguably, many nudges will meet these criteria. However, since unjustified nudging, in this context, would also be unjustified paternalism, the permissibility of nudging hinges on whether it is justified. Perhaps surprisingly, this is often not the case. In situations where the best medical judgement does not conclusively favour a single course of action but there are multiple viable options, patient preference ought to be the deciding factor. In such contexts of preference-sensitive care, there is no good reason for doctors to nudge the patient towards a specific course of action, and hence, nudging is unjustified. Outside such contexts, nudging may be both justified and permissible.

Nudging Public Health Behaviors to Prevent COVID-19: A Systematic Review

Many countries have implemented strict preventive measures and mandatory policies to curb virus transmission during the COVID-19 pandemic. Some have adopted softer approaches, such as nudge-based intervention, to influence public health behavior. This systematic review, conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines, aims to determine if the nudge-based intervention can effectively influence people's preventive behavior during the early period of the COVID-19 pandemic. The review indicated an overall positive outcome, but results were mixed as nudge-based interventions substantially depended on the situational context. While the review found that the nudging technique that presents and conveys decision-related information was essential to nudging people, a secondary nudge would often applied to deliver the interventions. In addition, there was no indication of an ideal nudge technique that would be effective in most situations. Conversely, our findings indicate that the nudge would likely suffer from habituation after repeated intervention or backfire due to inappropriate use of nudges. Also, the ceiling effect would inhibit any nudge influences regardless of the technique(s) used. In sum, the results and the applicability of nudge-based interventions were mixed, highlighting the need for further research to advance the theory and practical developments.

Clinicians' Use of Choice Framing in ICU Family Meetings

OBJECTIVES

To quantify the frequency and patterns of clinicians' use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU.

DESIGN

Secondary sequential content analysis.

SETTING

One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study.

SUBJECTS

Surrogate decision-makers and clinicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference-sensitive specific to the critical care context. Coders then examined each decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a "yes or no question" to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation.

CONCLUSIONS

Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.

Why we should not "help bad choosers:" screening, nudging, and epistemic risk

One prominent line of support for nudging in screening programs is the claim that nudging can help 'bad choosers' - that is, it can help some patients make choices more in line with their own values and preferences. In this article, I argue that due to the presence of epistemic risk in many screening programs, the argument that nudging can help 'bad choosers' should be revised or rejected. Expanding on the work of Biddle, J. B. 2020. Epistemic risks in cancer screening: Implications for ethics and policy. Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 79: 101200.), I argue that epistemic risk undermines the argument that nudging can help to promote patient autonomy in the context of screening. Specifically, I argue that epistemic risk results in the inclusion of non-patient values and preferences in the screening process, which challenges the claim that nudging can help patients make choices more in line with their own values and preferences. I present four reasons to think epistemic risk undermines the argument in this way: (1) conflicting values; (2) lack of transparency; (3) limited autonomy in opting out; (4) unjustified manipulation. The presence of epistemic risk in screening programs means that nudging may not always be an effective means of promoting patient autonomy and informed consent. As such, epistemic risk poses significant challenges to at least one ethical justification of nudging in screening programs, and raises further questions about the role of nudging in promoting patient decision-making.

Framing effects from misleading implicatures: an empirically based case against some purported nudges

Some bioethicists argue that a doctor may frame treatment options in terms of effects on survival rather than on mortality in order to influence patients to choose the better option. The debate over such framing typically assumes that the survival and mortality frames convey the same numerical information. However, certain empirical findings contest this numerical equivalence assumption, demonstrating that framing effects may in fact be due to the two frames implying different information about the numerical bounds of survival and mortality rates. In this paper, I use these findings to argue that framing is presumptively wrong because it violates the duty of proper disclosure. Along the way, I highlight morally relevant features affecting the permissibility of framing, tackle three objections and draw some general lessons for the ethics of nudging.

Is Suffering a Useless Concept?

"Suffering" is a central concept within bioethics and often a crucial consideration in medical decision making. As used in practice, however, the concept risks being uninformative, ambiguous, or even misleading. In this paper, we consider a series of cases in which "suffering" is invoked and analyze them in light of prominent theories of suffering. We then outline ethical hazards that arise as a result of imprecise usage of the concept and offer practical recommendations for avoiding them. Appeals to suffering are often getting at something ethically important. But this is where the work of ethics begins, not where it ends.

Can we 'Nudge' people to better waste separation behaviours? Policy interventions mediated by habit, sense of separation efficiency and external environmental perceptions

This article studies the impact of intervention measures with nudge characteristics on residents' waste separation behaviours under the background of new 'Beijing Municipal Regulation on Domestic Waste Management'. We analyse whether and how nudge interventions affect residents' waste separation behaviours through the Ordered Logit model and mediation analysis. Our research results show that three nudge tools, namely, the timing and fixed-point separation system, the cleaning staff guidance system and the uniform clothing and styling, can effectively promote residents from low classification levels to high classification levels. In the process of nudging interventions, factors such as residents' waste separation habit, external environmental perception and the sense of separation efficiency play a mediating role. Our study's findings suggest that effective nudge tools are helpful in cultivating residents' separation habits and hence we recommend that policy makers promote and popularise them in their attempt to improve domestic waste management behaviours.

Policy-makers' conception of patient non-attendance fees in specialist healthcare: a qualitative document analysis

OBJECTIVES

Patients missing their scheduled appointments in specialist healthcare without giving notice can undermine efficient care delivery. To reduce patient non-attendance and possibly compensate healthcare providers, policy-makers have noted the viability of implementing patient non-attendance fees. However, these fees may be controversial and generate public resistance. Identifying the concepts attributed to non-attendance fees is important to better understand the controversies surrounding the introduction and use of these fees. Patient non-attendance fees in specialist healthcare have been extensively debated in Norway and Denmark, two countries that are fairly similar regarding political culture, population size and healthcare system. However, although Norway has implemented a patient non-attendance fee scheme, Denmark has not. This study aimed to identify and compare how policy-makers in Norway and Denmark have conceptualised patient non-attendance fees over three decades.

DESIGN

A qualitative document study with a multiple-case design.

METHODS

A theory-driven qualitative analysis of policy documents (n=55) was performed.

RESULTS

Although patient non-attendance fees were seen as a measure to reduce non-attendance rates in both countries, the specific conceptualisation of the fees differed. The fees were understood as a monetary disincentive in Norwegian policy documents. In the Danish documents, the fees were framed as an educative measure to foster a sense of social responsibility, as well as serving as a monetary disincentive. The data suggest, however, a recent change in the Danish debate emphasising fees as a disincentive. In both countries, fees were partly justified as a means of compensating providers for the loss of income.

CONCLUSIONS

The results demonstrate how, as a regulative policy tool, patient non-attendance fees have been conceptualised and framed differently, even in apparently similar contexts. This suggests that a more nuanced and complex understanding of why such fees are debated is needed.

The role of attention and health goals in nudging healthy food choice

Introduction

Nudging is a promising intervention technique that supports people in pursuing their healthy eating goals. Recent research suggests that, despite previous assumptions, disclosure of the presence of a nudge does not compromise nudge effectiveness. However, it is unknown whether attention to a nudge affects nudge effects. We assessed the role of attention systematically, by examining explicit and implicit attention to nudges, while also exploring healthy eating goals as a potential moderator.

Methods

Participants were assigned to a nudge (i.e., a shopping basket inlay with pictures of healthy items) or control condition (i.e., a shopping basket inlay with neutral pictures) and chose a snack in an experimental supermarket field study. Explicit and implicit attention (with a mobile eye-tracker) to nudges, healthiness of snack choice, and healthy eating goals were assessed.

Results

Results showed that attention to the nudge did not hamper the nudge's effect. Furthermore, individuals with strong healthy eating goals made healthier food choices in the nudge condition. Individuals with weak to non-existent healthy eating goals were not influenced by the nudge.

Discussion

Findings are in line with the viewpoint that nudging does not by definition work 'in the dark', and suggests that nudges support people in adhering to their healthy eating goal.

Breaking ground: nursing-led approach to alleviating constipation in Parkinson's disease

BACKGROUND

Constipation is one of the most common non-motor symptoms in PD patients, and the constipation, can appear before motor symptoms. Incorrect treatment of constipation in PD patients can result in colonic volvulus and pseudo intestinal obstruction, as well as a reduction in the therapeutic effect of anti-PD drugs due to absorption issues. There is, however, no comprehensive and scientific nursing intervention plan for PD patients' constipation who are constipated.

METHODS

A multi-disciplinary nursing research group of five people was established to construct the first draft of intervention plan through literature review. We chose 15 experts from 7 universities and tertiary hospitals spread over 5 provinces (cities), including 4 neurologists, 9 clinical nursing specialists in neurology, 1 dietician, and 1 rehabilitator. Two rounds of consultations were held from April to July 2022 with 15 experts to screen and revise the indicators at each level, confirming their importance and feasibility at each level.

RESULTS

There were three primary indicators (pre-intentional stage, intentional stage, and action stage) in the two rounds of expert correspondence, nine secondary indicators (disease risk perception, adverse consequence expectation, self-efficacy and intention of action; action plan, coping plan and coping self-efficacy; produce healthy behaviors, maintain healthy behaviors, recover behaviors and recover self-efficacy), and 22 tertiary indicators.

CONCLUSIONS

After the implementation of two rounds of Delphi method, the final formed constipation intervention program for PD patients provides the basis for clinical nursing practice, which has the characteristics of convenience, comprehensiveness, dependence, scientific and feasibility. Therefore, it has application and promotion value.

Active vs. computer-based passive decision-making leads to discrepancies in outcome evaluation: evidence from self-reported emotional experience and brain activity

People prefer active decision-making and induce greater emotional feelings than computer-based passive mode, yet the modulation of decision-making mode on outcome evaluation remains unknown. The present study adopted event-related potentials to investigate the discrepancies in active and computer-based passive mode on outcome evaluation using a card gambling task. The subjective rating results showed that active mode elicited more cognitive effort and stronger emotional feelings than passive mode. For received outcomes, we observed no significant Feedback-Related Negativity (FRN) effect on difference waveshapes (d-FRN) between the 2 modes, but active decision-making elicited larger P300 amplitudes than the passive mode. For unchosen card outcomes, the results revealed larger d-FRN amplitudes of relative valences (Superior - Inferior) in responses to negative feedback in active mode than in passive mode. The averaged P300 results revealed an interplay among outcome feedback, decision-making mode, and relative valence, and the average P300 amplitude elicited by the received loss outcome in the active mode partially mediated the relationship between subjective cognitive effort and negative emotion ratings on loss. Our findings indicate discrepancies between active and computer-based passive modes, and cognitive effort and emotional experience involved in outcome evaluation.

Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke

PURPOSE

Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology.

METHODS

We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model.

RESULTS

From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004).

CONCLUSION

EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.

Changing patient preferences toward better trial recruitment: an ethical analysis

While randomized controlled trials are essential to health research, many of these trials fail to recruit enough participants. Approaching recruitment through the lens of behavioral science can help trialists to understand influences on the decision to participate and use them to increase recruitment. Although this approach is promising, the use of behavioral influences during recruitment is in tension with the ethical principle of respect for persons, as at least some of these influences could be used to manipulate potential participants. In this paper, we examine this tension by discussing two types of behavioral influences: one example involves physician recommendations, and the other involves framing of information to exploit cognitive biases. We argue that despite the apparent tension with ethical principles, influencing trial participants through behavior change strategies can be ethically acceptable. However, we argue that trialists have a positive obligation to analyze their recruitment strategies for behavioral influences and disclose these upfront to the research ethics committee. But we also acknowledge that since neither trialists nor ethics committees are presently well equipped to perform these analyses, additional resources and guidance are needed. We close by outlining a path toward the development of such guidance.

A Taxonomy of Non-honesty in Public Health Communication

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication.

Nudging attitudes toward IT innovations by information provision that serves as a reminder of familial support

There is concern among the general public that information technology (IT) innovations may make existing jobs redundant. This may be perceived to pose a greater problem to future generations because new technologies, not limited to IT innovations, will be sophisticated in the future. Our previous work revealed that messages reminding people of familial support as a nudge can moderate risk-averse attitudes toward risks that are perceived to threaten future generations, which could be effective for other kinds of risks. Therefore, we conducted a randomized controlled trial to examine the message effects for information provision on IT innovations. The study was conducted via an online questionnaire survey in January 2020, before the COVID-19 pandemic, and more than 3,200 samples were collected from respondents aged 20 years or older living in Japan. The treatment groups received basic information supplemented with additional text or additional text and an illustration that highlighted IT innovations as support from previous generations. The control group received only the basic textual information. The effects of the intervention were evaluated by comparing changes in average subjective assessment of IT in the treatment groups with those in the control group. The intervention effect was statistically significant, and the sense of familial support after receiving the intervention messages was significantly increased in the treatment group that viewed the illustration compared with the control group. Additionally, we discuss how each component of the HEXACO personality traits influences responses to the intervention messages. Through a series of surveys, we demonstrated the potential of our framework for a wide variety of applications involving information provision perceived to involve future generations.

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.

"If I Become a Vegetable, Then no": A Thematic Analysis of How Patients and Physicians Refer to Prognosis When Discussing Cardiopulmonary Resuscitation

Background: Documenting decisions about the relevance cardiopulmonary resuscitation (CPR) is a standard practice at hospital admission yet a complex task. Objective: Our aim was to explore how physicians approach and discuss CPR prognosis with older patients recently admitted to a post-acute care unit. Method: We recorded 43 conversations between physicians and patients about the relevancy of CPR that took place at admission at the geriatric rehabilitation service of a Swiss university hospital. Thematic analysis determined (i) who initiated the talk about CPR prognosis, (ii) at what point in the conversation, and (iii) how prognosis was referred to. Results: Prognosis was mentioned in 65% of the conversations. We categorized the content of references to CPR prognosis in five themes: factors determining the prognosis (general health, age, duration of maneuvers); life (association of CPR with life, survival); proximal adverse outcomes (broken ribs, intensive care); long-term adverse outcomes (loss of autonomy, suffering a stroke, pain, generic, uncertainty); and being a burden. Discussion and conclusion: Discussing CPR is important to all patients, including those for whom it is not recommended. Information about CPR prognosis is essential to empower and support patients in expressing their expectations from life-prolonging interventions and attain shared decision-making.

How Mandatory Can We Make Vaccination?

The novel coronavirus (SARS-CoV-2) pandemic has refocused attention on the issue of mandatory vaccination. Some have suggested that vaccines ought to be mandatory, while others propose more moderate alternatives, such as incentives. This piece surveys a range of possible interventions, ranging from mandates through to education. All may have their place, depending on circumstances. However, it is worth clarifying the options available to policymakers, since there is sometimes confusion over whether a particular policy constitutes a mandate or not. Further, I illustrate a different kind of alternative to mandatory vaccination. Rather than seeking less coercive alternatives to a mandate, we might instead employ an alternative mandate, which requires people to do something less than get vaccinated. For instance, we might merely require people to attend an appointment at a vaccine clinic. Whether this mandatory attendance policy is justified will depend on specific circumstances, but it represents another way to promote vaccination, without mandating it. In some cases, this may represent an appropriate balance between promoting public health goals and respecting individual liberty.

Reducing COVID vaccine hesitancy by inducing a comparative mindset

OBJECTIVE

To investigate if a behavioral nudge comprising a vaccination opportunity that employs a comparative probe first (i.e., which vaccine to take) versus the more commonly-used deliberative probe (i.e., willingness to take a vaccine), reduces vaccine hesitancy, while controlling for political partisanship.

METHODS

In a randomized study, conducted on Amazon Mechanical Turk and Prolific, we varied the manner in which the vaccination offer is posed. In one group, participants were asked to compare which vaccine they would like to take (i.e., the comparative probe), while, in another group, participants were asked to deliberate whether they would like to take the vaccine (i.e., the deliberative probe). Participants' political preferences were also measured. The primary outcome variable was vaccine hesitancy.

RESULTS

A LOGIT regression (N = 1736), was conducted to test the research questions. Overall, the comparative probe yielded a 6% reduction in vaccine hesitancy relative to the typical deliberative probe. Additionally, while vaccine hesitancy varies due to individual political views, the comparative probe is effective at reducing vaccine hesitancy even among the most vaccine hesitant population (i.e., Pro-Trump Republicans) by almost 10% on average.

CONCLUSIONS

Subtly changing the manner in which the vaccination offer is framed, by asking people to compare which vaccine to take, and not deliberate about whether they would like to take a vaccine, can reduce vaccine hesitancy, without being psychologically taxing or curtailing individuals' freedom to choose. The nudge is especially effective among highly vaccine hesitant populations such as Pro-Trump Republicans. Our results suggest a costless communication protocol in face-to-face interactions on doorsteps, in clinics, in Pro-Trump regions and in the mass media, that might protect 5 million Americans from COVID-19.

Nudging Strategies for Arable Land Protection Behavior in China

Arable land protection is critical to the sustainable development of agriculture in China and acceleration of the realization of the trinity protection goal of the quantity, quality, and ecology of arable land. As a new program of behavioral science to promote social development, nudge has gradually gained the favor of researchers and policy makers due to its unique advantages of small cost and substantial effect. However, current research and practical exploration of arable land protection behavior intervention based on the idea of nudging are still lacking. Implicit nudging strategies directly target the heuristic and analytic systems of arable land protection behavior of each stakeholder and possess more advantages than traditional intervention strategies. Therefore, this article designs six arable land protection behavior nudging strategies from the perspectives of cognition and motivation to realize the theoretical discussion of "generating medium-scale returns with nano-level investment". The nudging strategies of the cognitive perspective include default options, framing effects, and descriptive norms, while those of the motivation perspective aim to stimulate home and country, and heritage and benefit motives to promote arable land protection behavior of various stakeholders. The utility of nudge to arable land protection behavior may be controversial in practice. Therefore, the implementation in China should be based on the division of farmers, the number of options should be appropriate, and the external environment of arable land protection behavior should be fully considered.

Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review

PURPOSE OF REVIEW

This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework.

RECENT FINDINGS

MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide

BACKGROUND

Health decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others.

OBJECTIVES

To explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation (CPR) or do-not-attempt-resuscitation orders (DNAR).

METHODS

We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis.

RESULTS

Reference to what other people decide in regards to CPR is used five times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient's preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders ("Patients tell us 'no futile care'"). By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group.

CONCLUSIONS

Introducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms.

Ethical Issues in Social Media Recruitment for Clinical Studies: Ethical Analysis and Framework

BACKGROUND

Social media recruitment for clinical studies holds the promise of being a cost-effective way of attracting traditionally marginalized populations and promoting patient engagement with researchers and a particular study. However, using social media for recruiting clinical study participants also poses a range of ethical issues.

OBJECTIVE

This study aims to provide a comprehensive overview of the ethical benefits and risks to be considered for social media recruitment in clinical studies and develop practical recommendations on how to implement these considerations.

METHODS

On the basis of established principles of clinical ethics and research ethics, we reviewed the conceptual and empirical literature for ethical benefits and challenges related to social media recruitment. From these, we derived a conceptual framework to evaluate the eligibility of social media use for recruitment for a specific clinical study.

RESULTS

We identified three eligibility criteria for social media recruitment for clinical studies: information and consent, risks for target groups, and recruitment effectiveness. These criteria can be used to evaluate the implementation of a social media recruitment strategy at its planning stage. We have discussed the practical implications of these criteria for researchers.

CONCLUSIONS

The ethical challenges related to social media recruitment are context sensitive. Therefore, social media recruitment should be planned rigorously, taking into account the target group, the appropriateness of social media as a recruitment channel, and the resources available to execute the strategy.

Understanding the spread of COVID-19 misinformation on social media: The effects of topics and a political leader's nudge

The spread of misinformation on social media has become a major societal issue during recent years. In this work, we used the ongoing COVID-19 pandemic as a case study to systematically investigate factors associated with the spread of multi-topic misinformation related to one event on social media based on the heuristic-systematic model. Among factors related to systematic processing of information, we discovered that the topics of a misinformation story matter, with conspiracy theories being the most likely to be retweeted. As for factors related to heuristic processing of information, such as when citizens look up to their leaders during such a crisis, our results demonstrated that behaviors of a political leader, former US President Donald J. Trump, may have nudged people's sharing of COVID-19 misinformation. Outcomes of this study help social media platform and users better understand and prevent the spread of misinformation on social media.

The Ethics of AI-Powered Climate Nudging—How Much AI Should We Use to Save the Planet?

The number of areas in which artificial intelligence (AI) technology is being employed increases continually, and climate change is no exception. There are already growing efforts to encourage people to engage more actively in sustainable environmental behavior, so-called “green nudging”. Nudging in general is a widespread policymaking tool designed to influence people’s behavior while preserving their freedom of choice. Given the enormous challenges humanity is facing in fighting climate change, the question naturally arises: Why not combine the power of AI and the effectiveness of nudging to get people to behave in more climate-friendly ways? However, nudging has been highly controversial from the very beginning because critics fear it undermines autonomy and democracy. In this article I investigate the ethics of AI-powered climate nudging and address the question whether implementing corresponding policies may represent hidden and unacceptable costs of AI in the form of a substantive damage to autonomy and democracy. I will argue that, although there are perfectly legitimate concerns and objections against certain forms of nudging, AI-powered climate nudging can be ethically permissible under certain conditions, namely if the nudging practice takes the form of what I will call “self-governance”.

A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic

The coronavirus disease (COVID-19) pandemic has highlighted the link between individual behavior and public health, along with the importance of evidence-based efforts to promote prosocial individual behavior. Insights from behavioral science can inform the design of effective behavior change techniques, or nudges, to influence individual behavior. The MINDSPACE framework organizes 9 behavioral science principles that can be used to guide policy design: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments, and Ego. Using MINDSPACE as an organizing framework, this article provides a review of the literature on nudges to influence prosocial behaviors relevant during a pandemic: handwashing, avoidance of social gatherings, self-isolation and social distancing, and sharing public health messages. Additionally, empirical evidence on the use of nudges during the first several months of the COVID-19 pandemic in 2020 is summarized. Recommendations regarding the use of nudges to achieve public health policy goals during pandemics are provided. Organizational leaders, policymakers, and practitioners can use nudges to promote public health when mandates are not politically feasible or enforceable.

Functional Mechanisms of Health Behavior Change Techniques: A Conceptual Review

Background

Health behavior change is among the top recommendations for improving health of patients with lifestyle-related chronic diseases. An array of behavior change techniques (BCTs) have been developed to support behavior change initiation and maintenance. These BCTs often show limited success when they are not informed by theory, leading to a mismatch between the intention of the BCT and patients' needs or expectations. Previous studies have identified a number of resources (domains) which patients may require to initiate and maintain health behavior change. Indeed, not yet well established is how BCTs address these resources, i.e., the functional mechanisms of BCTs.

Purpose

Provide a theoretical framework of the functional mechanisms of BCTs for developing and implementing successful interventions for health behavior change.

Methods

Conceptual review, including literature analysis and synthesis as well as conceptualization of a new model based on the synthesis.

Results

Through the integration of dual-process models as well as reward and motivation proceeding, i.e., affective, emotional, or intuitive neurobiological cues, into the rational framework of rather linear cognitive or task-related decision progress, we categorize previously identified resources into three distinct sets: external, internal reflective, and internal affective resources. Based on this triad, we classify BCTs according to their functional mechanisms into facilitating (=providing external resources), boosting (=strengthening internal reflective resources), and nudging (=activating internal affective resources). Consequently, we present a simplified Behavior Change Resource Model (BCRM) that is centered on patients' resources.

Conclusion

The model can be applied to develop health behavior change interventions, which promote engagement and empowerment. Future studies should aim at testing the applicability and practicality of the BCRM.

Nudging food service users to choose fruit- and vegetable-rich items: Five field studies

Although nudging has been found to promote the choice of healthy foods in lab studies and ad-hoc field studies, relatively little research is available regarding effectiveness in real food venues that operate for profit. The paucity of empirical studies providing "proof of implementation" reveals the difficulty of applying previous empirical findings on nudging to mass-eating food services contexts, which serve meals to a lot of individuals daily. Based on the typology of choice architecture in food choice contexts, we closely collaborated with the in-house food service operator to devise and implement five nudge interventions to promote fruits and vegetables (FV) in university cafeterias. Each study was conducted for one 12-week semester or more over a three-year period. In the first two studies, non-verbal point-of-purchase prompting increased the choice of kale/spinach supplemented smoothies and whole fruits from baskets. In Study 3, the combination of sizing and point-of-purchase non-verbal prompting increased the sale of large size vegetable-rich bowls from a stir-fry grill. In Study 4, the proximity type of nudging by altering the position of the healthier option in a sandwich bar in combination with non-verbal prompting increased the sale of sandwiches containing spinach. In Study 5, the combination of sizing and proximity of large vs. small sized plates and serving spoons had no effect on sale of self-serve items in a salad bar. All the interventions except for Study 5 produced a moderate effect in increasing the choice of FV-rich items. We recommend that hospitality and food service operators consider operational parameters and simultaneously adopt more than one nudging components to achieve a sizable effect. Future randomized controlled trials are needed to implement choice architecture techniques in collaboration with food service companies.

Promoting Healthy Childhood Behaviors With Financial Incentives: A Narrative Review of Key Considerations and Design Features for Future Research

In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose 5 general considerations in designing and applying incentive interventions to children. These include: 1) the potential impact of incentives on intrinsic motivation, 2) ethical concerns about incentives promoting undue influence, 3) the importance of child neurodevelopmental stage, 4) how incentive interventions may influence health disparities, and 5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss vs gain), timing (immediate vs delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.

Informed consent and compulsory medical device registries: ethics and opportunities

Many high-risk medical devices earn US marketing approval based on limited premarket clinical evaluation that leaves important questions unanswered. Rigorous postmarket surveillance includes registries that actively collect and maintain information defined by individual patient exposures to particular devices. Several prominent registries for cardiovascular devices require enrolment as a condition of reimbursement for the implant procedure, without informed consent. In this article, we focus on whether these registries, separate from their legal requirements, have an ethical obligation to obtain informed consent from enrolees, what is lost in not doing so, and the ways in which seeking and obtaining consent might strengthen postmarket surveillance in the USA.

Effect of Patient Portal Messaging Before Mailing Fecal Immunochemical Test Kit on Colorectal Cancer Screening Rates: A Randomized Clinical Trial

Importance

Colorectal cancer (CRC) screening reduces CRC mortality; however, screening rates remain well below the national benchmark of 80%.

Objective

To determine whether an electronic primer message delivered through the patient portal increases the completion rate of CRC screening in a mailed fecal immunochemical test (FIT) outreach program.

Design, Setting, and Participants

In this randomized clinical quality improvement trial at the University of California, Los Angeles Health of 2339 patients enrolled in a FIT mailing program from August 28, 2019, to September 20, 2020, patients were randomly assigned to either the control or intervention group, and the screening completion rate was measured at 6 months. Participants were average-risk managed care patients aged 50 to 75 years, with a valid mailing address, no mailed CRC outreach in the previous 6 months, and an active electronic health record (EHR) patient portal who were due for CRC screening. Data were analyzed on an intention-to-treat basis.

Interventions

Eligible patients were randomly assigned to receive either (1) the standard FIT mailed outreach (control group) or (2) the standard FIT mailed outreach plus an automated primer to notify patients of the upcoming mailed FIT sent through the electronic patient portal (intervention group).

Main Outcomes and Measures

The primary outcome was the screening completion rate (ie, returning the FIT). Secondary outcomes were (1) were the time to CRC screening from the FIT mailing date, (2) screening modality completed, and (3) the effect of opening the electronic primer on screening completion rate.

Results

The study included 2339 patients (1346 women [57.5%]; mean [SD] age, 58.9 [7.5] years). The screening completion rate was higher in the intervention group than in the control group (37.6% [445 of 1182] vs 32.1% [371 of 1157]; P = .005). The time to screening was shorter in the intervention group than in the control group (adjusted hazard ratio, 1.24; 95% CI, 1.08-1.42; P = .003). The proportion of each screening test modality completed was similar in both groups. In a subanalysis of the 900 of 1182 patients (76.1%) in the intervention group who opened the patient portal primer message, there was a 7.3-percentage point (95% CI, 2.3-12.4 percentage points) increase in CRC screening (local mean treatment effect; P = .004).

Conclusions and Relevance

Implementation of an electronic patient portal primer message in a mailed FIT outreach program led to a significant increase in CRC screening and improvement in the time to screening completion. The findings provide an evidence base for additional refinements to mailed FIT outreach quality improvement programs in large health systems.

Trial Registration

ClinicalTrials.gov Identifier: NCT05115916.

Political affiliation moderates subjective interpretations of COVID-19 graphs

We examined the relationship between political affiliation, perceptual (percentage, slope) estimates, and subjective judgements of disease prevalence and mortality across three chart types. An online survey (N = 787) exposed separate groups of participants to charts displaying (a) COVID-19 data or (b) COVID-19 data labeled 'Influenza (Flu)'. Block 1 examined responses to cross-sectional mortality data (bar graphs, treemaps); results revealed that perceptual estimates comparing mortality in two countries were similar across political affiliations and chart types (all ps > .05), while subjective judgements revealed a disease x political party interaction (p < .05). Although Democrats and Republicans provided similar proportion estimates, Democrats interpreted mortality to be higher than Republicans; Democrats also interpreted mortality to be higher for COVID-19 than Influenza. Block 2 examined responses to time series (line graphs); Democrats and Republicans estimated greater slopes for COVID-19 trend lines than Influenza lines (p < .001); subjective judgements revealed a disease x political party interaction (p < .05). Democrats and Republicans indicated similar subjective rates of change for COVID-19 trends, and Democrats indicated lower subjective rates of change for Influenza than in any other condition. Thus, while Democrats and Republicans saw the graphs similarly in terms of percentages and line slopes, their subjective interpretations diverged. While we may see graphs of infectious disease data similarly from a purely mathematical or geometric perspective, our political affiliations may moderate how we subjectively interpret the data.

Ethical implications of economic compensation for voluntary medical male circumcision for HIV prevention and epidemic control

Despite tremendous efforts in fighting HIV over the last decades, the estimated annual number of new infections is still a staggering 1.5 million. There is evidence that voluntary medical male circumcision (VMMC) provides protection against men's heterosexual acquisition of HIV-1 infection. Despite good progress, most countries implementing VMMC for HIV prevention programmes are challenged to reach VMMC coverage rates of 90%. Particularly for men older than 25 years, a low uptake has been reported. Consequently, there is a need to identify, study and implement interventions that could increase the uptake of VMMC. Loss of income and incurred transportation costs have been reported as major barriers to uptake of VMMC. In response, it has been suggested to use economic compensation in order to increase VMMC uptake. In this discussion paper, we present and review relevant arguments and concerns to inform decision-makers about the ethical implications of using economic compensation, and to provide a comprehensive basis for policy and project-related discussions and decisions.

Public health nudges: weighing individual liberty and population health benefits

Libertarian paternalism describes the idea of nudging-that is, steering individual decision-making while preserving freedom of choice. In medicine, libertarian paternalism has gained widespread attention, specifically with respect to interventions designed to promote healthy behaviours. Some scholars argue that nudges appropriately balance autonomy and paternalistic beneficence, while others argue that nudges inherently exploit cognitive weaknesses. This paper further explores the ethics of libertarian paternalism in public health. The use of nudges may infringe on an individual's voluntary choice, autonomy and informed consent, but they are ethically justified when there is a clear public health benefit to the manipulation of choice.

Nudging toward vaccination: a systematic review

Background

Vaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. ‘Nudging’, defined as altering the environmental context in which a decision is made or a certain behaviour is enacted, has shown promising results in several health promotion strategies. We present a comprehensive synthesis of evidence regarding the value and impact of nudges to address VH.

Methods

We conducted a systematic review to determine if nudging can mitigate VH and improve vaccine uptake. Our search strategy used Medical Subject Headings (MeSH) and non-MeSH terms to identify articles related to nudging and vaccination in nine research databases. 15 177 titles were extracted and assessed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final list of included articles was evaluated using the Mixed Methods Appraisal Tool and the Grading of Recommendations, Assessment, Development and Evaluations framework.

Findings

Identified interventions are presented according to a framework for behaviour change, MINDSPACE. Articles (n=48) from 10 primarily high-income countries were included in the review. Nudging-based interventions identified include using reminders and recall, changing the way information is framed and delivered to an intended audience, changing the messenger delivering information, invoking social norms and emotional affect (eg, through storytelling, dramatic narratives and graphical presentations), and offering incentives or changing defaults. The most promising evidence exists for nudges that offer incentives to parents and healthcare workers, that make information more salient or that use trusted messengers to deliver information. The effectiveness of nudging interventions and the direction of the effect varies substantially by context. Evidence for some approaches is mixed, highlighting a need for further research, including how successful interventions can be adapted across settings.

Conclusion

Nudging-based interventions show potential to increase vaccine confidence and uptake, but further evidence is needed for the development of clear recommendations. The ongoing COVID-19 pandemic increases the urgency of undertaking nudging-focused research.

PROSPERO registration number

CRD42020185817.

Nudging healthy college dining hall choices using behavioral economics

To apply behavioral economics strategies (i.e., placement changes and signage) to nudge university students' healthy dining hall eating. Participants: A convenience sample of 4208 students exiting a university dining hall were asked to take a brief survey on meal selections. Methods: Three unique nudges (related to beverage, snack and dessert) were individually introduced and then removed for a week using a quasi-experimental design. Exit surveys during non-nudge and intervention periods were compared using chi-square analysis. Results: The beverage nudge significantly increased water consumption (p=.03) and the dessert nudge significantly increased healthy dessert consumption (p<.001) between comparison and intervention weeks. The snack intervention did not significantly affect snack choice. Conclusions: Simple signage interventions may be effective to encourage healthy eating behaviors in a college dining hall setting. Student health may be improved by nudging students to select healthier beverage and dessert options.

Dilemmas of nudging in public health: an ethical analysis of a Danish pamphlet

Nudging has been discussed in the context of public health, and ethical issues raised by nudging in public health contexts have been highlighted. In this article, we first identify types of nudging approaches and techniques that have been used in screening programmes, and ethical issues that have been associated with nudging: paternalism, limited autonomy and manipulation. We then identify nudging techniques used in a pamphlet developed for the Danish National Screening Program for Colorectal Cancer. These include framing, default nudge, use of hassle bias, authority nudge and priming. The pamphlet and the very offering of a screening programme can in themselves be considered nudges. Whether nudging strategies are ethically problematic depend on whether they are categorized as educative- or non-educative nudges. Educative nudges seek to affect people's choice making by engaging their reflective capabilities. Non-educative nudges work by circumventing people's reflective capabilities. Information materials are, on the face of it, meant to engage citizens' reflective capacities. Recipients are likely to receive information materials with this expectation, and thus not expect to be affected in other ways. Non-educative nudges may therefore be particularly problematic in the context of information on screening, also as participating in screening does not always benefit the individual.

What are the ethical implications of using prize-based contingency management in substance use? A scoping review

BACKGROUND

The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications.

PURPOSE

The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration.

METHODS

The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications.

RESULTS

We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics.

CONCLUSIONS

This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.

Why a Virtual Assistant for Moral Enhancement When We Could have a Socrates?

Can Artificial Intelligence (AI) be more effective than human instruction for the moral enhancement of people? The author argues that it only would be if the use of this technology were aimed at increasing the individual's capacity to reflectively decide for themselves, rather than at directly influencing behaviour. To support this, it is shown how a disregard for personal autonomy, in particular, invalidates the main proposals for applying new technologies, both biomedical and AI-based, to moral enhancement. As an alternative to these proposals, this article proposes a virtual assistant that, through dialogue, neutrality and virtual reality technologies, can teach users to make better moral decisions on their own. The author concludes that, as long as certain precautions are taken in its design, such an assistant could do this better than a human instructor adopting the same educational methodology.

Have we reached the limits in altruistic kidney donation?

Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision-making and paternalistic protection of the donor, the extent of outcome uncertainty and risk-benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation.

The moderating role of childhood socioeconomic status on the impact of nudging on the perceived threat of coronavirus and stockpiling intention

Communications that include nudges and framing strategies are ubiquitous in our daily lives. In this paper, we investigate how different nudging strategies during a public health campaign, particularly supplementary information and statistics, influence perceptions of threat and stockpiling intentions, while also considering the role of childhood socioeconomic status. Specifically, building upon prior work in behavioral economics, we hypothesize that the presence of additional statistics elicits lower perceived threat and intention to stockpile. In addition, we predict find that the childhood socioeconomic status of individuals influences these effects. Three studies offer evidence for those predictions and demonstrate the importance of message framing in uncertain circumstances. Overall, this work contributes to the literature on nudging and life history theory by investigating how communication strategies can be used to increase or decrease perceived threat in order to achieve desired outcomes (e.g., limiting stockpiling or respecting social distancing).

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The information presented and the design of health campaigns significantly influence perceived threats and irrational behaviors such as stockpiling intentions.

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Childhood socioeconomic status of individuals has an impact on the effectiveness of these advertising strategies.

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Health campaign design about COVID-19 and childhood SES influence perceived threat and stockpiling intentions.

Nudging Consumers toward Healthier Food Choices: A Field Study on the Effect of Social Norms

Food choices influence the health of individuals, and supermarkets are the place where part of the world population makes their food choices on a daily basis. Different methods to influence food purchasing habits are used, from promotions to food location. However, very few supermarket chains use social norms, the human need to conform to the perceived behavior of the group, to increase healthy food purchase habits. This research seeks to understand how a social norm nudge, a message conveying fruit and vegetable purchasing norms positioned in strategic places, can effectively change food choices. Using data from an intervention in a Portuguese supermarket, the fruit and vegetable purchase quantities of 1636 customers were measured over three months and compared with the corresponding period of the previous year. The results show that the nudge intervention positively affected those whose purchasing habits are categorized as less healthy, while those with healthy habits were slightly negatively affected. Moreover, a follow-up inferential statistical analysis allows us to conclude that applying this intervention at a larger scale would deliver significant financial results for the supermarket chain in which the study took place, by decreasing the costs related to produce perishability while simultaneously improving the health of the consumer and the sustainability of the planet.

The moral perils of conditional cash transfer programmes and their significance for policy: a meta-ethnography of the ethical debate

Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making.