Large numbers cause magnitude neglect: The case of government expenditures.

Four studies demonstrate that the public's understanding of government budgetary expenditures is hampered by difficulty in representing large numerical magnitudes. Despite orders of magnitude difference between millions and billions, study participants struggle with the budgetary magnitudes of government programs. When numerical values are rescaled as smaller magnitudes (in the thousands or lower), lay understanding improves, as indicated by greater sensitivity to numerical ratios and more accurate rank ordering of expenses. A robust benefit of numerical rescaling is demonstrated across a variety of experimental designs, including policy relevant choices and incentive-compatible accuracy measures. This improved sensitivity ultimately impacts funding choices and public perception of respective budgets, indicating the importance of numerical cognition for good citizenship.

A 680,000-person megastudy of nudges to encourage vaccination in pharmacies.

Encouraging vaccination is a pressing policy problem. To assess whether text-based reminders can encourage pharmacy vaccination and what kinds of messages work best, we conducted a megastudy. We randomly assigned 689,693 Walmart pharmacy patients to receive one of 22 different text reminders using a variety of different behavioral science principles to nudge flu vaccination or to a business-as-usual control condition that received no messages. We found that the reminder texts that we tested increased pharmacy vaccination rates by an average of 2.0 percentage points, or 6.8%, over a 3-mo follow-up period. The most-effective messages reminded patients that a flu shot was waiting for them and delivered reminders on multiple days. The top-performing intervention included two texts delivered 3 d apart and communicated to patients that a vaccine was "waiting for you." Neither experts nor lay people anticipated that this would be the best-performing treatment, underscoring the value of simultaneously testing many different nudges in a highly powered megastudy.

A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor's appointment.

Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment (N = 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor's appointment and indicated it was reserved for them. This successful script could be used as a template for campaigns to encourage the adoption of life-saving vaccines, including against COVID-19.

Perceptions of pediatric deceased donor consent: A survey of organ procurement organizations.

BACKGROUND: Children awaiting transplantation face a high risk of waitlist mortality due to a shortage of pediatric organ donors. Pediatric donation consent rates vary across Organ Procurement Organizations (OPOs), suggesting that some OPOs might utilize more effective pediatric-focused donor recruitment techniques than others. An online survey of 193 donation requestor staff sheds light on the strategies that OPO staff utilize when approaching potential pediatric deceased organ donors. METHODS: In collaboration with the Association of Organ Procurement Organizations, the research team contacted the executive directors and medical directors of all 57 of the OPOs in the US. Of these, 51 OPOs agreed to participate, and 47 provided contact information for donation requestor staff. Of the 379 staff invited to participate in the survey, 193 provided complete responses. RESULTS: Respondents indicated more comfort approaching adult donors than pediatric donors, and they endorsed approach techniques that were interpersonal and emotional rather than professional and informative. Respondents were accurate in their perceptions about which donor characteristics are associated with consent. However, respondents from OPOs with high consent rates (according to data from the Scientific Registry of Transplant Recipients), and those from OPOs with low consent rates were very similar in terms of demographics, training, experience, and reported techniques. CONCLUSIONS: Additional research is needed to better determine why some OPOs have higher consent rates than others and whether the factors that lead to high consent rates in high-performing OPOs can be successful when implemented by lower-performing OPOs.

Grouping Promotes Equality: The Effect of Recipient Grouping on Allocation of Limited Medical Resources.

Decisions about allocation of scarce resources, such as transplant organs, often entail a trade-off between efficiency (i.e., maximizing the total benefit) and fairness (i.e., dividing resources equally). In three studies, we used a hypothetical scenario for transplant-organ allocation to examine allocation to groups versus individuals. Study 1 demonstrated that allocation to individuals is more efficient than allocation to groups. Study 2 identified a factor that triggers the use of fairness over efficiency: presenting the beneficiaries as one arbitrary group rather than two. Specifically, when beneficiaries were presented as one group, policymakers tended to allocate resources efficiently, maximizing total benefit. However, when beneficiaries were divided into two arbitrary groups (by hospital name), policymakers divided resources more equally across the groups, sacrificing efficiency. Study 3 replicated this effect using a redundant attribute (prognosis) to create groups and found evidence for a mediator of the grouping effect--the use of individualizing information to rationalize a more equitable allocation decision.

Using machine learning to unveil relevant predictors of adherence to recommended health-protective behaviors during the COVID-19 pandemic in Denmark.

What were relevant predictors of individuals' proclivity to adhere to recommended health-protective behaviors during the COVID-19 pandemic in Denmark? Applying machine learning (namely, lasso regression) to a repeated cross-sectional survey spanning 10 months comprising 25 variables (Study 1; N = 15,062), we found empathy toward those most vulnerable to COVID-19, knowledge about how to protect oneself from getting infected, and perceived moral costs of nonadherence to be strong predictors of individuals' self-reported adherence to recommended health-protective behaviors. We further explored the relations between these three factors and individuals' self-reported proclivity for adherence to recommended health-protective behaviors as they unfold between and within individuals over time in a second study, a Danish panel study comprising eight measurement occasions spanning eight months (N = 441). Results of this study suggest that the relations largely occurred at the trait-like interindividual level, as opposed to at the state-like intraindividual level. Together, the findings provide insights into what were relevant predictors for individuals' overall level of adherence to recommended health-protective behaviors (in Denmark) as well as how these predictors might (not) be leveraged to promote public adherence in future epidemics or pandemics.

Measuring cognitive and affective constructs in the context of an acute health event.

The latest recommendations for building dynamic health behavior theories emphasize that cognitions, emotions, and behaviors--and the nature of their inter-relationships--can change over time. This paper describes the development and psychometric validation of four scales created to measure smoking-related causal attributions, perceived illness severity, event-related emotions, and intention to quit smoking among patients experiencing acute cardiac symptoms. After completing qualitative work with a sample of 50 cardiac patients, we administered the scales to 300 patients presenting to the emergency department for cardiac-related symptoms. Factor analyses, alpha coefficients, ANOVAs, and Pearson correlation coefficients were used to establish the scales' reliability and validity. Factor analyses revealed a stable factor structures for each of the four constructs. The scales were internally consistent, with the majority having an alpha of >0.80 (range: 0.57-0.89). Mean differences in ratings of the perceived illness severity and event-related emotions were noted across the three time anchors. Significant increases in intention to quit at the time of enrollment, compared to retrospective ratings of intention to quit before the event, provide preliminary support for the sensitivity of this measure to the motivating impact of the event. Finally, smoking-related causal attributions, perceived illness severity, and event-related emotions correlated in the expected directions with intention to quit smoking, providing preliminary support for construct validity.

Effects Of An Employee COVID-19 Vaccination Mandate At A Long-Term Care Network.

We assessed COVID-19 vaccination and employment status among employees of a long-term care network that announced an employee vaccination mandate on July 29, 2021. The day before the announcement, 1,208 employees were unvaccinated; of these workers, 56.2 percent subsequently were vaccinated, whereas 20.9 percent (3.7 percent of active employees) were terminated because of noncompliance with the mandate.

A Randomized Trial of Behavioral Nudges Delivered Through Text Messages to Increase Influenza Vaccination Among Patients With an Upcoming Primary Care Visit.

PURPOSE: To evaluate if nudges delivered by text message prior to an upcoming primary care visit can increase influenza vaccination rates. DESIGN: Randomized, controlled trial. SETTING: Two health systems in the Northeastern US between September 2020 and March 2021. SUBJECTS: 74,811 adults. INTERVENTIONS: Patients in the 19 intervention arms received 1-2 text messages in the 3 days preceding their appointment that varied in their format, interactivity, and content. MEASURES: Influenza vaccination. ANALYSIS: Intention-to-treat. RESULTS: Participants had a mean (SD) age of 50.7 (16.2) years; 55.8% (41,771) were female, 70.6% (52,826) were White, and 19.0% (14,222) were Black. Among the interventions, 5 of 19 (26.3%) had a significantly greater vaccination rate than control. On average, the 19 interventions increased vaccination relative to control by 1.8 percentage points or 6.1% (P = .005). The top performing text message described the vaccine to the patient as "reserved for you" and led to a 3.1 percentage point increase (95% CI, 1.3 to 4.9; P < .001) in vaccination relative to control. Three of the top five performing messages described the vaccine as "reserved for you." None of the interventions performed worse than control. CONCLUSIONS: Text messages encouraging vaccination and delivered prior to an upcoming appointment significantly increased influenza vaccination rates and could be a scalable approach to increase vaccination more broadly.

Using game theory to examine incentives in influenza vaccination behavior.

The social good often depends on the altruistic behavior of specific individuals. For example, epidemiological studies of influenza indicate that elderly individuals, who face the highest mortality risk, are best protected by vaccination of young individuals, who contribute most to disease transmission. To examine the conditions under which young people would get vaccinated to protect elderly people, we conducted a game-theory experiment that mirrored real-world influenza transmission, with "young" players contributing more than "elderly" players to herd immunity. Participants could spend points to get vaccinated and reduce the risk of influenza. When players were paid according to individual point totals, more elderly than young players got vaccinated, a finding consistent with the Nash equilibrium predicting self-interested behavior. When players were paid according to group point totals, however, more young than elderly players got vaccinated-a finding consistent with the utilitarian equilibrium predicting group-optimal behavior-which resulted in higher point totals than when players were paid for their individual totals. Thus, payout structure affected whether individuals got vaccinated for self-interest or group benefit.

Don't Throw Your Heart Away: Increased Transparency of Donor Utilization Practices in Transplant Center Report Cards Alters How Center Performance Is Evaluated.

BACKGROUND: Publicly available report cards for transplant centers emphasize posttransplant survival and obscure the fact that some centers reject many of the donor organs they are offered (reflecting a conservative donor acceptance strategy), while others accept a broader range of donor offers (reflecting an open donor acceptance strategy). OBJECTIVE: We assessed how the provision of salient information about donor acceptance practices and waitlist survival rates affected evaluation judgments of hospital report cards given by laypeople and medical trainees. METHODS: We tested 5 different report card formats across 4 online randomized experiments (n1 = 1,003, n2 = 105, n3 = 123, n4 = 807) in the same hypothetical decision. The primary outcome variable was a binary choice between transplant hospitals (one with an open donor acceptance strategy and the other with a conservative donor acceptance strategy). RESULTS: Report cards featuring salient information about donor organ utilization rates (transplant outcomes categorized by quality of donor offers accepted) or overall survival rates (outcomes from both waitlist and transplanted patients) led lay participants (studies 1, 3, and 4) and medical trainees (study 2) to evaluate transplant centers with open donor acceptance strategies more favorably than centers with conservative strategies. LIMITATIONS: Due to the nature of the decision, a hypothetical scenario was necessary for both ethical and practical reasons. Results may not generalize to transplant clinicians or patients faced with the decision of where to join the transplant waitlist. CONCLUSIONS: These findings suggest that performance evaluations for transplant centers may vary significantly based not only on what outcome information is presented in report cards but also how the information is displayed.

Doctor recommendations and parents' HPV vaccination intentions in Kenya: A randomized survey.

The causal effect of a doctor's recommendation for Human Papillomavirus (HPV) vaccination on parents' decisions in low-resource settings is not well understood. This study investigates how doctors' endorsement of the HPV vaccine communicated through a public health poster affects parents' decisions to vaccinate their daughters in Kenya. In January and February 2021, 600 parents of daughters eligible for the HPV vaccine but not yet vaccinated were recruited and completed a randomized survey. Participants saw a poster from a national campaign about HPV vaccination and either nothing further (Control) or an additional poster containing an HPV vaccine recommendation from a female (FDR) or male doctor (MDR). Primary outcomes are intentions to vaccinate and perceived safety of the HPV vaccine. Both recommendation arms increased the likelihood that participants reported the highest levels of vaccine intentions compared to control (FDR: 33.7% p = 0.01; MDR: 30.5%, p = 0.05, compared to Control (22.4%)) and safety perceptions (FDR: 24.2%. p = 0.09; MDR: 28.0%, p = 0.01, compared to Control (17.1%)) but there was no statistically significant increase in the likelihood to report above moderate vaccine intentions (FDR: 72.6%, p = 0.76; MDR: 72.5%, p = 0.77, compared to Control (71.4%)) or safety perceptions (FDR: 68.9%, p = 0.91; MDR: 75.0%, p = 0.17, compared to Control (68.6%)). We find no differential treatment effect by the recommending doctor's gender. In conclusion, our results suggest that visual communication of a doctor's support for the HPV vaccine can strengthen above-moderate intentions and safety perceptions but may not be enough to persuade the vaccine hesitant to vaccinate.

Physicians' communication of Down syndrome screening test results: the influence of physician numeracy.

PURPOSE: We investigated three questions: (1) How do obstetrician-gynecologists communicate positive and negative test results? (2) When reporting screening test results, do obstetrician-gynecologists use quantitative or qualitative information? and (3) Is physician numeracy (i.e., the ability to use and understand numbers) associated with use of quantitative or qualitative information? METHOD: Obstetrician-gynecologists (N = 203; 55.6% response rate) who were members of the American College of Obstetricians and Gynecologists completed a survey about their communication of Down syndrome screening test results, an Objective Numeracy Scale, and the Subjective Numeracy Scale. RESULTS: Higher scores on the Subjective Numeracy Scale and younger age predicted obstetrician-gynecologists' use of numbers to explain testing results. The Objective Numeracy Scale did not predict use of numbers. Gender was correlated with scores on the Subjective Numeracy Scale (r = 0.2) and the Subjective Numeracy Scale-Ability Subscale (r = 0.3), with men scoring higher than women when controlling for age. Open-ended questions revealed that communication strategies vary, with approximately one in three obstetrician-gynecologists providing numerical information, and frequency format being the commonly used numerical format. CONCLUSION: Although physicians are often overlooked in the problem of low health literacy, it is important that we continue to investigate the impact of physician numeracy on patient care.

Integrating epidemiology, psychology, and economics to achieve HPV vaccination targets.

Human papillomavirus (HPV) vaccines provide an opportunity to reduce the incidence of cervical cancer. Optimization of cervical cancer prevention programs requires anticipation of the degree to which the public will adhere to vaccination recommendations. To compare vaccination levels driven by public perceptions with levels that are optimal for maximizing the community's overall utility, we develop an epidemiological game-theoretic model of HPV vaccination. The model is parameterized with survey data on actual perceptions regarding cervical cancer, genital warts, and HPV vaccination collected from parents of vaccine-eligible children in the United States. The results suggest that perceptions of survey respondents generate vaccination levels far lower than those that maximize overall health-related utility for the population. Vaccination goals may be achieved by addressing concerns about vaccine risk, particularly those related to sexual activity among adolescent vaccine recipients. In addition, cost subsidizations and shifts in federal coverage plans may compensate for perceived and real costs of HPV vaccination to achieve public health vaccination targets.

How do people value life?

Who should be saved when health resources are limited? Although bioethicists and policymakers continue to debate which metric should be used to evaluate health interventions, public policy is also subject to public opinion. We investigated how the public values life when evaluating vaccine-allocation policies during a flu epidemic. We found that people's ratings of the acceptability of policies were dramatically influenced by question framing. When policies were described in terms of lives saved, people judged them on the basis of the number of life years gained. In contrast, when the policies were described in terms of lives lost, people considered the age of the policy's beneficiaries, taking into account the number of years lived to prioritize young targets for the health intervention. In addition, young targets were judged as more valuable in general, but young participants valued young targets even more than older participants did.

The dynamics of risk perceptions and precautionary behavior in response to 2009 (H1N1) pandemic influenza.

BACKGROUND: The trajectory of an infectious disease outbreak is affected by the behavior of individuals, and the behavior is often related to individuals' risk perception. We assessed temporal changes and geographical differences in risk perceptions and precautionary behaviors in response to H1N1 influenza. METHODS: 1,290 US adults completed an online survey on risk perceptions, interests in pharmaceutical interventions (preventive intervention and curative intervention), and engagement in precautionary activities (information seeking activities and taking quarantine measures) in response to H1N1 influenza between April 28 and May 27 2009. Associations of risk perceptions and precautionary behaviors with respondents' sex, age, and household size were analyzed. Linear and quadratic time trends were assessed by regression analyses. Geographic differences in risk perception and precautionary behaviors were evaluated. Predictors of willingness to take pharmaceutical intervention were analyzed. RESULTS: Respondents from larger households reported stronger interest in taking medications and engaged in more precautionary activities, as would be normatively predicted. Perceived risk increased over time, whereas interest in pharmaceutical preventive interventions and the engagement in some precautionary activities decreased over time. Respondents who live in states with higher H1N1 incidence per population perceived a higher likelihood of influenza infection, but did not express greater interests in pharmaceutical interventions, nor did they engage in a higher degree of precautionary activities. Perceived likelihood of influenza infection, willingness to take medications and engagement in information seeking activities were higher for women than men. CONCLUSIONS: Perceived risk of infection and precautionary behavior can be dynamic in time, and differ by demographic characteristics and geographical locations. These patterns will likely influence the effectiveness of disease control measures.

'100% of anything looks good': the appeal of one hundred percent.

People overweight certainty, even when certainty is only an illusion. A vaccine that was described as 100% effective against 70% of disease targets was preferred to one described as 70% effective against 100% of disease targets (Studies 1 and 2). The appeal of 100% extends beyond the probability attribute. In Study 2, participants preferred both of the vaccines above to normatively equivalent vaccines that were less than 100% effective toward fewer than 100% of targets. In Study 3, participants preferred a 100% discount on a cup of coffee every 10 days to other more frequent, but lower amount, discounts. This preference evaporated, however, when savings were framed as points rather than as percentage discounts. We propose that people view 100% as a salient reference point and overweight it in those domains where it cannot be exceeded (e.g., probability, discount); the overweighting is weaker in domains where 100% can be exceeded (e.g., target range, points).

Toward a Conceptual Model of Affective Predictions in Palliative Care.

CONTEXT: Being diagnosed with cancer often forces patients and families to make difficult medical decisions. How patients think they and others will feel in the future, termed affective predictions, may influence these decisions. These affective predictions are often biased, which may contribute to suboptimal care outcomes by influencing decisions related to palliative care and advance care planning. OBJECTIVES: This study aimed to translate perspectives from the decision sciences to inform future research about when and how affective predictions may influence decisions about palliative care and advance care planning. METHODS: A systematic search of two databases to evaluate the extent to which affective predictions have been examined in the palliative care and advance care planning context yielded 35 relevant articles. Over half utilized qualitative methodologies (n = 21). Most studies were conducted in the U.S. (n = 12), Canada (n = 7), or European countries (n = 10). Study contexts included end of life (n = 10), early treatment decisions (n = 10), pain and symptom management (n = 7), and patient-provider communication (n = 6). The affective processes of patients (n = 20), caregivers (n = 16), and/or providers (n = 12) were examined. RESULTS: Three features of the palliative care and advance care planning context may contribute to biased affective predictions: 1) early treatment decisions are made under heightened emotional states and with insufficient information; 2) palliative care decisions influence life domains beyond physical health; and 3) palliative care decisions involve multiple people. CONCLUSION: Biases in affective predictions may serve as a barrier to optimal palliative care delivery. Predictions are complicated by intense emotions, inadequate prognostic information, involvement of many individuals, and cancer's effect on non-health life domains. Applying decision science frameworks may generate insights about affective predictions that can be harnessed to solve challenges associated with optimal delivery of palliative care.

Do decision biases predict bad decisions? Omission bias, naturalness bias, and influenza vaccination.

PURPOSE: Numerous studies using hypothetical vignettes have demonstrated decision biases or deviations from utility theory. Do people who commit biases in questionnaire studies make worse real-world decisions than do less biased people? METHODS: Two hundred seventy university faculty and staff participated in a questionnaire study in which they reported whether they accepted a free influenza vaccine offered at their work place. Influenza vaccine acceptance was the measure of real-world decision making. Participants responded to 3 hypothetical scenarios. Two scenarios measured the omission bias and described a vaccine (scenario 1) and a medication (scenario 2) that prevented a negative health outcome but that itself could cause the negative health outcome. The omission bias is a preference for not vaccinating or medicating even when the vaccine/medication lowers the total risk of the negative outcome. A 3rd scenario measured the naturalness bias by presenting a choice between 2 chemically identical medications, one extracted from a natural herb and the other synthesized in a laboratory. Preference for the natural medication indicated the naturalness bias. RESULTS: The results indicated that a substantial proportion of participants exhibited these biases and that participants who exhibited these biases were less likely to accept the flu vaccine. CONCLUSIONS: To the extent that declining a free flu vaccine is a worse real-world decision, people who demonstrate the naturalness and omission biases in hypothetical scenarios make worse real-world decisions.

The influence of default options on the expression of end-of-life treatment preferences in advance directives.

BACKGROUND: Advance directives promise to preserve patient autonomy, but research indicates that end-of-life preferences can be influenced by the way in which questions are posed. OBJECTIVE: To determine whether preferences expressed by geriatric patients on advance directives are influenced by the default response inherent in the question. DESIGN: Mailed survey containing 1 of 3 versions of an advance directive. SETTING: General internal medicine outpatient medical practice. PARTICIPANTS: Outpatients aged 65 or older (n = 106, response rate = 27%). INTERVENTIONS: In the "withhold" version of the survey, participants indicated situations where they would want treatments withheld (i.e., the default preference was in favor of treatment). In the "provide" version, participants indicated situations where they would want treatment provided (i.e., the default preference was against treatment). In the forced-choice control version, participants made an explicit decision to withhold or provide treatment for each situation. MAIN OUTCOME MEASURE: Participants' treatment preferences. RESULTS: Preferences differed by condition, F(2, 103) = 3.61, MSE = 0.09, eta2 = .07, p = .03. Participants tended to express the default preference, and thus, were more likely to favor treatment in the "withhold" condition than in the "provide" condition. Preferences in the forced-choice control condition were intermediate. CONCLUSIONS: The default inherent in a question can impact preferences for medical treatment. This default effect limits the utility of advance directives.