A synthesis of evidence for policy from behavioural science during COVID-19.

Scientific evidence regularly guides policy decisions1, with behavioural science increasingly part of this process2. In April 2020, an influential paper3 proposed 19 policy recommendations ('claims') detailing how evidence from behavioural science could contribute to efforts to reduce impacts and end the COVID-19 pandemic. Here we assess 747 pandemic-related research articles that empirically investigated those claims. We report the scale of evidence and whether evidence supports them to indicate applicability for policymaking. Two independent teams, involving 72 reviewers, found evidence for 18 of 19 claims, with both teams finding evidence supporting 16 (89%) of those 18 claims. The strongest evidence supported claims that anticipated culture, polarization and misinformation would be associated with policy effectiveness. Claims suggesting trusted leaders and positive social norms increased adherence to behavioural interventions also had strong empirical support, as did appealing to social consensus or bipartisan agreement. Targeted language in messaging yielded mixed effects and there were no effects for highlighting individual benefits or protecting others. No available evidence existed to assess any distinct differences in effects between using the terms 'physical distancing' and 'social distancing'. Analysis of 463 papers containing data showed generally large samples; 418 involved human participants with a mean of 16,848 (median of 1,699). That statistical power underscored improved suitability of behavioural science research for informing policy decisions. Furthermore, by implementing a standardized approach to evidence selection and synthesis, we amplify broader implications for advancing scientific evidence in policy formulation and prioritization.

Algorithms as discrimination detectors.

Preventing discrimination requires that we have means of detecting it, and this can be enormously difficult when human beings are making the underlying decisions. As applied today, algorithms can increase the risk of discrimination. But as we argue here, algorithms by their nature require a far greater level of specificity than is usually possible with human decision making, and this specificity makes it possible to probe aspects of the decision in additional ways. With the right changes to legal and regulatory systems, algorithms can thus potentially make it easier to detect-and hence to help prevent-discrimination.

Conspiracy theory.

Chater & Loewenstein, superb and distinguished social scientists, have misfired. Their complaint is baseless: In the real world of policymaking, behavioral science is mostly being used to reform systems, not to alter individual behavior. Nor is there empirical support for the proposition that interventions aimed at helping individuals make systemic reform less likely.

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers.

BACKGROUND: Understanding factors that influence public support for "nudging" policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers' support for requiring pictorial warnings on cigarette packs. METHODS: In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US. RESULTS: Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (ß = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001). CONCLUSIONS: Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.

Should Governments Invest More in Nudging?

Governments are increasingly adopting behavioral science techniques for changing individual behavior in pursuit of policy objectives. The types of "nudge" interventions that governments are now adopting alter people's decisions without coercion or significant changes to economic incentives. We calculated ratios of impact to cost for nudge interventions and for traditional policy tools, such as tax incentives and other financial inducements, and we found that nudge interventions often compare favorably with traditional interventions. We conclude that nudging is a valuable approach that should be used more often in conjunction with traditional policies, but more calculations are needed to determine the relative effectiveness of nudging.

The Council of Psychological Advisers.

Findings in behavioral science, including psychology, have influenced policies and reforms in many nations. Choice architecture can affect outcomes even if material incentives are not involved. In some contexts, default rules, simplification, and social norms have had even larger effects than significant economic incentives. Psychological research is helping to inform initiatives in savings, finance, highway safety, consumer protection, energy, climate change, obesity, education, poverty, development, crime, corruption, health, and the environment. No nation has yet created a council of psychological advisers, but the role of behavioral research in policy domains is likely to grow in the coming years, especially in light of the mounting interest in promoting ease and simplification ("navigability"); in increasing effectiveness, economic growth, and competitiveness; and in providing low-cost, choice-preserving approaches.

Choosing not to choose.

Choice can be an extraordinary benefit or an immense burden. In some contexts, people choose not to choose, or would do so if they were asked. In part because of limitations of "bandwidth," and in part because of awareness of their own lack of information and potential biases, people sometimes want other people to choose for them. For example, many people prefer not to make choices about their health or retirement plans; they want to delegate those choices to a private or public institution that they trust (and may well be willing to pay a considerable amount to those who are willing to accept such delegations). This point suggests that however well accepted, the line between active choosing and paternalism is often illusory. When private or public institutions override people's desire not to choose and insist on active choosing, they may well be behaving paternalistically, through a form of choice-requiring paternalism. Active choosing can be seen as a form of libertarian paternalism, and a frequently attractive one, if people are permitted to opt out of choosing in favor of a default (and in that sense permitted not to choose); it is a form of nonlibertarian paternalism insofar as people are required to choose. For both ordinary people and private or public institutions, the ultimate judgment in favor of active choosing, or in favor of choosing not to choose, depends largely on the costs of decisions and the costs of errors.

Why and When Beliefs Change.

Why people do or do not change their beliefs has been a long-standing puzzle. Sometimes people hold onto false beliefs despite ample contradictory evidence; sometimes they change their beliefs without sufficient reason. Here, we propose that the utility of a belief is derived from the potential outcomes associated with holding it. Outcomes can be internal (e.g., positive/negative feelings) or external (e.g., material gain/loss), and only some are dependent on belief accuracy. Belief change can then be understood as an economic transaction in which the multidimensional utility of the old belief is compared against that of the new belief. Change will occur when potential outcomes alter across attributes, for example because of changing environments or when certain outcomes are made more or less salient.

A "sludge audit" for health system colorectal cancer screening services.

OBJECTIVES: "Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. STUDY DESIGN: Mixed methods sludge audit. METHODS: We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. RESULTS: Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. CONCLUSIONS: Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

Crowdsourcing interventions to promote uptake of COVID-19 booster vaccines.

Background: COVID-19 booster vaccine uptake rates are behind the rate of primary vaccination in many countries. Governments and non-governmental institutions rely on a range of interventions aiming to increase booster uptake. Yet, little is known how experts and the general public evaluate these interventions. Methods: We applied a novel crowdsourcing approach to provide rapid insights on the most promising interventions to promote uptake of COVID-19 booster vaccines. In the first phase (December 2021), international experts (n = 78 from 17 countries) proposed 46 unique interventions. To reduce noise and potential bias, in the second phase (January 2022), experts (n = 307 from 34 countries) and representative general population samples from the UK (n = 299) and the US (n = 300) rated the proposed interventions on several evaluation criteria, including effectiveness and acceptability, on a 5-point Likert-type scale. Findings: Sanctions were evaluated as potentially most effective but least accepted. Evaluations by expert and general population samples were considerably aligned. Interventions that received the most positive evaluations regarding both effectiveness and acceptability across evaluation groups were: a day off work after getting vaccinated, financial incentives, tax benefits, promotional campaigns, and mobile vaccination teams. Interpretation: The results provide useful insights to help governmental and non-governmental institutions in their decisions about which interventions to implement. Additionally, the applied crowdsourcing method may be used in future studies to retrieve rapid insights on the comparative evaluation of (health) policies. Funding: This study received funding from the Austrian Science Fund (SFB F63) and the University of Vienna.

The Modest Effects of Fact Boxes on Cancer Screening.

As health care becomes increasingly personalized to the needs and values of individual patients, informational interventions that aim to inform and debias consumer decision-making are likely to become important tools. In a randomized controlled experiment, we explore the effects of providing participants with published fact boxes on the benefits and harms of common cancer screening procedures. Female participants were surveyed about breast cancer screening by mammography, while male participants were surveyed about prostate cancer screening by prostate-specific antigen (PSA) testing. For these screening procedures, we expect consumers to have overly optimistic prior beliefs about the benefits and harms. We find that participants update their beliefs about the net benefits of screening modestly, but we observe little change in their stated preferences to seek screening. Participants who scored higher on a numeracy test updated their beliefs about screening benefits more in response to the fact boxes than did participants who scored lower on the numeracy test.

How people decide what they want to know.

Immense amounts of information are now accessible to people, including information that bears on their past, present and future. An important research challenge is to determine how people decide to seek or avoid information. Here we propose a framework of information-seeking that aims to integrate the diverse motives that drive information-seeking and its avoidance. Our framework rests on the idea that information can alter people's action, affect and cognition in both positive and negative ways. The suggestion is that people assess these influences and integrate them into a calculation of the value of information that leads to information-seeking or avoidance. The theory offers a framework for characterizing and quantifying individual differences in information-seeking, which we hypothesize may also be diagnostic of mental health. We consider biases that can lead to both insufficient and excessive information-seeking. We also discuss how the framework can help government agencies to assess the welfare effects of mandatory information disclosure.

How behavioural sciences can promote truth, autonomy and democratic discourse online.

Public opinion is shaped in significant part by online content, spread via social media and curated algorithmically. The current online ecosystem has been designed predominantly to capture user attention rather than to promote deliberate cognition and autonomous choice; information overload, finely tuned personalization and distorted social cues, in turn, pave the way for manipulation and the spread of false information. How can transparency and autonomy be promoted instead, thus fostering the positive potential of the web? Effective web governance informed by behavioural research is critically needed to empower individuals online. We identify technologically available yet largely untapped cues that can be harnessed to indicate the epistemic quality of online content, the factors underlying algorithmic decisions and the degree of consensus in online debates. We then map out two classes of behavioural interventions-nudging and boosting- that enlist these cues to redesign online environments for informed and autonomous choice.

Ten considerations for effectively managing the COVID-19 transition.

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.

Using social and behavioural science to support COVID-19 pandemic response.

The COVID-19 pandemic represents a massive global health crisis. Because the crisis requires large-scale behaviour change and places significant psychological burdens on individuals, insights from the social and behavioural sciences can be used to help align human behaviour with the recommendations of epidemiologists and public health experts. Here we discuss evidence from a selection of research topics relevant to pandemics, including work on navigating threats, social and cultural influences on behaviour, science communication, moral decision-making, leadership, and stress and coping. In each section, we note the nature and quality of prior research, including uncertainty and unsettled issues. We identify several insights for effective response to the COVID-19 pandemic and highlight important gaps researchers should move quickly to fill in the coming weeks and months.