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.

Fostering perceptions of authenticity via sensitive self-disclosure.

Leaders' perceived authenticity-the sense that leaders are acting in accordance with their "true self"-is associated with positive outcomes for both employees and organizations alike. How might leaders foster this impression? We show that sensitive self-disclosure, in the form of revealing weaknesses, makes leaders come across as authentic (Studies 1 and 2)-because observers infer that the discloser is not engaging in strategic self-presentation (Study 3). Further, the authenticity gains of sensitive self-disclosure have positive downstream consequences, such as enhancing employees' desire to work with the leader (Studies 4A and 4B). And, as our conceptual account predicts, these benefits emerge when the revealed weakness is made voluntarily (as opposed to by requirement; Study 5), and are more pronounced if the disclosure is made by a relatively high-status person (Study 6). We also present anecdotal field evidence (Study 7) consistent with the causal effects identified in Studies 1-6. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Opportunity Neglect: An Aversion to Low-Probability Gains.

Seven preregistered studies (N = 2,890, adult participants) conducted in the field, in the lab, and online documented opportunity neglect: a tendency to reject opportunities with low probability of success even when they come with little or no objective cost (e.g., time, money, reputation). Participants rejected a low-probability opportunity in an everyday context (Study 1). Participants also rejected incentive-compatible gambles with positive expected value-for both goods (Study 2) and money (Studies 3-7)-even with no possibility of monetary loss and nontrivial rewards (e.g., a 1% chance at $99). Participants rejected low-probability opportunities more frequently than high-probability opportunities with equal expected value (Study 3). Although taking some real-life opportunities comes with costs, we show that people are even willing to incur costs to opt out of low-probability opportunities (Study 4). Opportunity neglect can be mitigated by highlighting that rejecting an opportunity is equivalent to choosing a zero probability of success (Studies 6-7).

A Salient Sugar Tax Decreases Sugary-Drink Buying.

Many governments have introduced sugary-drink excise taxes to reduce purchasing and consumption of such drinks; however, they do not typically stipulate how such taxes should be communicated at the point of purchase. Historical, field, and experimental data consisting of more than 225,000 purchase decisions indicated that introducing a $0.01-per-ounce sugar-sweetened beverage (SSB) tax-without making it salient on price tags-had no significant effect on purchasing (-1.26%, p = .28). However, when the phrase "includes sugary drink tax" was added to tax-inclusive price tags, SSB purchasing was lower than (a) in the pretax period (-9.78%, p < .001), (b) in a posttax period when drinks did not bear price tags (-5.04%, p < .001), and (c) in a posttax period when drinks bore tax-inclusive price tags that did not mention the tax (-3.83%, p = .002). Making the tax's beneficiary (student programs) salient on price tags had no added effect. Two follow-up studies suggested that tax salience was effective partly because consumers overestimated the tax amount, leading to reduced purchase intentions.

Anger Damns the Innocent.

False accusations of wrongdoing are common and can have grave consequences. In six studies, we document a worrisome paradox in perceivers' subjective judgments of a suspect's guilt. Specifically, we found that people (including online panelists, n = 4,983, and working professionals such as fraud investigators and auditors, n = 136) use suspects' angry responses to accusations as cues of guilt. However, we found that such anger is an invalid cue of guilt and is instead a valid cue of innocence; accused individuals (university students, n = 230) and online panelists (n = 401) were angrier when they are falsely relative to accurately accused. Moreover, we found that individuals who remain silent are perceived to be at least as guilty as those who angrily deny an accusation.

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.

Effect of revealing authors' conflicts of interests in peer review: randomized controlled trial.

OBJECTIVE: To assess the effect of disclosing authors' conflict of interest declarations to peer reviewers at a medical journal. DESIGN: Randomized controlled trial. SETTING: Manuscript review process at the Annals of Emergency Medicine. PARTICIPANTS: Reviewers (n=838) who reviewed manuscripts submitted between 2 June 2014 and 23 January 2018 inclusive (n=1480 manuscripts). INTERVENTION: Reviewers were randomized to either receive (treatment) or not receive (control) authors' full International Committee of Medical Journal Editors format conflict of interest disclosures before reviewing manuscripts. Reviewers rated the manuscripts as usual on eight quality ratings and were then surveyed to obtain "counterfactual scores"-that is, the scores they believed they would have given had they been assigned to the opposite arm-as well as attitudes toward conflicts of interest. MAIN OUTCOME MEASURE: Overall quality score that reviewers assigned to the manuscript on submitting their review (1 to 5 scale). Secondary outcomes were scores the reviewers submitted for the seven more specific quality ratings and counterfactual scores elicited in the follow-up survey. RESULTS: Providing authors' conflict of interest disclosures did not affect reviewers' mean ratings of manuscript quality (Mcontrol=2.70 (SD 1.11) out of 5; Mtreatment=2.74 (1.13) out of 5; mean difference 0.04, 95% confidence interval -0.05 to 0.14), even for manuscripts with disclosed conflicts (Mcontrol= 2.85 (1.12) out of 5; Mtreatment=2.96 (1.16) out of 5; mean difference 0.11, -0.05 to 0.26). Similarly, no effect of the treatment was seen on any of the other seven quality ratings that the reviewers assigned. Reviewers acknowledged conflicts of interest as an important matter and believed that they could correct for them when they were disclosed. However, their counterfactual scores did not differ from actual scores (Mactual=2.69; Mcounterfactual=2.67; difference in means 0.02, 0.01 to 0.02). When conflicts were reported, a comparison of different source types (for example, government, for-profit corporation) found no difference in effect. CONCLUSIONS: Current ethical standards require disclosure of conflicts of interest for all scientific reports. As currently implemented, this practice had no effect on any quality ratings of real manuscripts being evaluated for publication by real peer reviewers.

Effect of Different Financial Incentive Structures on Promoting Physical Activity Among Adults: A Randomized Clinical Trial.

Importance: Few adults engage in recommended levels of physical activity. Financial incentives can promote physical activity, but little is known about how the structure of these incentives influences their effectiveness (eg, how incentives are disbursed over time). Objective: To determine if it is more effective to disburse fixed total financial incentives at a constant, increasing, or decreasing rate to encourage physical activity. Design, Setting, and Participants: A 2-week randomized clinical trial was conducted from June 2 to 15, 2014, using an online platform that automatically records daily steps of pedometer-wearing users and awards points redeemable for cash. The study population comprised 3515 adult users of the online platform in the lower 70th percentile of steps taken among all users before treatment. Data analyses were performed from August 20, 2014, to February 1, 2018. Analysis was performed on an intent-to-treat basis. Interventions: Participants were randomized to either a control group or to 1 of 3 intervention groups during the 2 weeks of the study. Participants in the control group received a constant daily rate of $0.00001 per step. The 3 intervention groups received a 20-fold incentive increase ($0.00020 per step) distributed differently during the 2 weeks of the study: at a constant, increasing, or decreasing rate. Reminder emails explaining incentive schedules were sent the day before the intervention and halfway through the 2-week intervention. Main Outcomes and Measures: Change in mean daily steps during the 2-week intervention and 3 weeks after the intervention. The study had 80% power to detect a difference of 280 steps per day during the intervention at α = .05. Results: The study included 3515 participants (879 in the control condition, 879 in the constant incentive condition, 881 in the increasing incentive condition, and 876 in the decreasing incentive condition). During the intervention, compared with participants in the control group, participants receiving constant incentives logged 306.7 more steps per day (95% CI, 91.5-521.9 steps; P = .005), those receiving decreasing incentives logged 96.9 more steps per day (95% CI, 15.3-178.5 steps; P = .02), and those receiving increasing incentives logged no significant change in steps per day (1.5 steps per day; 95% CI, -81.6 to 84.7 steps; P = .97). One week after the intervention, compared with participants in the control group, only participants receiving constant incentives logged significantly more steps per day (329.5; 95% CI, 20.6-638.4; P = .04). Two and 3 weeks after the intervention, there were no significant differences compared with participants in the control group. Overall, for each $1 spent, participants in the constant incentives group logged 475.4 more steps than those in the increasing incentives group and 429.3 more steps than those in the decreasing incentives group. Conclusions and Relevance: This study found that financial incentives for physical activity were more effective during a payment period when they were offered at a constant rate rather than an increasing or decreasing rate. However, this effectiveness dissipated shortly after the incentives were removed. Trial Registration: ClinicalTrials.gov identifier: NCT02154256.

Shooting the messenger.

Eleven experiments provide evidence that people have a tendency to "shoot the messenger," deeming innocent bearers of bad news unlikeable. In a preregistered lab experiment, participants rated messengers who delivered bad news from a random drawing as relatively unlikeable (Study 1). A second set of studies points to the specificity of the effect: Study 2A shows that it is unique to the (innocent) messenger, and not mere bystanders. Study 2B shows that it is distinct from merely receiving information with which one disagrees. We suggest that people's tendency to deem bearers of bad news as unlikeable stems in part from their desire to make sense of chance processes. Consistent with this account, receiving bad news activates the desire to sense-make (Study 3A), and in turn, activating this desire enhances the tendency to dislike bearers of bad news (Study 3B). Next, stemming from the idea that unexpected outcomes heighten the desire to sense-make, Study 4 shows that when bad news is unexpected, messenger dislike is pronounced. Finally, consistent with the notion that people fulfill the desire to sense-make by attributing agency to entities adjacent to chance events, messenger dislike is correlated with the erroneous belief that the messenger had malevolent motives (Studies 5A, 5B, and 5C). Studies 6A and 6B go further, manipulating messenger motives independently from news valence to suggest their causal role in our process account: the tendency to dislike bearers of bad news is mitigated when recipients are made aware of the benevolence of the messenger's motives. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Effect of Graphic Warnings on Sugary-Drink Purchasing.

Governments have proposed text warning labels to decrease consumption of sugary drinks-a contributor to chronic diseases such as diabetes. However, they may be less effective than more evocative, graphic warning labels. We field-tested the effectiveness of graphic warning labels (vs. text warning labels, calorie labels, and no labels), provided insight into psychological mechanisms driving effectiveness, and assessed consumer sentiment. Study 1 indicated that graphic warning labels reduced the share of sugary drinks purchased in a cafeteria from 21.4% at baseline to 18.2%-an effect driven by substitution of water for sugary drinks. Study 2 showed that graphic warning labels heighten negative affect and prompt consideration of health consequences. Study 3 indicated that public support for graphic warning labels can be increased by conveying effectiveness information. These findings could spur more effective labeling policies that facilitate healthier choices, do not decrease overall beverage purchases, and are publicly accepted.

What Does It Take to Change an Editor's Mind? Identifying Minimally Important Difference Thresholds for Peer Reviewer Rating Scores of Scientific Articles.

STUDY OBJECTIVE: We define a minimally important difference for the Likert-type scores frequently used in scientific peer review (similar to existing minimally important differences for scores in clinical medicine). The magnitude of score change required to change editorial decisions has not been studied, to our knowledge. METHODS: Experienced editors at a journal in the top 6% by impact factor were asked how large a change of rating in "overall desirability for publication" was required to trigger a change in their initial decision on an article. Minimally important differences were assessed twice for each editor: once assessing the rating change required to shift the editor away from an initial decision to accept, and the other assessing the magnitude required to shift away from an initial rejection decision. RESULTS: Forty-one editors completed the survey (89% response rate). In the acceptance frame, the median minimally important difference was 0.4 points on a scale of 1 to 5. Editors required a greater rating change to shift from an initial rejection decision; in the rejection frame, the median minimally important difference was 1.2 points. Within each frame, there was considerable heterogeneity: in the acceptance frame, 38% of editors did not change their decision within the maximum available range; in the rejection frame, 51% did not. CONCLUSION: To our knowledge, this is the first study to determine the minimally important difference for Likert-type ratings of research article quality, or in fact any nonclinical scientific assessment variable. Our findings may be useful for future research assessing whether changes to the peer review process produce clinically meaningful differences in editorial decisionmaking.

The Effect of Cost Sharing on an Employee Weight Loss Program: A Randomized Trial.

PURPOSE: To test the effects of employer subsidies on employee enrollment, attendance, and weight loss in a nationally available weight management program. DESIGN: A randomized trial tested the impact of employer subsidy: 100%; 80%, 50%, and a hybrid 50% subsidy that could become a 100% subsidy by attaining attendance targets. TRIAL REGISTRATION: NCT01756066. SETTING AND PARTICIPANTS: Twenty three thousand twenty-three employees of 2 US companies. MEASURES: The primary outcome was the percentage of employees who enrolled in the weight management program. We also tested whether the subsidies were associated with differential attendance and weight loss over 12 months, as might be predicted by the expectation that they attract employees with differing degrees of motivation. Analysis and Results: Enrollment differed significantly by subsidy level ( P < .0001). The 100% subsidy produced the highest enrollment (7.7%), significantly higher than each of the lower subsidies (vs 80% subsidy: 6.2%, P = .002; vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Enrollment in the 80% subsidy group was significantly higher than both lower subsidy groups (vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Among enrollees, there were no differences among the 4 groups in attendance or weight loss. CONCLUSION: This pragmatic trial, conducted in a real-world workplace setting, suggests that higher rates of employer subsidization help individuals to enroll in weight loss programs, without a decrement in program effectiveness. Future research could explore the cost-effectiveness of such subsidies or alternative designs.

Pseudo-set framing.

Pseudo-set framing-arbitrarily grouping items or tasks together as part of an apparent "set"-motivates people to reach perceived completion points. Pseudo-set framing changes gambling choices (Study 1), effort (Studies 2 and 3), giving behavior (Field Data and Study 4), and purchase decisions (Study 5). These effects persist in the absence of any reward, when a cost must be incurred, and after participants are explicitly informed of the arbitrariness of the set. Drawing on Gestalt psychology, we develop a conceptual account that predicts what will-and will not-act as a pseudo-set, and defines the psychological process through which these pseudo-sets affect behavior: over and above typical reference points, pseudo-set framing alters perceptions of (in)completeness, making intermediate progress seem less complete. In turn, these feelings of incompleteness motivate people to persist until the pseudo-set has been fulfilled. (PsycINFO Database Record

Temporary sharing prompts unrestrained disclosures that leave lasting negative impressions.

With the advent of social media, the impressions people make on others are based increasingly on their digital disclosures. However, digital disclosures can come back to haunt, making it challenging for people to manage the impressions they make. In field and online experiments in which participants take, share, and evaluate self-photographs ("selfies"), we show that, paradoxically, these challenges can be exacerbated by temporary-sharing media-technologies that prevent content from being stored permanently. Relative to permanent sharing, temporary sharing affects both whether and what people reveal. Specifically, temporary sharing increases compliance with the request to take a selfie (study 1) and induces greater disclosure risks (i.e., people exhibit greater disinhibition in their selfies, studies 1 and 2). This increased disclosure is driven by reduced privacy concerns (study 2). However, observers' impressions of sharers are insensitive to permanence (i.e., whether the selfie was shared temporarily versus permanently) and are instead driven by the disinhibition exhibited in the selfie (studies 4-7). As a result, induced by the promise of temporary sharing, sharers of uninhibited selfies come across as having worse judgment than those who share relatively discreet selfies (studies 1, 2, and 4-7)-an attributional pattern that is unanticipated by sharers (study 3), that persists days after the selfie has disappeared (study 5), is robust to personal experience with temporary sharing (studies 6A and 6B), and holds even among friends (studies 7A and 7B). Temporary sharing may bring back forgetting, but not without introducing new (self-presentational) challenges.

Psychologically Informed Implementations of Sugary-Drink Portion Limits.

In 2012, the New York City Board of Health prohibited restaurants from selling sugary drinks in containers that would hold more than 16 oz. Although a state court ruled that the Board of Health did not have the authority to implement such a policy, it remains a legally viable option for governments and a voluntary option for restaurants. However, there is very limited empirical data on how such a policy might affect the purchasing and consumption of sugary drinks. We report four well-powered, incentive-compatible experiments in which we evaluated two possible ways that restaurants might comply with such a policy: bundling (i.e., dividing the contents of oversized cups into two regulation-size cups) and providing free refills (i.e., offering a regulation-size cup with unlimited refills). Bundling caused people to buy less soda. Free refills increased consumption, especially when a waiter served the refills. This perverse effect was reduced in self-service contexts that required walking just a few steps to get a refill.

Hiding personal information reveals the worst.

Seven experiments explore people's decisions to share or withhold personal information, and the wisdom of such decisions. When people choose not to reveal information--to be "hiders"--they are judged negatively by others (experiment 1). These negative judgments emerge when hiding is volitional (experiments 2A and 2B) and are driven by decreases in trustworthiness engendered by decisions to hide (experiments 3A and 3B). Moreover, hiders do not intuit these negative consequences: given the choice to withhold or reveal unsavory information, people often choose to withhold, but observers rate those who reveal even questionable behavior more positively (experiments 4A and 4B). The negative impact of hiding holds whether opting not to disclose unflattering (drug use, poor grades, and sexually transmitted diseases) or flattering (blood donations) information, and across decisions ranging from whom to date to whom to hire. When faced with decisions about disclosure, decision-makers should be aware not just of the risk of revealing, but of what hiding reveals.

Financial incentives for exercise adherence in adults: systematic review and meta-analysis.

CONTEXT: Less than 5% of U.S. adults accumulate the required dose of exercise to maintain health. Behavioral economics has stimulated renewed interest in economic-based, population-level health interventions to address this issue. Despite widespread implementation of financial incentive-based public health and workplace wellness policies, the effects of financial incentives on exercise initiation and maintenance in adults remain unclear. EVIDENCE ACQUISITION: A systematic search of 15 electronic databases for RCTs reporting the impact of financial incentives on exercise-related behaviors and outcomes was conducted in June 2012. A meta-analysis of exercise session attendance among included studies was conducted in April 2013. A qualitative analysis was conducted in February 2013 and structured along eight features of financial incentive design. EVIDENCE SYNTHESIS: Eleven studies were included (N=1453; ages 18-85 years and 50% female). Pooled results favored the incentive condition (z=3.81, p<0.0001). Incentives also exhibited significant, positive effects on exercise in eight of the 11 included studies. One study determined that incentives can sustain exercise for longer periods (>1 year), and two studies found exercise adherence persisted after the incentive was withdrawn. Promising incentive design feature attributes were noted. Assured, or "sure thing," incentives and objective behavioral assessment in particular appear to moderate incentive effectiveness. Previously sedentary adults responded favorably to incentives 100% of the time (n=4). CONCLUSIONS: The effect estimate from the meta-analysis suggests that financial incentives increase exercise session attendance for interventions up to 6 months in duration. Similarly, a simple count of positive (n=8) and null (n=3) effect studies suggests that financial incentives can increase exercise adherence in adults in the short term (<6 months).

Converging to the lowest common denominator in physical health.

OBJECTIVE: This research examines how access to information on peer health behaviors affects one's own health behavior. METHODS: We report the results of a randomized field experiment in a large corporation in which we introduced walkstations (treadmills attached to desks that enable employees to walk while working), provided employees with feedback on their own and their coworkers' usage, and assessed usage over 6 months. We report how we determined our sample size, and all data exclusions, manipulations, and measures in the study. RESULTS: Walkstation usage declined most when participants were given information on coworkers' usage levels, due to a tendency to converge to the lowest common denominator-their least-active coworkers. CONCLUSION: This research demonstrates the impact of the lowest common denominator in physical activity: people's activity levels tend to converge to the lowest-performing members of their groups. This research adds to our understanding of the factors that determine when the behavior of others impacts our own behavior for the better-and the worse.