Strategies to reduce low-value care - An applied behavior analysis using a single-case design.

Introduction: Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach? Materials and methods: In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data. Results: Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies. Conclusion: The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

Management strategies to de-implement low-value care-an applied behavior analysis.

BACKGROUND: There is a lack of knowledge about management strategies being used to de-implement low-value care (LVC). Furthermore, it is not clear from the current literature what mechanisms are involved in such strategies and how they can change physicians' behaviors. Understanding the mechanisms is important for determining a strategy's potential impact. Applied behavior analysis focuses on processes involved in increasing and decreasing behaviors. Therefore, the aim of this study is to understand what management strategies are being used to de-implement LVC and the possible mechanisms involved in those strategies, using concepts from applied behavior analysis. METHOD: We applied a qualitative study design using an inductive approach to understand what management strategies are in use and then employed applied behavior analysis concepts to deductively analyze the mechanisms involved in them. RESULTS: We identified eight different management strategies intended to influence LVC. Five of the strategies were developed at a regional level and had the potential to influence physicians' LVC-related behaviors either by functioning as rules on which LVC to de-implement or by initiating local strategies in each health care center that in turn could influence LVC practices. The local strategies had a stronger potential for influencing de-implementation. CONCLUSION: Both strategies at a systemic level (regional) and on a local level (health care centers) must be considered to influence LVC-related behaviors. Strategies at the center level have a specific opportunity to impact LVC-related behaviors because they can be tailored to specific circumstances, even though some of them probably were initiated as an effect of strategies on a regional level. Using applied behavior analysis to understand these circumstances can be helpful for tailoring strategies to reduce LVC use.

Can in-store interventions reduce the socioeconomic gap in fruit and vegetable purchases in grocery stores? A descriptive study of volume sales from 2012 to 2020 in Norway's largest grocery store chain.

Fruits and vegetable (FVs) consumption is an essential determinant of health, and intake is strongly patterned by socioeconomic status (SES). Inside grocery store interventions have increasingly been explored to promote healthier diets, especially for people with lower SES. This study describes how the supermarket chain Kiwi used a combination of in-store interventions to increase annual sales of FVs between 2012 and 2020. In particular, this study examined how sales developed in counties with different demographic characteristics (e.g., education, income, overweight and obesity, and self-reported FVs consumption level) in order to evaluate whether the effect differs between different populations. The primary outcome measurement was annual volume sales, adjusted for new stores opening and closing during the study period, also called like-for-like sales. The study has used a descriptive study design. The chain used interventions such as better placement, promoting healthy foods, giving out discounts, and placing "on the go" FVs and cups with portioned FVs at the cash registry. Results show that like-for-like volume sales of FVs grew by 34.1% during the study period. The increase was especially strong for vegetables, which increased by 41.8%, compared to fruits and berries, which increased by 25%. Sales increased for all eleven counties in Norway. Using the Spearman correlation, a moderately positive association was found between the number of overweight or obese people in counties and the development in FVs sales. To conclude, in-store interventions positively impacted FVs sales. More research in an experimental context is needed to determine if interventions may reduce the socioeconomic gap in FVs consumption.

Reciprocity With Unequal Payoffs: Cooperative and Uncooperative Interactions Affect Disadvantageous Inequity Aversion.

Cooperation among unrelated individuals can evolve through reciprocity. Reciprocal cooperation is the process in which lasting social interactions provide the opportunity to learn about others' behavior, and to further predict the outcome of future encounters. Lasting social interactions may also decrease aversion to unequal distribution of gains - when individuals accept inequity payoffs knowing about the possibility of future encounters. Thus, reciprocal cooperation and aversion to inequity can be complementary phenomena. The present study investigated the effects of cooperative and uncooperative interactions on participants' aversion to disadvantageous inequity. Participants played an experimental task in the presence of a confederate who acted as a second participant. In reality, the participant interacted with a computer programed to make cooperative and uncooperative choices. After interacting with a cooperative or uncooperative computer, participants chose between blue cards to produce larger gains to the computer and smaller for him/her or green cards to produce equal and smaller gains for both. Results confirmed our first hypothesis that uncooperative interactions would produce aversion to disadvantageous inequity. Lastly, half of the participants were informed that points received during the experiment could be later exchanged for money, and half were not. Results indicated that information about monetary outcomes did not affect aversion to inequity, contradicting our second hypothesis. We discuss these results in the light of theories of reciprocal cooperation, inequity aversion, and conformity.

Efficiency of In-Store Interventions to Impact Customers to Purchase Healthier Food and Beverage Products in Real-Life Grocery Stores: A Systematic Review and Meta-Analysis.

Grocery stores are important settings to promote healthier food and beverage choices. The present paper aims at reviewing the effectiveness of different types of in-store interventions and how they impact sales of different product category in real grocery stores. Systematic search was conducted in six databases. In-store interventions were categorized according to the framework by Kraak et al. (2017) into one or more of eight interventions (e.g., place, profile, portion, pricing, promotion, healthy default picks, prompting and proximity). This systematic theme-based review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) data screening and selection. Thirty-six studies were included in the qualitative synthesis and 30 studies were included in the meta-analysis, representing 72 combinations of in-store interventions. The analysis demonstrates that interventions overall had small significant effect size (ES) using Cohen's d on food purchase behavior (d = 0.17, 95% CI [0.04, 0.09]), with largest ES for pricing (d = 0.21) and targeting fruits and vegetables (d = 0.28). Analysis of ES of in-store interventions show that pricing, and pricing combined with promotion and prompting, effectively impacted purchase behavior. Interventions significantly impacted both sales of healthy and unhealthy products and significantly increased sales of fruits and vegetables, healthy beverage and total volume of healthy products. Results should however be interpreted with some caution, given the relatively low quality of overall evidence and low number of studies and observations for some types of intervention. Further research exploring impact on different in-store interventions and targeting especially unhealthy products are needed.

Research and Training in Culturo-Behavior Science.

Culturo-behavior science (CBS) is a developing area and recently formalized specialization in behavior science that brings together principles and techniques from behavior analysis (e.g., Skinner, 1953), behavioral systems analysis (e.g., Brethower, 2008), cultural analysis (e.g., Glenn et al., 2016), and cultural systems analysis (Mattaini, 2020). Culturo-behavior scientists typically work within a selectionist and/or (ecological) systems perspective to advance our understanding of how cultural phenomena develop and change over time and how more effective cultures and systems can be designed (Cihon & Mattaini, 2019, 2020b). The purpose of the current article is to describe CBS, to introduce the recently formulated Association for Behavior Analysis International verified course sequence (VCS) and certificate program in CBS, and to present different pathways to training in CBS. We do this through the presentation of examples from the literature and from four universities that have adopted the CBS VCS and certificate program that are illustrative of how different programs may approach research and training in CBS.

Cooperative responding in rats maintained by fixed- and variable-ratio schedules.

The present study investigated the effects of fixed-ratio (FR) and variable-ratio (VR) reinforcement schedules on patterns of cooperative responding in pairs of rats. Experiment 1 arranged FR 1, FR 10, and VR 10 schedules to establish cooperative responding (water delivery depended on the joint responding of two rats). Cooperative response rates and proportions were higher under intermittent schedules than under continuous reinforcement. The FR 10 schedule generated a break-and-run pattern, whereas the VR 10 schedule generated a relatively high and constant rate pattern. Experiment 2 evaluated the effects of parametric manipulations of FR and VR schedules on cooperative responding. Rates and proportions of cooperative responding generally increased between ratio sizes of 1 and 5 but showed no consistent trend as the ratio increased from 5 to 10. Experiment 3 contrasted cooperative responding between an FR6 schedule and a yoked control schedule. Coordinated behavior occurred at a higher rate under the former schedule. The present study showed that external consequences and the schedules under which the delivery of these consequences are based, select patterns of coordinated behavior.

Contributions of Behavior Analysis to Behavioral Economics.

This article discusses behavior analysis' contribution to behavioral economics. Nobel Laureate Award winner Herbert Simon described the science of economics in an evolutionary context in A Behavioral Model of Rational Choice. Without claiming any relation between the two publications, it was published two years after B.F. Skinner's Science and Human Behavior. While popular behavioral economics continues the critique of Homo Economicus, the eagerness to prove that man is not rational carries the risk of substituting one mentalistic explanation for another. Behavior analysis may contribute to developing knowledge about behavioral economics and consumer behavior. The selectionist perspective, the generic principle of reinforcement, and single-subject research are its main contributions. The conceptual framework of behavior analysis enables investigation of the selection of functional relations between human choice behavior and its environmental contingencies. The circumstance-specific research methods of behavior analysis and the possibility to extend them into large-scale analysis provide the means to explain the psychological underpinnings of behavior. Behavior economics offers good descriptions of important phenomena, and behavior analysis contributes with the technology to explain and influence them.