A meta-analytic cognitive framework of nudge and sludge.

Public and private institutions have gained traction in developing interventions to alter people's behaviours in predictable ways without limiting the freedom of choice or significantly changing the incentive structure. A nudge is designed to facilitate actions by minimizing friction, while a sludge is an intervention that inhibits actions by increasing friction, but the underlying cognitive mechanisms behind these interventions remain largely unknown. Here, we develop a novel cognitive framework by organizing these interventions along six cognitive processes: attention, perception, memory, effort, intrinsic motivation and extrinsic motivation. In addition, we conduct a meta-analysis of field experiments (i.e. randomized controlled trials) that contained real behavioural measures (n = 184 papers, k = 184 observations, N = 2 245 373 participants) from 2008 to 2021 to examine the effect size of these interventions targeting each cognitive process. Our findings demonstrate that interventions changing effort are more effective than interventions changing intrinsic motivation, and nudge and sludge interventions had similar effect sizes. However, these results need to be interpreted with caution due to a potential publication bias. This new meta-analytic framework provides cognitive principles for organizing nudge and sludge with corresponding behavioural impacts. The insights gained from this framework help inform the design and development of future interventions based on cognitive insights.

An experimental investigation into whether choice architecture interventions are considered ethical.

Despite their increasing use, choice architecture interventions have faced criticism for being possibly manipulative and unethical. We empirically explore how an intervention's acceptability differs by the type of intervention used, by the domain, and by the way in which its implementation and benefits are explained. We employ a 5 × 5 × 5 factorial design with three fully crossed predictor variables: domain, type of intervention, and explanation. We measure participants' acceptance of the proposed intervention, perceived threat to autonomy and freedom of choice, and belief that the intervention will be successful. We hypothesized that acceptability of the intervention and perceived threat to autonomy will change as a function of the type of intervention used, the domain in which it is implemented, and the rationale for which its use is presented. We find that acceptability of the intervention, perceived threat to autonomy, and belief that the intervention will be successful differ by the type of intervention used and by the domain in which it is implemented. The rationale for the use of the intervention appears to change acceptability of the intervention depending on the type of intervention that is being used, and the domain in which it is implemented. Exploratory analyses were conducted to investigate differences between specific levels within factors, and interactions between factors. Given the variation in acceptability across the three factors, we believe that the discourse about the ethics of choice architecture should avoid generalizations and should instead be at the level of individual interventions in a specific situation. We conclude with a discussion about areas for future research. PROTOCOL REGISTRATION: The stage 1 protocol for this Registered Report was accepted in principle on 14 October 2022. The protocol, as accepted by the journal, can be found at: https://doi.org/10.6084/m9.figshare.21758666 .

Identifying heterogeneity using recursive partitioning: evidence from SMS nudges encouraging voluntary retirement savings in Mexico.

Individuals regularly struggle to save for retirement. Using a large-scale field experiment ( N = 97 , 149 ) in Mexico, we test the effectiveness of several behavioral interventions relative to existing policy and each other geared toward improving voluntary retirement savings contributions. We find that an intervention framing savings as a way to secure one's family future significantly improves contribution rates. We leverage recursive partitioning techniques and identify that the overall positive treatment effect masks subpopulations where the treatment is even more effective and other groups where the treatment has a significant negative effect, decreasing contribution rates. Accounting for this variation is significant for theoretical and policy development as well as firm profitability. Our work also provides a methodological framework for how to better design, scale, and deploy behavioral interventions to maximize their effectiveness.

Feasibility of three times weekly symptom screening in pediatric cancer patients.

OBJECTIVE: Primary objective was to determine the feasibility of three times weekly symptom reporting by pediatric cancer patients for eight weeks. METHODS: We included English-speaking patients 8-18 years of age with cancer. Patients were sent reminders by text or email to complete Symptom Screening in Pediatrics Tool (SSPedi) three times weekly for eight weeks. When patients reported at least one severely bothersome symptom, the symptom report was emailed to the primary healthcare team. Patient-reported outcomes were obtained at baseline, week 4 ± 1 and week 8 ± 1. Symptom documentation, intervention provision for symptoms and unplanned healthcare encounters were determined by chart review at weeks 4 and 8. The primary endpoint was feasibility, defined as at least 75% patients achieving adherence with at least 60% of SSPedi evaluations. We planned to enroll successive cohorts until this threshold was met. RESULTS: Two cohorts consisting of 30 patients (cohort 1 (n = 20) and cohort 2 (n = 10)) were required to meet the feasibility threshold. In cohort 1, 11/20 (55%) met the SSPedi completion threshold. Interventions applied after cohort 1 included engaging parents to facilitate pediatric patient self-report, offering mechanisms to remember username and password and highlighting potential benefits of symptom feedback to clinicians. In cohort 2, 9/10 (90%) met the SSPedi completion threshold and thus feasibility was met. Patient-reported outcomes and chart review outcomes were obtained for all participants in cohort 2. CONCLUSIONS: Three times weekly symptom reporting by pediatric patients with cancer for eight weeks was feasible. Mechanisms to enhance three times weekly symptom reporting were identified and implemented. Future studies of longitudinal symptom screening can now be planned.

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.

Salient knowledge that others are also evaluating reduces judgment extremity.

As companies increasingly conduct marketing research online (e.g., through social networking sites or their brand community platforms), the knowledge that others are also filling out the same surveys becomes increasingly salient to respondents. This research examines how the salience of this knowledge influences consumer judgments. Two important characteristics of our research paradigm are especially relevant to digital contexts: (1) judgements made by the consumers are neither observable nor subject to others' disapproval; and (2) consensus is not observable or verifiable. Nevertheless, in six main studies and one auxiliary study (Web Appendix), we found that high knowledge salience of others also evaluating reduced judgment extremity. Judgment extremity is quantified by the degree or strength of an evaluation or numeric estimate about a judgment target. This effect was driven by consumers' tendency to predict a moderate consensus and to conform to this perception. Implications for marketing research and crowdsourcing are discussed. Supplementary Information: The online version contains supplementary material available at 10.1007/s11747-021-00807-w.

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.

Feasibility of a randomized controlled trial of symptom screening and feedback to healthcare providers compared with standard of care using the SPARK platform.

PURPOSE: Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web-based application that enables symptom screening and access to clinical practice guidelines for symptom management. Objective was to determine the feasibility of a randomized trial of daily symptom screening for 5 days among children receiving cancer treatments. METHODS: We included English-speaking pediatric cancer and hematopoietic stem cell transplantation (HSCT) patients who were 8-18 years of age at enrollment and who were expected to be in the hospital or in clinic daily for five consecutive days. We randomized children to either undergo daily symptom screening with symptom reports provided to the healthcare team using the SPARK vs. standard of care. The primary endpoint was feasibility, defined as being able to enroll at least 30 participants within 1 year, and among those randomized to intervention, at least 75% completing symptom screening on at least 60% of on-study days. RESULTS: From July 2018 to November 2018, we enrolled and randomized 30 participants. The median age at enrollment was 12.5 (range 8-18) years. Among the intervention group, the median number of days Symptom Screening in Pediatrics Tool (SSPedi) was completed at least once was 5 (range 4 to 5), with one participant missing 1 day of symptom screening. Among all participants, baseline and day 5 SSPedi scores were obtained in 29/30 participants. CONCLUSION: A randomized trial of the SPARK with daily symptom screening for 5 days was feasible. It is now appropriate to proceed toward a definitive multi-center trial to test the efficacy of SPARK to improve symptom control.

Longitudinal evaluation of Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK), a symptom screening and management application.

BACKGROUND: Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web application focused on improving symptom control. It enables pediatric cancer and hematopoietic stem cell transplant (HSCT) patients to self-report and track symptoms, and allows healthcare professionals to access guidelines for symptom management. Objective was to determine the feasibility of longitudinal collection of symptom data. METHODS: In this longitudinal, single-armed feasibility study, respondents were children 8-18 years of age with cancer or pediatric HSCT recipients. Participants completed symptom reporting daily for 5 days. Cognitive interviews were conducted on day 5. Quantitative evaluation included SPARK ease of use and understandability of SPARK reports. Qualitative feedback on facilitators and barriers to daily symptom screening was solicited. Feasibility was defined as ≥75% of participants completing symptom screening on at least 60% of on-study days during the five-day study. RESULTS: Among the 30 children enrolled, the median number of days SSPedi was completed at least once was 5 (range 3 to 5). Overall, 28/29 (96.6%) thought completing symptom screening using SPARK was easy or very easy. All participants understood SPARK symptom reports. Severe symptoms was the most common barrier to daily reporting while an alarm reminder system was the most commonly identified facilitator. CONCLUSIONS: Daily completion of symptom screening using SPARK over 5 days was feasible in children aged 8 to 18 years with cancer and pediatric HSCT recipients. SPARK is now appropriate for use in randomized trials to evaluate the effect of symptom screening and symptom feedback.

Initial development of Supportive care Assessment, Prioritization and Recommendations for Kids (SPARK), a symptom screening and management application.

BACKGROUND: We developed Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK), a web-based application designed to facilitate symptom screening by children receiving cancer treatments and access to supportive care clinical practice guidelines primarily by healthcare providers. The objective was to describe the initial development and evaluation of SPARK from the perspective of children. IMPLEMENTATION: Development and evaluation occurred in three phases: (1) low fidelity focused on functionality, (2) design focused on "look and feel" and (3) high fidelity confirmed functionality and design. Cognitive interviews were conducted with children receiving cancer treatments 8-18 years of age. Evaluation occurred after every five interviews and changes were guided by a Review Panel. Quantitative evaluation included SPARK ease of use and understandability of SPARK reports. RESULTS: The number of children included by phase were: low fidelity (n = 30), design (n = 30) and high fidelity (n = 30). Across phases, the median age was 13.2 (range 8.5 to 18.4) years. During low-fidelity and design phases, iterative refinements to SPARK improved website navigation, usability and likability from the perspective of children and established symptom report design. Among the last 10 children enrolled to high-fidelity testing, all (100%) understood how to complete symptom screening, access reports and interpret reports. Among these 10 respondents, all (100%) found SPARK easy to use and 9 (90%) found SPARK reports were easy to understand. CONCLUSIONS: SPARK is a web-based application which is usable and understandable, and it is now appropriate to use for research. Future efforts will focus on clinical implementation of SPARK.

Criteria to assess potential reverse innovations: opportunities for shared learning between high- and low-income countries.

BACKGROUND: Low- and middle-income countries (LMICs) are developing novel approaches to healthcare that may be relevant to high-income countries (HICs). These include products, services, organizational processes, or policies that improve access, cost, or efficiency of healthcare. However, given the challenge of replication, it is difficult to identify innovations that could be successfully adapted to high-income settings. We present a set of criteria for evaluating the potential impact of LMIC innovations in HIC settings. METHODS: An initial framework was drafted based on a literature review, and revised iteratively by applying it to LMIC examples from the Center for Health Market Innovations (CHMI) program database. The resulting criteria were then reviewed using a modified Delphi process by the Reverse Innovation Working Group, consisting of 31 experts in medicine, engineering, management and political science, as well as representatives from industry and government, all with an expressed interest in reverse innovation. RESULTS: The resulting 8 criteria are divided into two steps with a simple scoring system. First, innovations are assessed according to their success within the LMIC context according to metrics of improving accessibility, cost-effectiveness, scalability, and overall effectiveness. Next, they are scored for their potential for spread to HICs, according to their ability to address an HIC healthcare challenge, compatibility with infrastructure and regulatory requirements, degree of novelty, and degree of current collaboration with HICs. We use examples to illustrate where programs which appear initially promising may be unlikely to succeed in a HIC setting due to feasibility concerns. CONCLUSIONS: This study presents a framework for identifying reverse innovations that may be useful to policymakers and funding agencies interested in identifying novel approaches to addressing cost and access to care in HICs. We solicited expert feedback and consensus on an empirically-derived set of criteria to create a practical tool for funders that can be used directly and tested prospectively using current databases of LMIC programs.

Crossing the virtual boundary: the effect of task-irrelevant environmental cues on task implementation.

Task-oriented activities often involve a certain degree of waiting before the actual activities commence. We suggest that seemingly irrelevant situational cues in the task environment, such as queue guides, area carpets, or the location of another person, can serve as virtual boundaries that divide the task system into two categories: inside the system versus outside the system. Results from two laboratory and two field studies show that in-system individuals (i.e., those who have crossed the virtual boundary demarcated by these cues) are more likely than out-system individuals to adopt an implemental mind-set, as manifested by increased immediacy of action initiation, increased persistence in task-oriented behavior, and increased optimism. Further, these effects are attenuated when people are given sufficient extrinsic incentives to fulfill the task.

Sealing the emotions genie: the effects of physical enclosure on psychological closure.

This research investigated whether the physical act of enclosing an emotionally laden stimulus can help alleviate the associated negative emotions. Four experiments found support for this claim. In Experiments 1a and 1b, emotional negativity was reduced for participants who placed a written recollection of a regretted past decision or unsatisfied strong desire inside an envelope. However, enclosing a stimulus unrelated to the emotional experience did not have the same effect (Experiment 2). In Experiment 3, we showed that the effect was not driven by participants simply doing something extra with the materials, and that the effect of physical enclosure was mediated by the psychological closure that participants felt toward the event.

Pricing and the psychology of consumption.

Most executives know how pricing influences the demand for a product, but few of them realize how it affects the consumption of a product. In fact, most companies don't even believe they can have an effect on whether customers use products they have already paid for. In this article, the authors argue that the relationship between pricing and consumption lies at the core of customer strategy. The extent to which a customer uses a product during a certain time period often determines whether he or she will buy the product again. So pricing tactics that encourage people to use the products they've paid for help companies build long-term relationships with customers. The link between pricing and consumption is clear: People are more likely to consume a product when they are aware of its cost. But for many executives, the idea that they should draw consumers' attention to the price that was paid for a product or service is counterintuitive. Companies have long sought to mask the costs of their goods and services in order to boost sales. And rightly so--if a company fails to make the initial sale, it won't have to worry about consumption. So to promote sales, health club managers encourage members to get the payment out of the way early; HMOs encourage automatic payroll deductions; and cruise lines bundle small, specific costs into a single, all-inclusive fee. The problem is, by masking how much a buyer has spent on a given product, these pricing tactics decrease the likelihood that the buyer will actually use it. This article offers some new approaches to pricing--how and when to charge for goods and services--that may boost consumption.