Megastudies improve the impact of applied behavioural science.

Policy-makers are increasingly turning to behavioural science for insights about how to improve citizens' decisions and outcomes1. Typically, different scientists test different intervention ideas in different samples using different outcomes over different time intervals2. The lack of comparability of such individual investigations limits their potential to inform policy. Here, to address this limitation and accelerate the pace of discovery, we introduce the megastudy-a massive field experiment in which the effects of many different interventions are compared in the same population on the same objectively measured outcome for the same duration. In a megastudy targeting physical exercise among 61,293 members of an American fitness chain, 30 scientists from 15 different US universities worked in small independent teams to design a total of 54 different four-week digital programmes (or interventions) encouraging exercise. We show that 45% of these interventions significantly increased weekly gym visits by 9% to 27%; the top-performing intervention offered microrewards for returning to the gym after a missed workout. Only 8% of interventions induced behaviour change that was significant and measurable after the four-week intervention. Conditioning on the 45% of interventions that increased exercise during the intervention, we detected carry-over effects that were proportionally similar to those measured in previous research3-6. Forecasts by impartial judges failed to predict which interventions would be most effective, underscoring the value of testing many ideas at once and, therefore, the potential for megastudies to improve the evidentiary value of behavioural science.

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.

Patients and their family members prioritize post-transplant survival over waitlist survival when considering donor hearts for transplantation.

Heart transplant providers often focus on post-transplant outcomes when making donor decisions, potentially at the expense of higher waitlist mortality. This study aimed to assess public opinion regarding the selection of donor hearts and the balance between pre- and post-transplant risk. The authors generated a survey to investigate public opinion regarding donor acceptance. The survey was shared freely online across social media platforms in April-May 2019. A total of 718 individuals responded to the survey, with an equal distribution between patients and family members. Respondents consistently favored post-transplant outcomes over waitlist outcomes. About 83.9% of respondents favored a hospital with longer waitlist times, worse waitlist outcomes, but excellent post-transplant survival over a hospital with short waitlist times, a high waitlist survival, and inferior post-transplant survival. This preference was no different between pediatric and adult populations (P = .7), patient and family members (P = .935), or those with a pre- vs post-transplant perspective (P = .985). Patients and their family members consistently favor improved post-transplant survival over waitlist survival when considering the risks of accepting a donor organ. These findings suggest that current practice patterns of donor selection align with the opinions of patients and family members with heart failure or who have undergone heart transplantation.

Behavioral economics-A framework for donor organ decision-making in pediatric heart transplantation.

The high discard rate of pediatric donor hearts presents a major challenge for children awaiting heart transplantation. Recent literature identifies several factors that contribute to the disparities in pediatric donor heart usage, including regulatory oversight, the absence of guidelines on pediatric donor heart acceptance, and variation among transplant programs. However, a likely additional contributor to this issue are the behavioral factors influencing transplant team decisions in donor offer scenarios, a topic that has not yet been studied in detail. Behavioral economics and decision psychology provide an excellent foundation for investigating decision-making in the pediatric transplant setting, offering key insights into the behavior of transplant professionals. We conducted a systematic review of published literature in pediatric heart transplant related to behavioral economics and the psychology of decision-making. In this review, we draw on paradigms from these two domains in order to examine how existing aspects of the transplant environment, including regulatory oversight, programmatic variation, and allocation systems, may precipitate potential biases surrounding donor offer decisions. Recognizing how human decision behavior influences donor acceptance is a first step toward improving utilization of potentially viable pediatric donor hearts.

Tasting with your eyes: Sensory description substitutes for portion size.

A field study conducted in a diner explored whether a sensory rich description of an indulgent dessert prompts consumers to be willing to pay just as much for a small serving as for a large serving. Diner customers (N = 809) who ordered an entrée received a free piece of chocolate cake if they filled out a questionnaire indicating the amount of cake they ate, their willingness to pay (WTP) for the cake, their fullness after eating, and other measures. A between-subjects 2 × 3 design varied the serving size of the cake (6 oz. vs. 12 oz.) and the description of the cake (no description control, nutrition description, or sensory description). Self-reported amount eaten showed a smaller portion size effect in the nutrition description condition than in the other two conditions. Of primary interest, relative to the other conditions, the sensory description caused customers to be willing to pay as much for the small piece as for the large piece and to feel almost as full after eating from the small piece as from the large piece. These results indicate that a sensory rich description makes customers' evaluations of an indulgent dessert less sensitive to serving size. As a result, sensory descriptions can be used to make customers just as content with a small dessert as they would be with a large dessert.

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.

Medical students' attitude towards influenza vaccination.

BACKGROUND: Influenza vaccination is recommended for all healthcare personnel (HCP) and most institutions offer vaccination for free and on site. However, medical students do not always have such easy access, and the predictors that might guide the motivation of medical students to get vaccinated are largely unknown. METHODS: We conducted a cross-sectional survey study among pre-clinical medical students in a German University hospital to assess the social cognitive predictors of influenza vaccination, as well as reasons for refusal and acceptance of the vaccine. RESULTS: Findings show that pre-clinical medical students have comparable knowledge gaps and negative attitudes towards influenza vaccination that have previously been reported among HCP. Lower injunctive norms and higher feelings of autonomy contribute to no intention to get vaccinated against influenza, while a positive instrumental attitude and higher feelings of autonomy contribute to a high intention to get vaccinated. The variables in the regression model explained 20% of the variance in intention to get vaccinated. CONCLUSIONS: The identified factors should be addressed early in medical education, and hospitals might benefit from a more inclusive vaccination program and accessibility of free vaccines for their medical students.

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.

The impact of donor consent mechanism on organ procurement organization performance in the United States.

BACKGROUND: Lack of donor organ availability represents a major limitation to the success of solid organ transplantation. The Scientific Registry of Transplant Recipients (SRTR) publishes performance reports of organ procurement organizations (OPO) in the United States, but does not stratify by the mechanism of donor consent, namely first-person authorization (organ donor registry) and next-of-kin authorization. This study aimed to report the trends in deceased organ donation in the United States and assess the regional differences in OPO performance after accounting for the different mechanisms of donor consent. METHODS: The SRTR database was queried for all eligible deaths (2008-2019) which were then stratified based on the mechanism of donor authorization. Multivariable logistic regression was performed to assess the probability of organ donation across OPOs based on specific donor consent mechanisms. Eligible deaths were divided into 3 cohorts based on the probability to donate. Consent rates at the OPO level were calculated for each cohort. RESULTS: Organ donor registration among adult eligible deaths in the U.S. increased over time (2008: 10% vs 2019: 39%, p < 0.001), coincident with a decline in next-of-kin authorization rates (2008: 70% vs 2019: 64%, p < 0.001). At the OPO level, the increased organ donor registration was associated with lower next-of-kin authorization rates. Among eligible deaths with medium- and low-probability of donation, recruitment was highly variable across OPO's, ranging from 36% to 75% in the medium-probability group (median 54%, IQR 50%-59%) and 8% and 73% in the low-probability group (median 30%, IQR 17%-38%). CONCLUSION: Significant variability exists across OPOs in the consent of potentially persuadable donors after adjusting for population demographic differences and the mechanism of consent. Current metrics may not truly reflect OPO performance as they do not account for consent mechanism. There is further opportunity for improvement in deceased organ donation through targeted initiatives across OPOs, modeled after regions with the best performance.

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.

Effects of Ownership Text Message Wording and Reminders on Receipt of an Influenza Vaccination: A Randomized Clinical Trial.

Importance: Despite the availability of safe and effective vaccines, many people fail to get vaccinated. Messages using behavioral science principles may increase vaccination rates. Objective: To determine the effect on influenza vaccination rates of a text message telling patients that an influenza vaccine had been reserved for them. Design, Setting, and Participants: As part of a larger influenza vaccine messaging megastudy, in this randomized clinical trial, 11 188 patients in 2 large health systems were assigned to receive a text message that stated "a flu shot has been reserved for you," a text message that stated "flu shots will be available," or no text message. Both messages included the option to reply yes (Y) or no (N) to indicate that the patient wanted to get vaccinated. Patients 18 years or older were included if they had new or routine (nonsick) primary care appointments scheduled from September 20, 2020, through March 31, 2021. Interventions: The evening before the scheduled appointment, patients in the 2 message conditions were sent 3 back-to-back SMS messages containing the study wording. Patients in the usual care control group did not receive any study messages. Main Outcomes and Measures: Receipt of an influenza vaccine on the date of the patient's scheduled appointment. Results: A total of 11 188 patients were randomized to the reserved or the available message conditions or to usual care. The 10 158 patients analyzed in the study had a mean (SD) age of 50.61 (16.28) years; 5631 (55.43%) were women; and 7025 (69.16%) were White. According to health records, 4113 (40.49%) had been vaccinated in the previous influenza season, and 5420 (53.36%) were patients at Penn Medicine. In an intent-to-treat analysis, changes in vaccination rates in response to the reserved message did not reach statistical significance (increase of 1.4 percentage points, or 4% [P = .31]) compared with the message conveying that influenza vaccines were available. Relative to the usual care control, the reserved message increased vaccination rates by 3.3 percentage points, or 11% (P = .004). Patients in the reserved message condition were more likely to text back Y (1063 of 3375 [31.50%]) compared with those in the available message condition (887 of 3351 [26.47%]; χ2 = 20.64; P < .001), and those who replied Y were more likely to get vaccinated (1532 of 1950 [78.56%]) compared with those who did not (749 of 4776 [15.68%]; χ2 = 2400; P < .001). Conclusions and Relevance: This study found that patients who received text messages regarding flu vaccination had greater vaccine uptake than those who received no message. Messages that increase the likelihood that patients will indicate their intention to be vaccinated may also increase vaccination behavior. Clinical Trial Registration: ClincalTrials.gov Identifier: NCT04565353.

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.