Public response to government alerts saves lives during Russian invasion of Ukraine.

War is the cause of tremendous human suffering. To reduce such harm, governments have developed tools to alert civilians of imminent threats. Whether these systems are effective remains largely unknown. We study the introduction of an innovative smartphone application that notifies civilians of impending military operations developed in coordination with the Ukrainian government after the Russian invasion. We leverage quasi-experimental variation in the timing of more than 3,000 alerts to study civilian sheltering behavior, using high-frequency geolocation pings tied to 17 million mobile devices, 60% of the connected population in Ukraine. We find that, overall, civilians respond sharply to alerts, quickly seeking shelter. These rapid postalert changes in population movement attenuate over time, however, in a manner that cannot be explained by adaptive sheltering behavior or calibration to the signal quality of alerts. Responsiveness is weakest when civilians have been living under an extended state of emergency, consistent with the presence of an alert fatigue effect. Our results suggest that 35 to 45% of observed civilian casualties were avoided because of public responsiveness to the messaging system. Importantly, an additional 8 to 15% of civilian casualties observed during the later periods of the conflict could have been avoided with sustained public responsiveness to government alerts. We provide evidence that increasing civilians' risk salience through targeted government messaging can increase responsiveness, suggesting a potential policy lever for sustaining public engagement during prolonged episodes of conflict.

On the Efficacy of Accuracy Prompts Across Partisan Lines: An Adversarial Collaboration.

The spread of misinformation is a pressing societal challenge. Prior work shows that shifting attention to accuracy increases the quality of people's news-sharing decisions. However, researchers disagree on whether accuracy-prompt interventions work for U.S. Republicans/conservatives and whether partisanship moderates the effect. In this preregistered adversarial collaboration, we tested this question using a multiverse meta-analysis (k = 21; N = 27,828). In all 70 models, accuracy prompts improved sharing discernment among Republicans/conservatives. We observed significant partisan moderation for single-headline "evaluation" treatments (a critical test for one research team) such that the effect was stronger among Democrats than Republicans. However, this moderation was not consistently robust across different operationalizations of ideology/partisanship, exclusion criteria, or treatment type. Overall, we observed significant partisan moderation in 50% of specifications (all of which were considered critical for the other team). We discuss the conditions under which moderation is observed and offer interpretations.

Understanding patterns of accumulation: Improving forecast-based decisions via nudging.

In this study we investigated challenges associated with comprehension of graphical patterns of accumulation (Experiment 1) and how to improve accumulation-based reasoning via nudging (Experiment 2). On each trial participants were presented with two separate graphs, each depicting a linear, saturating, or exponential data trajectory. They were then asked to make a binary decision based on their forecasts of how these trends would evolve. Correct responses were associated with a focus on the rate of increase in graphs; incorrect responses were driven by prior knowledge and beliefs regarding the context and/or selective attention towards the early phases of the line trajectories. To encourage participants to think more critically and accurately about the presented data, in Experiment 2, participants completed a nudge phase: they either made a forecast about a near horizon or read particular values on the studied trajectories prior to making their decisions. Forecasting about how the studied trajectories would progress led to improvements in determining expected accumulation growth. Merely reading values on the existing trajectory did not lead to improvements in decision accuracy. We demonstrate that actively asking participants to make specific forecasts prior to making decisions based on the accumulation trajectories improves decision accuracy.

Long-Term Effectiveness of a Multi-Strategy Choice Architecture Intervention in Increasing Healthy Food Choices of High-School Students From Online Canteens (Click & Crunch High Schools): Cluster Randomized Controlled Trial.

BACKGROUND: School canteens are a recommended setting to influence adolescent nutrition due to their scope to improve student food choices. Online lunch ordering systems ("online canteens") are increasingly used and represent attractive infrastructure to implement choice architecture interventions that nudge users toward healthier food choices. A recent cluster randomized controlled trial demonstrated the short-term effectiveness (2-month follow-up) of a choice architecture intervention to increase the healthiness of foods purchased by high school students from online canteens. However, there is little evidence regarding the long-term effectiveness of choice architecture interventions targeting adolescent food purchases, particularly those delivered online. OBJECTIVE: This study aimed to determine the long-term effectiveness of a multi-strategy choice architecture intervention embedded within online canteen infrastructure in high schools at a 15-month follow-up. METHODS: A cluster randomized controlled trial was undertaken with 1331 students (from 9 high schools) in New South Wales, Australia. Schools were randomized to receive the automated choice architecture intervention (including menu labeling, positioning, feedback, and prompting strategies) or the control (standard online ordering). The foods purchased were classified according to the New South Wales Healthy Canteen strategy as either "everyday," "occasional," or "should not be sold." Primary outcomes were the average proportion of "everyday," "occasional," and "should not be sold" items purchased per student. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases. Outcomes were assessed using routine data collected by the online canteen. RESULTS: From baseline to 15-month follow-up, on average, students in the intervention group ordered significantly more "everyday" items (+11.5%, 95% CI 7.3% to 15.6%; P<.001), and significantly fewer "occasional" (-5.4%, 95% CI -9.4% to -1.5%; P=.007) and "should not be sold" items (-6%, 95% CI -9.1% to -2.9%; P<.001), relative to controls. There were no between-group differences over time in the mean energy, saturated fat, sugar, or sodium content of lunch orders. CONCLUSIONS: Given their longer-term effectiveness, choice architecture interventions delivered via online canteens may represent a promising option for policy makers to support healthy eating among high school students. TRIAL REGISTRATION: Australian Clinical Trials ACTRN12620001338954, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380546 ; Open Science Framework osf.io/h8zfr, https://osf.io/h8zfr/.

Efficacy of Behavioral Economic Nudges to Assist Teen Mothers: the Healthy Adolescent Transitions Randomized Controlled Trial.

Communities may often lack the resources to deliver intensive programs to assist teen mothers, and many eligible adolescents may decline participation in lengthy interventions. Therefore, alternative approaches involving less resource and time may be needed. Behavioral economics (BE) can inform the development of such novel interventions. BE often feature low-intensity approaches designed to "nudge" people to help them reach their long-term goals. Nudges can include giving reminders, making the desired behavior more convenient, and optimizing the verbal presentation of recommended options. Three hundred thirty-one American adolescents (ages 14 to 19) who were 22 to 35 weeks pregnant were enrolled in the present trial. One hundred sixty-six participants were randomly assigned to the intervention condition featuring a three-month BE intervention delivered by a registered nurse and social worker. The remaining 165 youths were assigned usual care. Surveys were completed at baseline, 3 months, 12 months, and 18 months. Data collection occurred from 2017 to 2021. Qualitative feedback indicated that the BE intervention was well-received by adolescents. However, there were no significant differences between the intervention and control groups at any time point regarding repeat pregnancy, contraceptive usage, financial literacy, school completion, job attainment, HPV vaccinations, nicotine usage, perception of having a medical home, urgent care/ED usage, and nutritional intake (all p > .05). Our findings suggest that a BE-based intervention may not be sufficient to facilitate change for teen mothers. Future programs should consider lasting longer, featuring a higher dose, and/or incorporating systems-level changes. This trial was prospectively registered (NCT03194672 clinicaltrials.gov).

Interventions based on sensory-hedonic strategies and on nudging to facilitate vegetable and pulses consumption in the school environment.

Childhood and adolescence shape lifelong taste preferences and dietary habits, making them crucial periods for promoting healthy and sustainable eating. As students consume up to half of their daily energy intake at school, school interventions can have a significant impact on promoting plant-based diets. Although the benefits of promoting plant-based diets on children's and adolescents' health and environmental sustainability are well established and various studies report promising effects of interventions based on sensory-hedonic strategies and on nudging in promoting vegetables and pulses in schools, a comprehensive collection of those reports is lacking. Therefore, this systematic review aims to collect published literature on the above interventions in schools that focus on promoting the consumption of vegetables and pulses to children and adolescents. Three databases-PubMed, Scopus, and Web of Science-were searched over all years until March 2022 using pre-specified terms. From the 10.488 studies identified, a total of 57 studies reporting sensory-hedonic (e.g., manipulating food sensory properties or their hedonic value) or nudging (e.g., changing the presentation) interventions targeting children and/or adolescents in schools and aiming at promoting vegetables and/or pulses were included. Overall, interventions based on sensory-hedonic strategies (either enhancing the perception of well-accepted flavor and texture or manipulating their hedonic value) and on nudging (through incentives and prompts) are effective in promoting vegetables and pulses. A gap in the literature was identified for interventions targeting adolescents and promoting pulses. Finally, multicomponent interventions, rather than using one strategy alone, could be more successful.

How do defaults and framing influence food choice? An intervention aimed at promoting plant-based choice in online menus.

Nudging consumers towards plant-based foods by making these choices the default option is a promising strategy for effecting sustainable dietary change. In the hypothetical context of online food ordering in a Northern European country, we examined the underlying mechanisms and effectiveness of swapping the default in menus from meat to a plant-based meat alternative. Results showed that pre-selecting a plant-based option in the online setting was not enough to increase choice of plant-based meals alone. Rather, additionally framing the plant-based default as the more sustainable or tasty option was needed to significantly increase choice. While ease was unimportant and held constant in this online setting, endowment and implied endorsement were found to mediate default success such that the positive influence of endowment outweighed the (surprising) negative effect via endorsement. In contrast to general theoretical expectations of default nudges, an endorsement by an online food provider is unlikely to encourage plant-based choices.

Exploratory analysis of a cluster randomized controlled trial of a multi-strategy intervention delivered via online canteens on improving the nutritional quality of primary school students' pre-ordered foods & drinks at recess.

School canteens are a recommended setting to deliver public health nutrition strategies given their wide reach, and frequent use by children. Online canteens, where users (i.e. students or their carers) pre-order and pay for food and drinks online, represent attractive systems to deliver strategies that encourage healthier food choices. There have been few studies exploring the efficacy of public health nutrition interventions in online food ordering environments. Therefore, this study aims to assess the efficacy of a multi-strategy intervention implemented in an online school canteen ordering system in reducing the energy, saturated fat, sugar, and sodium content of students' online recess orders (i.e. foods ordered during the mid-morning or afternoon snack period). This was an exploratory analysis of recess purchases for a cluster randomized controlled trial that initially sought to examine the efficacy of the intervention on lunch orders. A total of 314 students from 5 schools received the multi-strategy intervention (involving menu labelling, placement, prompting and availability) that was integrated into the online ordering system, and 171 students from 3 schools received the control (usual online ordering). Analysis of main outcomes found that the mean energy (difference: -269.3 kJ; P = 0.006), saturated fat (difference: -1.1 g; P = 0.011) and sodium (difference: -128.6 mg; P = 0.014) content per student recess order was significantly lower in the intervention group than the control group at 2-month follow-up. Findings suggest that embedding strategies to encourage healthier choices within online canteen ordering systems can improve the nutrient composition of student recess purchases. These results add to the current evidence base suggesting that interventions delivered via online food ordering systems represent an effective strategy for improving child public health nutrition in schools.

A mixed-methods evaluation of a health-promoting café located in a small health service in rural Victoria, Australia.

INTRODUCTION: Residents of rural areas internationally typically experience chronic disease risk profiles worse than city dwellers. Poor diet, a key driver of chronic disease, has been associated with unhealthy food environments, and rural areas often experience limited access to healthy, fresh and affordable food. OBJECTIVE: This study aimed to evaluate the first three years of a health promoting social enterprise café established in a small rural health service. DESIGN: A mixed-methods evaluation study. Quantitative sales data, surveys and key informant interviews that included both quantitative and qualitative responses. FINDINGS: Three years of sales data were included; 111customer surveys and five key informant interviews were conducted. Food and beverages on displayed and sold consistently met or exceeded the healthy criteria set by policy. Stakeholders supported the traffic light system, the social enterprise model and rated the likelihood of sustainability of the café as high. DISCUSSION: Customers used the 'traffic light' system to inform food choices, placed value on the warmth of the staff and on the welcoming environment created through the social enterprise model. Resources remain tight although all stakeholders are committed to the sustainability of the YarriYak café. CONCLUSION: The study shows the acceptability, feasibility and sustainability of a health promoting social enterprise café in a rural area.

Acceptance of healthy lifestyle nudges in the general population of Singapore.

BACKGROUND: In recent years, behaviourally driven policies such as nudges have been increasingly implemented to steer desired outcomes in public health. This study examines the different nudges and the socio-demographic characteristics and lifestyle behaviours that are associated with public acceptance of lifestyle nudges. METHODS: The study used data from the nationwide Knowledge, Attitudes and Practices study (KAP) on diabetes in Singapore. Three types of nudges arranged in increasing order of intrusiveness were examined: (1) information government campaigns, (2) government mandated information and (3) default rules and choice architecture. Acceptance was assessed based upon how much respondents 'agreed' with related statements describing heathy lifestyle nudges. Multivariable linear regressions were performed with socio-demographics and lifestyle behaviours using scores calculated for each nudge. RESULTS: The percentage of respondents who agreed to all statements related to each nudge were: 75.9% (information government campaigns), 73.0% (government mandated information), and 33.4% (default rules and choice architecture). Respondents of Malay/Others ethnicity (vs. Chinese) were more likely to accept information government campaigns. Respondents who were 18 - 34 years old (vs 65 years and above), female, of Malay/Indian ethnicity (vs Chinese), were sufficiently physically active, and with a healthier diet based on the DASH (Dietary Approach to Stop Hypertension) score were more likely to accept nudges related to government mandated information. Respondents of Malay/Indian ethnicity (vs Chinese), and who had a healthier diet were more likely to accept default rules and choice architecture. CONCLUSION: Individuals prefer less intrusive approaches for promoting healthy lifestyle. Ethnicity and lifestyle behaviours are associated with acceptance of nudges and should be taken into consideration during the formulation and implementation of behaviourally informed health policies.

Intervention strategies to promote healthy and sustainable food choices among parents with lower and higher socioeconomic status.

BACKGROUND: A global shift towards more healthy and sustainable diets is necessary for the prevention of obesity and chronic diseases, as well as for the growing pressure on our ecosystems. Given that parents are important actors in affecting dietary behaviors of their children, developing intervention strategies targeting families and their practices is promising to reach positive behavior change among children. Also, it is important to tailor these interventions to the needs of parents with different socioeconomic statuses (SES), given that health inequalities continue to grow. This study aims to investigate perspectives of lower and higher SES parents on the usability and acceptability of various innovative intervention strategies. METHODS: Fourteen focus groups and four individual interviews (n = 78, nlowerSES = 17; nhigherSES = 61) were conducted in Belgium. A semi-structured interview guide was used to facilitate the discussions. The interviews were recorded, transcribed, and analyzed via thematic content analysis using NVivo. RESULTS: To encourage healthy and sustainable food choices, interventions via online food shopping platforms and nudging strategies in grocery stores were mostly cited by higher SES parents, but these were less applicable for lower SES parents as they buy less online and mainly consider the price of products. Mobile applications that provide inspiration for healthy and sustainable recipes and easily accessible shopping lists received moderate support among lower and higher SES parents. Furthermore, both lower and higher SES parents showed interest in meal boxes delivered at home, but lower SES parents have not yet tried such meal boxes because of their higher prices. Still, both groups of SES parents mentioned many advantages of these meal boxes, such as the convenience and time-saving component, as well as the cooking inspiration aspect. CONCLUSION: Our study reveals the preferences of lower and higher SES parents for practical intervention strategies, providing insight in what features these strategies should have to be acceptable and useful. Hence, the findings can inform the development of a tailored family-based intervention strategy to improve parental food choices in favor of increased health and sustainability.

Nudges and hard choices.

Nudges are small changes in the presentation of options that make a predictable impact on people's decisions. Proponents of nudges often claim that they are justified as paternalistic interventions that respect autonomy: they lead people to make better choices, while still letting them choose for themselves. However, existing work on nudges ignores the possibility of "hard choices": cases where a person prefers one option in some respects, and another in other respects, but has no all-things-considered preference between the two. In this paper, I argue that many significant medical decisions are hard choices that provide patients with an opportunity to exercise a distinctive sort of "formative autonomy" by settling their preferences and committing themselves to weigh their values in a particular way. Since nudges risk infringing formative autonomy by depriving patients of this opportunity, their use in medical contexts should be sensitive to this risk.

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide.

BACKGROUND: Health decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others. OBJECTIVES: To explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation (CPR) or do-not-attempt-resuscitation orders (DNAR). METHODS: We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis. RESULTS: Reference to what other people decide in regards to CPR is used five times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient's preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders ("Patients tell us 'no futile care'"). By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group. CONCLUSIONS: Introducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms.

Increasing engagement in price crowdsourcing initiatives: Using nudges in Nigeria.

African agriculture is yet to reach its full food production potential. One way of addressing this is a better distribution of market signals to farmers and other market participants, which can help them make better-informed decisions, leading to increased income and capacity for investment. Hence, increasing the availability of market information in Africa is a priority and alternative data sources, and new Information Communication Technologies (ICTs) offer huge potential to complement classic official statistics. This has given rise to a number of ICTs and citizen science projects to monitor data in real time, of which food price crowdsourcing in Africa is one. However, one of the main challenges faced by crowdsourcing initiatives is to ensure that individuals feed useful information into the system. In this paper, we test the potential of behavioural interventions to help sustain crowd contributions by leveraging intrinsic and/or extrinsic motivations. We used two randomised control trials (RCTs) to evaluate whether the inclusion of two nudges (one based on social norms and one based on information disclosure) in the design of a food price crowdsourcing initiative can improve crowd engagement. Our results show that social norms increase crowd participation while disclosing price information does not. The latter highlights the need for further research to identify which type of information and format to make it accessible would best help to sustain crowd effort levels. These findings have the potential to be useful in designing future crowdsourcing (or other types of) initiatives that require sustained citizen engagement over time.

Assessing the impact of green nudges on ozone concentration: Evidence from China's night refueling policy.

Ozone (O3) pollution poses health risks and premature mortality, and gas stations are one of the largest sources of urban volatile organic compounds (VOCs, the main precursor to O3). This paper investigates whether the government's call for night refueling, which can be regarded as a green nudge, can guide changes in consumer behavior and consequently improve environmental quality. Using a difference-in-differences (DID) estimation and weekly monitoring site air quality panel data, we analyze the effect of the Night Refueling Preferential Policy on O3 concentrations. We find that the policy can reduce O3 concentrations by 10% by encouraging consumers to refuel at night. The reduction in O3 has brought great benefits to human health, leading to a 4-5‰ reduction in non-accidental mortality and a 6-8‰ reduction in cardiovascular mortality in Jiangsu province. The economic benefits of this policy would be approximately 62-189 billion Chinese Yuan (CNY) if it were implemented nationwide. The findings of this study suggest that the government can influence consumer behavior to promote environmental quality.

Nudging Social Media toward Accuracy.

A meaningful portion of online misinformation sharing is likely attributable to Internet users failing to consider accuracy when deciding what to share. As a result, simply redirecting attention to the concept of accuracy can increase sharing discernment. Here we discuss the importance of accuracy and describe a limited-attention utility model that is based on a theory about inattention to accuracy on social media. We review research that shows how a simple nudge or prompt that shifts attention to accuracy increases the quality of news that people share (typically by decreasing the sharing of false content), and then discuss outstanding questions relating to accuracy nudges, including the need for more work relating to persistence and habituation as well as the dearth of cross-cultural research on these topics. We also make several recommendations for policy-makers and social media companies for how to implement accuracy nudges.

Using Incentives and Nudging to Improve Non-Targeted HIV Testing in Ecuador: A Randomized Trial.

Under-detection of HIV/AIDS still burdens many low- and middle-income countries (LMICs). Our randomized trial investigated the effects of financial incentives and a behavioral nudge to induce HIV testing and learning HIV status in Ecuador. In the control group, 12.2% of participants agreed to testing, and 5.3% learned results. A financial incentive paid at testing increased the fraction of participants tested by 50.1 percentage points (95% CI 38.8 to 61.4) and the fraction who learned their status by 8.9 percentage points (95% CI 5.3 to 12.5); the nudge had no effect. The HIV-positive rate was 1.2% in the control group, and incentives prompted a 4.7 percentage point (95% CI 0.5 to 8.9) higher proportion of HIV-positive detection. Incentives also induced earlier testing, suggesting reduced procrastination. This suggests that information with appropriately timed small financial incentives can improve HIV testing and detection of new cases in the general population in LMIC settings.

Tools for public health policy: nudges and boosts as active support of the law in special situations such as the COVID-19 pandemic.

In recent years, "nudging" has become a standard behavioral intervention at the individual level and for the design of social policies. Although nudges are effective, such interventions seem to be limited to a given space and time, and there is only scant evidence to support the contrary view. On the other hand, choice architects may utilize another type of intervention called "boosting," which shows the promise of generalized and lasting behavioral change. A government can use these tools to shape public policy. Behavioral interventions such as policy-making tools have their boundaries, as does the law. We argue that nudging and boosting may serve as active local or global aids in support of the legal system under certain circumstances. Nudging and boosting can also support the legal system, especially in relation to emerging social issues or events that are unprecedented, such as the recent global COVID-19 pandemic, where certain behavioral patterns are expected, but it would be difficult or impossible to enforce them through the law alone.

Nudging healthier food choices in a cafeteria setting: A sequential multi-intervention field study.

Creating more health-fostering environments is high on the agenda of public and private actors. The behavioral approach to nudge people towards healthier food choices is gaining popularity despite limited understanding about where, and for whom, which specific nudges work. This study contributes by reporting on three different nudging interventions in the same setting and presents effects on different sub-populations. We find overall small effects that are heterogeneous, ranging from robustly more to even less healthy choices. We discuss the importance of transparency and reactance to health interventions and the potential interplay of interventions with habitual behavior among different sub-populations.

Nudging for others' sake: An ethical analysis of the legitimacy of nudging healthcare workers to accept influenza immunization.

A core idea underlying nudging is that it helps individuals to achieve their own goals, yet many nudges actually aim at collective goals or specifically target the benefit of others. An example is nudging healthcare workers to be vaccinated against influenza. I distinguish between self-regarding nudges, which primarily benefit the nudgee, and other-regarding nudges, which mainly benefit others, and argue that the default justificatory reason to legitimize self-regarding nudges, namely the 'as judged by themselves' standard, does not apply and that we need to look for other justifications. I examine several possible moral justifications to support strong other-regarding nudges, namely beneficence, the harm principle and solidarity.