“Nudging” patients towards better adherence to improve outcomes
- “Nudging” involves influencing System 1 heuristics to orient people to act in a desired way.
- These techniques are increasingly used by governments to shape healthcare and other public policies.
- Nudging techniques can also be used to enhance treatment adherence.
As described in the previous articles, adherence to treatment of patients suffering from neurological conditions can be a big issue; for Parkinson’s disease, sub-optimal adherence is estimated to vary between 10 and 67%,1 and up to half of patients with conditions such as epilepsy and bipolar disorder are estimated to be non-adherent to medication.2,3 Low adherence comes with big costs for the patients, their families, and society as whole.1–3 The behavioral sciences help us to understand the decision-making processes that lead to non- adherence, but can they help patients make better choices?
How can people be “nudged” to make better choices for their health?
Previous articles in this series describe the two systems of human thinking and decision- making according to Daniel Kahneman and Amos Tversky: automatic and spontaneous system 1 and reflective and “lazy” system 2.4–6 System 1 is responsible for about 95% of all the choices that people make in their everyday lives.6 The reactions of System 1 happen according to “rules of thumb”, or heuristics and biases. These include framing, anchoring, and status quo bias, among others, as discussed previously.4
In their 2008 book “Nudge”, Nobel prize winner Richard Thaler and Holberg prize winner Cass Sunstein further developed this theory of decision-making and made the case for what they call “libertarian paternalism”.4 They argue that most people are not experts in the many domains that affect their day-to-day life and cannot therefore spontaneously make the best decisions when confronted with a choice. For example, when offered a large number of health insurance policies, how can a novice find the one that best fits his/her needs?*4 However, it is possible to help people and optimize their decision-making by designing the architecture of choice such that the best options appear more likely to be chosen – to “nudge” system 1 in other words.4
“Nudging” involves orienting the individual’s choices
Nudging techniques are not meant to eliminate choice. If a person wants to consider a decision “rationally” and employ his reflective thinking (system 2), he will always have the option to counter his system 1. Thaler and Sunstein point out that the choice will be presented either way, by paying attention to how it is presented, the “choice architecture” can be designed in such a way that while still providing complete freedom of choice, more beneficial choices become more likely for those who rely on system.1.4
Consider the example of organ donation. Having human organs readily available at hospitals can save countless lives. Yet, organ-donation remains a difficult issue in many societies, and their availability is scarce. In Austria, the government solved this problem by applying the following nudge technique: the default option for Austrians is to donate organs automatically should they find themselves in certain situations. Austrians are perfectly able to opt out of this program, but 99% of Austrians consent to organ donation as a result of this nudge. By comparison, neighboring Germany has not used donate default, and the rate of organ donation is only 12%. In other words, Austrians must opt-out of donation while Germans must opt-in. The default bias of the System 1 has operated.4,7
Nudging techniques can enhance adherence
Nudging techniques, such as opt-in/opt-out, are increasingly used by public authorities to shape public policy. Several countries and federated states, like the UK, USA, Germany, and many others have even created “nudge” units within their governments.8–10
A study on chronic disease patients was conducted by a group of UK and USA researchers in collaboration with the NHS. It concluded that intervening to highlight the personal health costs of non-compliance is efficient in improving adherence.11 This took the form of a reminder to the patient of the personal and societal costs of his non-adherence, and their commitment to adherence. The aim of this study was to “activate” the availability bias of the patient so that he/she could assess the benefits of taking the medications in a more vivid way.11
When is nudging needed?
According to Thaler and Sunstein, there are several cases in which nudges are particularly useful. These can be illustrated using desired health behaviors:4
- Benefits now, costs later: The individual does not seriously consider the future negative impact of his behavior – for example, a smoker who does not seriously weigh the potential health problems caused by cigarettes. To take another example, exercising and dieting bear a current cost of effort as compared to the pleasure (benefit) of having an ice cream. According to Kahneman’s “What You See Is All There Is” (WYSIATI)5 principle, most people are unable to fully appreciate the future benefits of costs borne today. Another example would be a patient with Parkinson’s disease who is unwilling to take physical exercise, which may have a positive impact on their mobility. Therefore, a nudge could be used to some help in taking the right decision for their health.
- Degree of difficulty: more difficult problems require more help to make the right decision. Take the example of a patient who is about to start a very complex treatment regimen, with which he has no experience. For example, a patient with Parkinson’s disease that has progressed is likely to be using three or more daily doses of medications.1 It is very likely that his adherence to treatment will be low12 if no help (nudge) is provided.
- Frequency: a person is confronted with rare and difficult decisions, and the stakes are high. Imagine a patient that must give his consent for a surgery or treatment with uncertain outcomes but that is much more likely to improve the situation than to exacerbate it. A nudge, such as stressing out the positive outcome rate (ex. 90% success) could be relevant in such a situation.
- Feedback: people need feedback on their choices to make further decisions. For example, when a pupil is not doing his homework properly, the feedback is immediate: a bad mark from the teacher. Next time, the pupil will be motivated to improve. However, if the feedback on a poor decision is not readily available, a nudge may be appropriate. Consider a patient with epilepsy who takes treatment which controls their seizures: without any feedback available (symptoms or health events), the patient may not to adhere to his treatment plan.
- Knowing what you want (and need): it is particularly hard for people to make choices when they cannot translate them into potential experiences. Thaler and Sunstein compare this to ordering food in a restaurant in a foreign language. Consider a patient who is facing a multitude of treatment options that have different cost / benefit outcomes: how could a patient choose one on her own? A nudge could be useful in this situation.
Conclusions and perspectives
Nudging techniques represent a major opportunity for dealing with non-adherence. Whatever the environment or culture, people have the same heuristics and two systems of thinking; therefore, nudging techniques can be adapted and applied. With the emergence of digital technologies and machine learning capabilities, it is increasingly possible to personalize nudge techniques to each patient, which can improve outcomes for him, his family and society in general.13,14 Future articles in this series will discuss how digital Patient Support Programs personalize nudging approaches and provide examples of how such techniques can influence adherence.
*In the state of Maine in the United States, the local government planned to assign a healthcare plan for its citizens. From 10 pre-selected plans, authorities evaluated each of them according to 3 months of historical data on prescription use. Thanks to this, they could propose to each citizen the plan that fit best their needs. Thaler and Sunstein calls this nudge Intelligent assignment.4
- Straka I, et al. Adherence to Pharmacotherapy in Patients With Parkinson’s Disease Taking Three and More Daily Doses of Medication. Frontiers in Neurology 2019;10:799.
- Ferrari CMM, et al. Factors associated with treatment non-adherence in patients with epilepsy in Brazil. Seizure 2013;22:384–9.
- Jawad I, et al. Medication nonadherence in bipolar disorder: a narrative review. Ther Adv Psychopharmacol 2018;8(12):349–63.
- Thaler RH and Sunstein CR. Nudge: Improving Decisions About Health, Wealth and Happiness. Yale University Press; 2008.
- Kahneman D. Thinking Fast and Slow. Penguin Books Ltd, November 2011. Available to purchase as eBook at: https://www.ebooks.com/en-gb/book/794540/thinking-fast-and-slow/daniel-kahneman/ [Accessed March 2021].
- Jordanov P. Thinking fast? Slow down. Available at: https://neurofied.com/thinking-fast-slow-down/ [Accessed March 2021].
- Damani H. Why 99% of Austrians donate their organs. 2015. Available at: http://www.behaviouraldesign.com/2015/08/11/why-99-of-austrians-donate-their-organs/#sthash.1ESiwL2p.s9Wb4rXQ.dpbs [Accessed March 2021].
- Forbes (Marron D). Obama’s Nudge Brigade: White House Embraces Behavioral Sciences To Improve Government. Available at: https://www.forbes.com/sites/beltway/2015/09/16/obama-nudge-government/?sh=2eb8cad2c996 [Accessed March 2021].
- The Behavioural Insights Team – About Us. Available at: https://www.bi.team/about-us/ [Accessed March 2021].
- Apolitico. These 10 governments are leading the world in behavioural science. Available at: https://apolitical.co/en/solution_article/these-10-governments-are-leading-the-world-in-behavioural-science [Accessed March 2021].
- Jachimowicz J, et al. Making medication stick: Improving medication adherence by highlighting the personal health costs of non-compliance. Behavioural Public Policy 2019;1– 21.
- Tavares NUL, et al. Factors associated with low adherence to medicine treatment for chronic diseases in Brazil. Rev Saude Publica 2016;50:10s.
- Gandapur Y, et al. The role of mHealth for improving medication adherence in patients with cardiovascular disease: a systematic review. Eur Heart J Qual Care Clin Outcomes 2016;2(4):237–44.
- Dolgin K. The SPUR Model: A Framework for Considering Patient Behavior. Patient Prefer Adherence 2020;14:97–105.