Nudge healthcare: case studies driving improved patient outcomes
- Nudge is a behavioral method that employs small changes in choice architecture to influence decision-making predictably, without prohibiting other options or economic incentives1.
- Nudge Healthcare utilizes Nudges to bring positive changes to patients’ health such as improving medication adherence1,8.
- Nudging has also been explored for improving lifestyle and enhancing preventive care such that even small changes in the environment have been demonstrated to produce desired behavioral change2,3.
An individual’s behavior can negatively impact the health outcomes. Adherence to therapies is a major factor that negatively impacts disease outcomes. In addition individual choices like unhealthy diet, smoking as well as limited physical activity also contribute to poor health outcomes leading to significant disease and economic burden for the patients as well as the healthcare system4,5. A variety of factors related to therapy, disease, individual, healthcare system, and socioeconomic status have been shown to affect medication adherence6. For more on medication compliance please read our articles “What is medication compliance”.
Medication adherence is a behavioral issue7. An understanding of patient behavior and its underpinning psychology plus the factors (both internal and external) that influence the decision-making process are crucial to change medication-taking behavior and improving adherence7. Recent times have seen increasing use of behavioral methods for enhancing adherence to therapies and improving lifestyle practices. For more on this please read our article “Methods of behavior change in medication non-adherence”
Nudging in healthcare is a theory-driven behavioral intervention employed to influence patients’ choices and decision-making processes to change health behavior. Nudges can be applied for preventive healthcare, health service provision, long-term care as well as for non-communicable diseases8. Nudge healthcare is a strategy to apply principles of behavioral and social sciences to improve healthcare with modest costs and effort9.
How nudge is different from economic incentives?
Reward-based behavioral techniques or incentives are commonly used by public and private sectors to encourage people to behave in desired ways5. Examples of incentive schemes include the mHealth applications that reward the users in the form of points for every healthy action (swimming, walking, biking, sleeping hours) tracked by the app. These points can be redeemed by the user in the form of money.
However, the use of incentives may create conditional behavior i.e. ‘I’ll only do it if I get the reward’. A study by Volpp et al. on the effects of incentives for weight loss demonstrated that the intervention arm lost more weight than the control group, but they did not keep the weight off once the program ended10.
Understanding nudge healthcare: rethinking what it means to provide care
‘Nudge theory’ by University of Chicago economist and Nobel Laureate Richard H. Thaler and Harvard Law School Professor Cass R. Sunstein is an approach that influences decision-making by modifying the choice architecture for a predictable change in behavior. The theory states that people make decisions based on the potential value of losses and gains rather than the outcome and that people evaluate these losses and gains using certain heuristics11. For heuristics, please read – Heuristics and decision-making: what are the effects on adherence for patients?
To put it in simple words, nudges are interventions that alter the way options are presented, but without forbidding any of them. This enables individuals to select the best option that matches their interests and expectations. As a result, the change in behavior of the patient is often subconscious and achieved without instructing a person to do so. A common nudging example is the display of calorie counts in food articles. If packaging displays calorie or sugar counts, it discourages unhealthy eating. As reported by Cioffi et al., nutrition labeling on packaged foods reflected a small but significant reduction in the purchase of high-calorie food and an increase in the purchase of low-calorie foods12.
A nudge has three basic features8:
- it does not force people to engage in a particular behavior,
- it preserves freedom of choice, and
- it does not offer economic incentives.
The nudge theory has gained popularity in various fields such as digital and AI, marketing, and others.Health systems have incorporated nudge therapy in recent years to improve clinical decision-making. Following are a few nudge theory examples in healthcare.
Examples of nudges in healthcare: Medication adherence
Non-adherence to statin therapy is a common issue as >50% of patients are non-compliant with medications resulting in poor cardiovascular outcomes. A recently concluded clinical trial, ENCOURAGE by Benjamine Horne and colleagues, successfully demonstrated the use of behavioral nudging for enhancing adherence to statin treatment over a course of 12 months. The study included 186 participants with baseline LDL-C of 82.5±32.7 mg/dL and a history of coronary disease (93.4%) as well as type 2 diabetes (39.0%) at the study initiation. The study measured adherence as a proportion of days covered (PDC) through insurance claims data. The interventional arm received multiple distinct nudges, 13.4% of nudges were delivered through computer-generated e-mails, 78.4% of nudges were delivered via text messages, and 8.2% of nudge therapy delivered with interactive voice response telephone calls at weeks 13, 26, 39, and 52. Nudges were developed and delivered by person-centered patient engagement platforms1.
A few of the text messages included were:
- Congrats! You Rank No. 1 in comparison to the rest of the participants! You’re almost there and keep responding! Did you manage to take all your meds last week? Text ‘Yes or ‘No in reply.
- Have noticed that you took all your meds the week before without fail. Good work! Continue doing it. Did you take all your meds this week? Text ‘Yes’ or ‘No’ in reply1.
The rate of adherence to statin therapy at the end of 12 months was on average higher in the nudge group as compared to the control (PDC: 74% vs. 64%, P = 0.042). Moreover, The percentage of adherent patients (PDC >80%) was also higher in the nudge group as compared to the control (66.3% vs 50.5%, P = 0.036) (Figure 1)1.
Figure 1: A higher percentage of patients were adherent to statin therapy in the intervention group receiving nudge as compared to controls (adapted from Horne et al., 20218)
Examples of nudges in healthcare: Lifestyle improvement
Nudge has also been utilized to influence healthier lifestyle choices. Fakir et al. used nudges to reduce tobacco consumption and encourage healthier lifestyle choices among Char Dwellers in Bangladesh3. The study used the following two nudge interventions:
- Logbook – Participants recorded their total smoking and use of smokeless tobacco products, and their estimated monetary cost in a pictorial logbook daily.
- Posters – Participants were nudged with two graphical posters in their sleeping quarters as visual reminders of the health costs of smoking.
- One poster depicted a male giving a piggyback ride to a child while smoking a cigarette
- The other poster showed the effect of smokeless tobacco product consumption on a pregnant woman and in-utero child.
The data from the study showed a reduction, although non-significant, in breath carbon monoxide levels (logbook: ~10%, poster: 8.7%) as well as the household’s expenditure on tobacco (logbook: 22.8%, poster: 25.3%) in the intervention groups3.
Examples of nudges in healthcare: Preventive care
Nudges have also been employed in preventive healthcare as demonstrated by Elia et al. for preventing contagious infections2. Despite the proven benefits of hand hygiene, people fail to adopt this healthy behavior. The study evaluated nudging as an approach to improve hand hygiene in hospitals. Usually, dispensers are mounted near the entrance of wards along with the information chart. The study used the following ways to nudge enhancement of hand hygiene:
- Mounting sanitizer dispensers at the foot of the patient’s bed.
- Displaying colorful visual reminders near each sanitizer dispenser.
- Posters promoting hand hygiene at commonly used visible places.
The study demonstrated enhanced compliance to correct hand sanitizing procedures in the post-intervention phase as compared to the initiation stage (18.71% vs. 11.45% )2.
Examples of nudges in healthcare: Organ donation
Worldwide, the demand for organ transplants outstrips the supply. An example of the nudge theory in healthcare is its use in boosting organ donations as seen with the opt-out vs. opt-in consent system13.
- The opt-out system concedes that all adults are considered to be organ donors unless they express their refusal in life.
- The Opt-in system allows people to express their will to donate their organs.
A study by Shepherd et al., comparing the data of organ donation and transplant in 48 countries over 13 years reported that the number of deceased donor rates was higher in opt-out than opt-in consent system, while the number of living donors was higher in opt-in consent system. Overall, both the liver and kidney transplant rates were higher in opt-out consent systems13.
Nudge theory in healthcare: Key considerations and best practices
Nudges in healthcare can be designed in several ways with a focus on optimizing and tailoring as per patients’ needs. Nudge therapeutics can range from small steps such as frequent messaging to guiding choices through defaults that exert a stronger influence.
Three steps to design an effective nudge are8:
- Identify target behavior: The foundation for nudging in healthcare depends on appropriately defined target behavior that is specific, clear, and meaningful. Once the target behavior is identified, it aids in identifying the specific intervention.
- Determine friction and fuel of the patient’s behavior: The second important step towards designing successful nudges in healthcare is to identify potential barriers and enablers that may pose a threat or promote the target population’s uptake. Identifying the right barriers and enablers is required for designing nudge tailored to the needs of the patient
- Design and implement nudges in healthcare: Among the available frameworks to design an effective nudge, the EAST framework can be useful. Developed by the U.K. BIT, it considers that the key pillars of behavioral nudging are that a nudge therapy should be easy to implement, attractive, social, and timely.
The success rates of treatments are determined by both clinician’s decisions and patient actions. It is the action of the patient outside the controlled environment that leads to the efficacy and effectiveness of the treatment. Nudging examples presented above suggest that nudging in healthcare is an effective approach to promote changes in patient behavior and can be used to improve medication adherence in conjugation with other conventional tools. For more on Nudge in improving adherence please read our article “Nudging” patients towards better adherence to improve outcomes
1. Horne BD, Muhlestein JB, Lappe DL, et al. Behavioral Nudges as Patient Decision Support for Medication Adherence: The ENCOURAGE Randomized Controlled Trial. Am Heart J. Feb 2022;244:125-134. doi:10.1016/j.ahj.2021.11.001
2. Elia F, Calzavarini F, Bianco P, et al. A nudge intervention to improve hand hygiene compliance in the hospital. Intern Emerg Med. Oct 2022;17(7):1899-1905. doi:10.1007/s11739-022-03024-7
3. Fakir AMS, Bharati T. Healthy, nudged, and wise: Experimental evidence on the role of information salience in reducing tobacco intake. Health Econ. Jun 2022;31(6):1129-1166. doi:10.1002/hec.4509
4. Jon M. Jachimowicz JJG, Dan Berry, Charlotte l. Kirkdale, Tracey Thornley and Adam D. Galinsky. Making medications stick: improving medication adherence by highlighting the personal health costs of non-compliance. Behavioural Public Policy. 2019;5(3):396-416. . doi:10.1017/bpp.2019.1
5. Vlaev I, King D, Darzi A, Dolan P. Changing health behaviors using financial incentives: a review from behavioral economics. BMC Public Health. Aug 7 2019;19(1):1059. doi:10.1186/s12889-019-7407-8
6. Gadkari AS, McHorney CA. Unintentional non-adherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res. Jun 14 2012;12:98. doi:10.1186/1472-6963-12-98
7. Easthall C, Song F, Bhattacharya D. A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication adherence. BMJ Open. Aug 9 2013;3(8)doi:10.1136/bmjopen-2013-002749
8. Murayama H, Takagi Y, Tsuda H, Kato Y. Applying Nudge to Public Health Policy: Practical Examples and Tips for Designing Nudge Interventions. Int J Environ Res Public Health. Feb 23 2023;20(5)doi:10.3390/ijerph20053962
9. Sant’Anna A, Vilhelmsson A, Wolf A. Nudging healthcare professionals in clinical settings: a scoping review of the literature. BMC Health Serv Res. Jun 2 2021;21(1):543. doi:10.1186/s12913-021-06496-z
10. Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA. Dec 10 2008;300(22):2631-7. doi:10.1001/jama.2008.804
11. Richard H. Thaler CRS. Nudge: Improving decisions about health, wealth, and happiness. Yale University Press; 2008.
12. Cioffi CE, Levitsky DA, Pacanowski CR, Bertz F. A nudge in a healthy direction. The effect of nutrition labels on food purchasing behaviors in university dining facilities. Appetite. Sep 2015;92:7-14. doi:10.1016/j.appet.2015.04.053
13. Shepherd L, O’Carroll RE, Ferguson E. An international comparison of deceased and living organ donation/transplant rates in opt-in and opt-out systems: a panel study.BMC Med. 2014 Sep 24;12:131. doi: 10.1186/s12916-014-0131-4.