Nudge

Behavioural insight, also known as ‘Nudge’, after the book by Thaler and Sunstein,1 is based on behavioural science and economics.  ‘Nudge’ is sometimes called libertarian paternalism.

The use of nudge in health is rooted in the idea of influencing our behaviour without compulsion e.g. by using subconscious cues to ‘nudge’ us towards making healthy choices or manipulating the environment to increase the chances that people act in a way that they would have chosen themselves.

A study by Ipsos Mori showed that most people recognise the role of the individual in improving their own health and whilst some also believe that government has a role to play, they do not want government interference in their personal health choices.2 If people are ‘nudged’, they still believe that they have made a personal choice, but Government has made it easier for them to ‘make the right choice’.

Examples of ‘nudges’ might work include informing us that assumptions about normal behaviour are incorrect e.g. informing students how much alcohol their peers really drink (as opposed to what they might assume is the case),3 making healthy food more prominent in workplace canteens4 or directing people to the stairs rather than the elevator.

The use of behavioural insight was included in the Coalition Commitment in May 20105 and then embedded in the public health white paper.6 The behavioural insights team in the Cabinet Office, made up of academics and civil servants, works to implement behavioural insight into areas such as public health.7

Many people regard behavioural insight as a means for government to avoid expensive legislation and regulation, but the Cabinet office view it as a complementary tool.8

At present there is a lack of well evaluated projects using ‘nudge’ in public health.

Evidence of the possible benefits

There is some evidence to demonstrate nudging works.8-10 Incentives have been shown to affect weight loss: people taking part in schemes where they deposited money that is forfeited if they do not attain their goals were successful in the short-term.8 In another study, smokers taking part in savings schemes were more likely to give up if, on proving they had quit, they were given access to their savings.10

However, there is not yet a good evidence base for the application of behavioural insight in public health, which is why the Cabinet Office is supporting a number of public health teams to develop an evidence base for this area.

Evidence of the possible risks

Focusing on individual responsibility is a key risk. Geoffrey Rose suggested in 1992 that population-level interventions could have a greater effect on public health than individual-level interventions13 and there is a range of evidence for this (for example, see 14).

There are also potential problems transposing schemes that have been shown to work in countries other than the UK, due to cultural differences.

The ‘nudge’ approach to behaviour change does not yet have a track record in public health, although it has been argued that many of the concepts are common to current behaviour change theory.3

Any implications for health and well-being

Health threatening behaviours are a common cause of premature illness and death in the developed world,15 but this area is underfunded.16,17 If we could identify behavioural interventions that work, there is potential to make great improvements in public health.

‘Nudge’ may prove a useful adjunct to current practice in behaviour change, but research will be needed on the application of findings from behavioural science and economics to health.

Author: Allison J Duggal PhD, Specialty Registrar Public Health, London Deanery