Changing behaviour isn’t easy, but maintaining behaviour change is even harder.
We know that by the tiny number of New Year’s resolutions we actually manage to keep, the number of gym memberships that are rarely used, the high relapse rates in people who have stopped smoking.
Behavioural economics is an important behavioural science that helps to explain our behaviour. Its importance in our current way of thinking and understanding human behaviour has been recognised in the award of Nobel prizes to two eminent behavioural economists: Daniel Kahneman and most recently, Richard Thaler. This approach to understanding behaviour is of the moment; governments and academic institutions have departments specifically devoted to this approach to behaviour change through choice architecture, nudging us to make the best choices for ourselves or society in finance, social responsibility and, increasingly, in health.
How nudges can change behaviour
Nudges tap into the automatic processing in the brain, the decision-making that we are not even aware of.
They build on an understanding of how we are generally programmed to behave in predictably irrational ways: that we like to stick with what we know, that we fear losing something we have more than we want to acquire something new, that we give more weight to messages from people we like and trust, that we respond to emotional stimuli, that we like to belong to a group, that we feel uncomfortable if we don’t keep promises we have made – and many other unconscious biases that drive our behaviour.
There is good evidence across different sectors that nudges can effectively change behaviour in relation to specific one-off or short-term decisions. They have successfully increased saving, reduced tax evasion, reduced energy wastage, reduced medication errors in hospitals and reduced non-attendance rates for doctors’ appointments. They have also
shown short-term effects in
reducing obesity, increasing hand-washing in hospitals and changing risky sexual behaviour in teenagers.
So, nudges seem to be effective when they are targeting one-off or infrequently-made decisions because they set a new default option and we then don’t pay any further attention to them unless our circumstances change.
Maintaining behaviour change
There is less convincing evidence that nudges alone are able to maintain a change in behaviour permanently or over a longer term in relation to decisions that we make frequently; for example, how much and what we eat, whether to have a cigarette, increase physical activity, take medication effectively as recommended, or which treatment to prescribe.
Nudges aimed at reducing obesity through paying incentives to lose weight are very effective in the short term (around half of people in the incentive interventions groups achieved their target weight loss compared with only 10.5% in the control group), but these effects wear off and after seven months there is no statistically significant difference between the incentive and the control groups. The same is true in smoking cessation. In a systematic review of the effectiveness of nudges based on incentives and competition (including investing their own money), only one of 19 initiatives was still effective after six months. Even the well-known, creative nudges don’t necessarily change behaviour outside their specific context. The effectiveness of the fly in the urinals at Schipol airport may not translate to a generalised behaviour change in other urinals.
So why is it more difficult for interventions based on nudges alone to achieve sustained behaviour change? The answer is that sustained behaviour change is complex – there are a multitude of different factors driving our behaviour and working to maintain it, to keep us doing the same thing time and time again.
Decision-making factors
After all, nudges only tap into one of the factors that drive our decision-making but there are a multitude of other factors that drive our behaviour: our experiences, expectations, drivers and motivations and, of course, the cultural and healthcare environment we operate within.
In order to achieve sustained behaviour change in relation to most health-related behaviour (adherence, weight loss, exercise, smoking cessation, clinical management/prescribing), we need a thorough understanding of all the different factors driving the behaviour so that we can work out what else we need to do to change behaviour. We need additional multifaceted interventions based on firm evidence about what is actually driving behaviour to target all these key factors – including our automatic processing. We need to provide an environment in which our nudges can be enhanced and supported.
Fiona Hammond is managing director of Hamell (fiona@hamell.co.uk)
