Thursday, March 23, 2017

Behavioual Science & Health: Links and Resources

I spoke recently at several venues on behavioural economics, behavioural science, and health. Below is a sample of useful papers on these areas, again intended to stimulate some discussion in the Irish context. The interplay between disciplines such as health psychology, public health, behavioural medicine, and behavioural economics is a particularly interesting discussion to have. Furthermore, it would be good to discuss further the extent to which behavioural research and teaching should be embedded into medical training in Ireland.  Thanks again to Sarah Breathnach who is helping on compiling resources for this blog. 

General Papers

Behavioural Economics & Health: Kessler & Zhang (2014)

Behavioral Economics combines the insights of Economics and Psychology to identify how individuals deviate from the standard assumptions of economic theory and to build systematic deviations into improved models of human behavior. These models allow researchers to better describe and predict individual behavior. Lessons from Behavioral Economics can be leveraged to design large-scale public health interventions and achieve policy goals. This chapter begins with a broad overview of Behavioral Economics and identifies settings in which policy makers may wish to intervene in health decisions. The rest of the chapter explores four major topic areas within Behavioral Economics — reward incentives, information and salience, context and framing, and social forces — and investigates their influence on health behaviors including medication adherence, obesity and weight control, and medical donation. Within each of the four topic areas we discuss the relevant predictions of standard economic theory, we provide evidence of the behavioral forces that lead individuals to deviate from these predictions, and then we describe various public health interventions that have leveraged the lessons of Behavioral Economics to achieve policy goals.

Kessler, J. B., & Zhang, C. Y. (2014). Behavioral Economics and Health. Paper for Oxford Textbook of Public Health. Available at:

Behavioral Economics and Health Economics. Frank (2014)

The health sector is filled with institutions and decision-making circumstances that create friction in markets and cognitive errors by decision makers. This paper examines the potential contributions to health economics of the ideas of behavioral economics. The discussion presented here focuses on the economics of doctor-patient interactions and some aspects of quality of care. It also touches on issues related to insurance and the demand for health care. The paper argues that long standing research impasses may be aided by applying concepts from behavioral economics.

Frank, R. G. (2004). Behavioral economics and health economics (No. w10881). National Bureau of Economic Research. Available from

The Behavioral Economics of Health and Health Care (2013)

People often make decisions in health care that are not in their best interest, ranging from failing to enroll in health insurance to which they are entitled, to engaging in extremely harmful behaviors. Traditional economic theory provides a limited tool kit for improving behavior because it assumes that people make decisions in a rational way, have the mental capacity to deal with huge amounts of information and choice, and have tastes endemic to them and not open to manipulation. Melding economics with psychology, behavioral economics acknowledges that people often do not act rationally in the economic sense. It therefore offers a potentially richer set of tools than provided by traditional economic theory to understand and influence behaviors. Only recently, however, has it been applied to health care. This article provides an overview of behavioral economics, reviews some of its contributions, and shows how it can be used in health care to improve people's decisions and health.

Rice, T. (2013). The behavioral economics of health and health care. Annual review of public health, 34, 431-447.

Asymmetric Paternalism to Improve Health Behaviors (2007).

Individual behavior plays a central role in the disease burden faced by society. Many major health problems in the United States and other developed nations, such as lung cancer, hypertension, and diabetes, are exacerbated by unhealthy behaviors. Modifiable behaviors such as tobacco use, overeating, and alcohol abuse account for nearly one-third of all deaths in the United States.1,2 Moreover, realizing the potential benefit of some of the most promising advances in medicine, such as medications to control blood pressure, lower cholesterol levels, and prevent stroke, has been stymied by poor adherence rates among patients.3 For example, by 1 year after having a myocardial infarction, nearly half of patients prescribed cholesterol-lowering medications have stopped taking them.4 Reducing morbidity and mortality may depend as much on motivating changes in behavior as on developing new treatments.5

Loewenstein, G., Brennan, T., & Volpp, K. G. (2007). Asymmetric paternalism to improve health behaviors. Jama, 298(20), 2415-2417. Available from$FILE/080214%20Attach%20H.pdf

Health-Related Behaviour Change Papers

Some current dimensions of the behavioral economics of health-related behavior change (2016).

Health-related behaviors such as tobacco, alcohol and other substance use, poor diet and physical inactivity, and risky sexual practices are important targets for research and intervention. Health-related behaviors are especially pertinent targets in the United States, which lags behind most other developed nations on common markers of population health. In this essay we examine the application of behavioral economics, a scientific discipline that represents the intersection of economics and psychology, to the study and promotion of health-related behavior change. More specifically, we review what we consider to be some core dimensions of this discipline when applied to the study health-related behavior change. Behavioral economics (1) provides novel conceptual systems to inform scientific understanding of health behaviors, (2) translates scientific understanding into practical and effective behavior-change interventions, (3) leverages varied aspects of behavior change beyond increases or decreases in frequency, (4) recognizes and exploits trans-disease processes and interventions, and (5) leverages technology in efforts to maximize efficacy, cost effectiveness, and reach. These dimensions are overviewed and their implications for the future of the field discussed.

Bickel, W. K., Moody, L., & Higgins, S. T. (2016). Some current dimensions of the behavioral economics of health-related behavior change. Preventive medicine92, 16-23. Available from

‘Nudging’ behaviours in healthcare: insights from behavioural economics (2015).

Since the creation of the Behavioural Insight Team (BIT) in 2010, the word “nudge” has become a popular one in social and public policy. According to policy makers and managers, applications of behavioural economics to public sector management results in increased policy efficiency and savings. In the present article, we offer a critical perspective on the topic and discuss how the application of behavioural economics can foster innovative healthcare management. We first review behavioural economics principles, and show how these can be used in healthcare management. Second, we discuss the methodological aspects of applying behavioural economics principles. Finally, we discuss limitations and current issues within the field.

Voyer, B. G. (2015). ‘Nudging’behaviours in healthcare: Insights from behavioural economics. British Journal of Healthcare Management, 21(3), 130-135. Available from:

Decision-Based Disorders: The Challenge of Dysfunctional Health Behavior and the Need for a Science of Behavior Change. (2017)

Dysfunctional health behavior is a contemporary challenge, exemplified by the increasingly significant portion of health problems stemming from people’s own behavior and decision making. The challenge not only includes the direct consequences of unhealthy behavioral patterns but also their origins and the creation of policies that effectively decrease their frequency. A framework rooted in behavioral economics identifies the processes and mechanisms underlying poor health. Two behavioral economic processes, economic demand and delay discounting, are discussed in detail. Through continued development, this behavioral economic framework can guide improved outcomes in treatment and policies related to dysfunctional health behavior. Approaches are evolving to alter demand and discounting. Current and prospective policies aimed at decreasing unhealthy behavior may profit from such research.

Bickel, W. K., Pope, D. A., Moody, L. N., Snider, S. E., Athamneh, L. N., Stein, J. S., & Mellis, A. M. (2017). Decision-Based Disorders: The Challenge of Dysfunctional Health Behavior and the Need for a Science of Behavior Change. Policy Insights from the Behavioral and Brain Sciences, 2372732216686085.

Health Behavior Change: Moving from Observation to Intervention (2017).

How can progress in research on health behavior change be accelerated? Experimental medicine (EM) offers an approach that can help investigators specify the research questions that need to be addressed and the evidence needed to test those questions. Whereas current research draws predominantly on multiple overlapping theories resting largely on correlational evidence, the EM approach emphasizes experimental tests of targets or mechanisms of change and programmatic research on which targets change health behaviors and which techniques change those targets. There is evidence that engaging particular targets promotes behavior change; however, systematic studies are needed to identify and validate targets and to discover when and how targets are best engaged. The EM approach promises progress in answering the key question that will enable the science of health behavior change to improve public health: What strategies are effective in promoting behavior change, for whom, and under what circumstances?

Sheeran, P., Klein, W. M., & Rothman, A. J. (2017). Health behavior change: Moving from observation to intervention. Annual Review of Psychology68, 573-600.

Behavioral economic incentives to improve adherence to antiretroviral medication (2017).

Objective: Fixed incentives have been largely unsuccessful in improving adherence to antiretroviral medication. Therefore, we evaluate whether small incentives based on behavioral economic theory can increase adherence to antiretroviral medication among treatment-mature adults in Kampala, Uganda.
Design: A randomized control trial design tests whether providing small incentives based on either attending timely clinic visits (intervention group 1) or achieving high medication adherence (intervention group 2) can increase antiretroviral adherence. Antiretroviral adherence is measured by medical event monitoring system (MEMS) caps.
Methods: Overall, 155 HIV-infected men and women age 19-78 were randomized into one of two intervention groups and received small prizes of US $1.50 awarded through a drawing conditional on either attending scheduled clinic appointments or achieving at least 90% antiretroviral adherence. The control group received the usual standard of care.
Results: Preliminary results based on pooling the intervention groups showed individuals receiving incentives were 23.7 percentage points more likely to achieve 90% antiretroviral adherence compared with the control group [95% confidence interval (CI), 6.7-40.7%]. Specifically, 63.3% (95% CI, 52.9-72.8%) of participants in the pooled intervention groups maintained at least 90% mean adherence during the first 9 months of the intervention, compared with 39.6% (95% CI, 25.8-54.7%) in the control group.
Conclusion: Small prize incentives resulted in a statistically significant increase in antiretroviral adherence. Although more traditional fixed incentives have not produced the desired results, these findings suggest that small incentives based on behavioral economic theory may be more effective in motivating long-term adherence among treatment-mature adults.

Linnemayr, S., Stecher, C., & Mukasa, B. (2017). Behavioral economic incentives to improve adherence to antiretrovirals: early evidence from a randomized controlled trial in Uganda. AIDS.

A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy (2010)

Background: Current reporting of intervention content in published research articles and protocols is generally poor, with great diversity of terminology, resulting in low replicability. This study aimed to extend the scope and improve the reliability of a 26-item taxonomy of behaviour change techniques developed by Abraham and Michie [Abraham, C. and Michie, S. (2008). A taxonomy of behaviour change techniques used in interventions. Health Psychology27(3), 379–387.] in order to optimise the reporting and scientific study of behaviour change interventions. Methods: Three UK study centres collaborated in applying this existing taxonomy to two systematic reviews of interventions to increase physical activity and healthy eating. The taxonomy was refined in iterative steps of (1) coding intervention descriptions, and assessing inter-rater reliability, (2) identifying gaps and problems across study centres and (3) refining the labels and definitions based on consensus discussions. Results: Labels and definitions were improved for all techniques, conceptual overlap between categories was resolved, some categories were split and 14 techniques were added, resulting in a 40-item taxonomy. Inter-rater reliability, assessed on 50 published intervention descriptions, was good (kappa = 0.79). Conclusions: This taxonomy can be used to improve the specification of interventions in published reports, thus improving replication, implementation and evidence syntheses. This will strengthen the scientific study of behaviour change and intervention development.

Michie, S., & Abraham, C. (2004). Interventions to change health behaviours: evidence-based or evidence-inspired? Psychology & Health19(1), 29-49.

Testing whether decision aids introduce cognitive biases: Results of a randomized trial (2010).

Objective: Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases. Methods: We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design. Results: Participants were susceptible to a cognitive bias – an order effect – such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks. Conclusion: We discovered that the order of risk/benefit information influenced women's perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks. Practice implications: We have demonstrated the feasibility of using factorial experimental designs to test whether DAs introduce cognitive biases, and whether specific elements of DAs can reduce such biases.

Ubel, P. A., Smith, D. M., Zikmund-Fisher, B. J., Derry, H. A., McClure, J., Stark, A., ... & Fagerlin, A. (2010). Testing whether decision aids introduce cognitive biases: results of a randomized trial. Patient education and counseling80(2), 158-163.
Overconfidence as a Cause of Diagnostic Error in Medicine (2008).

The great majority of medical diagnoses are made using automatic, efficient cognitive processes, and these diagnoses are correct most of the time. This analytic review concerns the exceptions: the times when these cognitive processes fail and the final diagnosis is missed or wrong. We argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. We present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.

Berner, E. S., & Graber, M. L. (2008). Overconfidence as a cause of diagnostic error in medicine. The American journal of medicine121(5), S2-S23.

A Meta-analysis of the Effects of Presenting Treatment Benefits in Different Formats (2007)

Purpose: The purpose of this article is to examine the effects of presenting treatment benefits in different formats on the decisions of both patients and health professionals. Three formats were investigated: relative risk reductions, absolute risk reductions, and number needed to treat or screen. Methods: A systematic review of the published literature was conducted. Articles were retrieved by searching a variety of databases and screened for inclusion by 2 reviewers. Data were extracted on characteristics of the subjects and methodologies used. Log-odds ratios were calculated to estimate effect sizes. Results: A total of 24 articles were retrieved that reported on 31 unique experiments. The meta-analysis showed that treatments were evaluated more favorably when the relative risk format was used rather than the absolute risk or number needed to treat format. However, a significant amount of heterogeneity was found between studies, the sources of which were explored using subgroup analyses and meta-regression. Although the subgroup analyses revealed smaller effect sizes in the studies conducted on physicians, the meta-regression showed that these differences were largely accounted for by other features of the study design. Most notably, variations in effect sizes were explained by the particular wordings that the studies had chosen to use for the relative risk and absolute risk reductions. Conclusions: The published literature has consistently demonstrated that relative risk formats produce more favorable evaluations of treatments than absolute risk or number needed to treat formats. However, the effects are heterogeneous and seem to be moderated by key differences between the methodologies used.

Covey, J. (2007). A meta-analysis of the effects of presenting treatment benefits in different formats. Medical Decision Making27(5), 638-654.
Designing and implementing behaviour change interventions to improve population health (2008).

Improved population health depends on changing behaviour: of those who are healthy (e.g. stopping smoking), those who are ill (e.g. adhering to health advice) and those delivering health care. To design more effective behaviour change interventions, we need more investment in developing the scientific methods for studying behaviour change. Behavioural science is relevant to all phases of the process of implementing evidence-based health care: developing evidence through primary studies, synthesizing the findings in systematic reviews, translating evidence into guidelines and practice recommendations, and implementing these in practice. 'Behaviour change: Implementation and Health', the last research programme to be funded within the MRC HSRC, aimed to develop innovative ways of applying theories and techniques of behaviour change to understand and improve the implementation of evidence-based practice, as a key step to improving health. It focused on four areas of study that apply behaviour change theory:defining and developing a taxonomy of behaviour change techniques to allow replication of studies and the possibility of accumulating evidence; conducting systematic reviews, by categorizing and synthesizing interventions on the basis of behaviour change theory; investigating the process by which evidence is translated into guideline recommendations for practice; developing a theoretical framework to apply to understanding implementation problems and designing interventions. This work will contribute to advancing the science of behaviour change by providing tools for conceptualizing and defining intervention content, and linking techniques of behaviour change to their theoretical base.

Michie, S. (2008). Designing and implementing behaviour change interventions to improve population health. Journal of health services research & policy, 13(suppl 3), 64-69.

Medical Decision Making Papers

Making better decisions: From measuring to constructing preferences. Johnson, Steffel & Goldstein (2005).

The authors examine how a constructive preferences perspective might change the prevailing view of medical decision making by suggesting that the methods used to measure preferences for medical treatments can change the preferences that are reported. The authors focus on 2 possible techniques that they believe would result in better outcomes. The 1st is the wise selection of default options. Defaults may be best applied when strong clinical evidence suggests a treatment option to be correct for most people but preserving patient choice is appropriate. The 2nd is the use of environments that explicitly facilitate the optimal construction of preferences. This seems most appropriate when choice depends on a patient's ability to understand and represent probabilities and outcomes. For each technique, the authors describe the background and literature, provide a case study, and discuss applications.

Johnson, E. J., Steffel, M., & Goldstein, D. G. (2005). Making better decisions: from measuring to constructing preferences. Health Psychology, 24(4S), S17. Available from:

Transplantation at the Nexus of Behavioral Economics and Health Care Delivery (2012).

The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous health-related risks and under the potential influence of considerable regulatory and institutional pressures. This decision affects the health of two distinct populations, those patients receiving organ transplants and those waiting to receive a transplant; it also influences the physician's life and their institute's productivity. The numerous, at times nonaligned, incentives established by the complex clinical and regulatory environment, have been derived specifically to influence physicians’ behaviors, and though well intended, may lead to responses that are nonoptimal when considering the myriad stakeholders being influenced. This may compromise the quality of care provided to the population at risk, and has potential to influence the physician–patient relationship. A synergistic collaboration between transplant physicians and economists that is focused on this decision environment may help to alleviate these strains. This viewpoint discusses behavioral economic principles and how they might be applied to transplantation. Specifically, the previous medical decision-making literature on transplantation will be reviewed and a discussion on how a behavioral model of physician decision making can be utilized will be explored. To date this approach has not been integrated into transplantation decision making.

Schnier, K. E., Cox, J. C., McIntyre, C., Ruhil, R., Sadiraj, V., & Turgeon, N. (2013). Transplantation at the nexus of behavioral economics and health care delivery. American Journal of Transplantation13(1), 31-35. Available From:

The Psychology of Medical Decision Making (2004)

Good decision making is an essential part of good medicine. Patients have to decide what symptoms warrant seeking medical attention and whether to accept the medical advice received. Physicians have to decide what diagnosis is most likely and what treatment plan to recommend. Health policy makers have to decide what health behaviors to encourage and what medical interventions to pay for. The study of the psychology of decision making should therefore have much to offer to the field of medicine. Conversely, medicine should provide a useful test bed for the study of decisions made by experienced decision makers about high-stakes outcomes. The current chapter reviews six intersections between the psychology of decision making and medicine.

Chapman, G. B. (2004). The psychology of medical decision making. 2004). Blackwell Handbook of Judgment and Decision Making. Malden (MA), Blackwell Publishing Ltd, 585-603. Available from:

How numeracy influences risk comprehension and medical decision making (2009).

We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medical decisions. Low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication (limiting prevention efforts among the most vulnerable), and, based on the scant research conducted on outcomes, appears to adversely affect medical outcomes. Low numeracy is also associated with greater susceptibility to extraneous factors (i.e., factors that do not change the objective numerical information). That is, low numeracy increases susceptibility to effects of mood or how information is presented (e.g., as frequencies vs. percentages) and to biases in judgment and decision making (e.g., framing and ratio bias effects). Much of this research is not grounded in empirically supported theories of numeracy or mathematical cognition, which are crucial for designing evidence-based policies and interventions that are effective in reducing risk and improving medical decision making. To address this gap, we outline four theoretical approaches (psychophysical, computational, standard dual-process, and fuzzy trace theory), review their implications for numeracy, and point to avenues for future research.

Reyna, V. F., Nelson, W. L., Han, P. K., & Dieckmann, N. F. (2009). How numeracy influences risk comprehension and medical decision making. Psychological bulletin135(6), 943.

Rationality in medical decision making: a review of the literature on doctors’ decision-making biases (2001).

The objectives of this study were to describe ways in which doctors make suboptimal diagnostic and treatment decisions, and to discuss possible means of alleviating those biases, using a review of past studies from the psychological and medical decision-making literatures. A number of biases can affect the ways in which doctors gather and use evidence in making diagnoses. Biases also exist in how doctors make treatment decisions once a definitive diagnosis has been made. These biases are not peculiar to the medical domain but, rather, are manifestations of suboptimal reasoning to which people are susceptible in general. None the less, they can have potentially grave consequences in medical settings, such as erroneous diagnosis or patient mismanagement. No surefire methods exist for eliminating biases in medical decision making, but there is some evidence that the adoption of an evidence-based medicine approach or the incorporation of formal decision analytic tools can improve the quality of doctors’ reasoning. Doctors’ reasoning is vulnerable to a number of biases that can lead to errors in diagnosis and treatment, but there are positive signs that means for alleviating some of these biases are available.

Bornstein, B. H., & Emler, A. C. (2001). Rationality in medical decision making: a review of the literature on doctors’ decision‐making biases. Journal of evaluation in clinical practice7(2), 97-107.

The Beguiling Pursuit of More Information (2001).

Background: The authors tested whether clinicians make different decisions if they pursue information than if they receive the same information from the start. Methods: Three groups of clinicians participated (N = 1206): dialysis nurses (n = 171), practicing urologists (n = 461), and academic physicians (n = 574). Surveys were sent to each group containing medical scenarios formulated in 1 of 2 versions. The simple version of each scenario presented a choice between 2 options. The search version presented the same choice but only after some information had been missing and subsequently obtained. The 2 versions otherwise contained identical data and were randomly assigned. Results: In one scenario involving a personal choice about kidney donation, more dialysis nurses were willing to donate when they first decided to be tested for compatibility and were found suitable than when they knew they were suitable from the start (65% vs. 44%, P =0.007). Similar discrepancies were found in decisions made by practicing urologists concerning surgery for a patient with prostate cancer and in decisions of academic physicians considering emergency management for a patient with acute chest pain. Conclusions: The pursuit of information can increase its salience and cause clinicians to assign more importance to the information than if the same information was immediately available. An awareness of this cognitive bias may lead to improved decision making in difficult medical situations.
Redelmeier, D. A., Shafir, E., & Aujla, P. S. (2001). The beguiling pursuit of more information. Medical Decision Making21(5), 376-381.

Problems for clinical judgement: 5 Principles of influence in medical practice (2002)

THE BASIC SCIENCE OF PSYCHOLOGY HAS IDENTIFIED specific ingrained responses that are fundamental elements of human nature, underpin common influence strategies and may apply in medical settings. People feel a sense of obligation to repay a perceived debt. A request becomes more attractive when preceded by a marginally worse request. The drive to act consistently will persist even if demands escalate. Peer pressure is intense when people face uncertainty. The image of the requester influences the attractiveness of a request. Authorities have power beyond their expertise. Opportunities appear more valuable when they appear less available. These 7 responses were discovered decades ago in psychology research and seem intuitively understood in the business world, but they are rarely discussed in medical texts. An awareness of these principles can provide a framework for physicians to help patients change their behaviour and to understand how others in society sometime alter patients' choices.

Redelmeier, D. A., & Cialdini, R. B. (2002). Problems for clinical judgement: 5. Principles of influence in medical practice. Canadian Medical Association Journal166(13), 1680-1684.

The role of decision analysis in informed consent: Choosing between intuition and systematicity (1997).

An important goal of informed consent is to present information to patients so that they can decide which medical option is best for them, according to their values. Research in cognitive psychology has shown that people are rapidly overwhelmed by having to consider more than a few options in making choices. Decision analysis provides a quantifiable way to assess patients' values, and it eliminates the burden of integrating these values with probabilistic information. In this paper we evaluate the relative importance of intuition and systematicity in informed consent. We point out that there is no gold standard for optimal decision making in decisions that hinge on patient values. We also point out that in some such situations it is too early to assume that the benefits of systematicity outweigh the benefits of intuition. Research is needed to address the question of which situations favor the use of intuitive approaches of decision making and which call for a more systematic approach.

Ubel, P. A., & Loewenstein, G. (1997). The role of decision analysis in informed consent: choosing between intuition and systematicity. Social science & medicine44(5), 647-656.

Medical Decision Making in Situations That Offer Multiple Alternatives (1995).

Objective.  —To determine whether situations involving multiple options can paradoxically influence people to choose an option that would have been declined if fewer options were available. Design.  —Mailed survey containing medical scenarios formulated in one of two versions. Participants.  —Two groups of physicians: members of the Ontario College of Family Physicians (response rate=77%; n=287) and neurologists and neurosurgeons affiliated with the North American Symptomatic Carotid Endarterectomy Trial (response rate=84%; n=352). One group of legislators belonging to the Ontario Provincial Parliament (response rate=32%; n=41). Intervention.  —The basic version of each scenario presented a choice between two options. The expanded version presented three options: the original two plus a third. The two versions otherwise contained identical information and were randomly assigned. Outcome Measures.  —Participants' treatment recommendations. Results.  —In one scenario involving a patient with osteoarthritis, family physicians were less likely to prescribe a medication when deciding between two medications than when deciding about only one medication (53% vs 72%; P<.005). Apparently, the difficulty in deciding between the two medications led some physicians to recommend not starting either. Similar discrepancies were found in decisions made by neurologists and neurosurgeons concerning carotid artery surgery and by legislators concerning hospital closures. Conclusions.  —The introduction of additional options can increase decision difficulty and, hence, the tendency to choose a distinctive option or maintain the status quo. Awareness of this cognitive bias may lead to improved decision making in complex medical situations.

Redelmeier, D. A., & Shafir, E. (1995). Medical decision making in situations that offer multiple alternatives. Jama273(4), 302-305.

Understanding Patients' Decisions: Cognitive and Emotional Perspectives (1993)

Objective.  —To describe ways in which intuitive thought processes and feelings may lead patients to make suboptimal medical decisions. Design.  —Review of past studies from the psychology literature. Results.  —Intuitive decision making is often appropriate and results in reasonable choices; in some situations, however, intuitions lead patients to make choices that are not in their best interests. People sometimes treat safety and danger categorically, undervalue the importance of a partial risk reduction, are influenced by the way in which a problem is framed, and inappropriately evaluate an action by its subsequent outcome. These strategies help explain examples where risk perceptions conflict with standard scientific analyses. In the domain of emotions, people tend to consider losses as more significant than the corresponding gains, are imperfect at predicting future preferences, distort their memories of past personal experiences, have difficulty resolving inconsistencies between emotions and rationality, and worry with an intensity disproportionate to the actual danger. In general, such intangible aspects of clinical care have received little attention in the medical literature. Conclusion.  —We suggest that an awareness of how people reason is an important clinical skill that can be promoted by knowledge of selected past studies in psychology
Redelmeier, D. A., Rozin, P., & Kahneman, D. (1993). Understanding patients' decisions: cognitive and emotional perspectives. Jama270(1), 72-76.

Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care (2016).

Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.

Emanuel, E. J., Ubel, P. A., Kessler, J. B., Meyer, G., Muller, R. W., Navathe, A. S., ... & Sen, A. P. (2016). Using behavioral economics to design physician incentives that deliver high-value carebehavioral economics, physician incentives, and high-value care. Annals of internal medicine164(2), 114-119.

Promising Approaches From Behavioral Economics to Improve Patient Lung Cancer Screening Decisions (2016).

Lung cancer is a devastating disease, the deadliest form of cancer in the world and in the United States. As a consequence of CMS’s determination to provide low-dose CT (LDCT) as a covered service for at-risk smokers, LDCT lung cancer screening is now a covered service for many at-risk patients that first requires counseling and shared clinical decision making, including discussions of the risks and benefits of LDCT screening. However, shared decision making fundamentally relies on the premise that with better information, patients will arrive at rational decisions that align with their preferences and values. Evidence from the field of behavioral economics offers many contrary viewpoints that take into account patient decision making biases and the role of the shared decision environment that can lead to flawed choices and that are particularly relevant to lung cancer screening and treatment. This article discusses some of the most relevant biases, and suggests incorporating such knowledge into screening and treatment guidelines and shared decision making best practices to increase the likelihood that such efforts will produce their desired objectives to improve survival and quality of life.

Barnes, A. J., Groskaufmanis, L., & Thomson, N. B. (2016). Promising approaches from behavioral economics to improve patient lung cancer screening decisions. Journal of the American College of Radiology13(12), 1566-1570.

Health-Policy Papers

Do Defaults Save Lives? Johnson & Goldstein (2003).

Default options can lead to striking differences in preferences, with significant economic impact. The authors of this Policy Forum use natural and experimental data to examine the impact of simple policy defaults on the decision to become an organ donor, finding large effects that significantly increase donation rates.

Johnson, E. J., & Goldstein, D. (2003). Do defaults save lives?. Science, 302(5649), 1338-1339. Available from

Behavioural Insights in Health Care: Nudging to reduce inefficiency & waste (2015)

‘Behavioural insights’ has been described as the ‘application of behavioural science to policy and practice with a focus on (but not exclusively) “automatic” processes’.1 Nudges are a behavioural insights. Nudge-type interventions – approaches that steer people in certain directions while maintaining their freedom of choice2 – recognise that many decisions – and ensuing behaviours – are automatic and not made consciously.3 Nudges have been proposed as an effective way to change behaviour and improve outcomes at lower cost than traditional tools4,5 across a range of policy areas. With health care spending rising and the NHS facing a significant funding gap, it is important to consider ways in which health care might be made more efficient and less wasteful. Given this backdrop, Ipsos MORI was commissioned by the Health Foundation to undertake a quick scoping review, supported and guided by expert interviews, to consider the evidence of and potential for the application of nudge-type interventions to health care for the purpose of improving efficiency and reducing waste.

Perry, C., Chhatralia, K., Damesick, D., Hobden, S., & Volpe, L. (2015). Behavioural insights in health care. London: The Health Foundation, 18-29. Available from

Applying behavioral insights simple ways to improve health outcomes (2016).

Applying new insights about behavior can lead to better health outcomes at a lower cost. This report gives an overview of these insights and shows how they can be applied in practice. It has four key messages: 1. In order to improve health outcomes, we need a better understanding of behavior. 2. Behavioral insights offer new solutions to policy problems. 3. Behavioral insights can improve health and healthcare. 4. Trialing interventions brings important advantages. There are many opportunities to improve health and healthcare worldwide by applying behavioral insights. Many of these opportunities can be realized by applying simple tools to make practical changes. We encourage policymakers to use these tools.

Hallsworth, M., Snijders, V., Burd, H., Prestt, J., Judah, G., Huf, S., & Halpern, D. Applying behavioral insights simple ways to improve health outcomes. Available from:

Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial (2016).

Background: Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England. Methods: In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed. Findings: Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126·98 (95% CI 125·68–128·27) in the feedback intervention group and 131·25 (130·33–132·16) in the control group, a difference of 4·27 (3·3%; incidence rate ratio [IRR] 0·967 [95% CI 0·957–0·977]; p<0·0001), representing an estimated 73 406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135·00 [95% CI 133·77–136·22] in the patient-focused intervention group and 133·98 [133·06–134·90] in the control group; IRR for difference between groups 1·01, 95% CI 1·00–1·02; p=0·105). Interpretation: Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes.

Hallsworth, M., Chadborn, T., Sallis, A., Sanders, M., Berry, D., Greaves, F., ... & Davies, S. C. (2016). Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. The Lancet, 387(10029), 1743-1752.

The Role of Behavioral Science Theory in Development and Implementation of Public Health Interventions (2010).

Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.

Glanz, K., & Bishop, D. B. (2010). The role of behavioral science theory in development and implementation of public health interventions. Annual review of public health, 31, 399-418. Available from:

Beyond carrots and sticks: Europeans support health nudges (2017).

All over the world, nations are using “health nudges” to promote healthier food choices and to reduce the health care costs of obesity and non-communicable diseases. In some circles, the relevant reforms are controversial. On the basis of nationally representative online surveys, we examine whether Europeans favour such nudges. The simplest answer is that majorities in six European nations (Denmark, France, Germany, Hungary, Italy, and the UK) do so. We find majority approval for a series of nudges, including educational messages in movie theaters, calorie and warning labels, store placement promoting healthier food, sweet-free supermarket cashiers and meat-free days in cafeterias. At the same time, we find somewhat lower approval rates in Hungary and Denmark. An implication for policymakers is that citizens are highly likely to support health nudges. An implication for further research is the importance of identifying the reasons for cross-national differences, where they exist.

Reisch, L. A., Sunstein, C. R., & Gwozdz, W. (2017). Beyond carrots and sticks: Europeans support health nudges. Food Policy69, 1-10.

Applying Behavioral Economics to Public Health Policy: Illustrative Examples and Promising Directions (2016)

Behavioral economics provides an empirically informed perspective on how individuals make decisions, including the important realization that even subtle features of the environment can have meaningful impacts on behavior. This commentary provides examples from the literature and recent government initiatives that incorporate concepts from behavioral economics in order to improve health, decision making, and government efficiency. The examples highlight the potential for behavioral economics to improve the effectiveness of public health policy at low cost. Although incorporating insights from behavioral economics into public health policy has the potential to improve population health, its integration into government public health programs and policies requires careful design and continual evaluation of such interventions. Limitations and drawbacks of the approach are discussed.

Matjasko, J. L., Cawley, J. H., Baker-Goering, M. M., & Yokum, D. V. (2016). Applying behavioral economics to public health policy: illustrative examples and promising directions. American journal of preventive medicine50(5), S13-S19.

Behavioural Insights and Healthier Lives (Halpern, 2016)

Discursive Articles

Voyer, B (2015). Behavioral Economics and Healthcare: A Match Made in Heaven. Available from:

Loewenstein, G., Asch, D. A., Friedman, J. Y., Melichar, L. A., & Volpp, K. G. (2012). Can behavioural economics make us healthier? BMJ344(7863), 23-25. Available from

Marteau (2011). Judging nudging: can nudging improve population health? Br. Med. J, 342, 263. Available from:

Additional Resources

Volpp, K., Loewenstein, G., & Asch, D. (2015). Behavioral economics and health. Health Behavior: Theory, Research, and Practice389.

Sola, D., & Couturier, J., Voyer, B.G. (2015), Unlocking patient activation: Coupling e-health solutions coupled with gamification. British Journal of Healthcare Management, 21 (5), pp 223-228

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: theory, research, and practice. John Wiley & Sons. Available online from:

Behavioural Insights Team Blog Health Section:

Chapman, G. B., & Elstein, A. S. (2000). Cognitive processes and biases in medical decision making. Decision making in health care: Theory, psychology, and applications, 183-210.

Tuesday, March 21, 2017

Behavioural Science and Irish Public Policy: Some readings and resources

In the last budget, the Irish Government Economic Evaluation Service (IGEES) released a document summarising the use of behavioural research in Irish government department. This followed a previous report they released summarising behavioural economics more generally (both of these documents are available here). Below gives a list of the different projects covered in the IGEES report, along with some relevant international examples in the given headings. The recent OECD report provides many more examples. The material below is intended to provide a source for discussion and reference in Ireland. Thanks to Sarah Breathnach for work on this. We are currently holding regular network events in Ireland to explore the potential of this research in the Irish context (see here for details and mailing list). 

1. Irish Project: Increasing Filings from Late Income Tax Returns. Department: Office of the Revenue Commissioners
International Example: Unpaid Car Tax, Behavioural Insights Team UK.
The Behavioural Insights Team (BIT) worked with the DVLA to test the efficacy of different messages upon individuals who fail to tax their vehicles. The BIT tested the original DVLA letter against a new letter with simpler, harder-hitting messages (such as ‘Pay Your Tax or Lose Your [Make of Vehicle]’) and an image of the owners vehicle. It is thought that the image would attract the attention of recipients and make the idea of losing their vehicle more salient. This image also involes a strong element of personalization, as drivers are shown an image of their own car. The results revealed that overall, sending letters to non-payers of road tax with a picture of the offending vehicle on the letter increased payment rates from 40 percent to 49 percent.

Service, O et al,. (2014) Behavioural Insights TeamEAST: Four simple ways to apply behavioural insights. Available from: EAST_FA_WEB.pdf
General Efforts to increase tax compliance:

Example US: Eliciting taxpayer preferences increases tax compliance. Lamberton, De Neve and Norton (2014)

While tax aversion has many causes, we suggest that a meaningful portion of that aversion can be understood — and addressed — by considering two psychological characteristics of the tax process. First, tax aversion is created by the decoupling of tax payments and the public goods obtained in return. This disconnect places distance between payment and benefit, and therefore decreases taxpayers’ perceptions of the tax-funded benefits they receive. Second, taxpayer frustration also results from the lack of agency or sense of influence over tax spending — which stands in sharp contrast to one’s control over private spending — and may prompt some degree of psychological reactance (Brehm, 1966). Academics and policymakers have begun to address the first source of frustration, aiming to better inform citizens on where tax money is being spent. To recouple payment and benefit, policymakers now widely publicize information on the allocation of tax dollars across expenditure categories (White House, 2011) and are introducing “Personal Tax Statements” (UK Treasury, 2012). We propose that the annual tax filing process offers an unexploited opportunity for governments to increase taxpayer engagement and compliance. We explore this possibility in a set of experiments that allow taxpayers to express non-binding (advisory) preferences regarding the use of their tax dollars, assessing the effects of this taxpayer agency treatment on tax compliance as well as satisfaction with tax payment and attitudes towards taxation. We find that providing taxpayers with such “taxpayer agency” — eliciting tax spending preferences — significantly increases tax compliance (16%). Additionally, allowing taxpayers to signal their preferences on the distribution of government spending results in a 15% reduction in the stated take-up rate of a questionable tax loophole.  We also observe that agency operates, in part, by recoupling payment and benefit. Giving taxpayers a voice may act as a two-way “nudge,” transforming tax payment from a passive experience to a channel of communication between taxpayers and government.

Lamberton, C. P., De Neve, J. E., & Norton, M. I. (2014). Eliciting taxpayer preferences increases tax compliance. Available at SSRN 2365751.

Example UK: Increasing tax compliance using social norms and fairness.  Hallsworth, List, Metcalfe, and Vlaev (2014).

Hallsworth et al. (2014) look at the propensity of taxpayers to pay their outstanding taxes and how norms and fairness messages affect payments. The Authors describe two large scale field experiments in the UK conducted in 2011 and 2012 using a subject pool of more than 100,000 individuals in each of the experiments. In the first experiment, the authors test two fairness and three normative messages which are added to the standard reminder letter for late payment of taxes. The authors report the largest effect for a normative message (‘Nine out of ten people in the UK pay their tax on time. You are currently in the very small minority of people who have not paid us yet.’). People in this treatment group were 5.1% more likely to make a payment towards their debts within 23 days after receiving the reminder letter compared to the control group. The second experiment is implemented the same way and tests for the psychological distance of normative messages as well as the effect of descriptive and injunctive norms. General descriptive norms were shown to have a larger effect compared to general injunctive norms. The psychological distance or the normative messages was varied by describing the behaviour of others in the same region (‘The great majority of people in your local area pay their taxes on time.’) or in a similar situation (‘Most people with a debt like yours have paid it by now.’). More specific norms were shown to have a larger effect. The authors argue that because including normative messages in the reminder letters is relatively cheap, also small effects can be cost effective.

Hallsworth, M., List, J., Metcalfe, R., & Vlaev, I. (2014). The behavioralist as tax collector: Using natural field experiments to enhance tax compliance (No. w20007). National Bureau of Economic Research.

Example UK: Social norms on tax debt payments. The HMRC Behaviour Change Team (2012).

The HMRC Behaviour Change Team are engaged in a series of randomised controlled trials. The first of these tested the influence of social norms on tax debt payments. 17 Letters were sent to 140,000 taxpayers, and took four forms. The first was the standard letter with no mention of social norms (the control group), the remaining three all contained the statement ‘9 out of 10 people pay their tax on time’ in the context of either Britain as a whole, for the taxpayers’ postcode, or taxpayers’ home town. The interventions appeared to be successful: 67.5 per cent made payments in the control group; 72.5 per cent for national social norms; 79 per cent for postcode social norms and, finally, 83 per cent for home town social norms. It is estimated in the report that the difference between the standard letter and the highest performing home town social norm letter (15 per cent) could advance £160 million of tax debts to HMRC over a six-week period.

Cabinet Office (2012). Applying behavioural insights to reduce fraud error and debt.

Example UK: The impact of personalised text messaging on fine repayments, BIT (2012).

The Courts Service and the Behavioural Insights Team wanted to test whether or not sending text messages to people who had failed to pay their court fines would encourage them to pay prior to a bailiff being sent to their homes. In the initial trial, individuals were randomly allocated to five different groups. Some were sent no text message (control group), while others (intervention groups) were sent either a standard reminder text or a more personalised message (including the name of the recipient, the amount owed, or both). The trial showed that text message prompts can be highly effective, 28.2% of the standard text recipients paid the fine whereas 33% of the recipients of the standard text with personalisation paid the fine.

Behavioural Insights Team (2012). Test, Learn, Adapt.  Available from

Example US: Taxpayer response to an increased probability of audit. Slemrod, Blumenthal  and Christian (2001).

Slemrod et al. (2001) describe one of the first field experiments in tax compliance. The authors explore the effect of differences in perceived audit rates by sending a letter to a group of taxpayers in Minnesota. In 1995 a group of 1724 randomly selected Minnesota taxpayers were informed by letter that the returns they were about to file would be ‘closely examined’. Compared to a control group that did not receive this letter, low and middle-income taxpayers in the treatment group on average increased tax payments compared to the previous year, which was interpret as indicating the presence of noncompliance. The effect was much stronger for those with more opportunity to evade; in fact, the difference in differences is not statistically significant for those who do not have self-employment or farm income, and do not pay estimated tax. Surprisingly, however, the reported tax liability of the high income treatment group fell sharply relative to the control group.

Slemrod J., Blumenthal M. and Christian C. (2001): ‘Taxpayer response to an increased probability of audit: evidence from a controlled experiment in Minnesota’, Journal of Public Economics, Vol. 79, No. 3, p. 455-483

Example Sweden: Tax compliance and loss aversion. Engström, Nordblom, Ohlsson and Persson (2015).

Engström et al., (2015) find that in Sweden, taxpayers are more aggressive about claiming deductions when they owe additional tax at the time of filing than when they expect a refund - a phenomenon that is consistent with the predictions of prospect theory. An obvious policy implication is that a tax collection strategy that relies on over withholding followed by refunds at the time of tax filing may increase tax compliance and total taxes paid. The authors therefore argue the practical applications of prospect theory to tax compliance. Interventions that recognize individuals’ aversion to loss may be particularly useful in increasing tax compliance.

Engström, P., Nordblom, K., Ohlsson, H., & Persson, A. (2015). Tax compliance and loss aversion. American Economic Journal: Economic Policy7(4), 132-164.

Example Austria: Tax compliance within the context of gain and loss situations. Kirchler & Maciejovsky, (2001)

This study on 60 self-employed and 59 business entrepreneurs investigates self-reported tax evasion within the context of taxpayers' previous expected tax payments at filing time (payment or refund), their asset position (expected versus current asset position), and their tax category (self-employed versus business entrepreneurs). It examines whether different tax categories have an impact on the habitual decision-making framework and hence influence the reference point employed in the decision process. The results indicate that for the self-employed in the study an unexpected surprise payment leads to low tax compliance, whereas an unexpected surprise refund leads to high tax compliance. Thus, their self-reported tax compliance can be best described by the current asset position. By contrast, the reference point business entrepreneurs employ in making tax decisions can be best described as dictated by their expected asset position. As a result, expected payments are associated with low and expected refunds are associated with high tax compliance on the part of these individuals. In addition, the findings of the study showed that knowledge of the legal principles of Austrian tax law is correlated with tax morality, and that women are less compliant than men. Attitudes towards the tax system and the perceived justice of the system are not correlated significantly with self-reported tax evasion.

Kirchler, E., & Maciejovsky, B. (2001). Tax compliance within the context of gain & loss situations, expected and current asset position, & profession. Journal of Economic Psychology. 22(2), 173–194

Example Estonia: Changing the perception of taxes (behaviourally-informed initiative). Tax and Customs Board (2011/ongoing).

According to Lillemets (2009), it is important to increase public awareness of the need to pay taxes because this is a means of increasing the public’s readiness to pay taxes voluntarily. Public research carried out in 2009 which covered attitudes of the population towards payment of taxes, indicated that awareness of the services people receive from the state is relatively low: 26% of respondents did not know what kind of services they receive from the state, while around half of those (11%) said that they get nothing from the state. The same survey also indicated that voluntary tax payment could be increased by higher trust towards the state, increased awareness of the use of tax income and good relationships between the state and the citizen. In an effort to modify tax behaviours and shift the focus from paying taxes as a burden to something which contributes to public good, the Estonian Tax and Customs Board (Ministry of Finance) launched an information campaign to raise awareness of how taxpayers’ money is being used by the state. The information campaign was implemented in two parts. The first part of the campaign was conducted in nine Estonian cities during January and February 2010. The main message used in the campaign was: “Unpaid taxes will leave a mark. You like highways in order, ambulances, efficient work of rescue workers and the police. So do we.” In addition, a thank you message was attached to rescue cars and ambulance cars in Tallinn saying that these cars had been bought with taxpayers’ money. The second part of the campaign was conducted in eight cities across Estonia during October 2011 and used radio commercials and outdoor ads. The messages were socially relevant and related to the Estonian context. Overall, the campaign was regarded as successful in that it was relatively well noticed and the average score was good compared to other state and educational campaigns. Also the follow-up campaign was effective in confirming the campaign message and making people think about why we pay taxes. It also helped to create an understanding that paying taxes helps the state to function and provide social guarantees to people.

Tax and Customs Board (2011), ‘Information campaign “Unpaid taxes will leave a mark” continues’. Available from

Example: Increasing tax compliance through positive rewards. Brockmann, Genschel, & Seelkopf, (2016)

Can governments increase tax compliance by rewarding honest taxpayers? We conduct a controlled laboratory experiment comparing tax compliance under a ‘deterrence’ baseline to tax compliance under two ‘reward’ treatments: a ‘donation’ treatment giving taxpayers a say in the spending purposes of their payments, and a ‘lucky’ treatment giving taxpayers the (highly unlikely) chance of winning a lottery. The reward treatments significantly affect tax behavior but not in a straight forward way. While female participants alter their behavior as expected and comply somewhat more, men strongly react in the opposite way: They evade a much higher percentage of taxes than under the baseline. Apparently, there is no one-size fits-all approach to boost tax compliance

Brockmann, H., Genschel, P., & Seelkopf, L. (2016). Happy taxation: increasing tax compliance through positive rewards?. Journal of Public Policy, 1-26.

Example Denmark: Simplification of the tax system & compliance. Danish Tax Authority

The Danish Tax Authority implemented an initiative to avoid tax evasion among young citizens (often due to the perceived excessive complexity of administrative procedures). This consisted of the creation of a simplified platform for tax payment targeting youth, featuring a human-centred design based on behavioural research. Changes increased the use of the tax guidelines by 7% and tax revenues from the target group are expected to increase by 20% compared to previous years.

Example Austria: Prepopulated tax forms: Increasing compliance through simplification. Federal Ministry of Finance (2014)

The Austrian Federal Ministry of Finance offers citizens the FinanzOnline, - "one-click link to the Austrian tax administration." This service allows, for example, citizens to file their tax return electronically using a pre-populated form. This is an example of a nudge to encourage individuals to file their taxes electronically and comply with tax return. In other words, this is achieved through the simplification of the tax return process (in line with the need to decrease information overload) and the reduction of the effort to comply. Moreover, the Ministry's website indicates that "96% rate the Finance Ministry´s application, which has received multiple international awards, as 'very good'" – an example of the use of social norms and framing for the promotion of FinanzOnline as a secure and quality service. There is also a mobile phone signature app, which saw a substantial increase in users from 106,754 in 2013 to 176,721 in 2014. Other countries across Europe including, Spain and France also use pre-populated fiscal and non-fiscal declarations, while Italy and Hungary are in the process of becoming more taxpayer friendly through the use of behaviorally inspired simplifications of tax administrative procedures.

Federal Ministry of Finance (2014). The Austrian Tax and Customs Administration Annual Report 2014 Overview. Available from

Meta-Analysis: A Meta-Analysis of Tax Compliance Experiments. Blackwell (2007).

Blackwell conducts a meta-analysis of twenty laboratory experiments, which were carried out between 1987 and 2006. Blackwell attempts to synthesize this literature in a meta-analysis to draw conclusions regarding the determinants of tax compliance. Specifically, the author examines the impacts of traditional economic determinants of tax compliance: the tax rate, the penalty rate, and the probability of audit. In addition, the author examines the effect of a public good “return” to taxes paid. The author finds strong evidence that increasing the penalty rate, the probability of audit and the marginal per capita return to the public good lead to higher compliance, but finds no statistically significant effect of the tax rate on compliance.

Blackwell C. (2007): ‘A Meta-Analysis of Tax Compliance Experiments’, International Center for Public Policy Working Paper Series at Andrew Young School of Policy Studies, Georgia State University

Additional Resources:

Weber, T. O., Fooken, J., & Herrmann, B. (2014). Behavioural economics and taxation (No. 41). Directorate General Taxation and Customs Union, European Commission.

Madrian, B. C. (2014). Applying insights from behavioral economics to policy design (No. w20318). National Bureau of Economic Research.

The British Psychological Society. Behaviour change: Tax & compliance (2016).  Available from

Lourenço J.S., Ciriolo E., Almeida S.R., & Troussard X. (2016). Behavioural Insights Applied to Policy European Report 2016. Available from

Leicester, A., Levell, P., & Rasul, I. (2012). Tax and benefit policy: insights from behavioural economics. Institute for Fiscal studies, Commentary C125.

2. Irish Projects: Increasing Responses to the SME Survey (2013) & PAYE Survey (2015)
Department: Office of the Revenue Commissioners.
& Encouraging Responses to the National Health Experience Survey.
Department of Health

Example US: Different Domain Similar idea: The impact of alternative incentive schemes on completion of health risk assessment surveys. Haisley et al., (2012).

Purpose: The biggest challenge for corporate wellness initiatives is low rates of employee participation. We test whether a behavioral economic approach to incentive design (i.e., a lottery) is more effective than a direct economic payment of equivalent monetary value (i.e., a grocery gift certificate) in encouraging employees to complete health risk assessments (HRAs).
Design: Employees were assigned to one of three arms. Assignment to a treatment arm versus the non-treatment arm was determined by management. Assignment to an arm among those eligible for treatment was randomized by office.
Patients: A total of 1299 employees across 14 offices participated.
Intervention: All employees were eligible to receive $25 for completing the HRA. Those in the lottery condition were assigned to teams of four to eight people and, conditional on HRA completion, were entered into a lottery with a prize of $100 (expected value, $25) and a bonus value of an additional $25 if 80% of team members participated. Those in the grocery gift certificate condition who completed an HRA received a $25 grocery gift certificate. Those in the comparison condition received no additional incentive.
Measures: HRA completion rates.
Results: HRA completion rates were significantly higher among participations in the lottery incentive condition (64%) than in both the grocery gift certificate condition (44%) and the comparison condition (40%). Effects were larger for lower-income employees, as indicated by a significant interaction between income and the lottery incentive.
Conclusion: Lottery incentives that incorporate regret aversion and social pressure can provide higher impact for the same amount of money as simple economic incentives.

Haisley E, Volpp KG, Pellathy T, Loewenstein G. (2012).  Promoting Completion of Health Risk Assessments with Lottery Incentives. American Journal of Health Promotion.

Example US: Total cost/response rate trade-offs in mail survey research: Impact of follow-up mailings and monetary incentives. Larson & Chow (2003).

This article reports results of a mail survey experiment in which several response-inducement methods were manipulated. The experiment assesses the impact of follow-up mailings and monetary incentives on total cost/response rate trade-offs. Experimental findings lead to a number of recommendations for researchers and managers who conduct mail surveys. First, follow-up mailings and monetary incentives should be used to maximize response rate. Second, given a limited budget for survey administration, follow-up mailings are preferred over monetary incentives. Third, if there is limited time for survey administration, monetary incentives may be preferred over follow-up mailings. Finally, follow-up mailings have the added benefit of enabling nonresponse bias estimation.
Larson, P. D., & Chow, G. (2003). Total cost/response rate trade-offs in mail survey research: impact of follow-up mailings and monetary incentives. Industrial Marketing Management32(7), 533-537.

Example Norway: Improving response rate and quality of survey data with a scratch lottery ticket incentive. Olsen, Abelsen & Olsen (2012)

Background: The quality of data collected in survey research is usually indicated by the response rate; the representativeness of the sample, and; the rate of completed questions (item-response). In attempting to improve a generally declining response rate in surveys considerable efforts are being made through follow-up mailings and various types of incentives. This study examines effects of including a scratch lottery ticket in the invitation letter to a survey.
Method: Questionnaires concerning oral health were mailed to a random sample of 2,400 adults. A systematically selected half of the sample (1,200 adults) received a questionnaire including a scratch lottery ticket. One reminder without the incentive was sent.
Results: The incentive increased the response rate and improved representativeness by reaching more respondents with lower education. Furthermore, it reduced item nonresponse. The initial incentive had no effect on the propensity to respond after the reminder.
Conclusion: When attempting to improve survey data, three issues become important: response rate, representativeness, and item-response. This study shows that including a scratch lottery ticket in the invitation letter performs well on all the three.

Olsen, F., Abelsen, B., & Olsen, J. A. (2012). Improving response rate and quality of survey data with a scratch lottery ticket incentive. BMC medical research methodology12(1), 52.

Example: The Influence of Advance Letters on Response in Telephone Surveys: A Meta-Analysis. De Leeuw et al. (2007).

Recently, the leading position of telephone surveys as the major mode of data collection has been challenged. Telephone surveys suffer from a growing nonresponse, partly due to the general nonresponse trend for all surveys and partly due to changes in society and technology influencing contactability and willingness to answer. One way to counteract the increasing nonresponse is the use of an advance letter. In mail and face-to-face surveys, advance letters have been proven effective. Based on the proven effectiveness in face-to-face and mail surveys, survey handbooks advise the use of advance letters in telephone surveys. This study reviews the evidence for this advice and presents a quantitative summary of empirical studies on the effectiveness of advance letters in raising the response rate for telephone surveys. The major conclusion is that advance letters are also an effective tool in telephone surveys, with an average increase in response rate (RR1) from 58 percent (no letter) to 66 percent (advance letter), and an average increase in cooperation rate (COOP1) from 64 percent (no letter) to 75 percent (advance letter). It seems advanced contact generally improves response rates and, often just as importantly, in a cost effective manner.

De Leeuw, E., Callegaro, M., Hox, J., Korendijk, E., & Lensvelt-Mulders, G. (2007). The influence of advance letters on response in telephone surveys a meta-analysis. Public opinion quarterly71(3), 413-443.

Example: The Role of Topic Interest in Survey Participation Decisions. Groves, Presser, & Dipko (2004).

While a low survey response rate may indicate that the risk of nonresponse error is high, we know little about when nonresponse causes such error and when nonresponse is ignorable. Leverage-salience theory of survey participation suggests that when the survey topic is a factor in the decision to participate, noncooperation will cause nonresponse error. We test three hypotheses derived from the theory: (1) those faced with a survey request on a topic of interest to them cooperate at higher rates than do those less interested in the topic; (2) this tendency for the “interested” to cooperate more readily is diminished when monetary incentives are offered; and (3) the impact of interest on cooperation has non-ignorability implications for key statistics. The data come from a three-factor experiment examining the impact on cooperation with surveys on (a) five different topics, using (b) samples from five different populations that have known attributes related to the topics, with (c) two different incentive conditions. The findings suggest that emphasising the importance of a topic will encourage those already interested in the research subject to take part. However, for those uninterested placing too much emphasis on the topic importance may put them off. Contacting a sampled individual or household in advance is an opportunity to make a contact aware of the sponsor of the research as well as aware of the importance, or salience, of the research. The findings suggest that survey commissioners need to be careful in balancing the message put across on advanced letters and in other contacts. Negatively affecting the participation of those who are already unlikely to take part in research may increase non-response bias.

Groves, R. M., Presser, S., & Dipko, S. (2004). The role of topic interest in survey participation decisions. Public Opinion Quarterly, 68(1), 2-31.
Example US: Improving response rates through better design. Clarkberg & Einarson (2008).

In an effort to address declining response rates on our campus, we considered the role of survey instrument design and how it can contribute positively or negatively to the experience of completing a web-based survey of student engagement. Existing research on survey design emphasizes that potential respondents evaluate signals from the survey instrument itself in deciding whether to respond. We focused on the following four considerations: 1) Survey length. The perceived burden of responding to a survey is tied directly to its overall length as well as the number of questions that appear per web screen. 2). Survey content. Surveys enjoy higher response rates when their contents are seen as relevant to the respondents’ own experiences and values. To enhance the salience of our survey, we asked our interview participants what they thought of the questions we had developed and what they wanted to tell us in a survey. 3) Visual appeal. Research suggests the visual design of a web-based survey affects response rates. Our study found that visual design elements – such as the borders and spacing used in questions, and the number of questions presented per page – elicited strong reactions from our pretesters. 4) Delivery of survey results. Providing respondents with survey results can help build rapport with respondents. In this project, we incorporated instant results into the survey. In this way, we immediately rewarded survey respondents with a handful of findings at key points. Consistent with past research (e.g., Couper et al., 2001; Dillman, 2000), our study found that differences in survey length and visual design seem to have accounted for significant differences in the proportion of students responding to the original and revised versions of our survey, as well as differences in the proportion of survey questions completed

Clarkberg, M., & Einarson, M. (2008). Improving response rates through better design: Rethinking a web-based survey instrument. New York: Institutional Research and Planning, Cornell University. Available from:

Example US: Using Norm-Based Appeals to Increase Response Rates. Misra, Stokols & Marino (2013)

Background: In an earlier experiment Misra, Stokols, & Marino (2012) found that participants who received a descriptive normative prompt in the message requesting them to complete an online survey were more likely to comply with the request compared to participants who did not receive any normative prompts.
Purpose: Building on that earlier study, the present field experiment compared the separate and additive effects of descriptive and injunctive norm- based persuasive messages on response rates of online surveys. We also investigate the influence of email reminders on response rates.
Intervention: Participants in an interdisciplinary conference were assigned to one of four groups. The three experimental groups received one of the following messages asking them to complete an online survey that highlighted: (1) a descriptive social norm indicating typical response rates among attendees of prior similar conferences; (2) an injunctive norm appealing them to join fellow participants in completing the survey; or (3) both social norms. The control group received a generic request to complete the online survey without any norm based appeals.
Findings: Participants receiving a message highlighting the descriptive social norm when asked to complete an online survey were more likely to comply with the request compared to all the other groups. Additionally, one and two email reminders were found to be effective in improving response rates of online surveys.

Misra, S., Stokols, D., & Marino, A. H. (2013). Descriptive, but not Injunctive, Normative Appeals Increase Response Rates In Web-based Surveys. Journal of MultiDisciplinary Evaluation, 9(21), 1-10.

Additional Resources:

The Scottish Government (2011). Methods in Survey Design to Improve Response Rates: A Review of the Empirical Evidence. Available from:

Improving Participation in Research (2012). The social research newsletter from Ipsos MORI Scotland. Available from:

3. Irish Project: Increasing Attendance at Group Information Sessions. Department of Social Protection.

Example US: The Power of Prompts: Using Behavioral Insights to Encourage People to Participate in Paycheck Plus Demonstration meetings. OPRE Report (2015).

The Paycheck Plus Demonstration is evaluating whether offering single New Yorkers a generous earnings supplement on top of the existing earned income tax credit improves their economic well-being and encourages employment. The report presents findings from two behavioral interventions designed to increase the number of participants who attended a meeting about the Paycheck Plus program. The Behavioral Interventions to Advance Self-Sufficiency (BIAS) team designed two types of postcards: one meant to reflect a typical message that program operators would have produced in the absence of a BIAS intervention (the “standard” version), and one that incorporated concepts from behavioral economics, including implementation prompting, loss aversion, and prominent deadlines (the “behavioral” version). Additionally, half of the participants were sent text messages. The study contained four research groups. Group 1 was sent only behavioral postcards, and Group 2 was sent behavioral postcards and behavioral text messages. Group 3 was sent only standard postcards, and Group 4 was sent standard postcards and standard text messages. Behavioral messaging led to a 7 percentage point increase in meeting attendance (over a base of 18.5 percent), compared with standard messaging. The strongest outcomes were found for the group that was sent both behavioral postcards and behavioral text messages, which improved response by 12 percentage points when compared with the lightest touch, sending only standard postcards. Behavioral messaging led to a large, statistically significant increase in the percentage of participants who attended the meeting.

US Office of Planning, Research and Evaluation. Available from:

Example US: Framing The Message: Using Behavioral Economics to Engage TANF Recipients. OPRE Report (2016)

In late 2013, Los Angeles County began scheduling appointments with needy families in receipt of temporary assistance who were formerly exempt from engaging with the welfare-to-work program in order to bring them into the program and engage them in activities. Despite extensive communication attempts only about half of the participants who received a reengagement notice between September 2013 and January 2014 attended the scheduled mandatory reengagement appointment. The report presents findings from an intervention designed to increase the number of Temporary Assistance for Needy Families (TANF) recipients who “reengaged” in the welfare-to-work program. Two different notices that employed behavioral techniques were designed; one highlighted the losses participants might experience by not attending the appointment and the other highlighted the benefits they might gain by attending. Participants were randomly assigned to one of three groups: (1) a program group that received the gain-framed notice; (2) a program group that received the loss-framed notice; or (3) a control group, which did not receive additional materials. The test found that receiving an additional behavioral message increased the percentage of program group members who engaged in the program within 30 days of their scheduled appointment by a statistically significant 3.6 percentage points. This increase was largely driven by the loss notice, which increased engagement at 30 days by 4.4 percentage points, while the gain notice, when compared with the control condition, did not produce a statistically significant impact at 30 days.

US Office of Planning, Research and Evaluation. Available from:

Example US: Cutting Through Complexity: Using Behavioral Science to Improve Indiana’s Child Care Subsidy Program. OPRE Report (2016).

The Indiana Office of Early Childhood and Out-of-School Learning (OECOSL) is the lead agency responsible for administering the state’s Child Care and Development Fund (CCDF), which provides child care subsidies to low-income parents who are working or in school. As part of the program, parents are required to verify their continued eligibility for child care subsidies at least every six months by submitting required documentation. Data reported by the OECOSL suggested that about 40 percent of parents missed their scheduled appointment date, about a third who attended any appointment had to attend multiple appointments to complete the process. As parents often struggle to comply with this requirement, the OECOSL aimed to use behavioral insights to encourage parents to attend their first scheduled appointment and to complete the process in one visit. In order to achieve this, the appointment materials were redesigned and a new reminder postcard was created. The redesigned materials incorporated the behavioral elements of simplification, personalization, loss aversion, and reminders. The findings of all interventions are discussed.

US Office of Planning, Research and Evaluation. Available from:

Example UK: Reducing Missed Hospital Appointments. Behavioural Insights Team (2015)

Missed hospital appointments are a major cause of inefficiency worldwide. Healthcare providers are increasingly using Short Message Service reminders to reduce ‘Did Not Attend’ (DNA) rates. Systematic reviews show that sending such reminders is effective, but there is no evidence on whether their impact is affected by their content. Accordingly, we undertook two randomised controlled trials that tested the impact of rephrasing appointment reminders on DNA rates in the United Kingdom. Participants were outpatients with a valid mobile telephone number and an outpatient appointment between November 2013 and January 2014 (Trial One, 10,111 participants) or March and May 2014 (Trial Two, 9,848 participants). Appointments were randomly allocated to one of four reminder messages, which were issued five days in advance. Message assignment was then compared against appointment outcomes (appointment attendance, DNA, cancellation by patient). In Trial One, a message including the cost of a missed appointment to the health system produced a DNA rate of 8.4%, compared to 11.1% for the existing message. Trial Two replicated this effect (DNA rate 8.2%), but also found that expressing the same concept in general terms was significantly less effective (DNA rate 9.9%). Moving from the existing reminder to the more effective costs message would result in 5,800 fewer missed appointments per year in the National Health Service Trust in question, at no additional cost.

Hallsworth, M., Berry, D., Sanders, M., Sallis, A., King, D., Vlaev, I., & Darzi, A. (2015). Stating Appointment Costs in SMS Reminders Reduces Missed Hospital Appointments: Findings from Two Randomised Controlled Trials. PloS one, 10(9), e0137306.

Example UK: Addressing Missed Hospital Appointments. NHS Bedfordshire (2013)

Missed appointments are a large source of inefficiency in the NHS: around 6 million appointments are wasted each year, at an estimated cost of £700–800 million (Martin et al. 2012). This initiative trialled a package of simple interventions, based on behavioural science, to increase patient attendance in a primary care setting. Reception staff at 2 primary care sites in NHS Bedfordshire were trained to implement 3 interventions. They were given time to reflect on the changes and ask any questions. Clinical staff were also briefed on the changes. The package of 3 interventions successfully reduced the number of appointments wasted by patients who did not attend (DNA) by 31.7% (124 appointments per month in total across the 2 sites). The interventions included: on the telephone, reception staff asking patients to repeat back verbally the day and time of the appointment they are given before completing the call in the primary care setting, providing patients with a card to write the details of their appointment themselves rather than a receptionist, nurse or doctor doing so replacing the poster highlighting the number of missed appointments with a poster that showed the much larger number of patients who do turn up on time. Reports 12 months after implementation show that a reduction in the DNA rate of about 30% has been maintained.

Example Australia: Increasing Cervical Screening Attendance with Behaviourally Informed Reminder Letters.

NSW Pap Test Register by the Cancer Institute NSW send over 300,000 every year. Less than 30% of women book an appointment within three months after receiving their letter. The aim of the study was to trial whether different reminder letters could increase the number of women who attend Pap tests, in order to increase early detection and cancer survival. Four new 27-month reminder letters were co-designed and trialled in an RCT against the existing letter. The outcome measure was whether women attend a Pap test within 3 months of being sent the letter. Letter 1 involved a gain framed message. Letter 2 involved a gain-framed message and an act now stamp and highlighted risks of not screening. Letter 3 used gain-framing and included a case study of cancer survivor. Finally, letter 4 used gain framing in combination with a commitment device. The results indicated that over 12 months, the Commitment Device letter could lead to an additional 7,500 Pap test appointments within three months of the reminders being received (32.2% of women sent the Commitment Device letter booked a Pap test within 3 months, compared to 29.7% in the control group).

4. Irish Project: Tackling Climate Change, Reducing Carbon Emissions. Department of Expenditure and Reform

Example Netherlands: Reducing traffic congestion through choice architecture.
In The Netherlands, the Ministry of Infrastructure and Environment has implemented the "Optimizing Use" project. In this context, national and regional governments and businesses collaborated to improve road, waterway and railway accessibility to reduce traffic congestion in the busiest regions. The project comprised behavioural measures, such as increasing the number of bicycle shelters at stations. This is an example of a measure addressing a barrier to cycling (i.e. availability of sufficient secure cycle parking) through a change to the choice architecture. This is in clear contrast with monetary incentives to promote sustainable transport like granting "eco vouchers" for buying green products, such as a bicycle or train tickets. A follow-up programme is scheduled for 2017.
Platform Beter Benutten, “Beter Benutten: less congestion in 2014, shorter journey times in 2017.” [Online]. Available from:
Example Finland: Reducing carbon emissions through simplification (2013).
In 2013, SITRA and the Finish City of Jyväskylä launched the "Towards Resource Wisdom" project, which aims at developing an operating model for regional resource efficiency. In spring 2015, the model was piloted in Forssa, Lappeenranta and Turku and, in June 2015, a network was created to support Finnish cities in making their regional activities carbon neutral and waste free. A set of indicators was also developed to measure progress towards these goals. As part of the Resource Wisdom project, a series of pilots were conducted, one such example is the "Bus Leap Project" aimed at increasing the use of public transport and reducing carbon emissions and fuel consumption. The project taps on behavioural levers such as simplification – i.e. development of a route guidance system to assist residents with basic logistic information – and is testing whether introducing staggered working hours would have an effect on decreasing periods of high traffic.
“Resource wisdom indicators,” Sitra, 2015. [Online]. Available from: wisdom/resource-wisdom-indicators.
Example Spain: Can Defaults Save the Climate? (2012)
A study by the University of Las Palmas de Gran Canaria used an RCT to test the effect of defaults and framing in the context of a policy for mitigating CO2 emissions. Results showed that framing influenced travellers’ willingness to pay €10 extra for a flight ticket to mitigate their CO2 emissions. That is, 81% paid extra when the question was framed as a rejection (i.e. tick in this box if you would like to deduct the additional amount) vs. 62% when this was framed as an addition (i.e. tick in this box if you would like to include the additional amount). Note however that rejection was also the default option. The implications are discussed.
J. E. Araña and C. J. León, “Can Defaults Save the Climate? Evidence from a Field Experiment on Carbon Offsetting Programs,” Environ. Resour. Econ., vol. 54, no. 4, pp. 613–626, 2013.
Example US: Reducing energy consumption using a social norms intervention (2011)

This paper evaluates a large-scale pilot program run by a company called OPOWER, to test the effects of mailing home energy use reports to residential utility consumers. The reports include energy conservation information as well as social comparisons between a household’s energy use and that of its neighbours. Using data from a randomized natural field experiment of 80,000 treatment and control households in Minnesota, it is estimated that the monthly program reduces energy consumption by 1.9 to 2.0 percent relative to baseline.  To prevent a "boomerang effect" which might cause those better than the norm to regress, the Social Comparison Module adds injunctive messages labelling low- and moderate-consumption households as "Great" and "Good" and adds "smiley face" emoticons.

Allcott, H. (2011). "Social Norms and Energy Conservation." Journal of Public Economics 95(9-10): 1082-1095

Example US: Encouraging Sustainable Practices Beyond Here and Now: The Case of Programmable Thermostats for Low-Income Tenants (2016).

Research has shown that programmable thermostats can help families save on energy costs while keeping homes at comfortable and healthy temperatures. By setting back the temperature when the homes are not occupied or overnight, the occupants can save and keep homes comfortable. 40% of the thermostats in use in America are programmable. We designed a randomized controlled experiment to evaluate the effect of two behavioral interventions in the willingness to keep using thermostat schedules. The experiment had three experimental groups: G1-Control: no intervention; G2-Ability: custom-program the thermostats according to occupants’ schedules and comfort preferences, and leave a sticker to remind the families to go-back to use schedules and keep home comfortable; G3-Motiviation: In addition to G2-Ability, we obtained verbal and signed commitments to keep the schedule during the heating season. We found energy savings for both groups G2-Ability (2%) and G3-Motivation (1.5%). Based on these results we suggest that the activity of programming the thermostats according to familial habits and remind occupants to press run to use the schedules should be adopted as a measure that is a part of a portfolio of energy efficiency offers designed to help low income families to adopt new sustainable habits that can help them adapt to scenarios of increasing energy prices and climate change.

Abreu, J. (2016). Encouraging sustainable practices beyond here and now: The case of programmable thermostats for lowincome tenants. Presentation at the 2016 Behavior, Energy & Climate Change Conference. October 20-22, 2016, Baltimore, MD.