When push comes to nudge – playing on behaviours to generate healthy action

I’m Jason Calvert, a pragmatist and a health economist with a passion for health promotion, non-communicable diseases and international development. This is the first article in a series which will attempt to demystify some key economic concepts for Global Health. The idea stemmed from a noticeable divide between development practitioners and economic theorists. By instilling a few basic concepts from the economic world into global health and development programming, I believe we could see improvements in both efficiency and foresight.

Let’s start exploring, concept by concept.

Concept #1: Nudging

It’s everyone’s favourite buzz word at the moment. You may have heard the term, but not be so familiar with what it means?

Nudging is a ‘carrot’-type incentive. You don’t force people and you don’t lure them using money either. You get a little creative and influence people’s behaviour (preferably for the better) using more inventive methods.

It might be changing a default option for people such as serving skim milk in coffee unless otherwise told not to. It might be making certain systems opt-out rather than opt-in such as organ donation. Or it might be just putting something right in front of people in true ‘carrot’ style such as putting the office stairwell in a prominent location, rather than relegating it to be behind a door marked ‘emergency’.

So what are these nudges really doing? They’re capturing people who are at the margin on all of these decisions. If I take myself as an example, I really can’t tell the difference between a skim coffee and a ‘full-fat’ coffee, and in many places the two cost exactly the same. By default, if I order a latte, it might come full-fat. Adding that extra word to my order just never crosses my mind, even though I would happily drink a skim coffee and it would be a healthier option. By changing the default to skim, cafes would effectively nudge people like myself to make a healthier choice. Same goes for the stairwell. In my office, the stairwell is hidden, dark and sterile – feeling like a true emergency-only feature of the building. As such I’ll often take the elevator just a couple of floors.


Many good examples of nudging exist in the developed world these days. But what about Low- and Middle-Income Countries (LMICs)?

There is great potential to address some of the underlying behavioural issues behind the rise of non-communicable diseases, with opportunities concerning chewing tobacco in India and potent home-brews in Kenya as examples. However the behavioural aspects behind communicable diseases also present opportunities – such as nudging people to practice safer sex or use proper toilet facilities where available.

As a public health economist, I’m in the market for fixes that are both effective and affordable. ‘Cost-effective’ one could say. And with development aid money always running scarce, there’s a large push to demonstrate cost-effectiveness in global health interventions. So are nudges cost-effective? Sometimes, but not necessarily. Simplicity is often the key.

Consider the huge public health issue of road accidents in LMICs. Singapore (albeit a high-income country) has taken a novel approach to this issue by painting horizontal lines on roads that have a high risk of accidents. This relatively cheap undertaking makes drivers appear to be travelling faster than they actually are, hence nudging them to slow down and reduce the risk of accident. Returning to the coffee example, switching the default to skim milk has practically no cost associated with it. Nudging a previous blood donor to donate again through a reminder is similarly cheap. Other nudges however – like plain packaging or restrictions on visual display of tobacco products – have significant political and legal costs associated with implementation that need to be carefully considered and weighed.

However, cost-effectiveness is not all we should be concerned about. What about equity? Where does this come into the cost-effectiveness equation?

Consider differences in education levels among a population. For some nudges, such as the horizontal lines on the road, there is no real issue if people don’t fully understand why they have been painted there. But consider something else like organ donation. By default in many countries you have to opt-in to be an organ donor. If all of a sudden the government decides to make this an opt-out system instead (whereby everyone is now automatically an organ donor unless they actively ask to be removed from the list), we have quite a significant equity issue if the entire population is not made fully aware of their rights and options, or isn’t able to properly interpret the information provided.

In some circumstances though nudging could improve equity. An example of this is traffic-light labelling on food products, which can help demystify the nutritional content of food for those who would otherwise find this process difficult (and let’s be honest, this is most of us!).

The moral of the story?

With the alarming growth in non-communicable diseases worldwide, we need to look for affordable and inventive health promotion approaches that can sit alongside larger interventions such as education campaigns, fiscal policies and other regulations. However, when appraising or evaluating nudge approaches, we need to think beyond cost. Are we creating more problems? Does our proposed nudge generate an equity issue? Do we need to push instead of nudge to generate an outcome?

Nudges are no silver bullet. But a well-considered nudge alongside other interventions could generate a nice additional health benefit at minimal cost.

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