The challenge of changing health behaviours

There is currently an increasing focus on teaching clinicians about ‘behaviour change theory’ to provide them with a better understanding of what shapes human behaviour. This understanding is key to designing more effective interventions to improve child health and health services.

Unhealthy behaviours make a significant contribution to the global burden of non-communicable diseases. With 5% of 15 year-olds reporting regular cigarette smoking, one in five 11–15 year-olds being obese and only 9% of girls and 17% of boys aged 13–15 achieving 1 hour of exercise a day, unhealthy behaviours among children and young people in the UK have proven difficult to change.1 Unhealthy behaviours initiated in childhood and adolescence often continue into later life, making it a priority to try and alter these behaviours earlier on. In addition, we have seen rising pressures observed on paediatric emergency departments over recent years, with children and young people increasingly presenting with minor illnesses.2 Children and young people can also be difficult to engage in longer term, secondary care.

What is behavioural economics?

The study of economics requires an understanding of how and why humans make decisions and therefore helps us to understand behaviour that affects health. It is important to note that achieving ‘good health’ may not be the sole objective of behaviour. It has been suggested that human behaviour is shaped by two systems.3 The first is a reflective goal-oriented system driven by our intentions, which requires mental capacity and time. The second system is an involuntary system which is driven by individual psychological processes such as emotions, social influences, mental short cuts and habits that require little or no thinking. These individual psychological processes are also known as cognitive biases. Cognitive biases are essentially ways of thinking that are not entirely rational.

Classical economic theory presumes that human behaviour is rational and based on the first system; that people coolly weigh up the pros and cons of different behaviours and choose the option of maximum personal benefit. However, it transpires instead that human behaviour is more commonly based on the second system, and therefore is not as rational as we imagined. As a result, some quite straightforward public health interventions simply do not seem to work.

Cognitive biases influence decision-making by both patients and healthcare practitioners, and can lead to unhealthy behaviours, inappropriate health-seeking behaviour4 and to illogical decisions that can affect the quality of clinical care provided.5

Understanding these biases thus might be useful in improving health. This is where behavioural economics comes in. Behavioural economics seeks to understand the influence of the cognitive biases driving the second, irrational system of human behaviour and uses the knowledge of these biases to ‘nudge’ behaviour into better outcomes for the individual or society.6 7

Some key ideas in behavioural economics

There are three main groups of biases that are relevant for understanding health behaviours in children and young people, and also in their families and practitioners.

Why is behavioural economics relevant for practising paediatricians?

Sensible parents and young people can make decisions which are not always in the best interests of their longer term health, such as refusing vaccinations. An understanding of behavioural economic techniques can be used by paediatricians to influence decision-making by parents and young people and to develop effective interventions that promote healthy behaviours among children and young people. Having an understanding of behavioural economic techniques can also help us shape the behaviour of healthcare professionals, improving both clinical outcomes and the quality of care provided.

There are a number of ways in which the concepts could be applied to paediatrics. These relate to the healthcare environment, methods of communicating with patients, the ways in which information is presented, other elements of the medical consultation and choice of different interventions. For example:

• By framing the consultation in certain ways paediatricians can use the knowledge of mental short cuts to help parents and young people make decisions that improve their child’s or their own welfare without limiting their choices (box 1).

• Changing the physical environment can be a way of shaping physical behaviour, including, for example, altering the way food is presented to consumers in shops and canteen settings to encourage healthy eating in shops and canteen settings (box 2). This could be extended into the hospital environment.

• Well-timed and phrased reminders through text messages, for example, in box 3, to patients and families could ‘nudge’ them into attending appointments and reducing wastage.

• Sharing information about social norms can promote healthy behaviour among patients and can also reduce undesirable variations in clinical paediatric practice.

• Using knowledge of mental short cuts used by staff can help develop quality improvement projects. For example, the inpatient visual colour-coded paediatric emergency warning score charts can ‘nudge’ practitioners to identify a deteriorating child or young person earlier if observations are abnormal and plot in the yellow zone instead of the green zone.

• Changing the status quo , for example, to ‘out opt’ for seasonal influenza vaccinations for paediatric healthcare workers may increase vaccination rates.

Criticisms of a behavioural economics approach

Behavioural economics and ‘nudges’ are not without their criticisms. Some argue that interventions based on behavioural economic concepts put too much emphasis on individual behaviour and on the downstream determinants of ill health.15 There have been concerns about the ethics around ‘nudges’ and their impact on individual autonomy. It has been argued that the behavioural economics approach is too paternalistic and that although these strategies may change behaviour in a modest way, they cannot change more complex social problems such as child abuse, for example.15 Nudge techniques can however be used alongside other public health strategies and do not attempt to replace strategies to reduce health/social inequality.

Recent arguments suggest an ethical justification for nudging towards healthier behaviours in paediatrics. Nudging—if done correctly and ethically—should alter the environment in a way that does not take away parental choice but enables families to make decisions that are in the child’s interests, especially when the recommended intervention is proven to be of a high benefit individually.16 Children and families in paediatric care are likely to be in a state of stress, affecting their ability to process information. Aggarwal et al 17 have argued that understanding how this works and using that knowledge to help patients make the right decisions is a justifiable way of restoring their autonomy, not a way of taking it away. It is also possible to argue that the population is being constantly manipulated by the ‘nudge’ techniques of advertising and sales and so using these techniques transparently within healthcare is a way to redress the balance in favour of positive health outcomes. The issue is not so much whether we use our understanding of behavioural economics to inform practice, but how we do so in a way that is transparent and responsible. More evidence is needed on the effectiveness of interventions designed specifically for children and young people.