Here are the slides from John Beshears's and Katy Milkman's talk on Temptation Bundling and other behavioral-economics interventions to improve health. From the Action Design DC Meetup on April 16th, 2013, hosted at 1776 DC.
In order to understand how should decisions can be encouraged through “nudges”, it’s important to consider some of the psychological obstacles to doing what we should.
First study demonstrating that forgetfulness plagues decision makers conducted in 1885: Recollection of memorized material initially drops off steeply, then becomes more gradual (Ebbinhaus, 1885)Two relevant types of forgetfulness:Transience: we lose access to information as time passesAbsent-mindedness: we often engage in “inattentive or shallow processing that contributes to weak memories of ongoing events or forgetting to do things in the future”
Imagine only allowing yourself to… Receive a pedicure while completing an overdue manuscript reviewIndulge in the burger you crave when spending time with your cranky uncleEnjoy the next episode of your favorite TV show while doing laundryDrink your morning coffee while studying
past experimental research has shown that enjoying a want stimulus (such as watching a comedy video) restores the willpower depleted by an initial act of self-regulation to baseline levels and significantly more successfully than engaging with a neutral stimulus (Tice, Baumeister, Shmueli and Muraven, 2007). Specifically, after enjoying a want film, experimental participants across three studies (Tice, Baumeister, Shmueli and Muraven, 2007) exerted more willpower by persisting for longer on a frustrating ball-rolling task (one study), an uncomfortable handgrip task (a second study), and a puzzle-solving task (a third study).
Avg WTP: $7.29; % WTP > 0: 59%
Participants appeared to make sophisticated decisions about their stated reservation prices for the device: participants with more internal locus of control over their medical outcomes placed significantly lower value on the program. Furthermore, participants who benefitted the least from self-imposed temptation bundling were most willing to pay a non-zero amount for an externally-imposed temptation bundling device.
Add addictive shows…
Quick Enrollment: Sign your name on a short form, mail it in, and have contributions to the 401(k) deducted from your paycheck every pay cycle thereafterStanford Permit-return bonus: Get a $100 bonus (and stop paying regular permit fees) for turning in your parking permit, and walk/bike/shuttle/train to work every day, unless you want a $60 parking ticketStanding Desk: Get a gentle workout every time you need to use your computer
Temptation Bundling and other Health Interventions: ADDC April 2013
Behavioral Economics Ideas for Action Design April 16th, 2013 John Beshears Stanford Graduate School of Business Katherine L. Milkman The Wharton School, The University of Pennsylvania
What are prominent psychologicalobstacles to doing what we should?
Obstacle #1: Procrastination• Of course we’ll do what we should, but tomorrow…• Evidence: DVD rental + return data from• People watch wants quickly, but procrastinate when it comes to watching shoulds (Milkman et al. 2009) Alien vs. Kokoda Kokoda Alien vs. Predator Frontline Frontline Predator rented first rented second rented first rented second 6% chance of returning 19% chance of returning out-of-order out-of-order
Two Types of Big Problems1. Infrequent, one-off decisions – Whether to get a flu shot, colonoscopy, or buy an energy-efficient washing machine2. Repeated actions – Whether to eat healthfully, exercise regularly, turn off lights when you leave the room
Today’s Agenda• We study “nudges” to help people make better decisions• We’ll tell you about three experiments testing nudge solutions to the following problems: – Getting people to receive flu shots and colonoscopies – Getting people to exercise more frequently
A nudge to help with one-off decisionsJoint work with James Choi, David Laibson, Katherine Milkman and Brigitte Madrian
Prompt Planning• Planning prompts encourage people to form plans: “When situation x arises, I will implement response y”• Desired behavior is linked to concrete future moment • Procrastination more difficult: requires breaking explicit past commitment • Forgetfulness less likely: linked cue triggers memory• Can planning prompts nudge should behaviors? • Study 1: Flu shots (Milkman et al., 2011) • Study 2: Colonoscopies (Milkman et al., 2012)
Why shoulds studied are important• Benefits of flu shots: • Benefits of – Flu afflicts 10-20% of colonoscopies: U.S. population each – Colon cancer causes year (Centers for Disease 50,000 U.S. fatalities per Control) year (U.S. Preventative Services – Flu causes >8,000 Task Force, 2008) deaths yearly (Thompson – 18,800 lives could be et al., 2003) saved each year if – Causes >200,000 everyone complied with hospitalizations yearly (Thompson et al., 2004) colonoscopy recommendations (Zauber – Causes millions of lost et al., 2012) workdays/schooldays
Evive Health• Partner company – Sends health reminders to employees of client corporations• Sent workplace flu shot clinic reminders in Fall ‘09• RCT with employees at a large Midwestern utility company with vaccine indications • > 50 or chronic disease
Control Condition Employees informed of the dates/times of workplace flu clinics
Date Plan Condition Employees invited to choose a concrete DATE for getting a flu vaccine Employees informed of the dates/times of workplace flu clinics
Time Plan Condition Employees invited to choose a concrete DATE AND TIME for getting a flu vaccine Employees informed of the dates/times of workplace flu clinics
Randomized Controlled Trial Control Date Plan3,272 Employees Time Randomized Plan
Results: Effectiveness of Prompts Impact of Planning Prompts on Influenza Vaccination Rates (Relative to Control Group) Influenza Vaccination Rate 8 6.0 * 7 6 5 * 4.2 * 4.0 4 3 5.3 2 1 2.4 1.5 0 Date plan (relative to control) Time plan (relative to control) Control group vaccination rate: 33.1%
Results: 1-Day vs. Multi-Day Clinics Results Segmented by Single-Day vs. Multi-Day Clinics * 10 9.4(Relative to Control Group)Influenza Vaccination Rate 7.9 * 8 6 4.5 4.1 4 1.7 2 0.3 0 Sites with single- Sites with multi- Sites with single- Sites with multi- day clinics (full day clinics (full day clinics (PPO day clinics (PPO sample) sample) subsample) subsample) Date Plan (relative to control) Time Plan (relative to control) Effects driven by sites with single-day clinics (where forgetfulness is most costly)
Putting these results in context• Effect on influenza vaccination rates of: – Reminder letters: 8% increase – Providing info on clinic dates/times: 9% increase – Setting a default appt. date/time: 12% increase
Would This Work for Colonoscopies? Control Condition Planning Prompt Condition
Randomized Controlled Trial Control Plan11,918 Employees at Four Companies Randomized
Results: Effectiveness of Prompts 10.0% *Received Colonoscopy within 6 Months 8.0% 7.2% ≈ to ↑ in6.2% compliance associated 6.0% with a 10% ↑ in fraction of 4.0% colonoscopy’s cost covered by insurance 2.0% 0.0% Control Condition Treatment Condition (N = 5,989) (N = 6,020)
Planning prompt: Most valuable for groups predicted to be more forgetful 3.00% Category Classified as MORE ForgetfulEstimated II Treatment Effect on Category Classified as LESS Forgetful Colonoscopy Take-up 2.00% 1.00% 0.00% Overall Gender 1+ Children Second Age Coverage (M / F) (Y / N) Reminder (75 / 45) (70% / 100%) (Y / N) p = 0.02
Planning Prompts: Conclusion• Planning prompts have enormous potential as a new standard “nudge” for encouraging shoulds – Effect sizes are large – Interventions relatively low-cost to no-cost – Powerful enough to change behavior even… • In the absence of social pressure • In the absence of demand effects • When the behavior is unpleasant • When the behavior is not imminent • When the behavior requires considerable advance-planning
A nudge to help with repeated decisions Joint work with Julia Minson and Kevin Volpp
Liz Lemon •Wishes she exercised more but lacks the motivation •Loves thrilling novels but feels guilty wasting her time reading “trash”Temptation Bundling
Benefits of Temptation Bundling• Solves two problems at once• Likely complementarities• Possible repletion benefits (Tice, Baumeister, Shmueli and Muraven, 2007; Muraven and Baumeister, 2000; Muraven, Tice, and Baumeister, 1998; Baumeister et al., 1998)• No penalties or monetary exchanges
Study Participants• 10 week gym study (paid $100) – Own ipod – Workout on aerobic machines – Belong to gym Hispanic 5%• 226 participants African American – 34% male 13% Grad Caucasian students – 22 (SD = 5.3) age 49% 7% Staff 7% – Asian 23.2 (SD = 3.9) BMI 31% – 1.5 (SD = 1.6) gym visits in first week of school Undergrads 86%
Experimental Conditions• Full Treatment (N = 75): – Receive 4 tempting audio novels on loaned iPod – Intake visit with 30 min. workout (listening to novel) – Only listen to novels while exercising• Intermediate Treatment (N = 75): – Receive 4 tempting audio novels on personal iPod – Intake visit with 30 min. workout (listening to novel) – Try to only listen to novels while exercising• Control (N = 76): – Receive $25 gift certificate to B&N – Intake visit with 30 min. workout
Randomized Controlled Trial Control Intermediate Treatment226 Gym Members Full + Randomized Treatment
Group Total # of Gym Visits (pre-T) Avg. % at Gym >0x Weekly (pre-T)Full Treatment 8.8 (study week 1: 1.16) 51%Intermediate 7.5 (study week 1: 0.87) 44%Control 7.1 (study week 1: 0.75) 42%
0.00 Full Treatment GroupDifference in Avg. # of Gym Visits per Person in Intermediate Treatment Group Week 1 of the Term vs. During Intervention Control Group -0.20 -0.40 -0.60 -0.80 -1.00 Weeks Into Intervention
Who gets the biggest boost?• Participants who particularly enjoyed their initial workout• The busiest study participants
Will Anyone Buy It?• After 10 week study, all participants: – Told they might win a new iPod shuffle pre-loaded with a tempting audio novel of their choice + – Asked willingness to pay to have access to iPod restricted for one month so they could only use it at the gym? (a REAL choice with REAL consequences)
0.6 61% would pay $1 or more% Who Would Buy at a Given Price 64.2% interested in program 0.5 $6.91 average WTP 32% would pay 0.4 $10 or more 0.3 0.2 10% would pay $20 or more 0.1 0 $0 $5 $10 $15 $20 $25 $30 $35 $40 Price for One Month of Temptation Bundling
Temptation Bundling: Conclusions• Temptation bundling devices are valued• Temptation bundling initially increased exercise 56%• Important open questions: • Can the “wearing off over time” problem be combatted? • What would the effect size be with a better bundle? (e.g. Gymflix) • What are the benefits of offering temptation bundling? • Where else besides the gym can we successfully leverage this idea?
Stepping Back• Nudges to encourage a repeated action can be effective, but they are often harder to set up• Can we design a nudge to induce a one-time action that sets off a chain of repeated actions?• Examples – Quick enrollment in a 401(k) plan – Stanford parking “permit-return bonus” – Standing desk
Thank You• Roybal Pilot Grant • Wharton Behavioral Lab• Dean’s Resarch Fund – Kaity Moore• Max Bazerman – Joshua Carrigan• “Junior Juniors” • Alex Rogala• Max’s Non-Lab • Evive Health• Devin Pope – Prashant Srivistava• Roybal Retreats ‘10, ’12 – Jennifer Lindner• PECO Pilot Grant • Kevin Volpp• Pottruck Gym • Todd Rogers – Liz Herrick • Alison Buttenheim – Amy Wagner • NBER Summer Institute 2011 • National Institute on Aging