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Background:Previous research has indicated that women with a chronic inflammatory disease (CID) are likely to discontinue treatment during pregnancy. [1] Reasons for this are complex, including sub-optimal integration of shared decision-making (SDM) into practice.Objectives:The purpose of this study was to assess: 1) physicians’ competencies in risk assessment, treatment and management of women of reproductive age (WoRA) with a CID, and 2) clinical gaps, barriers and challenges to SDM with these patients.Methods:A mixed-methods needs assessment was conducted. [2] Participants included rheumatologists and dermatologists practicing in Germany, United Kingdom, or United States, with at least three years of experience. Exposure to patients diagnosed with rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis or psoriasis was required. A first phase involved collection and thematic analysis of data from semi-structured interviews to identify main challenge areas. The second phase consisted of online surveys to validate and quantify identified challenges, gaps and barriers. Chi-square and Kruskal Wallis H statistical tests were performed to assess differences by specialty, country and gender. Qualitative and quantitative findings were triangulated with insight from experts in medical education and relevant behavioural and clinical fields. [3] The present summary reports data pertaining to rheumatologists only.Results:A total of 24 interviews and 173 surveys were completed with rheumatologists. Depending on the country and specific item, 22% to 64% reported having sub-optimal knowledge of treatment options, patient education aids, and strategies to assess treatment adherence among WoRA with a CID (see figure 1). In addition, 36% reported having sub-optimal knowledge of methods to achieve SDM. Unplanned pregnancies were reported as a barrier to prescribing biologics to WoRA with a CID. Yet, 61% of rheumatologists reported having sub-optimal skills discussing contraceptive methods with patients. In addition, 41% reported having sub-optimal skills adjusting treatment according to changes in pregnancy status or child-bearing aspirations. Few differences in clinical gaps were observed by gender. Notably, a greater proportion of male rheumatologists reported having sub-optimal skills approaching WoRA in a way that makes them feel comfortable discussing their health concerns, compared to female rheumatologists (52% vs. 30%, p=0.046). This skill gap was identified as a contributing barrier to SDM with these patients.Conclusion:This study identified multiple challenges, gaps and barriers relevant to rheumatologists that prevent optimal SDM, risk assessment, treatment and management of WoRA with CID. Findings may be used to develop medical education and continuous professional development interventions for target learners.References:[1]Tsao NW, Lynd LD, Sadatsafavi M, Hanley G and De Vera MA. Patterns of biologics utilization and discontinuation before and during pregnancy in women with autoimmune diseases: a population-based cohort study.Arthritis Care Res.,2018;70(7):979-986.[2]Creswell JW, Klassen AC, Plano Clark VL, Smith KC. Best practices for mixed methods research in the health sciences, 2nd Ed. Bethesda: NIH, 2018:541-545,.[3]Turner SF, Cardinal LB, Burton RM, A triangulation-based framework and roadmap.Organ. Res. Methods,2017;20(2): 243-26.Acknowledgments:This research was financially supported with educational funds from UCB BioPharma SRL. The authors thank T. Kellner for his contribution.Disclosure of Interests:Suzanne Murray: None declared, Rebecca Fischer-Betz Consultant of: UCB, Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Chugai, GSK, Janssen, Lilly, Medac, MSD, Novartis, Roche, UCB, Pfizer., Monica Augustyniak: None declared, Jenny Murase Consultant of: I have led advisory boards for UCB., Speakers bureau: I have done non-branded talks on psoriasis management in women for UCB., Catherine Nelson-Piercy Consultant of: I have received consultancy fees from UCB, Speakers bureau: I have received fees for speaking from UCB., Ivo Vlaev Consultant of: For UCB., Speakers bureau: For UCB, Pfizer, Novartis and boehringer Ingelheim., Cecile Ecoffet Shareholder of: UCB, Employee of: UCB, Morgan Peniuta: None declared, Dean Jenkins Employee of: UCB

ObjectivesGoodSAM is a mobile phone app that integrates with UK ambulance services. During a 999 call, if a call handler diagnoses cardiac arrest, nearby volunteer first responders registered with the app are alerted. They can give cardiopulmonary resuscitation (CPR) and/or use a public access automated external defibrillator (AED). We aimed to identify means of increasing AED use by GoodSAM first responders.MethodsWe conducted semistructured telephone interviews, using the Theoretical Domains Framework to identify and classify barriers to AED use. We analysed findings using the Capability, Opportunity, Motivation, Behaviour (COM-B) model and subsequently used the Behaviour Change Wheel to develop potential interventions to improve AED use.SettingLondon, UK.ParticipantsGoodSAM first responders alerted in the previous 7 days about a cardiac arrest.ResultsWe conducted 30 telephone interviews in two batches in July and October 2018. A public access AED was taken to scene once, one had already been attached on scene another time and three participants took their own AEDs when responding. Most first responders felt capable and motivated to use public access AEDs but were concerned about delaying CPR if they retrieved one and frustrated when arriving after the ambulance service. They perceived lack of opportunities due to unavailable and inaccessible AEDs, particularly out of hours. We subsequently developed 13 potential interventions to increase AED use for future testing.ConclusionsGoodSAM first responders used AEDs occasionally, despite a capability and motivation to do so. Those operating volunteer first responder systems should consider our proposed interventions to improve AED use. Of particular clinical importance are: highlighting AED location and providing route/time estimates to the patient via the nearest AED. This would help single responders make appropriate decisions about AED retrieval. As AED collection may extend time to reach the patient, where there is sufficient density of potential responders, systems could send one responder to initiate CPR and another to collect an AED.

Introduction: Pulmonary Rehabilitation (PR) is a cost-effective, internationally recommended intervention for COPD patients suffering breathlessness and/or functional limitation. Referral is largely health care practitioner led, but referral & patient uptake remains poor worldwide. Aim: To use behavioural theory to explore the reported practice of primary health care practitioners (PHPs) in the referral of COPD patients to PR. Methods: Semi-structured interviews were conducted with PHPs in General Practices across Cambridgeshire & West Midlands, UK. Interviews were completed to theme saturation, audio recorded & transcribed verbatim. Content & thematic analysis was mapped to the Theoretical Domains Framework (TDF) s a 14 domain behavioural framework used to diagnose & solve behavioural barriers to implementation problems. Results: PHPs reported referral to PR is low. Barriers: Lack of awareness of PR & its benefits (knowledge), uncertainty about referral process (skills), limited consultation time (environmental context and resources), other priorities (goals), uncertain patients will attend (belief about consequences) or don’t want to go (social influences). Enablers: COPD Annual review (behavioural regulation), stable disease (beliefs about capabilities), template prompts (memory, attention & decision processes), financial reward (reinforcement), believing benefits (belief about consequences) & peer support/engagement, including from PR providers (social influences). Recommendations: These results aim to inform behaviour change interventions that seek to increase PR referral numbers.

ObjectiveConflicting evidence exists regarding the impact of financial incentives on encouraging attendance at medical screening appointments. The primary aim was to determine whether financial incentives increase attendance at diabetic eye screening in persistent non-attenders.Methods and analysisA three-armed randomised controlled trial was conducted in London in 2015. 1051 participants aged over 16 years, who had not attended eye screening appointments for 2 years or more, were randomised (1.4:1:1 randomisation ratio) to receive the usual invitation letter (control), an offer of £10 cash for attending screening (fixed incentive) or a 1 in 100 chance of winning £1000 (lottery incentive) if they attend. The primary outcome was the proportion of invitees attending screening, and a comparative analysis was performed to assess group differences. Pairwise comparisons of attendance rates were performed, using a conservative Bonferroni correction for independent comparisons.Results34/435 (7.8%) of control, 17/312 (5.5%) of fixed incentive and 10/304 (3.3%) of lottery incentive groups attended. Participants who received any incentive were significantly less likely to attend their appointment compared with controls (risk ratio (RR)=0.56; 95% CI 0.34 to 0.92). Those in the probabilistic incentive group (RR=0.42; 95% CI 0.18 to 0.98), but not the fixed incentive group (RR=1.66; 95% CI 0.65 to 4.21), were significantly less likely to attend than those in the control group.ConclusionFinancial incentives, particularly lottery-based incentives, attract fewer patients to diabetic eye screening than standard invites in this population. Financial incentives should not be used to promote screening unless tested in context, as they may negatively affect attendance rates.

PurposeThe purpose of this paper is to explore the behavioural determinants of work-related benefits claimants’ training behaviours and to suggest ways to improve claimants’ compliance with training referrals.Design/methodology/approachQualitative interviews were conducted with 20 Jobcentre Plus staff and training providers, and 60 claimants. Claimants were sampled based on whether or not they had been mandated to training and whether or not they subsequently participated. Along with general findings, differences between these groups are highlighted.FindingsClaimants’ behaviours are affected by their capabilities, opportunities, and motivations in interrelated ways. Training programmes should appreciate this to better ensure claimants’ completion of training programmes.Originality/valueWhilst past papers have largely examined a limited number of factors that affect claimants’ training behaviours, this report offers a synchronised evaluation of all the behavioural factors that affect claimants’ training behaviours.

Recent advances in communication technologies enable potential provision of remote education for patients using computer-generated environments known as virtual worlds. Previous research has revealed highly variable levels of patient receptiveness to using information technologies for healthcare-related purposes. This preliminary study involved implementing a questionnaire investigating attitudes and access to computer technologies of respiratory outpatients in order to assess potential for use of virtual worlds to facilitate health-related education for this sample. Ninety-four patients with a chronic respiratory condition completed surveys, which were distributed at a Chest Clinic. In accordance with our prediction, younger participants were more likely to be able to use and have access to a computer, and some patients were keen to explore use virtual worlds for healthcare-related purposes: Of those with access to computer facilities, 14.50% expressed a willingness to attend a virtual world focus group. Results indicate that future virtual world health education facilities should be designed to cater to younger patients because this group is most likely to accept and use such facilities. Within the study sample, this is likely to comprise of people diagnosed with asthma. Future work could investigate the potential of creating a virtual world asthma education facility.

BACKGROUND/OBJECTIVES: According to the COM-B ('Capability', 'Opportunity', 'Motivation' and 'Behaviour') model of behaviour, three factors are essential for behaviour to occur: capability, opportunity and motivation. Obese children are less likely to feel capable of exercising. The implementation of a new methodological approach to investigate the relationship between perceived exercise capability (PEC) and childhood obesity was conducted, which involved creating a new instrument, and demonstrating how it can be used to measure obesity intervention outcomes. SUBJECTS/METHODS: A questionnaire aiming to measure perceived exercise capability, opportunity and motivation was systematically constructed using the COM-B model and administered to 71 obese children (aged 9-17 years (12.24±0.2.01), body mass index (BMI) standard deviation scores (SDS) 2.80±0.660) at a weight-management camp in northern England. Scale validity and reliability was assessed. Relationships between PEC, as measured by the questionnaire, and BMI SDS were investigated for the children at the weight-management camp, and for 45 Spanish schoolchildren (aged 9-13 years, (10.52±1.23), BMI SDS 0.80±0.99). A pilot study, demonstrating how the questionnaire can be used to measure the effectiveness of an intervention aiming to bring about improved PEC for weight-management camp attendees, was conducted. No participants withdrew from these studies. RESULTS: The questionnaire domain (exercise capability, opportunity and motivation) composite scales were found to have adequate internal consistency (a=0.712-0.796) and construct validity (χ(2)/degrees of freedom=1.55, root mean square error of approximation=0.072, comparative fit index=0.92). Linear regression revealed that low PEC was associated with higher baseline BMI SDS for both UK (b=-0.289, P=0.010) and Spanish (b=-0.446, P=0.047) participants. Pilot study findings provide preliminary evidence for PEC improvements through intervention being achievable, and measurable using the questionnaire. CONCLUSIONS: Evidence is presented for reliability and validity of the questionnaire, and for feasibility of its use in the context of a childhood obesity intervention. Future research could investigate the link between PEC and childhood obesity further.

This article lies at the crossroads of education, technology, and culture, examining the assumption that societal cultures can exert influence on educational technologies. It is informed by a hypothesis that educational technology is not merely a matter of education and technology alone but is also about the societal culture wherein that educational technology is implemented. The study explores those societally and culturally informed factors that promote the rejection of educational technologies. It answers the research question: To what extent do societal cultures challenge educational technologies? This question is addressed by carrying out a quantitative enquiry into Israel and Saudi Arabia. Having analyzed the collected data using an exploratory factor analysis, societally and culturally directed factors were revealed that flew in the face of educational technologies. The theoretical proposition that could be drawn from this is that educational technologies can be rejected not based on educational or technological interests alone but rather based on societally and culturally promoted anxieties. The recommendation for research policy is thus that, when researching an educational technology, there should be constant consideration of how societally and culturally compatible it is with the wider societal culture wherein it will be or already is situated.

Traditional theories of behavior change rely mostly on influencing higher-order mental processes as a route to altering deliberate responses, whereas more recent theorizing postulates that interven...

Rational explanation is ubiquitous in psychology and social sciences, ranging from rational analysis, expectancy-value theories, ideal observer models, mental logic to probabilistic frameworks, rational choice theory, and informal “folk psychological” explanation. However, rational explanation appears to be challenged by apparently systematic irrationality observed in psychological experiments, especially in the field of judgement and decision-making (JDM). Here, it is proposed that the experimental results require not that rational explanation should be rejected, but that rational explanation is local, i.e., within a context. Thus, rational models need to be supplemented with a theory of contextual shifts. We review evidence in JDM that patterns of choices are often consistent within contexts, but unstable between contexts. We also demonstrate that for a limited, though reasonably broad, class of decision-making domains, recent theoretical models can be viewed as providing theories of contextual shifts. It is argued that one particular significant source of global inconsistency arises from a cognitive inability to represent absolute magnitudes, whether for perceptual variables, utilities, payoffs, or probabilities. This overall argument provides a fresh perspective on the scope and limits of human rationality.

IntroductionCompliance with hand hygiene recommendations in hospital is typically less than 50%. Such low compliance inevitably contributes to hospital-acquired infections that negatively affect patients’ well-being and hospitals’ finances. The design of the present study is predicated on the assumption that most people who fail to clean their hands are not doing so intentionally, they just forget. The present study will test whether psychological priming can be used to increase the number of people who clean their hands on entering a ward. Here, we present the protocol for this study.Methods and analysisThe study will use a randomised cross-over design. During the study, each of four wards will be observed during four conditions: olfactory prime, visual prime, both primes and neither prime. Each condition will be experienced for 42 days followed by a 7-day washout period (total duration of trial=189 days). We will record the number of people who enter each ward and whether they clean their hands during observation sessions, the amount of cleaning material used from the dispensers each week and the number of hospital-acquired infections that occur in each period. The outcomes will be compared using a regression analysis. Following the initial trail, the most effective priming condition will be rolled out for 3 months in all the wards.Ethics and disseminationResearch ethics approval was obtained from the South Central—Oxford C Research Ethics Committee (16/SC/0554), the Health Regulatory Authority and the sponsor.Trial registration numberISRCTN (15397624); Edge ID 86357.

Serotonin has been implicated in promoting self-control, regulation of hunger and physiological homeostasis, and regulation of caloric intake. However, it remains unclear whether the effects of serotonin on caloric intake reflect purely homeostatic mechanisms, or whether serotonin also modulates cognitive processes involved in dietary decision making. We investigated the effects of an acute dose of the serotonin reuptake inhibitor citalopram on choices between food items that differed along taste and health attributes, compared with placebo and the noradrenaline reuptake inhibitor atomoxetine. Twenty-seven participants attended three sessions and received single doses of atomoxetine, citalopram, and placebo in a double-blind randomised cross-over design. Relative to placebo, citalopram increased choices of more healthy foods over less healthy foods. Citalopram also increased the emphasis on health considerations in decisions. Atomoxetine did not affect decision making relative to placebo. The results support the hypothesis that serotonin may influence food choice by enhancing a focus on long-term goals. The findings are relevant for understanding decisions about food consumption and also for treating health conditions such as eating disorders and obesity.

Evidence from the behavioral sciences, notably economics and psychology, has profoundly changed the way policymakers and practitioners present expert advice to consumers. This chapter examines the behavioral science evidence on financial advice and explores its implications for the financial advisory profession. It explains how consumers of retail financial advice respond to certain aspects of the advice in predictable ways, sometimes exhibiting behavioral biases or following certain conventions in their decision making. By recognizing and anticipating these responses, financial advisors can offer a more complete service, offering benefits beyond the strictly financial return. But the behavioral needs of consumers may also provide advisors with incentives that are not strictly aligned with their clients’ financial interests. Finally, the increasing role of technology will play an important role in shaping the financial advisory services of the future.

This paper presents results from two large-scale natural field experiments that tested the effect of social norm messages on tax compliance. Using administrative data from > 200,000 individuals in the United Kingdom, we show that including social norm messages in standard reminder letters increases payment rates for overdue tax. This result offers a rare example of social norm messages affecting tax compliance behavior in a real world setting. We find no evidence that loss framing is more effective than gain framing. Descriptive norms appear to be more effective than injunctive norms. Messages referring to public services or financial information also significantly increased payment rates. The field experiments accelerated the collection of tax revenue at little cost.

Previous research has shown that risk preferences are sensitive to the financial domain in which they are framed. In the present paper, we explore whether the effect of negative priming on risk taking is moderated by financial context. A total of 120 participants completed questionnaires, where risky choices were framed in six different financial scenarios. Half of the participants were allocated to a negative priming condition. Negative priming reduced risk-seeking behaviour compared to a neutral condition. However, this effect was confined to non-experiential scenarios (i.e., gamble to win, possibility to lose), and not to ‘real world’ financial products (e.g., pension provision). The results call into question the generalisability of priming effects on different financial contexts.

BackgroundThe UK national diabetic eye screening (DES) programme invites diabetic patients aged > 12 years annually. Simple and cost-effective methods are needed to increase screening uptake. This trial tests the impact on uptake of two financial incentive schemes, based on behavioural economic principles.ObjectivesTo test whether or not financial incentives encourage screening attendance. Secondarily to understand if the type of financial incentive scheme used affects screening uptake or attracts patients with a different sociodemographic status to regular attenders. If financial incentives were found to improve attendance, then a final objective was to test cost-effectiveness.DesignThree-armed randomised controlled trial.SettingDES clinic within St Mary’s Hospital, London, covering patients from the areas of Kensington, Chelsea and Westminster.ParticipantsPatients aged ≥ 16 years, who had not attended their DES appointment for ≥ 2 years.Interventions(1) Fixed incentive – invitation letter and £10 for attending screening; (2) probabilistic (lottery) incentive – invitation letter and 1% chance of winning £1000 for attending screening; and (3) control – invitation letter only.Main outcome measuresThe primary outcome was screening attendance. Rates for control versus fixed and lottery incentive groups were compared using relative risk (RR) and risk difference with corresponding 95% confidence intervals (CIs).ResultsA total of 1274 patients were eligible and randomised; 223 patients became ineligible before invite and 1051 participants were invited (control,n = 435; fixed group,n = 312; lottery group,n = 304). Thirty-four (7.8%, 95% CI 5.29% to 10.34%) control, 17 (5.5%, 95% CI 2.93% to 7.97%) fixed group and 10 (3.3%, 95% CI 1.28% to 5.29%) lottery group participants attended. Participants offered incentives were 44% less likely to attend screening than controls (RR 0.56, 95% CI 0.34 to 0.92). Examining incentive groups separately, the lottery group were 58% less likely to attend screening than controls (RR 0.42, 95% CI 0.18 to 0.98). No significant differences were found between fixed incentive and control groups (RR 0.70, 95% CI 0.35 to 1.39) or between fixed and lottery incentive groups (RR 1.66, 95% CI 0.65 to 4.21). Subgroup analyses showed no significant associations between attendance and sociodemographic factors, including gender (female vs. male, RR 1.25, 95% CI 0.77 to 2.03), age (≤ 65 years vs. > 65 years, RR 1.26, 95% CI 0.77 to 2.08), deprivation [0–20 Index of Multiple Deprivation (IMD) decile vs. 30–100 IMD decile, RR 1.12, 95% CI 0.69 to 1.83], years registered [mean difference (MD) –0.13, 95% CI –0.69 to 0.43], and distance from screening location (MD –0.18, 95% CI –0.65 to 0.29).LimitationsDespite verification, some address details may have been outdated, and high ethnic diversity may have resulted in language barriers for participants.ConclusionsThose receiving incentives were not more likely to attend a DES than those receiving a usual invitation letter in patients who are regular non-attenders. Both fixed and lottery incentives appeared to reduce attendance. Overall, there is no evidence to support the use of financial incentives to promote diabetic retinopathy screening. Testing interventions in context, even if they appear to be supported by theory, is important.Future workFuture research, specifically in this area, should focus on identifying barriers to screening and other non-financial methods to overcome them.Trial registrationCurrent Controlled Trials ISRCTN14896403.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

This study tests for causality from exercise and physical activity to life satisfaction (LS) by applying an instrumental variable approach with the respondents’ perceived benefits of exercise participation as instruments. Using data across 25 countries from the Eurobarometer survey, our results confirm the positive association between exercise and LS. In terms of causality, the results indicate that being active increases LS for both gender, though more for men than women. One main reason for this relationship is that exercise is perceived as being pleasurable, something that policy-makers should keep in mind when designing programmes to get us off the sofa.

Obese individuals are known to be more impulsive than their normal-weight counterparts. Impulsivity has been postulated to be a predictor of weight loss.A pre-post study was designed to determine for the first time whether impulsivity changed with weight loss during a lifestyle and physical activity intervention programme lasting 2-8 weeks.Fifty-three obese adolescents with a body mass index (BMI) of 33.75 ± 7.9 attending a residential camp were tested and compared at baseline with 50 non-obese adolescents with a mean BMI of 20.6 ± 2.3.Inhibitory control was measured with the CANTAB (Cambridge Cognition, Cambridge, UK) Stop Signal Task. MATLAB (The Mathswork Inc., Natick, MA, USA) was used to measure the temporal discounting constant.The obese group was more impulsive than the normal weight adolescents. BMI reduced significantly from 33.76 kg m(-2) to 30.93 kg m(-2) after completing camp. The stop signal reaction time (SSRT) decreased from 225.38 ± 94.22 to 173.76 ± 107.05 ms (n=47, P=0.0001). A reduction in inhibitory control during camp was predictive of those who showed the greatest reduction in BMI (Wilks' Lambda=0.9, F(1,50)=4.85, P=0.034). The number of weeks in camp (Wilks' Lambda=0.83, F(1,50)=9.826, P=0.003) and the age of the adolescents (Wilks' Lambda=0.87, F(1,50)=5.98, P=0.02) were significantly associated with a reduction in inhibitory control as measured by the SSRT. A longer stay in camp was associated with a greater reduction in SSRT (B=25.45, t=2.02, P=0.05). Increasing age had a significant moderating role in the reduction of inhibitory control (B=-0.3, t=-0.034, P=0.05). Temporal discounting for monetary reward also fell significantly during camp.This study highlights the potential to identify those who are obese by using an easy-to-measure psychometric test. Furthermore, it is the first study to report a reduction in impulsivity and an improvement in well-being as part of a government-approved residential camp for obese adolescents. The potential mechanisms for change in impulsivity with weight are discussed.

The reported study advances psychological theory of well-being by offering deeper insight into the factors underlying financial well-being (FWB) in particular. An empirical investigation conducted into the determinants of FWB for two population groups, young workers and families with young children in the UK. Their financial decisions have important consequences for their households. A substantial internet survey of 654 people was conducted, which identified the most significant drivers of FWB or satisfaction, which is analogous to the measurement of subjective well-being in the domain of healthcare. The most significant finding from the regression is the significance for both groups of having control over their finances; control is even more important than the amount of available money for this population. A conclusion of the research is that the FWB would be increased if individuals could experience a greater sense of overall control of their money. In particular, financial institutions could provide products and processes to improve the FWB of their customers. There are also potential policy implications from the benefits of lower unsecured debt and increased savings to mitigate unexpected life events.

The incidence of proximal humeral trauma continues to rise. Treatment of complex proximal humeral trauma remains challenging and controversial. So far, classification of humeral fractures is an unsatisfactory process. In this paper we explore how we make decisions in this unique setting and present early results of using Markov Chain Monte Carlo modeling to assess concepts in surgical pattern recognition.

Policies that change the environment or context in which decisions are made and "nudge" people toward particular choices have been relatively ignored in health care. This article examines the role that approaches based on behavioral economics could play in "nudging" providers and patients in ways that could slow health care spending growth. The basic insight of behavioral economics is that behavior is guided by the very fallible human brain and greatly influenced by the environment or context in which choices are made. In policy arenas such as pensions and personal savings, approaches based on behavioral economics have provided notable results. In health care, such approaches have been used successfully but in limited ways, as in the use of surgical checklists that have increased patient safety and reduced costs. With health care spending climbing at unsustainable rates, we review the role that approaches based on behavioral economics could play in offering policy makers a potential set of new tools to slow spending growth.

The process and consequences of change to a health care system can have unintended, detrimental effects. Various types of simulations have been developed in order to try to predict the effects of change in a health care system. Such methods are in widespread use in industrial, military and higher educational institutions. This review essay focuses on participatory behavioural simulations, in which multiple participants are placed into a realistic, interactive simulation environment and asked to respond to a given set of circumstances, such as a change in policy. The processes and outcomes are driven by the actions and interactions of the participants and not by chance, allowing participants to see the consequences of their actions in a safe environment. The use of simulation in health care policy is presented, together with the evidence for its contribution to policy prediction, education and behaviour change among those designing and implementing health care policies. A method based on best evidence for design, implementation and evaluation of future simulations and participants is proposed.

Purpose The purpose of this paper is to assess whether the dissemination systems that hospitals use to spread information about particular safety incidents can be enhanced using behavioural economics concepts. Design/methodology/approach The current service evaluation took place within eight wards in a single acute care hospital. It was conducted as a randomized controlled trial with two groups. In the control group nothing was altered. In the intervention group ward managers received additional support to disseminate information to their nurses. Nurses were randomly selected to be surveyed during their scheduled shifts. The surveys revealed how the nurses learned about particular safety incidents and how many they remembered. Findings Nurses in the intervention group were more likely to learn about particular safety incidents than nurses in the control group. Practical implications Enhancing common dissemination systems in hospitals can increase organizational learning about safety incidents. The current study presents some means by which dissemination systems can be enhanced. Originality/value The current service evaluation is a unique application of behavioural economics concepts to enhance organizational learning of particular adverse safety incidents in an NHS hospital.

© 2016 Informa UK Limited, trading as Taylor & Francis GroupObjectives: Obesity is a rising problem in adolescents related to unhealthy behaviours. Commitment devises are one type of behavioural intervention that may help people change their behaviours. The current pilot trial tests whether commitment devices delivered via text message help adolescents maintain their recent weight loss. Methods: During a 12-week pilot trial, adolescents who attended a weight loss camp were randomly assigned to either received text messages that contained only information, i.e. advice, about weight loss management (n = 13) or asked for them to commit to following the same advise (n = 14). Results: The BMI of the adolescents in the commitment group did not change. In contrast, the BMI of adolescents in the information group increased. A linear regression revealed that group was a significant predictor of BMI change. A logistic regression revealed that adolescents in the information group were nearly eight times more likely to regain weight than those in the commitment group. Conclusions: This is the first study with adolescents to show weight maintenance using a commitment device. The results suggest that commitment devices can help adolescents maintain their recent weight loss.

Objective There is evidence that executive function, and specifically inhibitory control, is related to obesity and eating behavior. The goal of this study was to determine whether personality traits and inhibitory control predict weight loss after bariatric procedures. Although the impressive weight reduction after bariatric surgery has been shown in short- and medium-term studies, the effect of personality traits on this reduction is uncertain. Specifically, the effect of impulsivity is still largely unknown. Setting Patients attending either a multidisciplinary information session or outpatient clinic at the Imperial Weight Management Centre were recruited with informed consent into the trial over a 4-month period from January to April 2013. Participants were invited to attend behavioral testing on an outpatient basis in a silent room invigilated by a single researcher. Methods Forty-five bariatric patients participated in the study (25 patients had a gastric bypass, with a mean BMI of 41.8 and age of 39.0 years; 20 had a sleeve gastrectomy, with a mean BMI of 47.2 and age of 49.0 years). All patients completed personality measures of impulsivity—Barratt's Impulsivity Scale, as well as behavioral measures of impulsivity—the stop-signal reaction-time (SSRT) task measuring inhibitory control and the temporal discounting task measuring reward processing. Those measures were examined in relation to weight loss 6 months after surgery. Results The surgical procedure and changes in the behavioral measure of inhibitory control (SSRT) were found to be significant predictors of reduction in body mass index (BMI) in patients undergoing bariatric surgery. The sleeve gastrectomy group found a reduction in BMI of 14.1%, which was significantly less than the 25% reduction in BMI in the gastric bypass group. The direction (parameter estimate) of the significant effect was positive for SSRT change, which indicates that pre- and postreduction in impulsivity predicts reduction in BMI. Conclusion Impulsivity measures predict weight reduction in patients undergoing bariatric surgery. This result has implications for predicting outcomes from surgical treatments of obesity.

Childhood obesity is a major public health concern; behavioural interventions induce weight reduction in some, but success is variable. Heart rate variability (HRV) has been associated with impulse control and extent of dieting success. This study investigated the relationship between HRV and post childhood obesity intervention weight-management success, and involved recording the frequency-domain HRV measures ratio between low frequency and high frequency power (LF/HF) and high frequency power (HF), and the time-domain measure, percentage of successive beat-to-beat intervals that differ by more than 50ms (PNN50). It was expected that greater LF/HF and lower HF would be associated with greater post-intervention weight gain, and that greater PNN50 would be associated with greater impulse control. Seventy-four participants aged 9–14 (M=10.7; s.d.: 1.1) attended a weight-management camp, where HRV was recorded. Stop signal reaction time (SSRT) was also recorded as a measure of impulse control. As expected, SSRT was positively associated with pre-intervention body mass (r=0.301, P=0.010) and negatively associated with PNN50 (β=0.29, P=0.031). Post-intervention body mass change was positively associated with LF/HF (β=0.34, P=0.037), but was not associated with HF. Lifestyle interventions may have a greater chance of effectively supporting long-term weight-management for children with lower LF/HF; assessing HRV of obese children may be helpful in informing obesity treatment decisions.

Graphs presenting healthcare data are increasingly available to support laypeople and hospital staff's decision making. When making these decisions, hospital staff should consider the role of chance—that is, random variation. Given random variation, decision-makers must distinguish signals (sometimes called special-cause data) from noise (common-cause data). Unfortunately, many graphs do not facilitate the statistical reasoning necessary to make such distinctions. Control charts are a less commonly used type of graph that support statistical thinking by including reference lines that separate data more likely to be signals from those more likely to be noise. The current work demonstrates for whom (laypeople and hospital staff) and when (treatment and investigative decisions) control charts strengthen data-driven decision making. We present two experiments that compare people's use of control and non-control charts to make decisions between hospitals (funnel charts vs. league tables) and to monitor changes across time (run charts with control lines vs. run charts without control lines). As expected, participants more accurately identified the outlying data using a control chart than using a non-control chart, but their ability to then apply that information to more complicated questions (e.g., where should I go for treatment?, and should I investigate?) was limited. The discussion highlights some common concerns about using control charts in hospital settings.

Adults with Intellectual Disability (ID) are at high risk of being in poor health as a result of exercising infrequently; recent evidence indicates this is often due to there being a lack of opportunities to exercise. This pilot study involved an investigation of the use of motion-sensor game technology to enable and encourage exercise for this population. Five adults (two female; 3 male, aged 34-74 [M = 55.20, SD = 16.71] with ID used motion-sensor games to conduct exercise at weekly sessions at a day-centre. Session attendees reported to have enjoyed using the games, and that they would like to use the games in future. Interviews were conducted with six (four female; two male, aged 27-51 [M = 40.20, SD = 11.28]) day-centre staff, which indicated ways in which the motion-sensor games could be improved for use by adults with ID, and barriers to consider in relation to their possible future implementation. Findings indicate motion-sensor games provide a useful, enjoyable and accessible way for adults with ID to exercise. Future research could investigate implementation of motion-sensor games as a method for exercise promotion for this population on a larger scale.

Objectives: Hospital board members are asked to consider large amounts of quality and safety data with a duty to act on signals of poor performance. However, in order to do so it is necessary to distinguish signals from noise (chance). This article investigates whether data in English National Health Service (NHS) acute care hospital board papers are presented in a way that helps board members consider the role of chance in their decisions. Methods: Thirty English NHS trusts were selected at random and their board papers retrieved. Charts depicting quality and safety were identified. Categorical discriminations were then performed to document the methods used to present quality and safety data in board papers, with particular attention given to whether and how the charts depicted the role of chance, that is, by including control lines or error bars. Results: Thirty board papers, containing a total of 1488 charts, were sampled. Only 88 (6%) of these charts depicted the role of chance, and only 17 of the 30 board papers included any charts depicting the role of chance. Of the 88 charts that attempted to represent the role of chance, 16 included error bars and 72 included control lines. Only 6 (8%) of the 72 control charts indicated where the control lines had been set (eg, 2 vs 3 SDs). Conclusions: Hospital board members are expected to consider large amounts of information. Control charts can help board members distinguish signals from noise, but often boards are not using them. We discuss demand-side and supply-side barriers that could be overcome to increase use of control charts in Q1 healthcare.

Rationale, aims and objectives Despite the widespread inclusion of consultation skills in undergraduate healthcare curricula, patient–doctor interactions are often an imparting of evidence or information rather than an exchange. Evidence-based practice may be further enhanced by increasing explicit understanding of decision-making processes used by healthcare professionals and patients. This exploratory investigation evaluated the impact of an educational intervention on understanding of decision-making processes and practice. The effect of session schedule was assessed to inform the future delivery strategy of such approaches. Methods Three groups of primary care health professionals (n = 85) completed questionnaires using Likert scales to assess strength of agreement with decision-making statements exploring four themes – Theory, Applied Theory, Practice and Joint Practice – pre-intervention and post-intervention. Responses were analysed, firstly to assess the impact of the intervention on understanding of decision-making processes and practice across all participants and then by group to determine the effect of session schedules on outcome measures. Results Overall agreement with the decision-making statements significantly increased after the learning set (Mean = −0.162, SD = 0.355); t(64) = −3.666, p

Obesity and overweight continue to raise in Qatar due to a confluence of factors such as genetics, overeating, inactivity, tradition of food-centered social events, convenience, and advertising of energy-dense fast foods, and hot climate making outdoor activities impractical most of the year. Estimates by experts within and outside Qatar point to an extremely high rate of obesity and overweight in Qatar, with the World Health Organization placing the rate at 78%. This places Qatar among the top of countries worldwide in the overall prevalence of obesity and overweight. Childhood obesity in particular has also been rapidly increasing with the combined rate of obesity and overweight hovering around 40%, up from below 30% less than ten years ago. This trend is alarming due to the increased risks for obesity-related conditions such as diabetes, coronary heart diseases, and lower quality of living. Hence, comprehensive obesity prevention interventions are needed to stem the rise of obesity among Qatari children. This study was conducted to evaluate the effectiveness of an integrated weight loss intervention incorporating lifestyle education, physical activity, and behavioral psychology nudges among Qatari school children. The intervention was designed to integrate family and school support and fit within Qatari school system calendar and schedule. The study was branded Agdar/أقدر and conducted by an interdisciplinary team of collaborators from Qatar (Qatar University, Supreme Education Council, Aspire, Hamad Medical Corporation) and external partners (Imperial College, Leeds Metropolitan University/MoreLife, UK).In the first year of a three-year intervention study, four randomly chosen schools in Qatar participated in the intervention with a total of 941 Qatari children (316 girls and 625 boys) between 9 to 12 years of age of whom 430 children were qualified to participate in the study. A group of four other randomly chosen schools served as control. Out of 430 qualified children, one hundred children (50 boys and 50 girls) with BMI in the 95th percentile from the intervention schools were enrolled in a two phase weight loss intervention. Phase 1 consisted of an intensive weight loss camp with a highly structured set of activity which combined a range of physical activity, lifestyle learning, dietary control, behavioral nudge techniques, and social activity. The second phase consisted of a ten week after school sessions on lifestyle education and weight management for those children who successfully completed camp. These after school/community clubs were run on school premises to facilitate integration in school schedule. The two phases were designed to be complementary: the camp helps children lose weight and introduces them healthy lifestyle behavior, whereas the after school phase embeds/consolidates the knowledge already learnt and helps in long term weight management. During the camp, children participated in a range of structured interactive and skill based activities including a mixture of water based activity, contact games and electives, where the children were able to choose from a range of physical activities. At camp, participants were subjected to a series of assessments including anthropometric (Weight, Height, BMI, Waist Circumference, Blood pressure), Lifestyle and Physical Activity Questionnaires (diet and physical activity), and Psychometric assessment (self-esteem and subjective well-being). During the clubs, only anthropometric measurements took place to ensure the children get the most out of the sessions focusing on reward and recognition and celebrating success regardless of the magnitude of the health improvement. This phase was designed to provide children and parents with the tools, know-how, and the confidence to carry on with the new healthy lifestyle at home as means to ensure durable weight management.Data show that out of the 941 children in intervention schools, 430 children or 45.7% were either overweight or obese, having BMI in the top 95th centile by age. This rate is higher than the 42% we observed in a pilot study conducted by our team in 2014 and the 40% prevalence of overweight and obesity among children reported by other studies.A total of 100 children aged 9–12 completed the camp with a significant reduction in percent BMI SDS of 12.5% (p These improvements in percent BMI SDS reduction (weight loss) and self-esteem occurred in a group that reported an unhealthy lifestyle profile with respect to physical activity and diet. In fact, participant responses painted a profile characterized by little or no physical activity (1 to 2 times/week) with two thirds of participants reporting fewer than 3 occasions of physical activity in their previous week. Participants' diet was characterized by low intake of fruits and vegetables and high intake of calorie-dense foods including sweets, soft drinks, and fast foods. Girls reported eating more fruits than boys but they seem to indulge more frequently in sweets.As the camp phase resulted in a significant weight loss among all participants (100% of participant lost weight at variable levels), particularly girls who were more serious in participation, the clubs were found to help participants in weight management. After an initial weight gain during a 3 week period between camp and club phases (percent BMI SDS reduction down to 10%), participants were able to recover and maintain their post camp levels of BMI SDS reduction. Correlations on data suggest that the more clubs participants (particularly boys) attended, the more likely they were to lose weight during the club phase (p = .028).In summary, the intervention camp was effective in significantly reducing the weight of all participants, despite its short duration of 11 days. After school clubs showed effectiveness in maintaining or further enhancing weight loss achieved in the camp and in engaging parents. The synergistic effect of the camp and after school/community clubs suggests promising potential for successful incorporation of this integrated intervention into the school curriculum, especially since the camp occurs during mid-year school break and the after school clubs during school days. The succeeding cohorts will provide further data for validation of this potential. The one year follow up data are being collected to assess the durability of weight changes and the stickiness of behavioral changes induced by the different phases of this intervention.

Objective: To investigate differences in the quality, confidence, and consistency of intraoperative surgical decision making (DM) and using functional neuroimaging expose decision systems that operators use.\ud \ud Summary Background Data: Novices are hypothesized to use conscious analysis (effortful DM) leading to activation across the dorsolateral prefrontal cortex, whereas experts are expected to use unconscious automation (habitual DM) in which decisions are recognition-primed and prefrontal cortex independent.\ud \ud Methods: A total of 22 subjects (10 medical student novices, 7 residents, and 5 attendings) reviewed simulated laparoscopic cholecystectomy videos, determined the next safest operative maneuver upon video termination (10 s), and reported decision confidence. Video paradigms either declared (“primed”) or withheld (“unprimed”) the next operative maneuver. Simultaneously, changes in cortical oxygenated hemoglobin and deoxygenated hemoglobin inferring prefrontal activation were recorded using Optical Topography. Decision confidence, consistency (primed vs unprimed), and quality (script concordance) were assessed.\ud \ud Results: Attendings and residents were significantly more certain (P < 0.001), and decision quality was superior (script concordance: attendings = 90%, residents = 78.3%, and novices = 53.3%). Decision consistency was significantly superior in experts (P < 0.001) and residents (P < 0.05) than novices (P = 0.183). During unprimed DM, novices showed significant activation of the dorsolateral prefrontal cortex, whereas this activation pattern was not observed among residents and attendings. During primed DM, significant activation was not observed in any group.\ud \ud Conclusions: Expert DM is characterized by improved quality, consistency, and confidence. The findings imply attendings use a habitual decision system, whereas novices use an effortful approach under uncertainty. In the presence of operative cues (primes), novices disengage the prefrontal cortex and seem to accept the observed operative decision as correct.

Decision researchers conduct laboratory experiments of choice between real rewards, but also often rely on asking people to provide hypothetical answers to fictitious situations. Applying results from such studies to real-world situations requires understanding how decision making in cases involving real rewards correspond to decisions with hypothetical rewards. This article reports two key differences between hypothetical and real decisions in social dilemmas. First, hypothetical and real decisions cause different cognitive biases in social dilemmas: hypothetical judgements and choices stem from perceptual processes and cause contrast effects; while judgements and actions in real interaction are biased by assimilation processes involved in action selection and learning. Second, without the corrective real social interaction, people overestimate theirs and others propensity to act cooperatively. However, individuals are more confident in their predictions during real interaction, which suggests that such metacognitive judgments can predict actual behaviour and also signal when respondents provide biased responses. Overall, our results call into question established methodologies that rely on hypothetical answers, and indicate that people should be observed and measured in real or incentivised social interactions.

This article reviews interventions that are effective in changing behaviours in ways that enhance financial capability. Traditionally, behavior change has been seen through the lens of “changing minds”: if we can change the way people think—their beliefs, attitudes, and goals—then we can change the way they behave. More recent developments in behavioral theory show that “changing contexts” can have a powerful effect on behavior: we can change behavior by sometimes quite subtle changes to the environment or context within which decisions are made. We focus largely on the influence of context and provide examples from current UK banks that have changed the “choice architecture” of their products.

Social dilemmas pit the interests of the individual against the interests of the group. Thus, the interests of everyone in the group may be best served by some kind of collective restraint or coope...

We investigated whether financial risk preferences are dependent on the financial domain (i.e., the context) in which the risky choice options are presented. Previous studies have demonstrated that risk attitudes change when gambles are framed as gains, losses, or as insurance. Our study explores this directly by offering choices between identical gambles, framed in terms of seven financial domains. Three factors were extracted, explaining 68.6% of the variance: Factor 1 (Positive)-opportunity to win, pension provision, and job salary change; Factor 2 (Positive-Complex)-investments and mortgage buying; Factor 3 (Negative)-possibility of loss and insurance. Inspection of the solution revealed context effects on risk perceptions across the seven scenarios. We also found that the commonly accepted assumption that women are more risk averse cannot be confirmed with the context structure suggested in this research; however, it is acknowledged that in the students' population the variance across genders might be considerably less. These results suggest that our financial risk attitude measures may be tapping into a stable aspect of "context dependence" of relevance to real-world decision making.

Motivational theories of pain highlight its role in people’s choices of actions that avoid bodily damage. By contrast, little is known regarding how pain influences action implementation. To explore this less-understood area, we conducted a study in which participants had to rapidly point to a target area to win money while avoiding an overlapping penalty area that would cause pain in their contralateral hand. We found that pain intensity and target-penalty proximity repelled participants’ movement away from pain and that motor execution was influenced not by absolute pain magnitudes but by relative pain differences. Our results indicate that the magnitude and probability of pain have a precise role in guiding motor control and that representations of pain that guide action are, at least in part, relative rather than absolute. Additionally, our study shows that the implicit monetary valuation of pain, like many explicit valuations (e.g., patients’ use of rating scales in medical contexts), is unstable, a finding that has implications for pain treatment in clinical contexts.

Many models of consumer behaviour assume that people evaluate price and quality independently. However, evidence shows that consumers perceive price and quality as positively related even when they are weakly correlated in the real markets. This paper explores whether this perceived relationship can be cognitively de-coupled by providing explicit reasons why low price and high quality may be compatible. The participants were asked to rate existing stores and fictitious stores in a two-dimensional price-quality space. When the participants were given plausible reasons why the seemingly high quality fictitious stores could have lower than average prices, their judgement of the price-quality relationship was significantly less correlated than when these stores were judged without such reasons. Therefore, the demonstrated phenomenon of reason-based judgments can be used to attenuate the typical price-quality overestimation, or heuristic, which has important implications for decision making research and marketing practice. (C) 2009 Elsevier B.V. All rights reserved.

Estimating the financial value of pain informs issues as diverse as the market price of analgesics, the cost-effectiveness of clinical treatments, compensation for injury, and the response to public hazards. Such valuations are assumed to reflect a stable trade-off between relief of discomfort and money. Here, using an auction-based health-market experiment, we show that the price people pay for relief of pain is strongly determined by the local context of the market, that is, by recent intensities of pain or immediately disposable income (but not overall wealth). The absence of a stable valuation metric suggests that the dynamic behavior of health markets is not predictable from the static behavior of individuals. We conclude that the results follow the dynamics of habit-formation models of economic theory, and thus, this study provides the first scientific basis for this type of preference modeling.

We show that preferences depend on the attributes that can be directly manipulated when people need to integrate multiple sources of information because direct manipulation causes focusing bias. This effect appears even when all relevant information is simultaneously and explicitly presented at the time the decisions are made. Participants decided how much to save, what investment risk to take and observed the future financial consequences in terms of the mean and variability of the expected retirement income. Participants who manipulated only the future income distribution saved more and took less risk. This effect disappears when the risk-related variables are removed. which indicates that task complexity is a mediator of such focusing effects. A more balanced trade-off between the choice attributes was selected when all attributes were manipulated. However, when there is a dichotomy between manipulating versus observing choice attributes, then decisions were based mostly on the manipulated attributes. Copyright (c) 2008 John Wiley & Sons. Ltd.

In this article, we presented evidence that people are more risk averse when investing in financial products in the real world than when they make risky choices between gambles in laboratory experiments. In order to provide an account for this discrepancy, we conducted\ud experiments, which showed that the range of offered investment funds that vary in their riskreward\ud characteristics had a significant effect on the distribution of hypothetical funds to those products. We also showed that people are able to use the context provided by the choice set in order the make relative riskiness judgments for investment products. This context\ud dependent relativistic nature of risk preferences is proposed as a plausible explanation of the risk preference discrepancy between laboratory experiments and real-world investments. We also discuss other possible theoretical interpretations of the discrepancy.

We report three studies in which methodologies from psychophysics are adapted to investigate context effects on individual financial decision-making under risk. The aim was to determine how the range and the rank of the options offered as saving amounts and levels of investment risk influence people's decisions about these variables. In the range manipulation, participants were presented with either a full range of choice options or a limited subset, while in the rank manipulation they were presented with a skewed set of feasible options. The results showed that choices are affected by the position of each option in the range and the rank of presented options, which suggests that judgments and choices are relative. Copyright (c) 2006 John Wiley & Sons, Ltd.

Two types of social norm message frame for encouraging seeking of alcohol-related health information by excessive drinkers were compared: (a) how much the average person actually drinks and (b) how their drinking ranks among others. It was hypothesized, in accordance with recent evidence of how the brain represents value, that Frame (b) would be more effective than Frame (a). This is the first test comparing these frames in any domain of social norms research.U.K. university students with excessive alcohol intake (n = 101; 66 female) were sent 4 weekly messages containing 1 of 4 types of information depending upon the experimental condition to which each participant was randomly allocated: (a) official alcohol consumption guidelines, (b) how their alcohol consumption compared with official guidelines, (c) how their consumption compared with the sample mean, or (d) how their consumption ranked among the sample. They then had the opportunity to request up to 3 types of alcohol-related health information.Participants informed of how their consumption ranked were more likely to request information (p.01, odds ratio = 6.0) and tended to request a greater number of types of information (p.01, Wald = 7.17) than those in other conditions.Informing excessive drinkers of how their alcohol consumption ranked was more effective in eliciting their seeking of alcohol-related health information than informing them of how their consumption compared with the mean. Research investigating the effectiveness of this message frame in social norms interventions more generally is needed.

Objective To test the ethical acceptability of using financial incentives to increase diabetic retinopathy screening attendance. Background Financial incentives could be an effective way to increase attendance at screening for diabetic retinopathy, although there can be ethical concerns about this approach. Design Survey of people with diabetes in North West London. Those who were due to attend a screening appointment were invited to complete a questionnaire. Key demographic variables included age, gender, and deprivation. Setting and participants A questionnaire was issued to those invited to attend screening in North West London and those who run the screening service. The questionnaire captured views on aspects of the ethical problem and different incentive types. Main variables studied It captured views on the different dimensions of the ethical problem and different types of incentive. In order to understand how views might vary within a population, demographic variables were used to analyze the results. Results and conclusions Vouchers were found to be the most acceptable form of incentive, significantly more so than cash payments. Most rejected the notion of targeting those who need incentivizing, preferring equality. Age was an important factor, with those aged between 40 and 64 the most optimistic about the potential benefits. Higher levels of deprivation were linked to increased acceptability scores. While some ethical concerns are strongly held among certain groups, there is also much support for the principle of incentivizing positive behaviors. This paves the way for future research into the effectiveness of incentivizing diabetic retinopathy screening attendance.

Framing remains one of the pillars of behavioral economics. While framing effects have been found to be quite important in the lab, what is less clear is how well evidence drawn from naturally-occurring settings conforms to received laboratory insights. We use debt obligation to the UK government as a case study to explore the ‘omission bias’ present in decision making with large stakes. Using a natural field experiment that generates nearly 40,000 observations, we find that repayment rates are roughly doubled when the act is reframed as one of commission rather than omission. We estimate that this reframing of the perceived nature of the action generated over $1.3 million of new yield. We find evidence that this behavior may result from a deliberate ‘omission strategy’, rather than a behavioral bias, as is often assumed in the literature. Our natural field experiment highlights that behavioral economics is much more than a series of empirical exercises to quench the intellectual curiosity of academics.

Framing remains one of the pillars of behavioral economics. While framing effects have been found to be quite important in the lab, what is less clear is how well evidence drawn from naturally-occurring settings conforms to received laboratory insights. We use debt obligation to the UK government as a case study to explore the 'omission bias' present in decision making with large stakes. Using a natural field experiment that generates nearly 40,000 observations, we find that repayment rates are roughly doubled when the act is reframed as one of commission rather than omission. We estimate that this reframing of the perceived nature of the action generated over $1.3 million of new yield. We find evidence that this behavior may result from a deliberate 'omission strategy', rather than a behavioral bias, as is often assumed in the literature. Our natural field experiment highlights that behavioral economics is much more than a series of empirical exercises to quench the intellectual curiosity of academics.

People show empathic responses to others’ pain, yet how they choose to apportion pain between themselves and others is not well understood. To address this question, we observed choices to reapportion social allocations of painful stimuli and, for comparison, also elicited equivalent choices with money. On average people sought to equalize allocations of both pain and money, in a manner which indicated that inequality carried an increasing marginal cost. Preferences for pain were more altruistic than for money, with several participants assigning more than half the pain to themselves. Our data indicate that, given concern for others, the fundamental principle of diminishing marginal utility motivates spreading costs across individuals. A model incorporating this assumption outperformed existing models of social utility in explaining the data. By implementing selected allocations for real, we also found that while inequality per se did not influence pain perception, altruistic behavior had an intrinsic analgesic effect for the recipient.