To avoid making mistakes when applying behavioural insights in healthcare, we need to understand why people do what they do

Behavioural Science is now mainstream.

We have come a long way since the first signs that behavioural science was being applied to change the behaviour of populations with the formation of the Behavioural Insights Team in 2010 under David Cameron’s government and the publicised use of behavioural experts by Barak Obama to guide his election and re-election campaigns.

Governments and public health bodies are now routinely and openly employing behavioural science to improve the health of their populations. The United Nations (UN) has just issued a ‘Guidance Note on Behavioural Science’ recommending that all UN agencies and departments start implementing behavioural science in their work to help achieve their mandates laid out in the Sustainable Development Goals, and the WHO is using behavioural science to help increase acceptance and uptake of COVID-19 vaccines globally.

But we still have a lot to learn and we are still making mistakes. We often launch behaviour change strategies without knowing what the outcome will be and are surprised by unintended consequences.

An initiative to reduce rates of teenage pregnancy had the opposite effect because teenage girls from deprived social backgrounds did not hear the messages of missed opportunity and loss of freedom, but instead saw the teenage mother delivering the messages as independent, together and confident, with rights and financial support, and they wanted what she had.

Some behavioural experts believe we are making mistakes in offering incentives to people to have COVID-19 vaccinations. Many countries across the world, including India, Russia, Serbia, Thailand, the UK and the USA have offered cash payments, savings bonds, lottery tickets, tickets to the theatre, sports clubs and local attractions, free food or alcohol or discounts on fast food and Uber rides to boost COVID-19 vaccination rates.

While this may solve the short-term problem, COVID-19 vaccines, like flu vaccines, are likely to be a regular part of our lives for years to come and we need longer-term solutions that are based on a clear understanding of why people do not want to be vaccinated. There is quite a body of evidence suggesting that offering incentives can backfire, especially if the reason people are not being vaccinated is the fear of side effects. Rather than encouraging people to take up vaccines, offering incentives reinforces the belief that vaccines are dangerous (so people need to be paid to have them). Instead of applying behavioural principles on the basis of general assumptions, “it is important to look at what people want, what they feel their lives are currently missing and how we can build that knowledge into a solution or incentive”, said consumer behaviour and design expert Janneke Blijlevens.

Because it is not clear which behavioural interventions will work, or will work best, several different interventions are often tested at the same time. This approach of launching 100 ships to see which make it across the ocean can be effective if you have time and unlimited resources but we don’t have that in healthcare.

We have limited populations of specialists, patients and other healthcare professionals, restricted timelines, as we need to change behaviour quickly, and limited resources. There is also an ethical consideration. Should we launch behaviour change interventions with patients if we really have no idea whether or not they will work and what the unintended consequences will be?

If we first took the time to understand why people such as patients, healthcare professionals and caregivers are doing what they are doing, what their deeper motivations and drivers are, and what they want from their lives, we would be better able to generate or select the behaviour change interventions that will be effective – and we will be able to predict the consequences.

We aren’t all the same. We don’t all respond in the same way to messages, incentives, encouragement and punishment. Some of us are risk-takers; some prefer to stick with what they have always done. Some are optimists, others are pessimists. Some live in the moment and make decisions based on the here and now, others think and plan ahead and play the long game. We need to know all of this to design and implement interventions that truly change behaviour for good and for better.

‘We need to design and implement interventions that truly change behaviour for good and for better’