Pragmatic Opposition to Nudging

tongs

In the United Kingdom, great credence has been placed in nudge theory, but apparently a certain amount of disillusionment has already set in. Behavior change brought on by the effects of nudge theory is not by itself enough to make a big dent in obesity and the attendant chronic disease, according to public health leader Professor Mike Kelly.

Kelly even feels that “the jury is still out” on whether nudge theory actually has a useful place in the public health sector. Others are critical because if nudge theory is to make a difference, it will take systemic change and massive work on the built environment including physical architecture, food and transport systems, etc.

Interventions

Mark Egan of Stirling Behavioral Science Center compiled a list of nudgy interventions. He talks about the effects of framing, which is one type of nudge:

When patients are told that 90% of those who have a certain operation are alive after five years, they are more likely to have the operation than when they are told that after five years, 10% of patients are dead.

Good to know. Egan also discusses a paper called “Nudge to nobesity I: Minor changes in accessibility decrease food intake.” This was one of the school-lunch studies, by Hanks et al:

One of two lunch lines was arranged so as to display healthier foods. In the healthier line, sales of healthier food increased by 18% and grams of less healthy food consumed decreased by 28%.

Another study, by Rozin et al, found that the consumption of unhealthy food could be decreased from 8% to 16% by making the unhealthy stuff harder to reach and — get this — by changing the serving utensil from a spoon to a pair of tongs. Tongs!

Egan speaks of another, rather complex study having to do with primary school children, fresh fruits and vegetables, and incentives. The followup move was to assess the kids’ attitudes at intervals afterward. Apparently it was disappointing in some ways, but the big takeaway was that, compared to their more economically privileged age-mates, children from lower income groups emerged from the study with a longer-lasting willingness to try fruits and vegetables.

Nudging has many useful applications. A hotel buffet reduced food waste by 20% merely by changing the signage over the spread. In a full-service restaurant, researchers learned that dishes sold better when their blurbs were printed at the beginning or end of the menu, rather than in the middle.

Another study employed self-refilling bowls. Even though the subjects did not believe they had consumed more, as it turns out, they ate 73% more than the participants who had normal bowls. Astonishingly, the people who ate 73% more did not even feel full.

Egan describes in detail a randomized controlled trial (RCT) using lotteries to encourage weight loss, with noteworthy success. (It is example #7 in the paper.) Item #27 describes a study whose title says it all: “Inviting Consumers To Downsize Fast-Food Portions Significantly Reduces Calorie Consumption.” But what fast-food outlet is going to do that? “Excuse me, ma’am, would you like less food? So that the franchise can make less money and I can lose my job?” Not likely!

Your responses and feedback are welcome!

Source: “A nudge and a think: the architecture of choice and health,” PreventionCentre.org, 05/20/15
Source: “Nudge Database v1.2,” Stir.ac.uk, undated
Photo credit: Rusty Clark – 100K Photos on Visualhunt/CC BY

Nudging Meets MyPlate

fortune-cookie

This post ties up a couple of different strands. Childhood Obesity News talked about nudge theory, the idea that because of human cognitive biases, subtle and non-coercive actions can have large effects. This is good news for parents whose goal is to civilize children. But when the government sets up behavior-shaping programs, some people are uncomfortable with the concept, while others may become over-enthusiastic.

Then we went back over the difficulties encountered during the last revision of the official U.S. Dietary guidelines (which affect much of the world) and their pictorial counterpart, the MyPlate graphic.

In his Forbes article, Andrea Renda describes nudging as “a way to gently steer individuals towards specific forms of behaviour by engaging in so-called ‘choice architecture’.” Nobody in the field could legitimately claim there is anything new here. Marketing has existed forever, and so has public policy.

But never before has such an effort been made to employ one in the service of the other. Renda says:

The same techniques that had been applied for decades by corporations to conquer end users’ attention and willingness to pay were now being put to use in public policy, with a view to improving social welfare and policy effectiveness.

He describes two very recognizable forms of nudging. One type intends to help people act in ways that are more desirable for themselves, and the other attempts to steer people toward acting in ways that are better for society as a whole, rather than the self. To put it another way:

Conceptually, these are two different approaches: one aims at de-biasing individual decision-making, the other at steering individual decisions towards outcomes that are determined by government with no reference to the individual’s own welfare.

Renda mentions “the myplate.gov approach to indicating how to reach a balanced and healthy diet” as an example of the first kind of nudge, the one meant to promote greater individual self-actualization. Why is a mystery, because it almost seems more like the second type.

It could be argued, and often is, that if obesity can be reduced, the budgets of every healthcare system in the world will be considerably relieved. That is definitely a universal good.

At any rate, Renda admits that “the contribution that behavioral economics and nudging have made to public policy is still unclear.” He writes:

For example, while in the short term modifying the order in which food is presented in a canteen might lead to increased consumption of healthy food over junk food, it is unclear whether individuals end up maintaining these new consumption choices over time, or simply learn where to find the food they wanted in the first place, thus neutralizing the nudge.

Here is a thought. Laboratory rodents navigate mazes and withstand shocks to procure snacks. The single-celled organism Physarum polycephalum, or slime mold, can learn to overcome artificial barriers and find the food it wants. So if middle-school students bypass the slightly inconvenient or hidden junk foods, and choose healthful ones, we can probably assume that they are doing it on purpose. Renda goes on to say:

Similar findings have been highlighted in healthcare, for example in addressing obesity.

Your responses and feedback are welcome!

Source: “When The Nobel Prize Goes Pop: Richard Thaler And The Uncertain Future Of ‘Nudge’,” Forbes.com, 10/21/17
Photo credit: scomedy via Visualhunt/CC BY-ND

Choice Architecture, Honesty, and Language

two-yellow-doors

Digital consultant Paul Wood listed the six principles of good choice architecture for interactive websites, starting with the importance of incentive, because the natural human response is to ask “What’s in it for me?” Then there is mapping, which helps the customer understand exactly what they are getting. This is crucial for website design because an actual person is not present to explain, or answer questions.

Because people tend to do whatever is easiest, choice architecture demands that the response desired by the architect is the default choice. The architect must also build in a feedback mechanism, and carefully structure complex ideas, and expect error.

Research needs carefully structured architecture

An issue particularly vital to obesity research is that self-reporting can be accidentally inaccurate, and it can also be purposefully misleading. Bureaucracies benefit from the discovery that asking a person to sign her or his name at the beginning of a form, rather than at the end, encourages honest answers.

A recent study showed that saying to participants “Please don’t be a cheater” is twice as effective as asking them not to cheat. A self-relevant noun like “cheater” invokes a group identity, and cheaters is a group that people don’t want to admit belonging to, even if they are cheaters.

“Please don’t cheat,” where the word is a verb instead of a noun, is too abstract to have the same psychological effect. The study authors say:

These results demonstrate the power of a subtle linguistic difference to prevent even private unethical behavior by invoking people’s desire to maintain a self-image as good and honest.

Psychologist Christopher J. Bryan learned that children age 3 to 6 will respond better to the suggestion that they “be a helper” (noun) rather than asking them to help (verb). A similar experiment in generosity, centered around giving away marbles, also showed the efficacy of linguistic finesse. The New York York Times writer Adam Grant wrote:

The message from this research is loud and clear: If you don’t model generosity, preaching it may not help in the short run, and in the long run, preaching is less effective than giving while saying nothing at all.

However, the window where this works best is rather narrow. At age 5 it is effective in the moment, but soon wears off; and 10 is too old, in the sense that praising character does not provide an edge any longer, but is equally as effective as praising action.

Making the connection between generosity and character (rather than to a discrete action) works best around age 8 when, Grant says, “children may be starting to crystallize notions of identity.” He also carefully examines the important difference between shame and guilt, and explains why the latter is healthy and useful.

Obesity Prevention: The Role of Brain and Society on Individual Behavior by Laurette Dube (lead editor) and six other authors, is an 832-page book published in 2010, available online as a PDF file. It contains a chapter titled “The Choice Architecture and What it Means for Obesity Prevention,” with a section titled “A Whole-of-Society Approach to Obesity Prevention.”

Your responses and feedback are welcome!

Source: “The Six Principles of Good Choice Architecture,” White.net, 08/19/14
Source: “When cheating would make you a cheater: Implicating the self prevents unethical behavior,” APA.org, 2016
Source: “Raising a Moral Child,” NYTimes.com, 04/11/14
Source: “Obesity Prevention: The Role of Brain and Society on Individual Behavior,” IodineThailand.fda, 2010
Photo credit: Barbara Eckstein (beckstei) on Visualhunt/CC BY

Nudges, Mirrors, and Food Choice

woman-in-a-mirror

Tech and marketing writer James Curtis contributes this definition of the social engineering tool called the nudge:

It is a subtle push that aims to alter a person’s behavior without really being noticed. Instead of forbidding choices, or using overt incentives, a nudge acts more like a light breeze that our mind catches like a sail, pushing us into a preferred direction.

He gives seven great examples of applied choice architecture, this one having to do with persuading shoppers to choose more healthful items. Researchers used duct tape to divide each grocery customer’s cart into two sections, and they were instructed to place their fresh produce purchases in front of the tape, and all the rest of their groceries on the other side. The result, Curtis says, was a “102% increase in purchases of fruits & veggies.”

And if you want customers to steer toward the produce department, just paint big green arrows on the floor — which they will follow even if they don’t know why! Now, here is an interesting “awareness” trigger that helps grocery consumers just when they need it most:

This nudge tugs shoppers out of the overloaded marketing circuitry of a grocery store and hopefully back in control by simply placing a mirror at the end of shopping carts. Serving as a constant self-reminder, this grocery store nudge aims to keep shoppers constantly aware of their health when making purchasing decisions, as opposed to running on autopilot…

Another mirror story, this one from a Monday morning breakfast challenge, was reported on by Design Incubation Centre. Researchers set up a buffet table that offered fruits and muffins, and during one time period most people helped themselves to fruits, while during an equal time period, they mostly chose muffins. Why?

To influence choices, we placed a mirror behind the breakfast table as research shows that causing people to self-reflect prior to making a decision encourages them to take healthier options.

They also experimented with taller or shorter serving dishes, and during the “fruit condition,” when the choice architecture was aimed at influencing the subjects to prefer fruit, they played Caribbean music.

Childhood Obesity News previously mentioned how the staff of Massachusetts General Hospital took part in a long-term study meant to nudge them away from unhealthful choices in the cafeteria. Other examples of choice architecture associated with healthier food choices are health labelling at point of purchase, manipulating plate size, assortment manipulation, and payment option manipulation. A promising school study offered fresh vegetarian specials daily, stickers on sandwiches containing salad, promotional posters, and a decorative display of whole fresh fruits.

Your responses and feedback are welcome!

Source: “How Placing a Fly in a Urinal Might Be Just What Your Business Needs: 7 Awesome Nudging Examples,” USImprints.com, 03/04/14
Source: “Nudge,” DesignIncubationCentre.com, undated
Photo on Visualhunt

Authority, Responsibility, and the Dietary Guidelines

congress-session

When the U.S. Dietary Guidelines (foundation of the MyPlate recommendations) came up for revision a couple of years back, and a committee was formed to figure things out, many voices wanted to be heard. It turns out that an amazing number of people take an interest in the nutritional guidelines — lobbyists, consultants, investors, food and beverage industry executives, and “thought leaders,” or at least persons with impressive spheres of influence.

Michael F. Jacobson, President of the Center for Science in the Public Interest, could not find any good words to say about the process, and declared the committee members clueless about the field of nutrition in general, and the Dietary Guidelines in particular. Jacobson went so far as to call the whole procedure “theater of the absurd.” Certainly, a fascinating chain of events ensued, worthy of adaptation by Hollywood.

The BMJ published a very controversial article by Nina Teicholz, who recalled old charges of perfidy, including lies and payoffs. She suggested that, despite new research, the people in charge of the guidelines were willfully ignoring very pertinent studies of the “carbs bad, fat okay” genre. For 35 years, they had been dispensing outdated and fundamentally flawed advice, to shun fat and welcome carbs, and they appeared ready to continue giving it forever.

Follow the money

A lot of potential profit is involved, whenever revision time comes around. The previous (2011) MyPlate graphic, for instance, had cost $2 million to design. Teicholz raised all the questions to be expected from a journalist: about the committee members and their intentions, ingrained biases, and special reasons to be attached to various outcomes. Were there conflicts of interest? Was influence exerted improperly?

And then, critics turned the tables and questioned Teicholz’s integrity. They didn’t much care whether she had the science right or wrong, but deplored the idea of wealthy influencers buying a platform for a writer. The patrons who paid to have her article published were billionaire philanthropists John and Laura Arnold. The couple had their own research institute, Nutrition Science Initiative, staffed with experts who advocated a low-carbohydrate diet.

Meanwhile, the Nutrition Coalition (another Arnold project) came into existence to support Teicholz and the dietary-fat-friendly book she had published. The group attracted doctors, nutritionists, and other experts. They did not necessarily share the same opinions on every nutritional policy issue, but were unanimous in believing that the guidelines creation process needed to be changed.

Then came a Congressional hearing where the House Agriculture Committee had questions about the members of the advisory committee and their findings. Even there, it seemed that the representatives had other matters on their minds than the best possible health outcomes for all Americans. One politician spoke in favor of red meat, and another in favor of milk, and another in favor of the restaurant industry.

There was a question about “the impact of the Guidelines on commodity markets.” Michael F. Jacobson, President of the Center for Science in the Public Interest, told the press:

What we are seeing […] is the coordinated effort of the meat, dairy, soda, restaurant, and packaged-food industries that fear for their bottom lines if people consume less of their products.

The composition of the U.S. Dietary Guidelines is not a problem that can be solved by shrugging, “Well, too bad for the misguided Americans, then.” The thing about being a world leader is, the world looks to you for leadership. Many other countries trust the American findings on nutrition, and adopt our guidelines on the assumption that we have the best information, and would not steer them wrong.

Your responses and feedback are welcome!

Source: “House Agriculture Hearing Shows Why Experts, not Politicians, Should Guide Government Nutrition Guidelines,” CSPINet.org, 10/07/15
Photo credit: inyucho on Visualhunt/CC BY

The MyPlate Unrest

myplatex4

This review of the MyPlate situation will tie back to another recent subject, but first, what is the situation? MyPlate is a graphic that was created to replace the old Food Pyramid. Its message is described more thoroughly by the official dietary guidelines, which are revised every five years. The revision rule was made for excellent reasons — because new information is acquired, and knowledge grows.

During the most recent committee’s efforts, some parties tried to remind the authorities that things had changed since the previous edition. For starters, it had been discovered that scientists took payola to blame obesity on dietary saturated fat, instead of sugar and carbohydrates. Everybody just went along with it for decades.

The U.S. Dietary Guidelines still recommend carbohydrates over fats, and by doing that, science writer Matt Ridley says they ignore too many scientific findings. He cites Professor Christopher Ramsden’s re-analysis of a 45-year-old study, which actually showed that the risk of death is higher with vegetable oils than with butter.

It also found that cutting fats from the diet can do much more harm than good. Ridley says:

Scientists are performing a screeching U-turn on dietary advice, away from demonizing fats and towards demonizing carbohydrates. In the case of obesity, they cannot quite bring themselves to admit it. They want to tell us not to eat sugars, yet they won’t exonerate fat.

The National Cattlemen’s Beef Association publicized its opinion that the proposed guidelines should be critiqued from a “purely scientific and methodological perspective,” implying that the guidelines — as they stood — were not entirely scientific, or even very methodological. It is always tempting to be skeptical, when lobbyists step into an affray. But these days, lobbyists are everywhere, and unavoidable. They can’t always be wrong, and occasionally might be right, even if for the wrong reasons, like naked greed, as sometimes happens.

Language problem

Traditionally, the six food groups are: veggies, fruits, grains, dairy, beans/meats, and fat. Protein is a nutrient contained in some of those food groups. For the sake of rational parallelism, the items on the plate should all be same-level entities.

The Physicians Committee for Responsible Medicine (PCRM) said:

MyPlate is an illustration that divides a serving plate into three common food groups — vegetables, fruits, and grains — and one nutrient category — protein — an anomaly that perpetuates the myth that protein is absent in vegetables, fruits, and grains, and that people must take special care to include protein in their diets.

The PCRM would like to remove the dairy group altogether, maintaining that the consumption of dairy products “fuels the nation’s diet-related disease epidemics.” Dairy products have not really done a whole lot for bone health, and they negatively impact health by increasing the risk of several cancers, along with Parkinson’s, Alzheimer’s, and cardiovascular disease. Also, somewhere between 30 and 50 million Americans face the daily discomfort and embarrassment brought on by lactose intolerance.

The organization also wants to replace “protein” with “legumes,” to discourage the eating of meat, especially red meat, which is described as high in fat, saturated fat, and cholesterol. They are keeping their old-school attitude:

Evidence indicates that meals high in saturated fat adversely affect the compliance of arteries, increasing the risk of heart attacks.

From Harvard’s T. H. Chan School of Public Health came a rival paradigm, the Healthy Eating Plate (HEP), which its creators pointedly mention “was not subjected to political or commercial pressures from food industry lobbyists.” Here’s the quick rundown of the main differences:

  • MyPlate did not used to advocate whole grains, but was revised to recommend that at least half a person’s grains be whole. The HEP is whole grains all the way.
  • MyPlate is fine with red meat and processed meat, while the HEP recommends limiting red meat, and getting protein through fish, poultry, and beans.
  • MyPlate “does not distinguish between potatoes and other vegetables.” The HEP is anti-potato.
  • MyPlate doesn’t mention oils or fat. The HEP is in favor of olive, canola, and other plant oils, and against butter.
  • MyPlate recommends dairy, but the HEP wants everyone to drink water.

Your responses and feedback are welcome!

Source: “The Exoneration of Dietary Fat,” RationalOptimist.com, 04/14/16
Source: “The money behind the fight over healthy eating,” Politico.com, 10/07/15
Source: “USDA’s MyPlate Is Making Americans Sick, Says Doctors Group,” PCRM.org, 08/10/17
Source: “Healthy Eating Plate vs. USDA’s MyPlate,” HSPH.Harvard.edu, 09/14/11
Image by ChooseMyPlate.gov

Nudge-o-Nomics

deciding-quote

Childhood Obesity News looked at the work of University of Chicago behavioral economist Richard Thaler, who studied people’s decision-making around money. With law professor Cass Sunstein, Thaler developed the notion of the nudge, “a subtle, non-coercive government intervention that can have outsize impacts because of human cognitive biases.” An example of how this principle is applied can be found in our post, “Behavioral Economics and School Lunches.”

For Forbes.com, Andrea Renda describes nudging as “a way to gently steer individuals towards specific forms of behavior by engaging in so-called ‘choice architecture‘.” And what might that be? Renda elaborates on the concept:

It was, de facto, the consolidation of two fields of social science: marketing and public policy, where the former was convincingly applied to the latter. The same techniques that had been applied for decades by corporations to conquer end users’ attention and willingness to pay were now being put to use in public policy, with a view to improving social welfare and policy effectiveness.

So, in other words, this is all manipulation, which is often regarded as a sneaky and underhanded way of doing things. Is manipulation always bad? Some philosophers would say yes. Others would say it’s the only way to get things done.

Folk wisdom has always recognized the successful techniques that characterize relationships between the sexes. Women whisper to each other the secret of getting a man to do something. Trick him into thinking it was his idea. Men pass along the arcane knowledge of how to handle a woman. Listen to her advice, say “Yes, dear,” and then go ahead and do what you meant to in the first place.

The “gently steer” language pertaining to choice architecture is reminiscent of a technique shared in parenting classes. Don’t ask a child, “What do you want for supper?” Instead, structure the question to preclude any unacceptable answer. “Do you want peas or corn?” Both are vegetables, so the parent wins either way. Meanwhile, the child is given the illusion of choice, and blissfully enjoys a fantasy of autonomy.

Experts have discovered how to take that principle and scale it up to the science of running an entire country. Renda says:

Finally, with the advent of big data analytics and artificial intelligence, the possibilities for governments to nudge individuals by engaging in advanced choice (or code) architecture appear to be exponentially increasing… The popularization of behavioral economics in the form of relatively straightforward experiments paved the way for a successful age of direct implementation in policymaking…

There are two main forms of nudging. One persuades the individual to choose a course of action more beneficial to himself; the other aims to persuade a person to do what is best for society as a whole. Ostensibly, the government practices these techniques to wisely guide, as a mother or a father would, the choices the citizens make.

One type of gentle, mental manipulation convinces a person to go for health, safety and prosperity, instead of cigarettes. Another type convinces people to not toss leftover medications into the toilet, because it harms the environment and the creatures living in it. In a perfect world, it would stop there.

Your responses and feedback are welcome!

Source: “This headline is a nudge to get you to read about Nobel economist Richard Thaler,” Vox.com, 10/09/17
Source: “When The Nobel Prize Goes Pop: Richard Thaler And The Uncertain Future Of ‘Nudge’,” Forbes.com, 10/21/17
Photo credit: symphony of love on Visualhunt/CC BY-SA

Gurus of the Irrational

parrying-duo

We have been discussing the work of Daniel Kahneman and Amos Tversky. In the words of Michael Lewis, they demonstrated that people, including experts of every kind, “unwittingly use all sorts of irrelevant criteria in decision-making.” One of those fallacious criteria is cognitive bias, which is so insidious because it is largely unconscious.

Lewis lists several of the research team’s examples of how thinking goes astray. The examples are reminiscent of a certain genre of riddle that has been a cultural feature for decades. For example:

A window cleaner is cleaning the windows on the 25th floor of a skyscraper. He slips and falls. He is not wearing a safety harness and nothing slows his fall, yet he suffers no injuries. Explain.

Answer: The window cleaner is cleaning the inside windows.

It’s not a trick question, but it could baffle someone whose cognitive bias brings up a mental picture of a window cleaner situated on a suspended platform outside a building. As long as a person is oblivious to the alternative possibility, that the cleaner could be working on the inner side of the glass, the riddle will not be solved. To entertain the cognitive illusion that window washers can only be in one place — outside — is to blind oneself to reality and guarantee that the answer will not be found.

Kahneman and Tversky also identified a logical error they called the conjunction fallacy, which is too complicated to go into here; and developed a school of thought around decision-making. Lewis says:

In their most cited paper, cryptically titled “Prospect Theory,” they convinced a lot of people that human beings are best understood as being risk-averse when making a decision that offers hope of a gain but risk-seeking when making a decision that will lead to a certain loss.

Dylan Matthews describes the work of Richard Thaler, another behavioral economist who proves that humans are not rational in their decision-making. He took an interest in “identifying specific kinds of irrationality that could be predicted and modeled ahead of time.”

Thaler described the peculiar mental accounting by which a person decides how to spend or save, depending on where the money comes from. Then, there is the endowment effect:

The basic idea is that people are strongly averse to giving up goods they already have, to the point of refusing to sell the goods for a price higher than what they paid for the goods to start with.

The endowment effect is closely related to loss aversion — the finding that people try harder to avoid losses, and put forth less of an effort to pursue gains. Writer Carl Richards phrased the concept like this:

We feel the pain of loss more acutely than we feel the pleasure of gain. In other words, we may like to win, but we hate to lose.

Childhood Obesity News has brought this up before in relation to the Fear of Missing Out (FOMO) syndrome. First, admittedly it is rational to miss something we once had, and that we lost. But the other face of FOMO is people getting all bent out of shape over missing stuff they never had. FOMO fever gets out of control and drives bad decisions. If you stop and think about it, it is pretty unreasonable to miss something we never had in the first place.

The weirdness

Paradoxically, this is exactly what we encourage an obese child to do. We hope the young person will feel desire for something he or she has never known: the pleasure of living in a fit, agile, non-obese physical frame. More importantly, we want them to abandon all the survival skills and coping mechanisms they have learned over the years. They know that sweets heal emotional pain. They know that binge eating fills up the emptiness. These are the pillars of truth on which the universe rests.

And then… there is pressure to change everything. Imagine if someone comes to you with a fabulous plan for living on the moon. “You’ll love it,” they gush. “You’ll be a whole new person!” But the person you are has already put in a lot of hard work figuring out how to make it in the Terran environment. You know how to breathe Earth’s air and walk around in Earth’s gravity. For these and other reasons, the moon colony will probably be a hard sell.

We want to maintain the status quo. As the old saying goes, “Better the devil you know than the devil you don’t.” Richards says:

The endowment effect is so powerful, people value their existing level of health so much, that they’d pay 50 times more to preserve their current level of health than to get a little healthier.

It has been an ongoing mystery, why many kids admit to several horrendous varieties of misery, and yet seem so unwilling to work for change. Is it possible that an obese teenager would pay 50 times more to preserve her current level of health than to get a little healthier? What an absurd idea — yet apparently, the endowment effect is a powerful force working against the efforts to help teens get healthy.

Your responses and feedback are welcome!

Source: “The King of Human Error,” VanityFair.com, December 2011
Source: “10 Smart Riddles,” Psysci.co, undated
Source: “This headline is a nudge to get you to read about Nobel economist Richard Thaler,” Vox.com, 10/09/17
Source: “Overcoming an Aversion to Loss,” NYTimes.com, 12/09/13
Photo credit: darkday via Visualhunt/CC BY

The Contradictions Within

lion-woman

Childhood Obesity News left off last time with speculation about whether clinical trial subjects, who might otherwise be tempted to somehow violate protocol, could be inspired by altruism to do better. This question is especially interesting for children and adolescents, who already have issues around their relative lack of power in the world.

Can the chance to take part in an important scientific study help to rev up the motivation? Can the vital nature of the mission impress kids enough so they take very seriously the need for full cooperation? Can a simple appeal to scientific integrity inspire them?

Various authorities have explored the issue of ownership, and language is a tool in promoting this idea. For instance, the Cenduit corporation characterizes their experimental subjects as “stakeholders,” which of course they are. The literature for one of their products reads as follows:

Patient Reminders are personalized, automated SMS, email, and voice messages sent to the patient or caregiver. Reminders help stakeholders arrive on time and prepared for their clinic visit. The result is higher quality investigational procedures completed within the time window demanded by the protocol and reduced instances of patient early withdrawal and lost to follow-up.

Perhaps that is a clue. A fertile field for inquiry is how to gain a real investment of commitment from the participants. Dr. Fred Kleinsinger mentions this detail:

I know that the term “nonadherence” has replaced “noncompliance” in some circles because “nonadherence” is less value-laden and does not imply a rigid hierarchical relationship between physician and patient.

Of course, we always hope that people will act in a way that makes sense. Whether undergoing a course of treatment laid out by the family physician, or participating as a subject in a big formal research project, we hope that people will act in ways that benefit themselves, but surprisingly they often do not. We also hope they will do the right thing regarding the study protocol, perform the actions they are supposed to perform, and refrain from the others.

In 2002, psychologist Daniel Kahneman was awarded the Nobel in economic science. His research and writing partner Amos Tversky would have won too, were he not already deceased. Together they proved that humans are not nearly as rational as we suppose. They did what Jim Holt calls “ingeniuous experiments” and discovered more than a score of cognitive biases that can twist our thinking processes into knots of futility.

The two-person team posited the existence of two separate operating systems in each of our minds. For convenience they are called System 1 (automatic, instinctual impulses and reactions) and System 2 (self-control, which is effortful). Kahneman wrote:

Constantly questioning our own thinking would be impossibly tedious, and System 2 is much too slow and inefficient to serve as a substitute for System 1 in making routine decisions. The best we can do is a compromise: learn to recognize situations in which mistakes are likely and try harder to avoid significant mistakes when the stakes are high.

This may seem far afield from obesity, but exactly what is going on when an obese person is confronted by a brand new bag of chips? System 1 urges immediate and thorough consumption, while System 2 struggles to think rationally over the rustling sound of a torn package. By the time System 2 reports in with the logical analysis — “This will not benefit your effort to achieve better health” — the mouth is already experiencing a crunch orgy and a salt rush.

The words of a famous commercial — “Bet you can’t eat one!” — prove true once again, as the heedlessly delinquent System 1 taunts, “Are you kidding? I can eat one whole party-size package! Ha ha ha!”

Your responses and feedback are welcome!

Source: “Patient & Protocol Compliance In Clinical Trials,” ClinicalLeader.com, 03/30/15
Source: “Understanding Noncompliant Behavior: Definitions and Causes,” NIH.com, Fall 2003
Source: “Two Brains Running,” NYTimes.com, 11/25/11
Source: “Of 2 Minds: How Fast and Slow Thinking Shape Perception and Choice [Excerpt],” ScientificAmerican.com, 06/15/12
Photo credit: cajsa.lilliehook on Visualhunt/CC BY-SA

Protocol Compliance and Data Quality

writing-at-the-desk

Protocol compliance is the professional term for what the clinician/researcher needs from the subject/patient. Data quality is what the practicing physician and the inquiring scholar both hope to gain from their relationships with everyday people.

More and more, it is assumed that technology is the answer to everything, and should be deployed early and often. Technology seems to promise protocol compliance throughout the treatment or study, which it can only measure but not deliver.

At the very least, technology can tip off the researcher that some confabulation is going on. Moe Alsumidaie writes:

To elaborate, if a study team detects via engagement analytics that a patient is at risk of not adhering to study requirements, study teams can implement proactive methods to re-engage the patient; essentially reacting through targeted engagement strategies.

To put it more simply, “The key to patient adherence is early and responsive intervention” which is coincidentally true of so many things, for instance, childhood obesity. For another publication, Alsumidaie elaborated on how the non-adherence issue can “easily be addressed with novel technologies” like Artificial Intelligence and patient-centric study design models:

In the future, it is likely that advanced technologies and patient centric study design will not only make studies more convenient and accessible for patients, but also improve patient compliance with study procedures and IMP, generate higher data quality and ultimately shorten study duration and minimize cost impact.

But what is a patient-centric study? Jim Lane says:

Patient centricity initiatives frequently focus on trial awareness, protocol design, advocacy reach-out, and communication of study results. The fundamental issue of non-compliant patient behaviour and its mitigation, through such measures as continuous trial support, encouragement, and patient engagement, must feature prominently and be part of core trial activities.

Can patient compliance be encouraged by appeals to altruism? When drug trial subjects are released from the constant observation stage, they know they are expected to take their pills and maintain their diaries. The weight-losers know they are supposed to measure, calibrate, and record according to protocol. But for some people, a word like “compliance” can trigger their anti-fascist paranoia, and those quirks need to be taken into account.

When subjects revert to being part of the outpatient population once again, it is probably an innate human tendency to shout “Free at last!” — and act accordingly — even when the freedom is spurious, and even when the behavior is against the person’s own best interests.

For the subjects of a study, non-compliant behavior is inimical to the best interests of society as a whole, because it messes up an expensive scientific project and delays the discovery of new ways to save lives. But sometimes, a person just doesn’t care.

Within the narrow confines of a delusion, this makes sense. If even one’s own self-interest does not count for much, the desire to help the world is unlikely to be very strong, either.

Your responses and feedback are welcome!

Source: “Technology Tips on Improving Clinical Trial Patient Adherence,” AppliedClinicalTrialsOnline.com, 02/13/15
Source: “Non-Adherence: A Direct Influence on Clinical Trial Duration and Cost,” AppliedClinicalTrialsOnline.com, 04/24/17
Source: “Can Patient Engagement Improve Protocol Compliance?,” Longboat.com, 02/21/17
Source: “The Secrets of a Successful Clinical Trial: Compliance, Compliance, and Compliance,” NIH.gov, April 2011
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Childhood Obesity News | OVERWEIGHT: What Kids Say | Dr. Robert A. Pretlow
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