Paul Rozin found that if you move an easy-to-reach food item to the middle of the salad bar, people are less likely to reach for that item — the 10-inch difference is too far. This change significantly reduces the amount of food people will eat.
“If 10 inches could make that kind of difference, it has big implications for how we design interventions,” says Roy Rosin, Chief Innovation Officer at Penn Medicine. “We need to start thinking about, how do you get the outcome that you want while requiring an absolute minimum amount of effort — or maybe no effort at all — if you can structure the environment where no choice gets you what you want? How do you make the right choice the easy choice?”
There aren’t many examples of achieving outcomes with zero behavior change, but the ones that do exist are worth consideration, says Rosin, because you can replicate the thinking behind them. One of these was the addition of fluoride to drinking water, begun in 1945 in Grand Rapids, Michigan. The city had a high incidence of tooth decay, but 11 years into a 15-year study with 30,000 schoolchildren, Dr. H. Trendley Dean from the NIH announced a 60% drop in tooth decay in children born after fluoridation started. “That’s a tremendous outcome when there’s no behavior change,” says Rosin. “Just keep drinking the water and you get the outcome you want of reduced decay.”
A more recent example is the Sonic Signature Slinger. Sonic replaced 25% of the beef in this burger with chopped mushrooms, reducing the burger’s calorie count from 600 down to 350. This beef reduction also benefits the environment: If 30% of beef in the 10 million burgers eaten annually by Americans were replaced with mushrooms, this would accomplish the equivalent of taking more than 2 million cars off the road and saving 83 billion gallons of water.
Where zero effort isn’t feasible, minimal effort can still produce desired outcomes — a “set it and forget it” action. “Just do that one thing one time, and that’s all you have to do,” says Rosin. He describes the Lucky Iron Fish by Christopher Charles, a Canadian medical student living in Cambodia. Charles noticed a high incidence of anemia in Cambodians, and that for many residents, changing their diet or taking expensive supplements to minimize iron deficiency was not feasible. At first, Charles put iron blocks that would leach iron — replicating iron pans — inside Cambodians’ cookware. But people did not want to cook with the blocks because they were concerned they’d scratch the cookware. After learning about the try kantrop fish, a symbol of luck in Cambodia, Charles created a bunch of these fish out of iron and handed them out across several communities, asking folks to cook with the fish. He found incredibly high compliance — plus a 90% increase in the iron status of those who regularly cooked with the fish and a 50% drop in severe anemia, with no change in diet or supplements.
“People just put it in the pot and then do whatever they were doing already,” explains Rosin. “No change in behavior. Keep cooking the same foods that you’re always eating.”
Rosin acknowledges how that industry has numerous examples of driving behavior change with minimal effort. After the 2010 Haiti earthquake, for example, relief organizations raised $43 million in texted donations, a majority from people who had no other engagement with the issue. They simply saw an ad and made an impulse donation. Texting the word “Haiti” to a short code is much simpler than making a phone call or navigating a website.
“You can drive behavior that you want by simply getting a lot of the work out of the way,” says Rosin. But, he notes, “since I’ve been in health care, I have noticed that we require a lot of work of our patients. We ask them to assemble their own care more often than not.”
He describes a project at Penn Medicine’s Center for Health Care Innovation that removes work for colorectal surgery patients as part of Enhanced Recovery After Surgery (ERAS). The Penn Med team identified three key pre-op behaviors for patients: skin prep, drinking Gatorade, and taking antibiotics during bowel preparation. Addressing zero compliance for all three behaviors together, they asked, “Why do we make them assemble the kit? Why do you have to go over there to show your prescription? Why do you have to go over here to the store to buy your Gatorade?”
Their response: “Why don’t we just do the work? Why don’t we assemble care for them?”
They created game plan bags to hand over to patients with everything they needed. With these bags, the percentage of patients who conducted all three behaviors rose from 0 to 64%. When adding a bit more help in the form of text or phone tips and reminders — “because these patients are very stressed; they’re anxious before surgery; they’ve got a lot of other things on their mind other than what we want them to do” — doing all three behaviors rose to 100%.
“This idea of taking work off their plates is extremely important,” Rosin says.
Returning to choice architecture in other industries, Rosin points out Richard Taylor’s work that led to the 2006 law allowing companies to auto-enroll employees in retirement savings plans. Auto-enrollment makes a big difference. If you’re automatically enrolled and do nothing, you still save for retirement, and the likelihood of opting out is low because that requires action.
Mitesh Patel’s team in the Nudge Unit at Penn employs choice architecture nudge philosophy to achieve different outcomes with minimal or no effort, such as setting default preferences that increased generic medication prescribing. In another Nudge Unit example, making referrals to cardiac rehab the default increased referral rates from 15% to 80%, in turn reducing mortality. And changing opioid prescription defaults in the ER to fewer pills dramatically reduced the number of unnecessary pills floating around.
“This is something that we know we can replicate. This is not pessimism in people, that they will not change behavior or sustain behavior change. It’s optimism that once we understand that people will not take a significant effort so they can conserve energy, we could use that knowledge to focus our efforts in ways that enable the kind of outcomes that we really care about,” Rosin concludes. “The thing that I would like to see more often is focus on making the right choice the easiest choice. Change the environment so that if people take no action at all, the right thing still happens. Make it easy for people to do the right thing.”
From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.