Nudging is a slippery business. Here’s a primer to help get you started with your design for better health decisions.
Designing settings and scenarios in which people make healthy choices requires presenting those choices in a way that takes the all-too-human side of decision making into account. People need (and want) choices, but they also need (and want) help—a nudge—when they’re not sure what to do.
Richard Thaler and Cass Sunstein’s book Nudge steers toward a “middle way” that encourages people to make better decisions without taking away their freedom to choose. They seek a centrist path between one side that believes that freedom comes from having as many choices as possible, and the other that believes that freedom comes from the simplicity of being able to accept or reject one good choice.
Research shows us that humans make decisions based on a variety of factors, many of which are not necessarily rational, logical, economic or even self-interested. Decisions are driven by an array of often-conflicting incentives, desires and intentions. The result is many people making many choices that aren’t the best for them, even when it comes to their own health.
So how do you create a successful health nudge?
First, you must specifically define the behavior or choice that you are trying to influence. People who need a nudge to pick the right health plan, exercise, take their medicines, or donate their organs make lots of health choices every day, but nudges at this broad level don’t produce the same results as a targeted nudge. Nudging people to “exercise regularly” is too broad to be meaningful. Nudging people to take the stairs instead of the elevator, go for a walk after lunch instead of going back to sit at their desks, or committing to go to a favorite exercise class three time a week targets a specific decision point that will be easier to influence with a nudge. Focus on the decision point rather than big goals.
Next, think about the type of decision you are trying to influence. Thaler and Sunstein point out that there are certain types of decisions that respond to nudges well. They are:
- Delayed Consequences Decisions—where the impact of the decision (or non-decision) and its consequence are separated in time (such as smoking now and the risk of lung cancer later).
- Complex Decisions—where there are many variables to consider in the decision, such as choosing the right health care insurance.
- Overwhelming Decisions—when there are too many choices, or the choices are unfamiliar, such as which exercise routine is best for you.
- Low Feedback Decisions—where there is no obvious feedback from the decision, such as taking vitamins everyday.
- Infrequent Decisions—where the decision points come up very rarely, such as choosing between surgeries, medicines or other treatment options for a diagnosis.
Decisions like these are the best for nudging. Ask yourself if the decision you want to influence is a good candidate for nudging.
The Flavors of Nudging
So now you’re ready to design the nudge. Nudges can come in any form, but they typically fall into four flavors:
- Default rule changes are best for situations when not choosing is common or has a big impact. Smartly setting the default for people who neglect to choose a health care plan or who forget to decide if they want to donate their organs, will have far-reaching impact.
- Environmental reminders can be anything that reminds people of what’s important—like a checklist or a poster. These are best for routine decisions, like taking medication or following infection-control procedures.
- Designed decisions place alternatives in front of people at the moment in which they need to make a choice. This flavor of nudging is best for decisions between two or more alternatives, like treatment plans for a diagnosis or choosing among prescription drug plans.
- Processes and programs that help people remember their commitments are best for decisions where it’s challenging to continuously keep on track, like eating right, exercising or quitting smoking.
Making nudges is like making art, so it’s hard to pin down the perfect process—but a few things can be said about good health nudges. In the sidebar are some "Dos and Don'ts" for nudge designers. Not all rules apply for every type of decision and every flavor of nudge. You’ll have to figure what’s best for your design.
Finally, think about how to promote the nudge. Lots of big ideas and little encouragements fall by the wayside because these ideas don’t stick with us, or they get crowded out by all the other messages we are exposed to everyday. How will you make the health nudge public and get people thinking and talking about it? Out of sight equals out of mind.
When designing a nudge, remember that you’re following the middle way. You don’t want to take away choices, but you don’t want to force a particular choice either. Nor do you want to overwhelm people with too many alternatives or ignore human fallibility that often leads to poor choices. Rational, logical, predictable robots are easy to design for. You’re designing for people. Understanding and respecting their right to choose is the first principle of nudging. Accepting that people make mistakes and need some help is the last.
Rules for Nudging
- Specifically define the behavior that you are trying to influence.
- Make a nudge that respects people’s right to choose . . . even to make what could be considered to be poor choices.
- Take the perspective of the decider—which choice is best according to them?
- Simplify the number of alternatives and reduce the complexity of the choices.
- Make it easier to make a choice.
- Make the nudge public.
- Take advantage of existing social norms and community practices to make your nudge stick. Get everyone in the decision environment involved.
- When possible, set the default for the best decision.
- Remember that when you create a decision point, you cannot escape influencing the outcome—so think about how your influence will enter the decision and design for it.
- Don’t take away all the choices but one—good designers for health leave the freedom to choose.
- Don’t force people to make choices without creating room for them to reflect on the decision—good nudging makes people think more, not less.
- Don’t expect that everyone will understand all the aspects of the decision—good designers for health understand that people take shortcuts and make mistakes when deciding, and they design for it.
- Don’t give people too many choices—good designers for health help decision making by keeping it simple.
- Don’t confuse an incentive and a nudge—good designers for health think of ways to encourage good decision-making without having to pay dearly for it. If you want to use financial incentives, think carefully about how people will (or won’t) respond to them. Nudges sometimes work better . . . and cost less.
- Don’t underestimate the power of the small details—good designers for health understand that people pick up on environmental and social cues (like which choice comes first or which is the shortest to read) when they make decisions.
- Don’t expect people will make error-free decisions in the environment you create. Design nudges that can help people learn and adjust for different types of needs, preferences or circumstances.
- Don’t set the default position without a good deal of careful research and consideration.
- Don’t feel constrained by technological limits. If a technology does not yet exist, part of your nudge can be the creation of it.