More effective implementation strategies can be developed when an informed understanding of motivators of behavior change is incorporated within the implementation strategy. Behavioral economics in implementation research (BEIR) is anchored in the premise that an implementation strategy can be explicitly designed and maintained to optimize the desired behaviors (i.e., actions) with ease, efficiency, and consistency, if one has identified the desired outcome(s) and the recommended behaviors/action(s) needed to support those desired outcomes (as specified in an evidence-based practice (EBP)). Behavioral economics strategies include: performance assessment; choice architecture; hovering (i.e., observation); incentives, including behavioral nudges; maintaining consistency; making harms more immediate/salient; modelling behavior; remuneration; social proofs, etc.. Behavioral economic strategies incorporated within an implementation strategy to deploy an EBP are designed and tested to achieve the intended performance objectives recognizing importance of cultural context and patterns of behavior change. Some intervention research projects and system-wide quality assurance programs for EBP for heart, lung, blood, and sleep disorders (HLBS) are now being sub-optimally designed. The use of BEIR may lead to less-disruptive, user-driven sustainable intervention strategies.
The use of behavioral economic strategies to evoke appropriate decision making (behavior) in fulfillment of the objectives of EBPs for HLBS was well recognized. Our understanding of factors influencing behavior is continuing to evolve. Initially, we understood that in order for an optimal decision to be made, education and knowledge would need to be provided so that a correct decision would be made. More advanced behavioral theory recognized that people are rational and to change their behavior you give rewards or incentives. More recent models of understanding of behavior, reflect the complexity of behavior. It can be very important to recognize that people can be irrational in predictable ways. It is critical to harness these biases and/or restructure the environment so that the best decisions are made, as intended by EBPs. Participants emphasized the importance of extending on-going advancements: discernment of which BEIR approaches are easier or harder to implement for various HLBS conditions and why; need for information-driving behavior to be readily accessible and actionable; ability to describe behavioral economics as an approach in order educate the scientific community and to garner support and use of BEIR; critical need for clarification and extended discussion on the interface between behavioral economics strategies/models and implementation frameworks to support EBP implementation strategies; and, importance for on-going dialogue between behavioral economic and late-stage implementation research experts. Participants emphasized the importance that the decision making process and the cultural context be accurately depicted. BEIR studies should be designed to reflect the realities of human behavior, humans employ heuristics, or mental shortcuts, to make decisions. These shortcuts can be incorporated into the design of more effective implementation strategies. The integration of behavioral economics in implementation research is a promising approach that may lead to more-efficient, less-disruptive, and sustainable intervention strategies. The participants recognized that additional support and research is needed in order to understand interrelationship of behavioral economics and implementation research. It is important to design BEIR studies with the goal that they be sustainable beyond grant funding — as such, the appropriateness of financial incentives should be carefully considered. The term "behavioral economics" was used to convey the rigor of the scientific method of the approach; some expressed concern that the term “economics” may be misleading for researchers who are not aware of BEIR constructs and methods. Participants were very enthusiastic about timeliness to convene the workshop as an effort to generate insights on successful strategies and evidence gaps, as highlighted below.
Highlights of considerations to advance the use of BEIR to address HLBS disorders include:
Work Group Participants/Moderators in Order Listed in Workshop Agenda
Video: Asch, D. A. (2018). Why it’s so hard to make healthy decisions. TEDMED 2018. https://www.ted.com/talks/david_asch_why_it_s_so_hard_to_make_healthy_decisions?language=en
Use-Case Presentations: (5 minutes each)
Joseph Ladapo, M.D., Ph.D.
Behavioral Economics and Implementation Research to Reduce Cardiovascular Risk in HIV-Infected Adults
Pamela Peterson, M.D., M.S., M.S.P.H.
Enhancing Cardiac and Pulmonary Rehabilitation Adherence Through Home-based Rehabilitation and Behavioral Nudges: E.R.A. Nudge
Davene Wright, Ph.D.
Behavior Modification or Commodification? Using Behavioral Economics to Improve Child and Adolescent Obesity Management
Shivan Mehta, M.D., M.S., M.S.H.P.
EMPOWER: Pragmatic Randomized Trial of Automated Hovering in Patients With Congestive Heart Failure
Andy Ryan, Ph.D.
Using Behavioral Economics to Improve Cardiovascular Outcomes in the Merit-Based Incentive Payment System
Max Crowley, Ph.D.
Example of BEIR Use-Case Under Development
Execute Polling Questions 1 and 2
David Asch, M.D., M.B.A.
Participant Consent and Validity in Studies about Health Behavior Interventions.
Steven Persell, M.D., M.P.H.
Health Systems Research using I.T. for Delivery and Moving from Pilot to System
Sara Bleich, Ph.D.
Improving the Reach and Impact of Scientific Communication