Best Behaviour: Nudging people towards better oral health
By Amina Ibrahimpašić, Slovenia
The science behind making profit by predicting people’s actions and (oral) health are not quite related. Or are they?
In a world where everyone strives for success and large corporations fight for profit, analyzing people’s choices and behavior can be of a great use. Behavioral science, thus, nowadays plays an important part in economics, which is testified by two Nobel Prize winning theories.
First, the Nudge theory, described in 2008 by Thaler and Sunstein in an economics text – Nudge: Improving Decisions about Health, Wealth, and Happiness – suggests that people’s behavior can be altered in a predictable way (3). Take for instance grocery shopping. Everyone is likely to buy the items exposed, highlighted or reachable rather than the ones hidden across different parts of the market. People are, thus, nudged toward buying what we want them to, without being forced to.
Second, the Prospect theory, described in 1979 by Kahneman and Tversky in The Prospect Theory: An Analysis of Decision under Risk, suggests that decision making under risk can be viewed as a choice between prospects (i.e. chances or opportunities for success or wealth) and gambles (i.e. risky actions undertaken hoping for success). Whilst making decisions people tend to avoid losses (2). For example, you would be more affected by the message saying irregular tooth brushing increased your chances for losing teeth rather than by the message saying regular teeth brushing decreased your chances of losing teeth. This is used in presenting a persuasive message in terms of expected gains or losses associated with an advocated behavior – message framing.
So, if predicting one’s behavior can be majorly used in economics and profit making, could it be used in directing people toward making better health choices? And if it could be used in improving public health, could it also be used in preventing oral disease and improving oral health?
Choice Architecture in Public Health
Given the promising results in the domains of money saving, pro-environmental behavior, charity donations, and loss aversion, it is essential to think outside the box and imagine what effects nudges and message framing could have as public health strategies.
Being the first step towards better health, healthy diet is among first and possibly the most common subject of studies conducted on applying the nudge and prospect theories in public health improvement. The best ways to promote healthy food are usually simple and inexpensive – making healthy food more visible and desirable. Thus, commonly used strategy is placing healthy food at eye level or at the cash register, which has an enormous impact on purchase choices (whose eye does not catch something else the minute you need to pay?!). Others may include placing stickers of superheroes on fruit and vegetable containers and giving children tokens redeemable for small inexpensive toys, as it was done in a study of low-income elementary schools in Texas. The study found that this intervention increased the selection and consumption of fruits and vegetables (4), which is expected when you think of all the items you purchased just because they were, for instance, Frozen or Star Wars franchise, or had free gadget/toy in it. Given the nominal cost of the toys and stickers, and no cost for repositioning healthy food, these interventions could scaled up as cost-effective ways to improve nutrition of the whole population.
Message framing, on the other hand, may have stronger effects as it nudges people to think about the implications. But, what should the massages say? Should we create frightening, but scientifically correct messages and thus affect people’s opinions (i.e. negative framing)? Or should we create optimistic, but still accurate messages (i.e. positive framing)? The truth is that we cannot contend anything for sure, since unstable effects are observed across different studies. Although this is mainly the result of lack of knowledge about message framing, some suggest that risk-framing hypothesis has fundamental flaws, since its conceptualization of risk differs from the one of the prospect theory (6).
How About Oral Health?
Given the evidence based applications of the theories in public health, it is essential to investigate what effects, if any, they have in prevention of oral disease and/or oral health improvement.
In the case of oral health, investments in prevention generate potentially high returns through improved future health (e.g. less complicated, less painful and less costly treatments, social and professional benefits etc.). Therefore nudging people towards investing in preventive measures could be beneficial for both parties; patients and dentists. As described, manipulating people’s perception by making oral health tools more visible and desirable can have tremendous effects. Who does not want a toothbrush with their favorite princess or superhero?! Next step could be reminding patients to make check-up appointments. A study conducted in Germany found that reminders significantly increased the likelihood of scheduling check-up appointments and the frequency of actual check-ups. However, the nature of the reminder message (i.e. positive or negative framing) had no significant influence (1). In contrast, a study of the influence of gain- and loss-framed videos about oral health on flossing behavior and the roles of perceived susceptibility to oral health problems found that the likelihood of flossing at recommended levels significantly increased in groups in which the frame matched perceived susceptibility (5).
What Can We Conclude?
In conclusion, nudging significantly impacts one’s behavior toward oral health. Behavioral strategies that helped technology and large corporations evolve could, thus, help in public oral health improvement.
1. Altmann S, Traxler C, Nudges at the Dentist. IZA. 2012 Jul [cited 2019 Mar 8]; DP No. 6699. Available from: http://ftp.iza.org/dp6699.pdf
2. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 1979 Mar [cited 2019 Mar 8]; 47(2): 263–291. Available from: https://www.uzh.ch/cmsssl/suz/dam/jcr:00000000-64a0-5b1c-0000-00003b7ec704/10.05-kahneman-tversky-79.pdf
3. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven and London: Yale University Press; 2008. p. 3–6.
4. Thapa JR, Lyford CP. Nudges To Increase Fruits and Vegetables Consumption: Results From A Field Experiment. Journal of Child Nutrition and Management. 2018 [cited 2019 Mar 8]; Vol 42, Issue 1. Available from: https://schoolnutrition.org/uploadedFiles/5_News_and_Publications/4_The_Journal_of_Child_Nutrition_and_Management/Spring_2018/Nudges-to-Increase-Fruit-and-Vegetable%20Consumption-Results-from-a-Field-Experiment-Spring2018.pdf
5. Updegraff JA, Brick C, Emanuel AS, Mintzer RE, Sherman DK. Message Framing for Health: Moderation by Perceived Susceptibility and Motivational Orientation in a Diverse Sample of Americans. Health Psychol. 2015 Jan [cited 2019 Mar 8]; 34(1): 20–29. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691327/
6. Van’t Riet J, Cox AD, Cox D, Zimet GD, De Bruijn GJ, Van den Putte B, De Vries H et al. Does perceived risk influence the Effects of message framing? Revisiting the link between prospect theory and message framing. Health Psychology Review. 2016 Apr [cited 2019 Mar 8]; 10(4): 447–459. Available from: https://www.tandfonline.com/doi/full/10.1080/17437199.2016.1176865