Public health
A nudge in the right direction

ukactive’s ‘Turning the Tide on Obesity’ campaign is the latest to rely on nudging – but what is nudging and does it work? Tom Walker explores

By Tom Walker | Published in Health Club Management 2014 issue 4


We know that, in retail, loyalty scheme customers can be convinced to change their behaviour for £33,” says Sir Keith Mills, founder of two such schemes: Air Miles and the Nectar card. “Incentivising change is possible, but people need to feel there’s a clear benefit from changing their habits.”

Mills, the former deputy chair of LOCOG, made his comments at last November’s ukactive summit, where instigating a change in people’s behaviour was very much on the agenda. At the summit, ukactive announced a new collective ambition for the UK’s active leisure sector: to reduce inactivity levels by 1 per cent year-on-year for the next five years.

Giving a nudge
As there are no laws against inactivity, to achieve this ambitious target ukactive and its partners will have to rely on what Mills would call ‘nudging’ to change people’s habits. Nudging is a concept used in behavioural science, political theory and economics. The theory is based on the notion that positive reinforcement and indirect suggestions, which attempt to achieve non-forced compliance, can influence the motives, incentives and decision-making of groups and individuals more effectively than direct instruction, legislation or enforcement.

A book published in 2008 by American economists Richard H Thaler and Cass R Sunstein brought nudging into the general public’s consciousness. Simply entitled Nudge, the book draws on research in psychology and behavioural economics and defends the active engineering of the way people’s decisions can/may be influenced. While nudging has, arguably, always existed in some form, Thaler and Sunstein’s book was seen as groundbreaking in the depth of detail it offered on how nudging works and how it can be used.

There have been many examples of nudging successfully affecting people’s behaviour across a wide range of topics. One of these was the UK government’s efforts to entice households to invest in loft insulation to conserve energy. Despite large government subsidies, the initial uptake of the scheme was extremely slow.

Research to find out why people weren’t interested – despite it saving them money in the long run – returned a simple but rather unexpected answer. The hassle of clearing out an attic before it could be insulated was putting people off. To tackle this, a ‘nudge’ was created: from September 2011, insulation firms began offering to clear loft spaces and dispose of any unwanted junk. Within weeks, the uptake increased threefold, even though there was an additional cost.

Target practice
There’s a rich history of nudge-based health campaigns too. In 1991, the US National Cancer Institute joined forces with the Produce for Better Health Foundation to launch the ‘National Five-a-Day for Better Health’ campaign. Over the past 20 years, this Five-a-Day programme – which encourages people to eat more fruit and veg – has spread from a California-based scheme to become the world’s largest public-private nutrition education initiative.

More recently in Boston, US, two Harvard students – Yifan Zhang and Geoff Oberhofer – came up with a fitness concept reliant entirely on behavioural economics. The duo were conducting research on how financial incentives can influence behaviour, when they realised their work had applications outside the classroom. The research was turned into a real-world business plan and as a result the pair launched GymPact in January 2012 (now known as Pact – see also p50). The service offers ‘motivational fees’ – customers agree to pay more if they miss their workouts at the gym.

Based on an iPhone app, users sign up to exercise a certain number of times each week and are charged for failing to meet their goals. At a minimum, GymPact users must commit to one 30-minute workout a week and agree to pay a US$5 penalty for missing it. At the end of each week, GymPact charges those (via credit card) who fail to meet their goals; the money collected is distributed to users who kept their commitments.

Unlike most other incentive-based fitness apps, GymPact uses the inbuilt GPS of the iPhone to track movements and ensure users are honest. Each time a GymPact member checks in at a gym, swimming pool or a sports facility, they will receive credits to avoid being charged extra.

Social pokes
GymPact is a great example of how social media and mobile technology can be harnessed to assist with a nudging campaign. However, not all ‘nudges’ are universal successes.

Another social media-driven initiative was the UK government’s Change4Life campaign. The public health programme was launched in 2009 by the Department of Health and was the country’s first national social marketing campaign designed to tackle the causes of obesity.

The scheme encouraged people to adopt six healthy behaviours – relating to diet, activity levels and alcohol consumption – and adopted an integrated marketing approach. As part of this, the brand had a strong presence across a range of social media platforms, while NHS staff distributed more than 6 million items of Change4Life material to the public.

Change4Life adverts were also broadcast in a variety of marketing channels – including television advertising created by Aardman Animations.

As far as establishing the Change4Life brand went, the campaign was successful. For the first year, the Labour government set a target of ensuring 44 per cent of mothers with children aged under 11 would recognise the brand. This was exceeded, as nearly 90 per cent of mothers were able to identify the Change4Life logo a year after its launch. The overall success of the campaign in tackling obesity is still under debate, however, as obesity levels among young people have continued to rise.

In a campaign progress report, public health minister Anne Milton said: “In the past, we’ve generally tried to change attitudes as a precursor or accompaniment to changing behaviours. While this feels intuitively right, it’s troubling that, in health, people’s behaviours so often conflict with their stated attitudes.

“By changing the choice architecture – for example, by changing default options or changing perceptions of social norms – it may be possible to change what people do without necessarily changing their attitudes.”

In 2011, the government announced its Public Health Responsibility Deal (RD) – a public-private partnership that aims to “tap into the potential for businesses and other influential organisations” to improve public health by “helping us to create this environment”.

Consisting of core commitments, supporting pledges and collective and organisation-specific pledges, the initiative is another example of nudging in action. It has, however, come under criticism from public health advocates and others, who have suggested that it will be ineffective – and at worst perhaps even harmful.

Removing the smoke screen
So while there are nudges that work, there are also cases where results achieved using the method are mixed. Might nudging’s greatest strength – especially when used in large-scale public health drives – lie in preparing the ground for change, by altering perceptions and attitudes? Perhaps, rather than guaranteeing behavioural change, nudging might work best as a means to introduce legislation, softening the blow of forced compliance?

The experience of the no-smoking campaign seems to back this view. For years, a number of campaigning groups, charities and health professionals attempted to make more people quit smoking. The nudge was obvious: stop smoking and your life expectancy will rapidly rise. Despite the aggressive ways in which this message was broadcast – the ‘smoking kills’ warnings on tobacco packaging being one – in most countries it wasn’t until smoking was banned in public areas and heavy taxes were introduced that genuine progress was made.

While the bans have been fiercely opposed by the tobacco industry, they have been widely welcomed by the public: when the smoking ban was introduced in England in 2007, opinion polls showed strong support for it. It could be argued that the near-universal support experienced in both the UK and the US for the bans – countries that traditionally take a dim view of limiting the rights of individuals – are mainly thanks to a successful campaign of nudging. These campaigns helped people acknowledge the health threats of smoking to themselves, and identify the benefits associated with quitting, before measures were imposed.

Whether the approach used with smoking can – or should – be used in tackling obesity and inactivity by changing legislation remains to be seen. But it’s clear something needs to be done: ukactive says that, if everyone in England were sufficiently active, nearly 37,000 needless deaths a year could be prevented.

“By 2020, the average Brit will be so sedentary that they will use only 25 per cent more energy than if they spent the whole day sleeping,” says Fred Turok, chair of ukactive. “Over the last 50 years in the UK, physical activity levels have declined by 20 per cent. Even worse, they are projected to decline by a further 15 per cent by 2030.”

While Turok stops short of wanting to change legislation, he wants funding streams to be altered to aid the nudging: “Our best indication to date suggests that, on average, no more than 5 per cent of public health intervention budgets are targeted at reducing inactivity, compared with approximately 40 per cent on smoking cessation programmes and another 20 per cent on weight management programmes. If we’re to achieve our goal, this has to change.”

In retail, customers of loyalty schemes such as Air Miles can be convinced to change their behaviour for just £33 Credit: Photo: shutterstock.com/Serhiy Kobyakov
The nudging campaign that preceded the smoking ban helped ensure the legislation was widely supported by the public Credit: Photo: shutterstock.com/monkey business images
 


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SELECTED ISSUE
Health Club Management
2014 issue 4

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Leisure Management - A nudge in the right direction

Public health

A nudge in the right direction


ukactive’s ‘Turning the Tide on Obesity’ campaign is the latest to rely on nudging – but what is nudging and does it work? Tom Walker explores

Tom Walker, Leisure Media
Five-a-Day has successfully ‘nudged’ people to increase their fruit and vegetable intake Photo: shutterstock.com/l i g h t p o e t
In retail, customers of loyalty schemes such as Air Miles can be convinced to change their behaviour for just £33 Photo: shutterstock.com/Serhiy Kobyakov
The nudging campaign that preceded the smoking ban helped ensure the legislation was widely supported by the public Photo: shutterstock.com/monkey business images

We know that, in retail, loyalty scheme customers can be convinced to change their behaviour for £33,” says Sir Keith Mills, founder of two such schemes: Air Miles and the Nectar card. “Incentivising change is possible, but people need to feel there’s a clear benefit from changing their habits.”

Mills, the former deputy chair of LOCOG, made his comments at last November’s ukactive summit, where instigating a change in people’s behaviour was very much on the agenda. At the summit, ukactive announced a new collective ambition for the UK’s active leisure sector: to reduce inactivity levels by 1 per cent year-on-year for the next five years.

Giving a nudge
As there are no laws against inactivity, to achieve this ambitious target ukactive and its partners will have to rely on what Mills would call ‘nudging’ to change people’s habits. Nudging is a concept used in behavioural science, political theory and economics. The theory is based on the notion that positive reinforcement and indirect suggestions, which attempt to achieve non-forced compliance, can influence the motives, incentives and decision-making of groups and individuals more effectively than direct instruction, legislation or enforcement.

A book published in 2008 by American economists Richard H Thaler and Cass R Sunstein brought nudging into the general public’s consciousness. Simply entitled Nudge, the book draws on research in psychology and behavioural economics and defends the active engineering of the way people’s decisions can/may be influenced. While nudging has, arguably, always existed in some form, Thaler and Sunstein’s book was seen as groundbreaking in the depth of detail it offered on how nudging works and how it can be used.

There have been many examples of nudging successfully affecting people’s behaviour across a wide range of topics. One of these was the UK government’s efforts to entice households to invest in loft insulation to conserve energy. Despite large government subsidies, the initial uptake of the scheme was extremely slow.

Research to find out why people weren’t interested – despite it saving them money in the long run – returned a simple but rather unexpected answer. The hassle of clearing out an attic before it could be insulated was putting people off. To tackle this, a ‘nudge’ was created: from September 2011, insulation firms began offering to clear loft spaces and dispose of any unwanted junk. Within weeks, the uptake increased threefold, even though there was an additional cost.

Target practice
There’s a rich history of nudge-based health campaigns too. In 1991, the US National Cancer Institute joined forces with the Produce for Better Health Foundation to launch the ‘National Five-a-Day for Better Health’ campaign. Over the past 20 years, this Five-a-Day programme – which encourages people to eat more fruit and veg – has spread from a California-based scheme to become the world’s largest public-private nutrition education initiative.

More recently in Boston, US, two Harvard students – Yifan Zhang and Geoff Oberhofer – came up with a fitness concept reliant entirely on behavioural economics. The duo were conducting research on how financial incentives can influence behaviour, when they realised their work had applications outside the classroom. The research was turned into a real-world business plan and as a result the pair launched GymPact in January 2012 (now known as Pact – see also p50). The service offers ‘motivational fees’ – customers agree to pay more if they miss their workouts at the gym.

Based on an iPhone app, users sign up to exercise a certain number of times each week and are charged for failing to meet their goals. At a minimum, GymPact users must commit to one 30-minute workout a week and agree to pay a US$5 penalty for missing it. At the end of each week, GymPact charges those (via credit card) who fail to meet their goals; the money collected is distributed to users who kept their commitments.

Unlike most other incentive-based fitness apps, GymPact uses the inbuilt GPS of the iPhone to track movements and ensure users are honest. Each time a GymPact member checks in at a gym, swimming pool or a sports facility, they will receive credits to avoid being charged extra.

Social pokes
GymPact is a great example of how social media and mobile technology can be harnessed to assist with a nudging campaign. However, not all ‘nudges’ are universal successes.

Another social media-driven initiative was the UK government’s Change4Life campaign. The public health programme was launched in 2009 by the Department of Health and was the country’s first national social marketing campaign designed to tackle the causes of obesity.

The scheme encouraged people to adopt six healthy behaviours – relating to diet, activity levels and alcohol consumption – and adopted an integrated marketing approach. As part of this, the brand had a strong presence across a range of social media platforms, while NHS staff distributed more than 6 million items of Change4Life material to the public.

Change4Life adverts were also broadcast in a variety of marketing channels – including television advertising created by Aardman Animations.

As far as establishing the Change4Life brand went, the campaign was successful. For the first year, the Labour government set a target of ensuring 44 per cent of mothers with children aged under 11 would recognise the brand. This was exceeded, as nearly 90 per cent of mothers were able to identify the Change4Life logo a year after its launch. The overall success of the campaign in tackling obesity is still under debate, however, as obesity levels among young people have continued to rise.

In a campaign progress report, public health minister Anne Milton said: “In the past, we’ve generally tried to change attitudes as a precursor or accompaniment to changing behaviours. While this feels intuitively right, it’s troubling that, in health, people’s behaviours so often conflict with their stated attitudes.

“By changing the choice architecture – for example, by changing default options or changing perceptions of social norms – it may be possible to change what people do without necessarily changing their attitudes.”

In 2011, the government announced its Public Health Responsibility Deal (RD) – a public-private partnership that aims to “tap into the potential for businesses and other influential organisations” to improve public health by “helping us to create this environment”.

Consisting of core commitments, supporting pledges and collective and organisation-specific pledges, the initiative is another example of nudging in action. It has, however, come under criticism from public health advocates and others, who have suggested that it will be ineffective – and at worst perhaps even harmful.

Removing the smoke screen
So while there are nudges that work, there are also cases where results achieved using the method are mixed. Might nudging’s greatest strength – especially when used in large-scale public health drives – lie in preparing the ground for change, by altering perceptions and attitudes? Perhaps, rather than guaranteeing behavioural change, nudging might work best as a means to introduce legislation, softening the blow of forced compliance?

The experience of the no-smoking campaign seems to back this view. For years, a number of campaigning groups, charities and health professionals attempted to make more people quit smoking. The nudge was obvious: stop smoking and your life expectancy will rapidly rise. Despite the aggressive ways in which this message was broadcast – the ‘smoking kills’ warnings on tobacco packaging being one – in most countries it wasn’t until smoking was banned in public areas and heavy taxes were introduced that genuine progress was made.

While the bans have been fiercely opposed by the tobacco industry, they have been widely welcomed by the public: when the smoking ban was introduced in England in 2007, opinion polls showed strong support for it. It could be argued that the near-universal support experienced in both the UK and the US for the bans – countries that traditionally take a dim view of limiting the rights of individuals – are mainly thanks to a successful campaign of nudging. These campaigns helped people acknowledge the health threats of smoking to themselves, and identify the benefits associated with quitting, before measures were imposed.

Whether the approach used with smoking can – or should – be used in tackling obesity and inactivity by changing legislation remains to be seen. But it’s clear something needs to be done: ukactive says that, if everyone in England were sufficiently active, nearly 37,000 needless deaths a year could be prevented.

“By 2020, the average Brit will be so sedentary that they will use only 25 per cent more energy than if they spent the whole day sleeping,” says Fred Turok, chair of ukactive. “Over the last 50 years in the UK, physical activity levels have declined by 20 per cent. Even worse, they are projected to decline by a further 15 per cent by 2030.”

While Turok stops short of wanting to change legislation, he wants funding streams to be altered to aid the nudging: “Our best indication to date suggests that, on average, no more than 5 per cent of public health intervention budgets are targeted at reducing inactivity, compared with approximately 40 per cent on smoking cessation programmes and another 20 per cent on weight management programmes. If we’re to achieve our goal, this has to change.”


Originally published in Health Club Management 2014 issue 4

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