The Healthy Nudge
December 2020
Welcome to The Healthy Nudge. Each month, we'll get you up to speed on the latest developments in policy-relevant health behavioral economics research at CHIBE. Want more frequent updates? Follow us on Twitter @PennCHIBE and visit our website.
a year in review graphic
In 2020, CHIBE members used behavioral science to...
*in no particular order*

1. Establish a first-of-its-kind nudge unit focused on HIV prevention in South Africa. Learn more about Indlela: Behavioural Insights for Better Health, which is developing and testing behavioral solutions that increase uptake of HIV testing, linkage to HIV care, and re-engagement in HIV care, with funding from the Gates Foundation. 

2. Conduct the largest-ever study examining how text communications can boost vaccine uptake. The Penn Medicine Nudge Unit and Wharton’s Behavior Change for Good Initiative (both of which include several CHIBE leaders and affiliated faculty members) have partnered with Walmart to test different text communications encouraging Walmart pharmacy customers to get the flu vaccine. Alongside the Geisinger Behavioral Insights Team, these organizations have also been testing SMS interventions in two large health systems: Penn Medicine and Geisinger. The results of this mega study will soon be available and will inform communication strategies for vaccine uptake in 2021.

3.  Increase serious illness conversations among patients with cancer. A nudge combined with machine learning mortality predictions can help clinicians start serious illness conversations among patients with cancer. This intervention led to an increase in these important conversations from ~1% to 5% of all patient encounters and from ~4% to 15% of encounters with patients having high predicted mortality risk. 

4.  Work toward creating a healthy and equitable food system. CHIBE co-hosted an event this year with the PEACH Lab, the Leonard Davis Institute of Health Economics, and the Penn Prevention Research Center to share ways that the food industry can invest in the health of people, communities, and the planet. We heard from Vice Admiral Jerome Adams, MD, MPH, Surgeon General of the United States, as well as leaders from the New York City Department of Health & Mental Hygiene, Guiding Stars, Healthy Food America, and Just Salad. 

5. Think about how our field can fight racism. CHIBE has made a commitment to health equity and seeks to examine questions like the distributional equity implications of behavioral economic interventions through its research. Internally, CHIBE and the PAIR Center have partnered to create a Committee for Antiracism and Social Change (CASC), and several CHIBE members are also leaders in the Bold Solutions initiative to fight racism within the health care system. 

6.  Learn that smartphones may be better than wearable devices in remotely monitoring physical activity after hospital discharge. “Patients discharged from the hospital using smartphones transmitted data for a greater duration and proportion of time, with a 32% relative increase in patients completing the 180-day period compared with those using wearables,” the study authors found.

7.    Improve adherence in patients post-hospital discharge for acute coronary syndrome. In this study using a loss aversion behavioral economics-based telehealth intervention, adherence to aspirin was higher in the intervention group than the control group after 90 days (median adherence 90% vs 81%). Re-hospitalization was also lower in the intervention group (13% vs 24%).

8.  Determine that financial incentives may improve statin adherence but not LDL-C levels. This 6-month study found that while different financial incentive structures improved medication adherence, the incentive schemes did not reduce LDL-C levels from baseline to one year. “This result points to the importance of directly measuring health outcomes, rather than simply adherence, in trials aimed at improving health behaviors,” the study authors wrote. 

9.  Explore how behavioral phenotyping can help target behavioral interventions more effectively to individuals who are more likely to respond to them. In this secondary analysis of the STEP UP trial, the study authors grouped participants into distinct behavioral phenotypes and found that they had differential responses to a physical activity intervention. 

10. Show how peer comparisons can improve health care quality. This trial with Blue Cross Blue Shield of Hawaii looked at peer comparisons feedback among primary care providers and found that patients in the intervention group experienced a 3.1-percentage-point boost in quality scores compared to the control group, which involved individual feedback only. These results “support Medicare’s decisions to provide comparative feedback as part of recently implemented primary care and specialty payment reform programs,” they wrote.
In 2020, CHIBE also used its expertise to help address the COVID-19 pandemic by...
graphic of covid-19
1.   Providing guidance on COVID-19 vaccine roll-out. Our researchers have been elected to national committees to provide a framework for the equitable allocation of vaccines for the coronavirus. CHIBE researchers have also written op-eds on behavior change techniques to use to encourage vaccine uptake, offered 5 behaviorally informed strategies for a national COVID-19 vaccine promotion program, and published extensively on the topic of social justice in vaccine allocation.  

2.    Optimizing contact tracing. Behavioral science can inform decisions, such as when it’s best to call contacts, what the most successful way to identify the contact tracing team is (e.g. as a health system or public health department), and what the best way to reach people is (e.g. text, call, email).   

3.    Identifying cognitive bias in the response to the COVID-19 crisis. Read this JAMA paper that explains how we “prioritize the readily imaginable over the statistical, the present over the future, and the direct over the indirect” and what effect that has on our decision-making during the pandemic.

4.   Assisting Pennsylvania in creating and increasing sign-ups in COVID PA Alert, a free app designed to help reduce the spread of COVID-19 and which has been used by nearly 700,000 Pennsylvanians so far. The team has been testing message strategies and among other things got the Philadelphia Eagles to record a public service announcement.

5.   Creating an AI chatbot for common questions related to COVID-19 to help offload call volume to unburden clinicians and shorten wait times for patients. This had several advantages, including being available 24/7 without wait times and also ensuring that patients always got the best possible answer. This was done in partnership with Verily/Google and made available and free to health systems worldwide through Google’s Contact Center AI Initiative.  

6. Working with the Penn Medicine Center for Health Care Innovation and numerous other groups at Penn to create PennOpen Pass, a daily symptom tracking and triage tool used to expedite access to testing and contact tracing for the more than 60,000 faculty, staff, students, and employees of the University of Pennsylvania and Penn Medicine.
2020 Behavioral Science and Health Symposium
Thanks to all of those who joined us for CHIBE's 10th annual Behavioral Science and Health Symposium held virtually this year December 3-4. CHIBE hosted Emily Oster, PhD, Professor of Economics at Brown University, and Tali Sharot, PhD, Professor of Cognitive Neuroscience in the Department of Experimental Psychology, University College London, and Director of the Affective Brain Lab, as our keynote speakers.
An Interview with Richard Thaler, PhD
As part of CHIBE's Behavioral Science and Health Symposium, we co-hosted a thought leader interview with Richard Thaler, PhD, the Charles R. Walgreen Distinguished Service Professor of Behavioral Science and Economics at the Chicago Booth School of Business, and co-author of Nudge: Improving Decisions About Health, Wealth, and Happiness, alongside Cass Sunstein, JD. Thanks to the Behavior Change for Good Initiative for co-hosting this event, which was open to the public. Find selected highlights from the interview here or watch the full recording here.
CHIBE Leadership Additions and Promotions
CHIBE is delighted to announce that Alison Buttenheim, PhD, MBA, has been appointed as Scientific Director of CHIBE. Dr. Buttenheim is the Associate Professor and Patricia Bleznak Silverstein and Howard A. Silverstein Chair in Global Women’s Health at the School of Nursing, with a secondary appointment in the Department of Medical Ethics and Health Policy at the Perelman School of Medicine. 

We have also added Rinad Beidas, PhD, the Director of the Penn Implementation Science Center at the Leonard Davis Institute, and Kit Delgado, MD, MS, the Director of the Behavioral Science & Analytics for Injury Reduction (BeSAFIR) lab, to the Steering Committee as Associate CHIBE Directors. 

We are also excited to announce that current CHIBE steering committee members Christina Roberto, PhD, the Director of the PEACH Lab, and Mitesh Patel, MD, MBA, MS, the Director of the Nudge Unit, have become Associate Directors of CHIBE. Find more details on our website.
Team to Evaluate Health Outcomes Following Philly Beverage Tax
Congratulations to CHIBE Associate Director Christina Roberto, PhD, and CHIBE-affiliated faculty member Laura Gibson, PhD, who have received an NIH R01 to continue their research evaluating the Philadelphia beverage tax.
While there is evidence that taxes on sugary-sweetened beverages can lead to drops in purchases of these drinks, there is still a need to find out if this policy can lead to improvements in health outcomes, such as weight, type 2 diabetes status, and oral health.
Their specific aims, according to their project summary, are to:
  • “Evaluate the effectiveness of a sugar-sweetened beverage tax on preventing weight gain among youth (Aim 1) and adults (Aim 2) by analyzing electronic health record data using a natural experiment design.
  • Evaluate the effectiveness of a sugar-sweetened beverage tax on improving oral health among youth and adults in Philadelphia by analyzing electronic oral health records using a natural experiment design (Aim 3).”
Retail Strategies to Support Healthy Eating
CHIBE Associate Director Christina Roberto, PhD, co-edited a special issue of the International Journal of Environmental Research and Public Health called "Retail Strategies to Support Healthy Eating" with colleague Alyssa Moran, ScD. Dr. Roberto also co-wrote the leading editorial introducing the issue, and she is a co-author on one of the papers: Associations between Governmental Policies to Improve the Nutritional Quality of Supermarket Purchases and Individual, Retailer, and Community Health Outcomes: An Integrative Review.
CHIBE Q&A: Rachel Nugent, PhD
rachel nugent
Learn more about CHIBE’s newest External Advisory Boardmember Rachel Nugent, PhD, Vice President and Director of Global Noncommunicable Diseases, RTI International.

What made you want to join CHIBE's External Advisory Board?
I was pleased to be invited to join CHIBE’s External Advisory Board largely because of the high impact that CHIBE has demonstrated in influencing public policy through strong economic evidence, and also to bring that kind of rigorous economic analysis to lower-resourced countries that have many similar health challenges as the United States, but don’t have the behavioral economic training and skills to find innovative ways to resolve those challenges.

What projects are you working on these days?
I am working on the major contributors to noncommunicable diseases (NCDs), primarily on tobacco control and obesity, across countries and populations. Some of the most interesting work is on adolescent health and how to reduce mental disorders and other risk-taking. I am also looking at the interaction between infectious and noncommunicable diseases and how to cost-effectively integrate health services in developing countries, who have growing NCD burdens and very limited resources.

You have more than 30 years of experience in global development as a researcher, practitioner, and policy advisor to governments. What’s a project, paper, or moment that you’re especially proud of from your career?
I believe one of my most influential papers was not even published in a peer-reviewed journal, partly because of data challenges and partly because of my laziness! That paper was a very detailed look at what global health donors were spending on NCDs, and it was done more than 10 years ago before many people realized that NCDs were already a big problem in poorer countries. It turns out that global health donors spent less than 2% of their donor assistance for health on NCDs, which constituted almost 70% of the health burden in the world at that time. That imbalance came as a shock to many people, but it continues today. I believe at the root of the donor reluctance to fund prevention and control of NCDs is the belief that people are responsible for their own poor health when it comes to NCD risks and diseases. Behavioral economics has a role to play in changing the stigma attached to NCDs as well as in changing the opportunities to reduce them.
Penn Online Education Courses
February 2 – March 1, 2021
Foundations of Behavioral Economics
Kevin G. Volpp, MD, PhD

Clinicians, care teams, administrators, payers, digital health teams, entrepreneurs, and researchers may benefit from this professional development opportunity. Learn more and enroll here!


Penn faculty, staff, and graduate and professional students are invited to take this online, master's-level course with CHIBE's Director. Find out how to sign up for this course or others on Penn's Master of Health Care Innovation website.

March 2–April 12, 2021
Behavioral Economics and Decision Making
Kevin G. Volpp, MD, PhD

Course description: Behavioral economics provides a framework for understanding how humans make decisions within the health care system. Students will be able to demonstrate how key concepts in behavioral economics are used, critique existing programs, design new approaches, and apply lessons to challenges they face in their work environments.
*Employees may be able to apply tuition benefits.
Selected Media Coverage
Selected New Publications
The Center for Health Incentives and Behavioral Economics (CHIBE) at the University of Pennsylvania conducts behavioral economics research aimed at reducing the disease burden from major U.S. public health problems. Originally founded within the Leonard Davis Institute of Health Economics, our mission is to inform health policy, improve health care delivery, and increase healthy behavior.