The Healthy Nudge
March 2021
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.
Could text-based nudges boost flu vaccine uptake?
vaccine shot
What kind of text — from your doctor’s office or your pharmacy — might nudge you to get your flu vaccine? This was a question explored in two new "mega-studies" looking at text-based nudges by the Behavior Change for Good Initiative (BCFG) in collaboration with the Penn Medicine Nudge Unit.

One of the studies involved over 47,000 participants and tested 19 different nudges within Penn Medicine and Geisinger health systems. They found that certain texts that were sent prior to a visit to a primary care provider could increase vaccination rates by up to 11%. The most successful kinds of nudges were those framed as a reminder to get the flu shot — and specifically that it was already reserved for the patient — and those that had a tone patients expected from their health care provider. The findings of this study could be useful for campaigns encouraging uptake of other vaccines, such as COVID-19, the study authors wrote.

The other mega-study was with Walmart and involved 22 text-based nudges going out to over 700,000 Walmart pharmacy patients. “We demonstrate that the best behaviorally informed messages can increase pharmacy vaccination rates by up to 8.3% compared to the least effective messages over a roughly one month follow-up period,” the study authors found. This study also found that the most effective messages were those that reminded patients that a flu shot was waiting for them.

These two studies were led by Co-Director of BCFG Katy Milkman, PhD, in collaboration with Penn Medicine Nudge Unit Director Mitesh Patel, MD, MBA, MS; and Co-Director of BCFG Angela Duckworth, PhD, MA, MSc; and involved many other CHIBE affiliates and leadership members such as Alison Buttenheim, PhD, MBA; Kevin Volpp, MD, PhD; Gretchen Chapman, PhD; Leslie John, PhD; Silvia Saccardo, PhD; and Maurice Schweitzer, PhD, MA; among other authors.

Dr. Buttenheim provides testimony to the House Science, Space, and Technology Committee on vaccine science
House Science Space Technology Committee
Alison Buttenheim, PhD, MBA, Associate Professor of Nursing and Health Policy and CHIBE’s Scientific Director, provided testimony on vaccine science to the U.S. House of Representatives’ Committee on Science, Space, and Technology on February 19. As part of her testimony, Dr. Buttenheim provided 5 science-based recommendations that she hoped Congress would endorse, fund, and promote.

1. “Embrace the dual goal of vaccinating efficiently and equitably.”
“We have to be deliberate, intentional, and innovative in our approach to both tracking and achieving those complementary goals,” Dr. Buttenheim said.

2. “Fix the easy stuff.”
While hesitancy is a barrier to vaccination, Dr. Buttenheim noted that “hassle factors” can also deter people from getting vaccinated, even if they were initially excited to get the vaccine. Vaccine appointments should be easy to make and keep, for example.

3. “Keep doing the hard stuff even if it doesn’t scale.”
For those who may have concerns about the speed at which the COVID vaccines were developed or who may distrust the medical research establishment, one-on-one conversations with trusted peers can be an effective way to encourage vaccine uptake.

4. “Use fun and delight.”
Dr. Buttenheim pointed to the Sleeves Up, NOLA video created by the City of New Orleans as a great example of how to leverage fun and delight while encouraging vaccination.

5. “Fail fast, learn fast.”
Just as scientists tested hypotheses and conducted experiments to create the COVID-19 vaccines, we also need to use this approach to rigorously study vaccine acceptance, Dr. Buttenheim maintained. “Learning what works is critical,” she said.
STAT Madness competition for best innovation in biomedicine recognizes paper involving CHIBE affiliates
stat madness
A paper involving several CHIBE affiliates was selected as a top 64 contender for the STAT Madness competition for best innovation in biomedicine.

The paper explored using machine learning and behavioral nudges to prompt clinicians to start serious illness conversations among patients with cancer. Read the JAMA Oncology paper here: “Effect of Integrating Machine Learning Mortality Estimates With Behavioral Nudges to Clinicians on Serious Illness Conversations Among Patients With Cancer.”

Congratulations to the study authors (CHIBE members in bold): Christopher R. Manz, MD; Ravi B. Parikh, MD, MPP; Dylan S. Small, PhD; Chalanda N. Evans, BS; Corey Chivers, PhD; Susan H. Regli, PhD; C. William Hanson, MD; Justin E. Bekelman, MD; Charles A. L. Rareshide, MS; Nina O’Connor, MD; Lynn M. Schuchter, MD; Lawrence N. Shulman, MD; and Mitesh S. Patel, MD, MBA.
New CHIBE One-Pager
CHIBE has a new one-pager you can use to share about our center and the type we're involved in. Click here to view our one-pager, which details some of our impact stories and research areas, as well as info about our faculty leadership, publications, and affiliated faculty members.
CHIBE Q&A with Dr. Silvia Saccardo
Silvia Saccardo, PhD, is an Assistant Professor in the Department of Social and Decision Sciences at Carnegie Mellon University and a CHIBE affiliated-faculty member. She recently published a paper on "Lifestyle and mental health disruptions during COVID-19." Read our Q&A with Dr. Saccardo to learn more about this work by Osea Giuntella, PhD; Kelly Hyde, MA; Silvia Saccardo, PhD; and Sally Sadoff, PhD, MA.

Your study revealed major lifestyle and mental health disruptions among University of Pittsburgh students during the COVID-19 pandemic. For example, you found that 61% of the participants were at risk for depression, which was a 90% increase over the baseline rate of 32% two months earlier, prior to COVID-19. What do you think could be some of the factors associated with this rise in depression (beyond physical activity)?
As we document in the paper, the COVID-19 pandemic has disrupted the way students live, learn, and interact. On top of changes in physical activity and sleep habits, we also see big changes in how students spend their time, with a large increase in the number of hours students spend on screens (video games, browsing the web, etc., without considering online learning), which more than doubled at the onset of the pandemic. At the same time, we observed that time spent socializing declined by over half, to less than 30 minutes per day. The lack of social interactions might have contributed to the large rise in depression. At the beginning of the pandemic, students suddenly had to move away from campus, missing out on many opportunities to socialize. There are also other factors that we did not measure, which likely affected depression ratesfor example the difficulties related to the move to online education or the concerns over family and friends getting infected. 

Your team did find a link between physical activity and mental health, so you randomized half your participants to receive incentives for walking at least 10,000 steps per day for 2 weeks. While this intervention did lead to increased steps and physical activity, your team found that this did not translate to improvements in mental health. What do you make of that?
That’s correct. Motivated by the link between reduction in physical activity and depression we observed in our data, as well as by prior work suggesting that improving exercising could help mental well-being, we randomized half the participants to receive incentives for walking at least 10,000 steps per day for 2 weeks. The intervention helped restore pre-pandemic levels of exercising in the treated group. However, it did not have any meaningful impact on mental well-being. This result opens up a few possibilities. One possibility is the intervention was too short. Indeed, other work on physical activity and mental health has focused on interventions that encourage exercising over a more extended period. In our context, the decline in physical activity (and in mental health) happened rapidly, over the course of a few weeks, but it could be that restoring mental health requires a longer intervention. Another possibility is that the restoration of physical activity may be more effective if done in conjunction with the restoration of other lifestyle habits that have been disrupted by the pandemic (e.g., social interactions). Finally, another possibility is that the relationship between mental health and disruptions in physical activity during COVID-19 is driven more by mental health rather than lifestyle, and that changes in lifestyle may be symptoms of depression. More work is needed to further understand these possibilities and shed more light on the link between lifestyle habits and well-being.
What do you think colleges and universities should do with this information?
The large rise in depression rates we observed in our study which was also documented by other work is alarming. We continued tracking lifestyle and depression last fall 2020 and this spring 2021, and although the rates of depression are lower now than they were at the onset of the pandemic, we still see higher prevalence of depression symptoms than we saw before the beginning of the pandemic. My collaborators and I think colleges and universities should raise awareness and normalize the discussion around mental health in order to minimize the stigma associated with seeking help. As the pandemic continues to unfold, it would be also important to create opportunities for students to remain engaged and connected and to consider more flexible approaches to deadlines given the frequency of pandemic burnout. Finally, we think universities should start considering students’ physical and mental health together, as the two are closely connected. 

March 11 from 12 to 1 PM EST
Rena Conti, PhD, will join the CHIBE and LDI community for a Health Policy Work-In-Progress Research Seminar on March 11 to talk about repurposing generic drugs for COVID-19 and beyond. She will present new empirical economic work to inform COVID-related policymaking and future research efforts. Dr. Conti is an Associate Professor of Markets, Public Policy, and Law at the Questrom School of Business, Boston University.

March 12 from 12 to 1 PM EST
Co-sponsored by LDI and Health Transformation Institute
Since the passage of the Affordable Care Act, we have seen significant experimentation with value-based payment. Some of these alternative payment models have had success while others have had more mixed results, with many valuable lessons learned. But the question remains, where do we go from here? Join us for a virtual conversation with Ezekiel Emanuel, MD, PhD, Amol Navathe, MD, PhD, and Mai Pham, MD, MPH, moderated by Rachel Werner, MD, PhD.

March 18 from 12 to 1 PM EST
David Powell, PhD, will join the Health Policy and CHIBE community for a Work-In-Progress Research Seminar on March 18. Dr. Powell is a Senior Economist at the RAND Corporation and a faculty member at the Pardee RAND Graduate School.
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.