A Gentle Nudge: The New Push in Digital Healthcare

What is a Nudge?

In 2008, colleagues Richard Thaler and Cass Sunstein published their book Nudge: Improving Decisions About Health, Wealth and Happiness, which coined the term “nudge” and established a new area of behavioral study. So-called nudge theory examines the subtle psychological cues that can influence a person's behavior. ¹ According to the authors, a “nudge” is a small manipulation of our daily choices. For example, the default setting of accepting Web site cookies (with a click to opt out) or the magazines for sale in the checkout lane.

A nudge is an element of design that encourages people to make one choice over another—a minor intervention that guides a person to make a particular decision while still maintaining their free will. A nudge is not a mandate. It is a whisper rather than a bang.

Because nudges are small tweaks, it is tempting to think their impact is also small. However, nudges can be quite influential, and the world is taking note. Researchers, governments, and organizations such as the World Health Organization use nudges regularly to influence behavioral change. ² Since Thaler and Sunstein introduced the concept of nudging to the world, hundreds of “nudge units” (also called behavioral-insights teams) have popped up in public- and private-sector organizations worldwide. ³

Technology, too, has exponentially raised the profile of nudging. Digital nudges employ those online technologies we already use each day (e.g., text messaging, email, and push notifications) to encourage us to take specific actions. Our devices and applications are powered by algorithms that are designed to automate the choices we make, boosting both the scale and speed of nudging. As a result, the digital world is transforming human decision-making behavior.

Due to their nature, digital nudges are often simple and inexpensive, allowing for maximum influence with minimal resource expenditure. For example, a personal email compliment from a boss or a thumbs up emoji on a Slack group chat costs little but has a huge impact on self-esteem and motivation. Because they often feed on socially acceptable behaviors and rewards systems, digital nudges make desired behaviors easier and more compelling to choose.

For a digital nudge to work, it needs to address a user's automatic thoughts; appear when a user is open to making a choice; provide discrete, easy steps toward a goal; and offer positive reinforcement. The benefit of technology is that digital nudges can be personalized in each of these aspects, so that nudges appear when needed at a pace that is effective for each individual user. Beyond that, digital nudges can be designed to capture feedback in real time, allowing for adaptation of nudges according to an individual user's behavior.

Nudging for Health

As the world bursts into the information age, incorporating digital technologies into healthcare has become more and more common. With one in three adults living with at least one chronic disease ⁴ and the shortage of healthcare professionals growing grimmer by the day, technologies that assist people in taking care of their personal health play a pivotal role in public healthcare.

Establishing and maintaining healthy behaviors is one of the most significant challenges in healthcare today. Many believe that technology is the solution, as evidenced by the sheer explosion in mobile apps designed to help people improve their health by becoming more physically active, eating healthier, eliminating bad habits, and reducing stress. In 2017, a survey found that more than 200 new health apps were being published daily, with more than 318,000 health apps available for use that year alone. ⁴

There is a wealth of benefits to these digital health tools. For one, they provide healthcare content to a wide audience at low cost, enabling the dissemination of health-related information to hard-to-access populations in their homes and workplaces. Technology also allows for deeper personalization of that information, reaching each user with what they need when they need it.

Does Nudging Work?

As the use of digital healthcare solutions has grown in the past two decades, this growth has far outpaced the research in the area. And while health apps and devices often rely on digital nudges for efficacy, the truth is that these apps are rarely systematically tested in controlled settings.

So, do nudges actually work? The short answer is that it depends.

Recently, governments and other health organizations utilized nudging strategies to help encourage safe behaviors in COVID-19 public health campaigns. A series of experiments by researchers from King's College London examined these pandemic nudges. ¹ Their findings indicated that these nudges did not have significantly beneficial effects when used in the context of the pandemic. Another study of pandemic-era nudging indicated that while nudges did increase a person's intention to comply with guidelines, they did not result in actually changing their behavior. The study stated: “We can only conclude that nudges activate good intentions, but people find it hard to follow through because of all the other influences on their behaviour that crowd out nudges on this occasion.” ¹

There are several main criticisms within current nudge science. Some feel that scientists overly depend on certain types of experiments, or that they do not consider the costs–benefit ratio of using nudges, nor do they establish whether nudges are in fact the actual reason for positive behavioral effects. ² That said, these criticisms can be overcome by working to build an evidence base regarding the use of nudging and related strategies.

Is Nudging Ethical?

Of course, no strategy for influencing human behavior can exist without the appropriate caveats and cautions, and digital nudging, especially in the realm of healthcare, is no exception. As noted above, the science of nudging in general, and digital nudging in particular is still in the early stages. Therefore, caution must be used before applying the technique. Digital nudging may not be an appropriate practice for all situations. In some cases, technology can add unnecessary complexity and limit the scalability of an intervention. Whether due to lack of access or lack of expertise, not everyone equally benefits from the use of digital technology.

There is also the question of when nudging becomes coercion. The original definition of a nudge is that it must not eliminate free will. A nudge must be easy to avoid, allowing a user to make their choice freely. Nudging also becomes manipulation if used for dishonest purposes or to encourage a choice that does not benefit the user. Though these ethical predicaments are not limited to digital nudging because digital nudges can be scaled up at a low cost to reach a wider audience, these situations are especially important to examine in a digital context.

Finally, though digital nudges allow for greater personalization, that personalization is only possible with the collection of personal data, and the safety and security of that personal data are also of concern. Effective cybersecurity and privacy policies will need to be in force for all healthcare technologies that employ nudging techniques.

A recent research paper ⁵ suggested three considerations for nudge developers to take into account when designing nudges. First, designers should aim to preserve the autonomy of the user. Again, a nudge is a suggestion, not a command. Next, nudges should always be transparent; there should not be any trickery involved. For example, if personal data will be collected, this should be made apparent. Lastly, a nudge's goals should be matched with the user's goals. That is to say, a nudge should encourage a user to make a choice that aligns with their personal values. If a user is looking to be more active, then a nudge should steer them toward activities that get them moving. But if a user is concerned with quitting smoking, a nudge should never, for example, advertise a cigarette brand. All of these elements go toward establishing trust between users and the apps or devices that influence them.

Ultimately, the users are the ones who will determine whether nudging, digital or otherwise, is effective and acceptable. Though cultural differences shape this acceptance, the key to effective nudging, especially when it comes to healthcare, is establishing trust. Therefore, it is crucial that app and device developers and healthcare organizations work to create transparent, personalized nudges with user health in mind—because while nudging is already ubiquitous, the tactic is only useful when developed with noble intent.