Preventative Care and Behavioural Science: The Emotional Drivers of Healthcare Decisions

"A range of stakeholders need to take action to understand and address low vaccination coverage rates. Behavioural economics presents a way of aiding such efforts."

Based on research by the Economist Intelligence Unit (EIU) and sponsored by Pfizer Vaccines, this report assesses why, despite evidence supporting the medical and cost-saving benefits of preventative healthcare measures, people regularly choose not to adopt them. Through interviews with international experts, the report reviews the psychological factors affecting consumer and patient decision-making in relation to their health. It addresses what policymakers, public health campaigners, and healthcare professionals can do to mitigate these influences, with a particular focus on vaccination.

Pfizer Vaccines explains in the report that vaccine confidence is the belief that vaccination serves the best health interests of the public and its constituents. The success of vaccination programmes depends in part on population perception of the benefits and risk of vaccines and related confidence in vaccination. Professor Heidi Larson, one expert interviewed for the report, notes, "With more and more people going online in search of health and medical information, doctors are increasingly having their knowledge challenged. If they do not feel convinced themselves of the right course of action, or do not feel confident in dealing with potential challenges to their advice, they may not raise the issue of vaccination."

The report considers the many factors influencing vaccination decision-making, as well as other preventative healthcare measures, through the lens of behavioural science and behavioural economics - the application of psychology to the decision-making processes of individuals and institutions. Key principles of behavioural economics have been reported to benefit healthcare management and lend themselves to understanding and addressing "non-rational" influences on vaccination decision-making. Behavioural economics can also serve as a potential tool to help clinicians improve their interactions with patients.

A premise for this research is that decisions on preventative care, including vaccination, are typically subject to a variety of psychological influences. Among these are emotional triggers, advice from friends and family, advertising campaigns, and personal experiences with particular diseases. These decisions are also subject to a variety of cognitive biases, which the report finds have an outsized influence. Amidst a daily barrage of healthcare messages, people may be left confused.

Two cognitive phenomena arising from this confusion are so-called "omission bias" and the "nocebo effect". Report interviewee Dr. Alice Forster of University College London describes "omission bias" as "the tendency to avoid making a decision when confronted with complex and contradictory information". She describes a preference of patients, under conditions of uncertainty, to take no action rather than risk making the wrong decision. She notes that this phenomenon often influences parents' decisions about their children's vaccination: Parents say they would feel more at fault if their child were to have a negative reaction to a vaccination, than they would if their child were to contract an illness, such as measles, due to omitting the vaccination. The "nocebo effect" (opposite of "placebo effect") is a tendency to actually experience exaggerated side effects after having read or seen material that creates negative expectations.

In addition to exploring the range of influences preventative care decisions, this report outlines the types of messaging about preventative healthcare, and the types of policies and strategies aimed at influencing behaviour, that are most likely to be effective. The report includes examples of interventions that have supported preventative healthcare goals - and others that have failed - and offers advice on how to create interventions that deliver results.

More specifically, to address both the emotional and cognitive barriers to preventative care, healthcare providers and public health policymakers devising and carrying out preventative care programmes are encouraged to:

• Balance data and anecdote when making the case for preventative care.
• Take into account the range of sources people use for healthcare information, including physicians, affinity groups, and the internet.
• Use appropriate spokespeople - with cultural, ethnic, and community backgrounds similar to the group being reached - to deliver messages. Engaging trusted community leaders in the messaging can help to build trust and promote uptake of preventative measures.
• Understand the role played by emotions such as fear or happiness in spurring action. For example, research shows that sadness slows the impulse to take action, and anger can make people feel invulnerable to risks. These results suggest that using sad images and stories to encourage people to care for their health will likely not work. Similarly, messaging intended to outrage an audience about a potential risk might backfire by promoting a sense of invulnerability. Using fear to encourage preventative healthcare, on the other hand, can be a successful - albeit controversial - strategy. Research shows that happy messages promote a sense of empowerment that leads to action.
• Adopt a personalised and respectful approach when advising patients. Part of that respect is accepting the patient's circumstances, including his or her current readiness to change behaviour.
• Rely on shared decision-making with patients. Patients who are well-informed and involved in deciding a treatment path are more likely to adhere to it.

Case examples show that successful preventative care programmes do the following:

• Anticipate listeners' potential objections. (Examples: The DARE (United States) and "Beat Bullying" (England) campaigns)
• Use multi-media communication channels. (Example: Alcohol awareness in Norway)
• Change key aspects of the listeners' environment. (Examples: Weight loss in Ireland and France)
• Encourage peer-to-peer support. (Example: HIV prevention in Ukraine)
• Include endorsement by physicians. (Example: Colorectal cancer screening in the United Kingdom)