Using Insights From Behavioral Economics and Social Psychology to Help Patients Manage Chronic Diseases Authors
First Online: 15 November 2012 Received: 07 May 2012 Revised: 14 September 2012 Accepted: 11 October 2012 DOI:
Cite this article as: Mogler, B.K., Shu, S.B., Fox, C.R. et al. J GEN INTERN MED (2013) 28: 711. doi:10.1007/s11606-012-2261-8 Abstract
Despite a revolution in therapeutics, the ability to control chronic diseases remains elusive. We present here a conceptual model of the potential role of behavioral tools in chronic disease control. Clinicians implicitly accept the assumption that patients will act rationally to maximize their self-interest. However, patients may not always be the rational actors that we imagine. Major behavioral barriers to optimal health behavior include patients’ fear of threats to health, unwillingness to think about problems when risks are known or data are ambiguous, the discounting of risks that are far in the future, failure to act due to lack of motivation, insufficient confidence in the ability to overcome a health problem, and inattention due to pressures of everyday life. Financial incentives can stimulate initiation of health-promoting behaviors by reducing or eliminating financial barriers, but may not produce long-term behavior change without additional interventions. Strategies have been developed by behavioral economists and social psychologists to address each of these barriers to better decision-making. These include: labeling positive behaviors in ways consistent with patient life goals and priorities; greater focus on more immediate risks of chronic diseases; intermediate subgoals as steps to a large health goal; and implementation of specific plans as to when, where, and how an action will be taken. Such strategies hold promise for improving health behaviors and disease control, but most have not been studied in medical settings. The effectiveness of these approaches should be evaluated for their potential as tools for the clinician.
KEY WORDS chronic disease behavioral economics financial incentives social psychology References
Chronic Diseases and Health Promotion.
. Accessed October 2, 2012; 2009.
Egan BM, Zhao Y, Axon RN.
US trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA. 2010;303(20):2043–2050.
Cutler TW, Palmieri J, Khalsa M, Stebbins M.
Evaluation of the relationship between a chronic disease care management program and California pay-for-performance diabetes care cholesterol measures in one medical group. J Manag Care Pharm. 2007;13(7):578–588.
Harris M, Smith BJ, Veale A.
Patient education programs–can they improve outcomes in COPD? Int J Chron Obstruct Pulmon Dis. 2008;3(1):109–112.
A behavioral model of rational choice. Q J Econ. 1955;69(1):99–118.
von Neumann J, Morgenstern O. Theory of games and economic behavior. Princeton: Princeton University Press; 1944.
de Bes J, Legierse CM, Prinsen CA, de Korte J.
Patient education in chronic skin diseases: a systematic review. Acta Derm Venereol. 2011;91(1):12–17.
Hachinski V, Donnan GA, Gorelick PB, et al.
Stroke: working toward a prioritized world agenda. Stroke. 2010;41(6):1084–1099.
Lagger G, Pataky Z, Golay A.
Efficacy of therapeutic patient education in chronic diseases and obesity. Patient Educ Couns. 2010;79(3):283–286.
Optimizing chronic obstructive pulmonary disease management in primary care. South Med J. 2011;104(2):121–127.
Janz NK, Becker MH.
The health belief model: a decade later. Health Educ Q. 1984;11(1):1–47.
Brownlee-Duffeck M, Peterson L, Simonds JF, Goldstein D, Kilo C, Hoette S.
The role of health beliefs in the regimen adherence and metabolic control of adolescents and adults with diabetes mellitus. J Consult Clin Psychol. 1987;55(2):139–144.
Benartzi S, Thaler RH.
Myopic loss aversion and the equity premium puzzle. Q J Econ. 1995;110(1):73–92.
Gneezy U, Potters J.
An experiment on risk taking and evaluation periods. Q J Econ. 1997;112(2):631–645.
Kahneman D, Tversky A.
Prospect theory: an analysis of decision under risk. Econometrica. 1979;47(2):263–291.
Katz MH, Cunningham WE, Fleishman JA, et al.
Effect of case management on unmet needs and utilization of medical care and medications among HIV-infected persons. Ann Intern Med. 2001;135(8 Pt 1):557–565.
Cunningham WE, Andersen RM, Katz MH, et al.
The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States. Med Care. 1999;37(12):1270–1281.
Applegate BW, Ames SC, Mehan DJ Jr, McKnight GT, Jones GN, Brantley PJ.
Maximizing medication adherence in low-income hypertensives: a pilot study. J La State Med Soc. 2000;152(7):349–356.
Bewley A, Page B.
Maximizing patient adherence for optimal outcomes in psoriasis. J Eur Acad Dermatol Venereol. 2011;25(Suppl 4):9–14.
Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;(2):CD000011.
Lareau SC, Yawn BP.
Improving adherence with inhaler therapy in COPD. Int J Chron Obstruct Pulmon Dis. 2010;5:401–406.
John LK, Loewenstein G, Troxel AB, Norton L, Fassbender JE, Volpp KG.
Financial incentives for extended weight loss: a randomized, controlled trial. J Gen Intern Med. 2011;26(6):621–626.
Seal KH, Kral AH, Lorvick J, McNees A, Gee L, Edlin BR.
A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Drug Alcohol Depend. 2003;71(2):127–131.
Volpp KG, Loewenstein G, Troxel AB, et al.
A test of financial incentives to improve warfarin adherence. BMC Health Serv Res. 2008;8:272.
Volpp KG, Troxel AB, Pauly MV, et al.
A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360(7):699–709.
Wall J, Mhurchu CN, Blakely T, Rodgers A, Wilton J.
Effectiveness of monetary incentives in modifying dietary behavior:a review of randomized, controlled trials. Nutr Rev. 2006;64(12):518–531.
Dean AJ, Walters J, Hall A.
A systematic review of interventions to enhance medication adherence in children and adolescents with chronic illness. Arch Dis Child. 2010;95(9):717–723.
Hemodialysis knowledge and medical adherence in African Americans diagnosed with end stage renal disease: results of an educational intervention. Nephrol Nurs J. 2011;38(2):155–162. quiz 163.
Du S, Yuan C.
Evaluation of patient self-management outcomes in health care: a systematic review. Int Nurs Rev. 2010;57(2):159–167.
Warren-Findlow J, Seymour RB, Brunner Huber LR. The association between self-efficacy and hypertension self-care activities among African American adults. J Commun Health. 2011.
Frey D, Stahlberg D.
Selection of information after receiving more or less reliable self-threatening information. Personal Soc Psychol Bull. 1986;12(4):434–441.
Galai D, Sade O. The ‘Ostrich Effect’ and the relationship between the liquidity and the yields of financial assets. SSRN eLibrary. 2003.
A theory of disappointment aversion. Econometrica. 1991;59(3):667–686.
Karlsson N, Seppi DJ, Loewenstein GF. The ‘Ostrich Effect’: selective attention to information about investments. SSRN eLibrary. 2005.
Maddux JE, Rogers RW.
Protection motivation and self-efficacy: a revised theory of fear appeals and attitude change. J Exp Soc Psychol. 1983;19(5):469–479.
Rogers RW, Mewborn CR.
Fear appeals and attitude change: effects of a threat’s noxiousness, probability of occurrence, and the efficacy of coping responses. J Pers Soc Psychol. 1976;34(1):54–61.
Jacoby J, Szybillo GJ, Jacqueline B-S.
Information acquisition behavior in brand choice situations. J Consum Res Interdiscip Q. 1977;3(4):209–216.
Information load and consumer decision making. J Consum Res Interdiscip Q. 1982;8(4):419–430.
Fox CR, Tversky A.
Ambiguity aversion and comparative ignorance. Q J Econ. 1995;110(3):585–603.
Fox CR, Weber M.
Ambiguity aversion, comparative ignorance, and decision context. Organ Behav Hum Decis Process. 2002;88(1):476–498.
Hadar L, Sood S, Fox CR. Subjective knowledge in consumer financial decision making. J Mark Res. 2013.
Soman D, Ainslie G, Frederick S, et al.
The psychology of intertemporal discounting: why are distant events valued differently from proximal ones? Mark Lett. 2005;16(3):347–360.
Deci EL, Koestner R, Ryan RM.
A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychol Bull. 1999;125(6):627–668. discussion 692–700.
Prochaska JO, DiClemente CC.
Transtheoretical therapy: toward a more integrative model of change. Psychother Theory Res Pract. 1982;19(3):276–288.
Hettema J, Steele J, Miller WR.
Motivational interviewing. Annu Rev Clin Psychol. 2005;1(1):91–111.
Motivational interviewing with problem drinkers. Behav Psychother. 1983;11(2):147–172.
Victor RG, Leonard D, Hess P, et al.
Factors associated with hypertension awareness, treatment, and control in Dallas County, Texas. Arch Intern Med. 2008;168(12):1285–1293.
Skinner BF. Science and human behavior. New York: Macmillan; 1953.
Cahill K, Perera R. Competitions and incentives for smoking cessation. Cochrane Database Syst Rev. 2011;(4):CD004307.
Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G.
Financial incentive-based approaches for weight loss: a randomized trial. JAMA. 2008;300(22):2631–2637.
Cialdini RB, Eisenberg N, Green BL, Rhoads K, Bator R.
Undermining the undermining effect of reward on sustained interest. J Appl Soc Psychol. 1998;28(3):249–263.
Lepper MR, Greene D, Nisbett RE.
Undermining children’s intrinsic interest with extrinsic reward: a test of the “overjustification” hypothesis. J Personal Soc Psychol. 1973;28(1):129–137.
Frey BS, Jegen R.
Motivation crowding theory. J Econ Surv. 2001;15(5):589–611.
Soman D, Cheema A. Earmarking and partitioning: increasing saving by low-income households. J Mark Res. 2011;48(Special Issue):S14–S22.
Controllable risk factors—high blood pressure (Hypertension).
. Accessed October 2, 2012.
Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358(9287):1033–1041.
Heath C, Larrick RP, Wu G.
Goals as reference points. Cogn Psychol. 1999;38(1):79–109.
Latham GP, Locke EA.
Self-regulation through goal setting. Organ Behav Hum Decis Process. 1991;50(2):212–247.
Implementation Intentions: strong effects of simple plans. Am Psychol. 1999;54(7):493–503.
Gollwitzer PM, Brandstatter V.
Implementation intentions and effective goal pursuit. J Personal Soc Psychol. 1997;73(1):186–199.
Efficacy of a brief worksite intervention to reduce smoking: the roles of behavioral and implementation intentions. J Occup Heal Psychol. 2007;12(4):376–390.
Leventhal H, Singer R, Jones S.
Effects of fear and specificity of recommendation upon attitudes and behavior. J Pers Soc Psychol. 1965;34:20–29.
Thaler RH, Sunstein CR.
Libertarian paternalism. Am Econ Rev. 2003;93(2):175–179.
Thaler RH, Sunstein CR, Balz JP. Choice architecture. SSRN eLibrary. 2010.
Deutsch M, Gerard HB.
A study of normative and informational social influences upon individual judgment. J Abnorm Soc Psychol. 1955;51(3):629–636.
Johnson EJ, Goldstein D.
Do defaults save lives? Science. 2003;302(5649):1338–1339.
Thaler RH, Sunstein CR. Nudge. New Haven: Yale University Press; 2008.
Karlan D, McConnell M, Mullainathan S, Zinman J. Getting to the top of mind: how reminders increase saving. Yale University: 2010. Copyright information
© Society of General Internal Medicine 2012