1 Introduction
Due to the inherent cognitive biases in decision makers, it is necessary to guide individuals to make better decisions. Thaler and Sunstein
[1] introduced the concept of "nudging", arguing that our understanding of systematic biases in decision-making can be used to support people making optimal decisions. A nudge is defined as "any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any option or significantly changing their economic incentive" (p.6). For example, replacing the cake in the impulse shopping basket near the cash register by fruit renders people to buy more fruit and less cake when both options are available
[1]. Similarly, schools can encourage students to eat healthier food by changing the order of food placement
[2], where the default setting is a typical representative of nudge. It has been considered a significant impact on individual choice. For example, Egebark and Ekström
[3] found that paper consumption was reduced by 15% when the default printer option was replaced with "double-sided printing". In 2017, Thaler was awarded the Nobel Prize in Economics for his contribution to behavioral economics
[4].
The book "Nudge: Improving decisions about health, wealth, and happiness", authored by Thaler and Sunstein in 2009, shows how to use behavioral economics to improve public policy and personal welfare. This book got the bestseller status on New York Times and was named the economist's book of the year. Until now, it has received 22881 academic citations. In 2008, Sunstein was appointed by President Obama as the head of the White House Office of Information and Regulatory Affairs (OIRS), a role responsible for taking an informed attitude towards government actions. In 2010, the British Conservative government established the behavior insight group (BIT). BIT is believed to save millions of pounds of government revenue and significantly change citizens' behavior
[5].
Nudge has been widely applied in various fields, including fuel economy, finance, energy efficiency, environmental protection, highway safety, smoking, medical care and obesity, smoking cessation, energy efficiency, organ donation, consumer protection, employment, crime, gender equality, COVID-19 and general compliance strategy
[6], and HCI
[7, 8]. The term of nudge is not completely consistent in the literatures summarized by Jesse and Jannach
[9]. The used terms in early studies included influence on behavio
[10], tools of a choice architecture
[11, 12], choice architecture techniques, and intervention technology
[13]. The latter studies all used nudge and its variations such as nudge mechanism
[2], nudge technology
[14], nudge principle
[15], nudge element
[16] or simple (digital) nudge
[17].
Johnson, et al.
[11] provided two categories of tool catalogs used to influence the selection architecture: Tools for building selection tasks and tools for describing selection options. Thaler, et al.
[12] provided six concise summary principles for effective choice architecture: Defaults, expected errors, feedback, understanding mapping, structure complex choices, and incentives. Hansen and Jespersen
[18] classified nudges into four categories according to two variables: Mode of thinking engaged (i.e. automatic vs. reflective) and the transparency of a nudge (i.e. whether users can perceive the intentions behind the nudge). Münscher, et al.
[13] suggested three basic categories of choice architecture intervention techniques (i.e., nudge): Decision information, decision structure, and decision assistance. Based on the these categories, Jesse and Jannach
[9] introduced the fourth category named social decision appeal and identified the driving mechanism behind these categories. Caraban, et al.
[2] presented a framework of the 23 mechanisms of nudging, clustered in 6 overall categories: Facilitate, confront, deceive, social influence, fear, and reinforce.
The existing studies highlight the significant effect of nudges and its widespread use primarily in the field of marketing. However, the application of nudges is still limited in other areas, due to the fact that there is a lack of awareness of the role of nudges. Effective strategies should be integrated into complex systems to fully present their impact. Complex systems often involve numerous elements, the interactions of which are typically intricate. Therefore, it is difficult to smoothly operate a complex system. This article uses systematic thinking to understand the value of nudges, with the goal of expanding the application of the nudge theory across various fields. This article is organized as follows. Section 2 explains systems thinking and corresponding models by providing practical examples. The third section discusses the application of the nudge strategy in epidemic prevention and control. The fourth section concludes this article.
2 Systems Model and Analysis of Nudging
In this section, we show how to use systems thinking to analyze the important role of nudges in the system.
2.1 Systems Model
A system is defined as a set of two or more interrelated elements with the following three properties: 1. Each element has an effect on the functioning of the entire system; 2. Each element is affected by at least one other element in the system; 3. All possible subgroups of elements also have the first two properties
[19, 20]. Checkland
[21-23] divided systems into hard systems and soft systems. Hard systems are typically the domain of engineers that focus on addressing real-world issues, such as machinery, machines, aircraft, and power plants, which can be significantly complex. Soft systems center around human involvement. At the individual psychological level, multiple processes, including perception, interpretation, representation, and communication, simultaneously influence and shape our individual and collective cognitive maps.
Next, we provide two examples to illustrate the complexity of system operation.
Organ donation is an example of a complex process involving sequential steps (see Appendix for the specific process), which requires sophisticated allocation strategies and advanced medical technology. In this case, a greater emphasis is placed on soft system factors. After all, organ donation primarily depends on a person's will, specifically whether there are enough people willing to donate organs. The surgery operation process is another complex system, as shown in Figure 1. Despite doctors and nurses making careful preparations before the operation and maintaining focus during the entire process, mistakes can still occur, which lead to infections and even death of patients. What is the best way to reduce mistakes?
Figure 1 Schematic diagram of operation process |
Full size|PPT slide
Medical staff need to make hundreds of decisions in the daily medical care of patients, whose errors can lead to serious injuries. However, this does not mean that we are lack of intelligence or responsibility. It is human nature that people make mistakes unintentionally. Behind the mistakes that lead to accidents, there is a Heinrich accident pyramid principle, namely the 300:29:1 rule. When an enterprise has 300 hidden dangers or violations, there must be 29 minor injuries or failures. Among these 29 minor injuries or failures, there is typically one serious injury, death or major accident. Likewise, research conducted by David Bates, a doctor at Harvard University, has a similar finding
[24, 25]. For every patient who died of medical negligence, there are 5 to 10 patients were injured. For each medical injury, there were 5 to 10 "near injuries" and each "near injury" has 5 to 10 underlying mistakes. In other words, behind every patient who dies of medical negligence, there are 125 to 1000 mistakes. There are usually 30000 hazard sources behind a fatal accident. A study published by the American Medical Association shows that as many as 98000 of the patients admitted to hospital for treatment each year die of improper medical management, and the number of people infected during treatment is also comparable to this number
[25]. These figures do not include emergency medical care. According to the digital logic of Dr. David Bates, there are nearly 100 million mistakes behind the death of about 100000 people in the United States every year. It can be said that every medical worker may make mistakes every day. Preventing errors in surgical systems therefore appears to be difficult.
Based on the two examples regrading organ donation and surgical procedures, any system is complex. Even so, the system is composed of elements, and the elements have corresponding effects on the operation of the system.
Assume that the system has n factors denoted as , and the effect of each factor on the system is measured by the change in system performance resulting from adding one unit of the factor. The influence of these factors acting on the system is represented as . Here we have
This equation implies that the larger is, the th factor's has a greater effect on the system.
2.2 Organ Donation - Default
In the process of organ donation and transplantation, the most critical link is that someone is willing to donate organs. Encouraging more people to donate their organs is challenging according to the fact that organ donation rates are very low in many countries. For example, the Netherlands established a national donor registration center in 1998, and also carried out extensive education activities and mass mailing (more than 12 million letters in a country of 15.8 million people) to require citizens to register, but this did not change the effective consent rate of organ donation
[26, 27].
The effect of default options on organ donation is remarkable
[27]. It is very simple to set the default options for organ donation. If the default option is set to be "no donation", people need to fill in "if you want to become an organ donor, please register here" (choose to join). On the contrary, if the default is set to be "everyone donates organs", then people need to fill in "if you don't want to become an organ donor, please register here" (choose to quit). The adjustment of a seemingly minor default option has caused a huge difference in organ donation registration rates. The organ donation rate of countries that need to fill in the withdrawal application is as high as 90%, while the organ donation rate of countries that need to fill in the application is only 10%
[27]. These findings have influenced countries to change their defaults
[28]. Argentina became an opt out country in 2005, followed by Uruguay in 2012, Chile in 2013, Wales in 2015, France in 2017, and the Netherlands in 2020. They all set organ transplantation as the "default acquiescence" principle. This finding tells us that it does not seem to require any complicated strategy or superb technology to improve the organ donation rate. A simple adjustment in default settings can make such a huge difference in choices.
According to a classical economic viewpoint, decision makers have preferences - they feel that organ donation is too low in value. This view leads to the fact that the preference for becoming an organ donor can be constructed. Donation can affect the decision-maker's choice in three ways. First, the decision-maker may think that donation is a recommended action. Second, making decisions usually requires effort, while accepting acquiescence is effortless. Many people avoid making affirmative decisions about donations because it can be unpleasant and stressful. Manual tasks such as filling out forms can also increase acceptance of default settings
[29]. Finally, default usually represents the existing state or status quo, while change usually involves trade-offs. Psychologists have shown that losses are greater than equal gains, and this phenomenon is called loss aversion
[30]. Therefore, changes in the default settings may lead to different choices. Mastering people's psychological behavior can often yield significant results with minimal effort. In the whole social system, the inherent complexity and limitations of human behavior make the management of people the most difficult.
The value of mastering the key to the good operation of complex systems with less effort is obviously huge. Usually, people's preferences are unclear and shapeless, and their choices will inevitably be affected by default rules, frame effect and starting point. With the understanding of limited rationality and limited self-control behavior discovery, public policymakers should try to guide people to make choices in the direction of promoting welfare without eliminating freedom of choice
[31].
2.3 Procedure Execution - Checklist
In order to prevent mistakes, managers punish employees who make mistakes. The logical starting point of punishment is to attribute mistakes to employees' irresponsibility or incompetence. As a result, employees who seek benefits and avoid disadvantages will reflect some mistakes as improper work processes, or simply hide the alarm that needs to be corrected. Such actions will not reduce the probability of making mistakes.
Some doctors and hospital administrators have tried to use the list in surgery, which contains simple routine actions. These routine actions are typically part of a doctor's medical training but may be overlooked due to time constraints, stress, or distractions. For example, the list designed by critical care experts at Johns Hopkins Hospital for the treatment of catheter infection includes five simple steps, from washing hands with soap to placing sterile dressings at the catheter site once the catheter is inserted
[12].
The list has two purposes
[12]. Firstly, the list helps doctors to remember and recall detailed steps. Doctors may always forget the most basic things in their busy work, such as whether they washed their hands. Secondly, the list also breaks down the whole complex process into a series of manageable steps. This seeming application of the simple list has produced a shocking effect. The infection rate of ten antennas has dropped from 11% to zero. After another 15 months, only two patients developed intestinal infection. By applying the list, the hospital has prevented 43 infections and 8 deaths, saving 2 million dollar
[32, 33].
The list prevents expected errors, that is, we know that people will make mistakes due to various problems such as attention. In order to avoid such errors, we can use the list to remind and check gradually.
From the two examples above, both systems are relatively complex when we consider both the organ donation and transplantation process as well as the surgical process as systems. Encouraging more people to donate organs is the most critical part of the organ donation and transplantation system. And raising the donation rate only requires a very low-cost nudge technique: Default settings. It is also very important to reduce the infection rate and mortality rate of patients during the operation, otherwise, even if the doctors are skilled, their value will not be reflected. In the surgical system, a low-cost list can significantly reduce mistakes. These indicated that nudging has great potential and value in a relatively complex system, because it can be used in the most difficult places to obtain great benefits at a small cost.
2.4 Nudging in the System
The Netherlands tried to promote citizens' willingness to donate organs through extensive educational activities and mass e-mails, but these efforts did not produce significant results
[26, 27]. However, the organ donation rate became as high as 90% by changing the default, which created a miracle at almost no cost.
Finding the key factors is the most important thing to solve the problems in the system. The key factor is to use a relatively small cost (nudge: Change the default in organ donation) to achieve a great effect (90% donation rate), as shown in Figure 2.
Figure 2 Schematic diagram of nudge action |
Full size|PPT slide
In a complex system, it is difficult to ensure the normal operation of the system due to the interplay of various links. The low efficiency of a single link will lead to the low efficiency of the whole system. Therefore, using the nudge strategy in some key links of the system can significantly improve the system operation efficiency. This is the important role of nudge strategy in the system.
The key to the shocking power of nudge lies in understanding people's psychology and formulating strategies according to people's psychology. People's psychology is magical. Once the psychology is grasped correctly, it will be easy to achieve goals. Otherwise, even substantial investment may not have the desired outcomes. It's like the lever principle. We can lift a heavy object with little force. Therefore, the nudge strategy can be called the psychological lever principle.
Psychological leverage strategy: Use strategies that fit decision makers' psychology to change their behavior and obtain great benefits at minimal cost.
In different systems, people face different things and have different psychology. It is necessary to design different nudge strategies according to people's psychology, as shown in Figure 3.
Figure 3 Nudge strategies for different psychology |
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The mechanism of nudge can be expressed by the above systems model. Non-critical factors are denoted as and y represents key factors. The result of these factors acting on the system is .
Small change on the key factor y will cause a significant change in f, while variations in , considered non-critical factors, can only cause an inconsequential change in f, that is:
Suppose a simplest linear function:
Then:
Therefore, only a small value of y can significantly change the value of . Even if takes a large value, it may not change the value of f.
In the context of organ donation system, y represents the default. In the surgical system, y is the list.
3 The Role of Nudge in Epidemic Prevention and Control
Behavioral economics has played an important role in preventing COVID-19. The first point explicitly emphasized by behavioral economics is that make things easy for them to do if you want people to do it. They must know what to do and how to do it, and the step process should be straightforward, socially supported and timely
[6]. Complexity and chaos are the mortal enemies of public health and well-structured norms are its best friends
[6].
In order to guide people to make choices, we must address the key question: Why have people not done so yet? After getting the answer, government officials, employers, schools and others can take measures to remove the barriers.
Lehmann, et al.
[34] replaced the option to join the epidemic vaccination strategy with the option to exit the epidemic vaccination strategy,
t assuming that the user agrees to be vaccinated in advance, and an application needs to be filled in to opt out, which increases the possibility of vaccination. World Health Organization (WHO) officials are using behavioral economics to encourage people to make healthier choices. In 2020 and 2021, WHO relied on a team of behavioral scientists to put forward a series of recommendations directly derived from Behavioral Science. Governments of all countries and various medical and social institutions, including hospitals, universities and ordinary enterprises, use the nudge method to prevent epidemics
[6].
In China, the COVID-19 epidemic has been well controlled. Everyone could voluntarily self-isolate at home due to fear when the epidemic initially broke out. in the later stage, the epidemic prevention and control played an important role, as shown in the figure. With the easing of the epidemic, society gradually and orderly resumed various production and business operations and even leisure and entertainment activities. China maintained exchanges with foreign countries, so the epidemic always existed. In order to prevent the epidemic and recover the economy, China has taken a series of measures. The consensus reached by people was the importance of early detection and immediate isolation of relevant personnel to control the spread.
Timing is important. People's attention is limited. It is better to provide them with information (including warnings) before they make a decision. Under the background of COVID-19, when the country starts to relax stay-at-home orders and enterprise closures, they may do the best if people are arranged to see relevant health information immediately before making a choice
[6].
In the information age, China has made full use of the advantages of the network information system to establish a big data system. In particular, the positioning system of mobile phones can timely notify the people where the epidemic is located, achieve early detection and isolation, and minimize the impact on people's work and life.
Early detection of the epidemic requires nucleic acid for all people. The epidemic prevention department forms a journey code according to the severity of the epidemics. Nucleic acid is tested in 3 days, 2 days and 1 day to realize early detection. In areas with serious epidemic, nucleic acid testing needs to be carried out every day within a specific time interval, followed by testing every two days, and then testing every three days or discontinuing testing. Through the pop-up notifications, possible contacts can be alerted as soon as possible.
People are often averse to the existing losses, such as finding the nucleic acid location, queuing, and paying in the process of nucleic acid production. Therefore, it is very important to alleviate or even eliminate this aversion. Relevant institutions mainly take the following measures to reduce or eliminate people's aversion (see Figure 4).
Figure 4 Nudge and psychology in epidemic prevention and control |
Full size|PPT slide
Use eye-catching information boards to attract people. There are social distance signs in places where people gather, and even railings are arranged to instruct people to queue up in order. Nucleic acid detection shall be as convenient as possible. Nucleic acid locations are distributed widely, so that people can detect them nearby. Nucleic acid testing is provided free of charge, which eliminates the cost of testing and eliminates the financial barrier that stop people from getting tested.
Bavel, et al.
[35] discussed the impact of human psychology on epidemic prevention and control. Specifically, they discussed the impact of threat perception, social context, science communication, aligning individual and collective interests, leadership, and stress and coping on the pandemic. This may help public health officials mitigate the impact of the current pandemic.
4 Conclusion
We introduced the concept and various types of nudge aiming to analyze the role of nudge in the complex system.
Next, we built a simple model to understand how the nudge strategy affect the complex system by influencing human psychology. We summarized it as the principle of leverage, indicating that huge benefits can be obtained at a small cost. To clarify this, we used organ donation and surgical error prevention as examples. Furthermore, we analyzed the role of nudges in epidemic prevention and control in China.
The model presented in this article is a simple framework model, but it provides an innovative perspective for future research. When studying nudge strategies in different systems, specific models can be used to analyze the impact of various factors and thereby comparing to the role of nudges.
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), Hai YANG(
Figure 1 Schematic diagram of operation process
