Using Behavioral Economics to Encourage Parent Behavior Change: Opportunities to Improve Clinical Effectiveness

"Pediatricians are uniquely positioned to guide parental decisions, and behavioral economics holds the potential to empower parents to make healthier choices for themselves and their children."

Paediatric clinical practice often involves improving child health by changing parents' behaviour. This paper reviews the foundational concepts of behavioural economics, identifies the role of paediatricians in motivating parent behaviour change, and discusses how to apply key strategies in practice to support parental decision making in a way that improves child health.

A key contribution of the behavioural economics field is identifying predictable decision errors that characterise human decision making and may undermine healthy choices. For example, individuals are prone to present bias, meaning they over-weight immediate costs and benefits relative to those occurring in the future. This issue may be especially important in paediatrics, where the consequences of many decisions occur years later. There is limited but growing evidence for applying behavioural economics approaches to parent behaviour change, such as by increasing vaccine adherence in paediatric healthcare settings.

As outlined here, although paediatricians are uniquely positioned to intervene for family health, and most parents welcome their role in guiding decisions, several challenges complicate decision making in paediatric practice. When parents make decisions regarding vaccinations for their children, for example, the decision is strongly influenced by the idea that the potential harm that occurs as a result of deciding to vaccinate (commission) is less acceptable than the potential harm that occurs as a result of deciding not to vaccinate (omission). Parents may perceive those harms of commission as losses while significantly undervaluing the harms from omission. Research has found that this omission bias in parents can be corrected, or at least overcome, by simple advice from a trusted physician that emphasises the importance and direct benefit of the intervention. Simply stating, "the doctor recommends that you get the vaccine" can have a powerful impact on patient decisions.

The paper highlights 4 key behavioural economics strategies that could be applied more broadly in clinical practice to promote parent behaviour change:

1. Message framing - Gain-framed messages have been found to be more likely to have a positive impact on attitudes toward activities that target prevention and are low risk (i.e., the only thing risky about them is not engaging in them), whereas loss-based messages may be more effective at encouraging screening behaviour that has a higher degree of perceived risk (i.e., higher risk because of the possibility that a serious illness could be discovered).
2. Use of defaults - An opt-out approach signals the appropriate choice through an implicit recommendation, while leaving parents the choice to opt out if they have strong preferences. It can be a tool for steering patients and families toward making beneficial choices by reducing the effort required to choose the most health-promoting option. In paediatrics, the use of defaults has focused primarily on child vaccine receipt. Training paediatricians to use an opt-out communication style (e.g., an announcement or presumptive approach detailing that a child is due for routine vaccines) as opposed to an opt-in communication style (e.g., a participatory conversational approach) when discussing vaccines with parents has been shown to lead to a clinically meaningful increase in vaccination rates. Further, the efficacy of these defaults can be augmented by priming parents before the visit with information about "routine" vaccines due at the upcoming visit.
3. Enhanced active choice - Here, a choice is presented to an individual with an explanation of costs built into the question itself. It involves inserting a decision that is relevant in front of consumer at a time when he or she is primed to think about it and in a position to say "yes" or "no" without much effort. "Enhanced active choice avoids procrastination by empowering the decision maker to make a choice, increases perceived responsibility by having the individual commit to a choice, and leverages loss aversion for the new opportunity by highlighting disadvantages of not selecting the preferred option."
4. Leveraging social forces - Social comparisons, in which an individual's actions are visible to others, and social support systems, in which existing social relationships are leveraged in positive ways, can motivate health-promoting parent behaviour. For example, parents could be reminded that most children in a particular clinic receive their routine vaccines or that most families make their scheduled appointments. Further, paediatric institutions could sponsor adherence competitions or create simple platforms for peer support.

Despite the promise of behavioural economics approaches as applied within the paediatric setting, the researchers stress that additional study is needed to fully explore how to work best with parents to counter common decision-making errors and guide them toward healthier choices. Individuals crafting new programmes are urged to seek out and incorporate feedback from diverse groups, avoid oversimplifying solutions to complex problems, and be cautious in not misconstruing structural problems (e.g., lack of access to safe outdoor spaces for activity) as individual lifestyle choices or cultural norms. That said, the researchers conclude: "Leveraging behavioral economic principles around parental decision making has the potential to supercharge program effectiveness and improve patient and family health."