Application of Behavioral Economics Principles Improves Participation in Mailed Outreach for Colorectal Cancer Screening

Abstract

INTRODUCTION: Colorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality in the United States. Although various interventions have improved screening rates, they often require abundant resources and can be difficult to implement. Social psychology and behavioral economics principles offer an opportunity for low-cost and easy-to-implement strategies but are less common in clinical settings. METHODS: We randomized 2,000 patients aged 50–75 years eligible for CRC screening to one of the 2 mailed interventions: a previously used text-based letter describing and offering fecal immunochemical testing (FIT) and colonoscopy (usual care arm); or a letter leveraging social psychology and behavioral economics principles (e.g., implied scarcity and choice architecture), minimal text, and multiple images to offer FIT and colonoscopy (intervention arm). We compared total screening uptake, FIT uptake, and colonoscopy uptake at 1-month intervals in each group. RESULTS: There were 1,882 patients included in the final analysis. The mean age was 69.3 years, and baseline characteristics in the 2 groups were similar. Screening completion at 26 weeks was 19.5% in the usual care arm (16.3% FIT vs 3.2% colonoscopy, P < 0.01) and 24.1% in the intervention arm (22.1% FIT vs 2.0% colonoscopy, P < 0.01) (P = 0.02). DISCUSSION: Among primary care patients aged 50–75 years in an academic setting, mailed CRC outreach employing social psychology and behavioral economics principles led to a higher participation in CRC screening than usual care mailed outreach. TRANSLATIONAL IMPACT: Mailed interventions to increase CRC screening should incorporate social psychology and behavioral economics principles to improve participation.

Effect of Targeted Behavioral Science Messages on COVID-19 Vaccination Registration Among Employees of a Large Health System

“…However, competing demands on attention, behavioral inertia, and unwieldy processes that make it hard to follow through on intentions likely conspire to make a single, timely, targeted reminder helpful. [2][3][4][5] The emails' behavioral features-active choice, appeal to authority, and emphases on scarcity, social norms, and risk recalibration (eAppendix in Supplement 1)-may have contributed to their effect. The 3.17% absolute increase in vaccination appointments we observed is larger than many real-world nudges 6 and may be greater among recipients who are less hesitant about receiving the vaccine.…”

“…We sought to determine whether individually addressed emails designed with behaviorally informed features [1][2][3][4][5] could increase vaccination registration compared with a delayed control group.…”

Testing messages from behavioral economics to improve participation in a population-based colorectal cancer screening program in Cyprus: Results from two randomized controlled trials

“…The message builds in previous research which suggests that perceived scarcity may enhance the value of the medical service ( BROCK, 1968 ). Experiments have shown that people perceive products which are scarce because of limited availability as costlier and more appealing as products that are abundantly available ( Verhallen, 1982 , Verhallen and Robben, 1994 ) A recent US study found that a behavioral intervention, which also featured implied scarcity, increased CRC screening ( Bakr et al, 2020 ). Similar to our study, they implied scarcity by the unique opportunity of receiving a FIT kit (“you have been selected”).…”

“…While these interventions are effective at improving overall uptake, they have only partially been adopted, due to a lack of evidence supporting their cost-effectiveness (for example, telephone reminders are not recommended by the European Union Committee for Quality Assurance in Bowel Cancer Screening, as they are not considered cost-effective) ( von Karsa et al, 2013 ). As such, there is growing interest in the search for new low-cost interventions, such as those which involve enhancing existing invitation materials through the use of insights from behavioral economics ( von Karsa et al, 2013 , Purnell et al, 2015 , Barnes et al, 2016 , Schwartz et al, 2017 , Stoffel et al, 2019 , Bakr et al, 2020 , Huf et al, 2020 , Stoffel et al, 2021 ) These approaches build on the concept that the screening decision is influenced by the way in which the choice is presented, and are potentially cost-neutral, as they only involve manipulating the presentation and content of the invitation materials ( Purnell et al, 2015 , Schwartz et al, 2017 , Stoffel et al, 2019 , Bakr et al, 2020 , Huf et al, 2020 , Stoffel et al, 2021 , Mehta et al, 2017 , Mehta et al, 2018 , Stoffel et al, 2019 , Stoffel et al, 2020 ).…”

“…Only a few studies have investigated the effect of adding additional information, mainly on social norms. ( Schwartz et al, 2017 , Stoffel et al, 2019 , Bakr et al, 2020 , Huf et al, 2020 , Sieverding et al, 2010 , Stoffel et al, 2019 , von Wagner et al, 2019 ) Furthermore, several of these studies measured the effect on intention rather actual behavior, limiting the generalizability of their findings ( Howard and Salkeld, 2009 , Ferrer et al, 2012 , Sieverding et al, 2010 , Stoffel et al, 2019 , von Wagner et al, 2019 ). Finally, little is therefore known about the effect of using other messages, derived from behavioral economics, communicating information about the costs and benefits of CRC screening on screening uptake.…”