FV-122 | Revealing Attitudes Towards Health Policy
Research Topic
The goal of this project is to study preferences across the globe over offering
monetary incentives for health behaviors, particularly for promoting behaviors
such as vaccination, exercise, blood donation, and preventive health screenings.
While monetary incentives have consistently proven effective in improving health
behaviors, our initial research in Sweden with a newly developed experimental
approach has identified substantial public opposition to their use. The primary
objective of the current proposed research is to understand to which extent and
why this opposition exists across the globe, given that incentives are effective, and
to inform how policymakers can navigate ethical and practical challenges.
The study will extend our initial data collection by enabling collecting further data
from several countries including the UK, the US, and Germany. Our initial data was
confined to Swedish policy-makers (N=2,010) and citizens (N=2,008). The Swedish
data demonstrate that ethical concerns—such as the perception of incentives as
coercive and morally problematic—are central to the public‘s opposition. We will
use a new methodology developed by us, the policy lab, to investigate how different
populations globally perceive the use of monetary incentives across various health
behaviors such as organ donation, blood donation, and cancer screenings. We will
also assess the role of cultural, ethical, and demographic factors in shaping these
attitudes.
The research also broadly builds on earlier research of ours on ways to increase
vaccinations with different behavioral interventions and potential unintended
34 consequences of interventions published in Nature (Schneider et al., 2023) and
Science (Campos-Mercade et al., 2021).
Description of the Problem
Much of the public and private burden of diseases is linked to modifiable individual
behaviors, such as smoking, unhealthy eating, and not vaccinating (WHO 2023). To
improve healthy behaviors, governments use various policies, including providing
information, nudges and monetary incentives (Brewer et al. 2018). In our earlier
work, we found that monetary incentives are particularly effective in promoting
healthy behaviors (Campos-Mercade et al. Science 2021; Schneider et al. Nature
2023; see also Charness & Gneezy Econometrica 2009; Milkman et al. Nature 2021).
However, such payments have been a source of controversy, and our previous
results have sparked heated debates, with many arguing against the use of such
incentives (e.g., Jecker Science 2021).
Our research for Sweden (where we have already collected data) shows that despite
the effectiveness of these interventions, there is widespread public opposition
to monetary incentives for health-related behaviors. This opposition is driven by
ethical concerns—people perceive these incentives as undermining individual
autonomy, as coercive, or as a form of bribery. This presents a significant obstacle to
the adoption of such policies, as public and political support is crucial for successful
implementation.
With support from the WWZ Forum, we will extend our data collection beyond
Sweden and investigate two overarching questions:
1) What factors shape public attitudes toward incentives and other policies
to encourage healthy behaviors (also beyond vaccination) around the
globe?
2) How can health policy and prevention globally be designed so that it is
accepted by the population?
By answering these questions our project will make important progress in
understanding attitudes towards health policies globally. Understanding such
attitudes is important for policy making: On the one hand, public opposition
create barriers to the implication of otherwise effective policies, or may influence
the effectiveness of a policy once implemented. On the other hand, we may want
to implement policies that reflect the preferences of the population. To which
extend policies are acceptable for the population and under which circumstance
also matters for addressing key issues related to the rise in comorbidities and
cardiovascular disease including lacking medication adherence and incentives for
using integrated care models.
These are particularly important problems also in the context of the fragmented
healthcare system in Switzerland. Despite being a high-income country with an
advanced healthcare system, Switzerland is not immune to the growing pressure
from public health challenges related to behavioral risk factors, which are now
among the leading causes of premature death and disability in many countries. As
policymakers grapple with rising healthcare costs, aging populations, and health
inequalities, understanding how to promote healthy behaviors in a way that is
acceptable to the public—through incentives or other interventions—is critical.
Objectives
The overall project consists of three interlinked parts:
i) We developed novel methods to measure policy attitudes using incentivecompatible
methods from behavioral economics that allow for precise
characterizations of attitudes. We applied the new method in Sweden previously.
ii) With support from the WWZ Forum we would like to measure policy attitudes
for incentives for health behaviour change across the globe.
iii) Based on this data, we will be able to study the underlying foundations that
drive opposition for different policies across different demographics and cultures.
This will allow us to investigate whether public opposition reflects factors discussed
in the academic literature in economics, psychology, and public health. The new
data will also allow us to extend the scope of studied health behaviors beyond
vaccination.
iv) The funding also allows us to study more extensively whether more light-weight
but less effective policies, such as nudges that provide information, crowd-out the
use of more heavy-handed incentive policies (that is, we test whether the choice of
incentives is more frequent if there is no option to choose a nudge). And, we will
probe the acceptability of different incentive types and incentive sizes (e.g., in-kind
vs. cash incentives).
To measure policy attitudes, we will rely on incentive-compatible methods from
behavioral economics. We developed a new field-experimental framework, which
we label the Policy Lab and with which we have already collected data in Sweden.
In the Policy Lab, some participants, the policy planners, are tasked with deciding
whether to implement different health policies to a group of 100 other participants,
the policy targets. The choices of planners are then implemented, meaning that
planners’ decisions have actual consequences. In one subproject, for example, the
planners’ choice may affect targets’ vaccination rates.
Importance, Usefulness and Novelty of the Project
There has been a recent effort to better understand attitudes towards various
policies, including environmental and redistributive policies (Kuziemko et al. AER
2015; Almås et al. JPE 2020; Stantcheva QJE 2021). Attitudes in the area of health
policy are less well understood. Work in economics mostly focused on prosocial
health-related behaviors such as organ donations. Nobelprize winner Al Roth
famously pointed out that people seem to dislike offering payments for organ
donations (Roth 2007), which was confirmed in surveys (Ambühl, Niederle & Roth
AER 2015; Ambühl & Ockenfels AER 2017; Elías, Lacetera and Macis AER 2015, 2019).
A complementary literature in public health studies people’s support for various
health policies, including offering monetary incentives (e.g., Diepeveen et al. 2013;
Hoskins et al. 2019). However, there are two key limitations to the existing work.
The first limitation is that all existing work measures policy attitudes through
hypothetical choice scenarios. However, responses in hypothetical scenarios are
often systematically biased (“hypothetical bias”, see List & Gallet 2001; Vossler et al.
2012). We currently lack a method to reliably measure attitudes.
The second limitation is that the underlying foundations that drive opposition for
different policies are not well understood. There is a large theoretical literature
in economics, psychology and public health that argues against the use of some
policies to promote health behaviors, including offering monetary incentives.
Worries include that they may crowd out prosocial and intrinsic motivations and
reduce perceived safety, thereby also reducing healthy behavior (e.g., Titmuss 1970;
Bowles & Polanía-Reyes 2012; Cryder et al. 2010; Schneider et al. 2023). Existing
research does not address whether these concerns are shared by the public, to
which policies they apply, and whether they influence policy attitudes.
Our experimental design, the Policy Lab, overcomes these limitations. We employ a
state-of-the art approach from behavior sciences that elicits characteristics through
choices with real consequences, thereby avoiding “hypothetical bias”. Moreover,
our design enables us to precisely measure people’s beliefs regarding the impacts
of policies on different outcomes and cost considerations, thus allowing us to study
the underlying factors driving policy attitudes.