Kansas public health officials get lesson in behavioral science and why pandemic messages failed

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TOPEKA — When the University of Kansas wanted to encourage students to take a COVID-19 test upon returning to campus for the 2020 fall semester, administration turned to a team of behavioral scientists for advice.

The university could offer students a $5 incentive to get tested, a 50% shot at $10, or a one-in-20 chance at $100.

All of the options would cost the same, but research showed students were far more interested in a $100 gamble than a $5 guarantee. For Derek Reed, professor of applied behavioral science at KU, this was a rare opportunity to demonstrate the value his field of study could have on pandemic policies. The university ended up choosing the $5 option because it was easier to implement.

Reed presented this example and science involving ways to change behavior in a predictable way during a March 31 speech at the Governor’s Public Health Conference in Manhattan, which was attended by hundreds of public health officials from all 105 counties and the Kansas Department of Health and Environment.

The idea is to encourage people to make good choices without punishing them. Or, to use a highly scientific term, give them a “nudge.”

“The bad thing about a nudge is it comes with a bunch of political baggage. What about freedom and liberty? Who are you to manipulate my choices?” Reed said. “That’s a fair question. The reality here, though, is that no matter what you do, you’re manipulating a choice whether you want to or not. The wording will matter.”

KDHE staff and public health officials from across the state listen to a keynote speech March 31, 2022, at the Governor’s Public Health Conference at the Manhattan Convention Center in Manhattan. (Sherman Smith/Kansas Reflector)

Here’s an example of a nudge: Hotels have learned they can save money by deploying signs that say 70% of patrons reuse their towels, but you can call the front desk if you want a new one. This is appealing to people who want to fit in with the norm, Reed said. Do you want to be among the 30% who don’t reuse a towel? Other messaging — such as threatening patrons with a fee or referencing the environmental impact of frivolous towel usage — doesn’t work as well.

Research in this arena provides some explanation for why mandates and peer pressure are ineffective tools for public health officials.

In February, scientists revealed their findings from a “megastudy” of 689,693 Walmart pharmacy customers nationwide who received text messages about flu shots in the fall and winter of 2020. Each person was randomly assigned one of 22 different messages.

These messages didn’t work: Think about risk of catching the flu. People who get flu shots are healthier, wealthier, and more educated. Do others a favor by getting the flu shot.

The most effective message: A flu shot is waiting for you.

“You all are out there in the trenches doing this work and trying to make decisions to protect public health,” Reed said. “So we have that basis. And it’s unfortunately not that popular yet. But we know that everyone wants a longer life, they want a healthier life, they want to enjoy their family and friends and their hobbies.”

In an interview, Reed said he tried for years to engage with public health officials, and it took the pandemic to get their attention.

Public health officials who never had to think about the best way to communicate medical advice to an entire population discovered a one-size-fits-all approach doesn’t work, Reed said. And people were getting conflicting messages from other sources.

If the people from the Walmart study also received a text message that said vaccines will kill you, which message would prevail?

“That comes down to what’s your personal history? What are your biases? What’s your background? Who do you trust?” Reed said. “A lot of people don’t trust the government, for good reason, so when the government’s trying to tell you what to do, you’re not going to buy it. And that’s where I think there was some failure. They were relying on, ‘The scientists tell you you should do X.’ People don’t want to hear that. My own family doesn’t trust scientists.”

Reed said one of the lessons “of selling somebody” that public health officials could learn from the pandemic is that “there might not be a silver bullet to fix everything, but you’re going to pick up some people who are going to respond.”

In other words, “small successes add up.”

“I think a lot of people got discouraged because they couldn’t just change everybody, but that’s unrealistic,” Reed said. “And so one of the lessons is recognize the power that you have, and that any change for the better will be better than not changing it.”

Shruti Chhabra, director of the Finney County Health Department, appears March 31, 2022, at the Governor’s Public Health Conference at the Manhattan Convention Center in Manhattan. (Sherman Smith/Kansas Reflector)

Shruti Chhabra, director of the Finney County Health Department, said in an interview that public health officials might have avoided some of the “political factions” surrounding testing and vaccinations if they had used a nudge approach, “rather than being entirely paternalistic.”

“So far, we’ve relied a lot on a sort of social stigma to push vaccination, but instead of doing that, if we have positive incentives, that can help people adopt a vaccine,” Chhabra said. “That might lead to less political contentiousness.”

Chhabra, who stepped into her position three months ago, said lessons from the pandemic could be applied to other health concerns, such as high obesity. But as with vaccines, it is difficult to get people to adopt long-term healthy behavior in part because the results are not immediately visible. There is no instant gratification.

Reed made a similar point when talking about the value of “feedback,” which lets people know the effect of their behavior. A smartphone produces a satisfying shutter sound when you take a photo, he pointed out, even though its camera doesn’t have a shutter. That sound signals that the process is working.

Carl Lee, director of the Coffey County Health Department, said in an interview it is important for public health officials to get back to the basics, prove they are reliable, and speak the truth.

As it is, Lee said, “two extremes kind of took over the argument and punished the public health departments because we were the middle ground.”

“If you come up to me and start talking about the COVID vaccine, I would start to interview you about what’s your health, and what’s your health risk, so we can educate you about the risk and what’s the pros and cons of all of this, and yet still maintain your choice,” Lee said. “At the individual level, that’s what the health department should do.”

Kansas Reflector is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Kansas Reflector maintains editorial independence. Contact Editor Sherman Smith for questions: info@kansasreflector.com. Follow Kansas Reflector on Facebook and Twitter.

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