Advocates of “nudge”, an influential behaviour management technique, argue that, instead of imposing bans and mandates, governments and employers should discreetly, if not covertly, steer the choices of citizens and workers in ways that improve their lives. The theory’s Chicago-based pioneers, Cass Sunstein and Richard Thaler, recommend “non-intrusive” measures to create a “choice architecture” that can “influence people’s behaviour in order to make their lives longer, healthier, and better”.
The most widely cited illustration of this approach is the fly incorporated into the ceramic of airport urinals, providing careless men with something to aim at – and thereby it is claimed, dramatically reducing “spillage”. Since nudge was endorsed by former prime minister David Cameron when he established the Behavioural Insights Team in the Cabinet Office in 2010, this approach has been pursued in diverse public health areas, from teenage pregnancy to organ donation, and in relation to vaccine uptake and mask-wearing in the Covid pandemic.
Critics of nudge claim that the approach undermines the moral autonomy of the individual and avoids democratic debate over policy objectives. They object to what they consider to be an elitist presumption that people are incapable of making rational decisions but rather need expert guidance – or subliminal manipulation – to induce them to make the ‘right choices’, as determined by the new priesthood of behavioural psychology.
But does nudge work? Last year a widely-publicised “meta-analysis” of more than 200 studies conducted by Stephanie Mertens and colleagues at the University of Geneva found that, in a wide range of fields, nudge was “an effective and widely applicable behaviour change tool”. They concluded that changing individual behaviour through nudging was “key to tackling some of today’s most pressing societal problems, such as the Covid-19 pandemic and climate change”. In the small print, the authors acknowledged that the changes in behaviour measured were modest, with “small to medium effect sizes”, but this caveat was overshadowed by the positive headlines. So, should we carry on nudging?
Not so fast! Last month, a review of the same data by Maximillian Maier and colleagues at University College London, found that “after adjusting for publication bias” (the tendency of researchers to report studies showing successful outcomes rather than unsuccessful ones), “no evidence for the effectiveness of nudge remains”. After ten years of nudging – and continuing controversy over its philosophy – the jury is still out on whether it delivers the ambitious objectives proclaimed by its advocates.
Given the popularity of nudge among politicians and policy makers, it seems unlikely that the equivocal evidence of efficacy will deter its continuing implementation in public health. As the Barbara Ehrenreich, an American critic of the underlying theories of “positive psychology”, has observed, a combination of self-delusion and wishful thinking permeates this field.
A warning from the sewers
When I was a trainee GP many years ago in the East London borough of Newham, warm summer days and a mild breeze from the east would bring an unmistakable waft of human waste. This emanated from the Beckton Sewage Treatment Works a few hundred yards away, one legacy of the radical sanitary engineering pioneered in the capital by Joseph Bazalgette.
Smelly it may be, but Beckton remains useful, not just processing the effluent of four million Londoners, but also forming part of a network of surveillance of potential health hazards through monitoring wastewater. In recent months, public health authorities have identified a cluster of traces of the polio virus – in particular, the strain used in oral forms of the vaccine still used in some developing countries. This strain is reduced in potency – “attenuated” – so that it provokes immunity without causing active infection. It can, however pass through the gut, and where hygiene is poor it may, albeit rarely, cause active polio, though this is usually mild. This appears to have occurred in one recent case in New York.
Though the threat of polio in the UK is very small, there is some concern that uptake of this and other infant immunisations has fallen as a consequence of the disruption of services during the pandemic. The message from Beckton is that we need to get polio vaccinations up to the target of 92 per cent, and a new campaign aims to offer booster vaccinations to all children between the ages of one and nine.