Behavioral Economics: A Primer and Applications to the UN Sustainable Development Goal of Good Health and Well-Being

Round 1

Reviewer 1 Report

The research topic is interesting but some points are to be addressed.

The objectives of the analysis should be further described in the text.

The literature review should be enriched with recent contributions concerning innovation and well-being (Aldieri et al., 2020; Usai et al., 2020)

The results should be further discussed also in terms of policy implications.

The manuscript should be English proofread because some sentences are not clear.

References.

Aldieri L., Bruno B. & Vinci C. P. (2020). A multi-dimensional approach to happiness and innovation. Applied Economics, https://doi.org/10.1080/00036846.2020.1828807

Usai, A., B. Orlando, and A. Mazzoleni. (2020). Happiness as a Driver of Entrepreneurial Initiative and Innovation Capital. Journal of Intellectual Capital 21 (6): 1229–1255. https://doi.org/10.1108/JIC-11-2019-0250.

Author Response

Thank you for the careful review of our work and the opportunity to substantially improve our manuscript so that it enhances our contribution to the ongoing discussion of the potential benefit of behavioral economics to supporting healthy lives.  Below you will find our response to each of the concerns raised by the reviewers.

Response to Reviewer 1:
The research topic is interesting but some points are to be addressed.
Thank you for your kind words.  We address your remaining concerns below.

The objectives of the analysis should be further described in the text. AND The literature review should be enriched with recent contributions concerning innovation and well-being (Aldieri et al., 2020; Usai et al., 2020.

We have rewritten the introduction to more clearly identify our objectives.  We include a reference to Usai et al (2020) and Aldieri (2021) in that introduction:

1. Introduction

Behavioral economics (BE) is a relatively new field within the discipline of economics.  It harnesses insights from psychology to improve economic decision making in ways that have the potential to enhance good health and well-being of both individuals and societies, the third of the United Nations Sustainable Development Goals (UNSDG). While some of the psychological principles of economic decision-making were described by Adam Smith as early as the 1700s, BE emerged as a discipline in the 1970s because of the groundbreaking work of psychologists Daniel Kahneman and Amos Tversky.

Although Aldieri and colleagues (2021) find that inequality, inclusive of health inequality, can undermine well-being, Usai and colleagues (2020) note that studies over the past thirty years have successively supported that well-being is vital for the development of economies and societies.  Thus, this essay is intended to bring the principles of BE to a wider audience in a position to employ its concepts to improve health and well-being in support of the UNSDGs.  We describe the basic concepts of BE, how and why decision makers use heuristics (decision making short cuts), the biases entailed, and BE strategies to overcome these biases (framing, incentives, and economic nudging) for improved decision making.  We further survey the literature to identify how BE techniques have been employed in individual choice (focusing on childhood obesity), governments’ health policy, and patient and healthcare provider decision making. Additionally, we discuss how these BE-based efforts to improve health related decision making can lead to sustaining good health and well-being and identify additional health related areas that may benefit from including principles of BE in decision making.

The results should be further discussed also in terms of policy implications.

We have added the following summary paragraph with respect to our literature surveys before further discussing how as a policy tool BE can be used in support of the UN Sustainable Development Goal 3.

Our surveys of the BE intervention in healthcare point to several observations.  The first is that as Gordon and colleagues (2020) and others (Talati, Pettigrew et al. 2016, (Kelly and Jewell 2018) have found, system 1 is a more effective tool to support healthy decision making by children in cafeterias and in broader society-level decision making when information is provided for food items. Similarly, medical decision making on the part of both healthcare professionals and patients can be improved through the use of strategies such as default and opt-out systems. While previous research has focused on the risk of cognitive error when heuristics and other forms of cognitive bias are used in medical decision making, there is emerging evidence demonstrating the potential benefit of targeting cognitive biases to optimize choices. Furthermore, healthy decisions can be reinforced by using taxes to alter price signals in pursuit of public health goals.  Using bonuses and prices to incentivize choices tends to be less effective and less sustainable due to both the size of needed incentives and the ongoing costs of maintaining the incentives.  If the incentives are not maintained, the behaviors tend to revert to the initial less desirable ones.

The manuscript should be English proofread because some sentences are not clear.
Thank you for this suggestion.  We have carefully proof read the document for clarity, grammar and spelling.  We trust you will find it much improved.

We hope that we have addressed all your concerns.   Once again, we appreciate the opportunity to improve our work.

Sincerely,

Robert Siegel, Katelyn Gordon, Linda Dynan

Reviewer 2 Report

The authors provide a well-written survey on behavioral economics in the context of healthcare. As such the paper does not provide any novelty, but I do not expect this from a survey. Considering the typical reader of Reports, the authors have explained the main ideas and concepts of behavioral economics very well and in way that is understandable for non-economists. In my view to spread the respective ideas to non-economists with the help of empirical examples makes much sense, because the presented examples make clear that the knowledge gained in behavioral economics are quite useful for practice in health policy.

Minor concerns:

Line 275: correct “averion”

Line 297: correct: “is” or “presents”, not both.

Line 369: it is referred to Peterson and colleagues, but the year missing and it does appear in the reference list 412: correct: “a Lee”.

Author Response

Thank you for the careful review of our work and the opportunity to substantially improve our manuscript so that it enhances our contribution to the ongoing discussion of the potential benefit of behavioral economics to supporting healthy lives.  

Response to Reviewer 2:

The authors provide a well-written survey on behavioral economics in the context of healthcare. As such the paper does not provide any novelty, but I do not expect this from a survey. Considering the typical reader of Reports, the authors have explained the main ideas and concepts of behavioral economics very well and in way that is understandable for non-economists. In my view to spread the respective ideas to non-economists with the help of empirical examples makes much sense, because the presented examples make clear that the knowledge gained in behavioral economics are quite useful for practice in health policy.

Thank you for your generous assessment of our work.

Minor concerns:
Line 275: correct “averion”
The spelling has been corrected.

Line 297: correct: “is” or “presents”, not both.
Thank you for catching this –we have changed the sentence to:

As expected, front of pack labeling that relies on System 1 thinking and signifies the product as healthy or unhealthy tends to be more effective than those that rely on System 2 thinking that provides more cognitively costly numerical nutritional information (Talati, Pettigrew et al. 2016).

Line 369: it is referred to Peterson and colleagues, but the year missing and it does appear in the reference list

This is actually the Tulsky, J. P., L. Pilote, J. A. Hahn, A. J. Zolopa, M. Burke, M. Chesney and A. R. Moss (2000). "Adherence to isoniazid prophylaxis in the homeless: a randomized controlled trial." Archives of Internal Medicine 160(5): 697-702 study.  It has been fixed in the document:

In a randomized controlled study of isoniazid prophylaxis in the homeless in San Francisco, Tulsky and colleagues showed almost 100% improvement in adherence when a five-dollar incentive was given when participants took their medication as compared to no incentive (Tulsky, Pilote et al. 2000). 

412: correct: “a Lee”.
This has been corrected.

Experimentally, Lee and colleagues used an educational game to eliminate Anchoring, Availability and Representativeness Bias, but the effect was extinguished after 4 weeks (Lee, Dunbar et al. 2016).

We hope that we have addressed all your concerns.   Once again, we appreciate the opportunity to improve our work.

Sincerely,

Robert Siegel, Katelyn Gordon, Linda Dynan

Reviewer 3 Report

1. Keywords are missing.
2. The purpose of the review article is to objectively consider the degree of study of a particular problem, to give a reasonable assessment of the published works of other researchers, and to draw logical conclusions from the research done. I believe that the authors failed to achieve this goal.
3. There is no description of how the sources for the review article were selected (should include search strategies, inclusion and exclusion criteria, data sources and geographic information, characteristics of research subjects, and statistical analysis used.)
4. What is the function of a review article? •to organize literature •to evaluate literature •to identify patterns and trends in the literature •to synthesize literature •to identify research gaps and recommend new research areas. I believe that the authors have not completed their review article.

Author Response

Thank you for the careful review of our work and the opportunity to substantially improve our manuscript so that it enhances our contribution to the ongoing discussion of the potential benefit of behavioral economics to supporting healthy lives.

Response to Reviewer 3:

Keywords are missing.

We have added the following key words:  Behavioral Economics, UNSDG 3, Economic decision making in health care

The purpose of the review article is to objectively consider the degree of study of a particular problem, to give a reasonable assessment of the published works of other researchers, and to draw logical conclusions from the research done. I believe that the authors failed to achieve this goal.
There is no description of how the sources for the review article were selected (should include search strategies, inclusion and exclusion criteria, data sources and geographic information, characteristics of research subjects, and statistical analysis used.)
What is the function of a review article? •to organize literature •to evaluate literature •to identify patterns and trends in the literature •to synthesize literature •to identify research gaps and recommend new research areas. I believe that the authors have not completed their review article.

Thanks you for your assessment of our work.  We agree that the paper needs more focus and intent in the survey of the literature.  We have rewritten a portion of the introduction to clarify our intent. 
 

From the introduction:

Although Aldieri and colleagues (2021) find that inequality, inclusive of health inequality, can undermine well-being, Usai and colleagues (2020) note that studies over the past thirty years have successively supported that well-being is vital for the development of economies and societies.  Thus, this essay is intended to bring the principles of BE to a wider audience in a position to employ its concepts to improve health and well-being in support of the UNSDGs.  We describe the basic concepts of BE, how and why decision makers use heuristics (decision making short cuts), the biases entailed, and BE strategies to overcome these biases (framing, incentives, and economic nudging) for improved decision making.  We further survey the literature to identify how BE techniques have been employed in individual choice (focusing on childhood obesity), governments’ health policy, and patient and healthcare provider decision making. Additionally, we discuss how these BE-based efforts to improve health related decision making can lead to sustaining good health and well-being and identify additional health related areas that may benefit from including principles of BE in decision making.

From methods section:

Given that the intent of this study was a general review of behavioral economics and its application to healthcare rather than systematic review, a general search approach of the literature was used.  The three authors searched Google Scholar with the search terms “Behavioral Economics” + “Healthcare” from years 2017 to 2021  (28,800 results) and PubMed with the search term “Behavioral Economics” all years (11,627).  The results were then reviewed by the authors for pertinent articles.  Additionally, any other pertinent articles that were discovered in analyzing the literature were included.

We hope that we have addressed each of the concerns.  Once again, we appreciate the opportunity to improve our work.

Sincerely,

Robert Siegel, Katelyn Gordon, Linda Dynan

Round 2

Reviewer 1 Report

The paper is OK

Author Response

Thank you once again for the careful review of our work and the opportunity to substantially improve our manuscript so that it enhances our contribution to the ongoing discussion of the potential benefit of behavioral economics to supporting healthy lives.  Below you will find our response to each of the concerns raised by the

Response to Reviewer 1:
The paper is OK.

Once again, we appreciate the opportunity to improve our work.

Robert Siegel, Katelyn Gordon, Linda Dynan

Thank you for your generous assessment of our work.

Reviewer 3 Report

1. I recommend the authors use more recent literature. There are only a few sources 2020 in the reference.
2. I recommend the authors describe the scientific novelty, the author's contribution to theory and practice.

Author Response

Thank you once again for the careful review of our work and the opportunity to substantially improve our manuscript so that it enhances our contribution to the ongoing discussion of the potential benefit of behavioral economics to supporting healthy lives.  Below you will find our response to each of the concerns raised by the reviewers.

Response to Reviewer 3:

Thank you for your generous assessment of our work.

I recommend the authors use more recent literature. There are only a few sources 2020 in the reference

Thank you for this helpful suggestion.  We have added the following references:

1. Frank, H. R., Ubel, P. A., & Wong, C. A. (2020). Behavioral economic insights for pediatric obesity: suggestions for translating the guidelines for our patients. JAMA pediatrics, 174(4), 319-320.
2. Lwin, M. O., Yee, A. Z., Lau, J., Ng, J. S., Lam, J. Y., Cayabyab, Y. M., ... & Vijaya, K. (2020). A macro-level assessment of introducing children food advertising restrictions on children’s unhealthy food cognitions and behaviors. International Journal of Advertising, 39(7), 990-1011.
3. Navathe, Amol S; Volpp, Kevin G; Bond, Amelia M; Linn, Kristin A; Caldarella, Kristen L; et al.Health Affairs; Chevy Chase39, Iss. 5,  (May 2020): 852-51. DOI:10.1377/hlthaff.2019.01061

These are on lines:

316, 317 and 445

I recommend the authors describe the scientific novelty, the author's contribution to theory and practice.

Thank you for this important suggestion.  The following was added:

“Thus, this essay contributes to practice by bringing the principles of BE to a wider audience in a position to employ its concepts to improve health and well-being specifically as they could be used to support UNSDGs.”   On lines 34 to 36

Additionally, we have carefully reviewed the manuscript for typos and grammatical errors.  We hope that we have addressed each of the concerns raised by our three reviewers.  Once again, we appreciate the opportunity to improve our work.

Robert Siegel, Katelyn Gordon, Linda Dynan