Choice Architecture

Helping patients make better health decisions by design

written by Alexandra Schmidt
illustrations by Peter Hoey


Clip art with hearts and stock PHOTOS of grandparents reading to babies are not your typical scientifically innovative research tools. But in a joint National Institutes of Health (NIH)-funded UCLA Anderson and Geffen School of Medicine study on decision-making, sentimental imagery is just that.

The photos surround calendars, on which each date has two check boxes: "Took my meds" and "Checked my BP." The theory behind the study is that people with hypertension (high blood pressure) will do these two things more regularly if they are consistently reminded of the big picture goals behind maintaining good health–things like family, travel destinations and favorite activities. It's a classic experiment in choice architecture: the building of an environment where people have the conditions and information in place to help them make the best decisions possible.

Choice architecture can apply to nearly every facet of human life, but its principles originated in the economic world, where it intersects with psychology. Money, after all, is perhaps the most easily identifiable behavior "carrot" there is.

Choice architecture can apply to nearly every facet of human life, but its principles originated in the economic world, where it intersects with psychology.

Suzanne Shu, a UCLA Anderson professor and one of the investigators on the study, had not ventured outside economics much before undertaking this research, though she'd studied choice architecture in depth. Specifically, Shu had explored how the concept can be applied to financial decisions, such as helping people select mortgages. Recently, her research was incorporated into the national mortgage disclosure forms of the new Consumer Financial Protection Bureau. Shu notes that the same principles can be used to get employees working harder (by offering monetary bonuses), compel people to obey the speed limit (by painting symbols on asphalt that make cars appear to be moving faster than they are), even help men aim better in airport urinals (with targets, turning bathroom time into a game). And maybe, she posits, these principles will help sick people keep chronic illnesses in check.

One typical person in the health study is Maria (not her real name). She is 58 years old, has high blood pressure and has had a hard time keeping up with her meds. Some of the images around her calendar depict gardens, others are of her children and grandchildren, and there are a few from a trip to Mexico she took when she was younger. She's never been back and hopes to return one day.

The study has a financial incentive to it. Every month, just for coming in and getting her blood pressure checked at a clinic, Maria gets $10. She gets an additional $5 if she brings in the monitor she keeps at home for the study (which makes an electronic record each time she checks it), and she gets $5 more if she brings in her calendar showing the dates she's ticked.

The calendar's innovation lies in its assumption that people make decisions based on factors other than money. In past studies, most people like Maria would take their meds as long as an economic incentive was available. The moment the carrot was removed, the good behavior would stop. The hope is that by reinforcing longer-term goals and connecting them with these everyday behaviors, the good habits will stick after the economic incentive is gone.

At the core of the study is a debate Suzanne Shu often finds herself in with colleagues: Are humans rational or irrational actors? Not taking medication for easily controllable conditions suggests that we operate against our own self-interest. Shu disagrees, and in its central premise, so does the study. "We are rational about our decisions given the information we have in the moment," Shu says. "We make good decisions based on what's in front of us." In other words, it's not that we're irrational. It's that we're shortsighted.

The hope is that by reinforcing longer-term goals and connecting them with everyday behaviors, the good habits stick after the economic incentive is gone.

Another UCLA choice architecture study (this one jointly run with USC) is also working to prove that people will act rationally, if only they are prompted to in the moment of decision making. Led by Craig Fox, a UCLA Anderson professor who also is working on the calendar study, this study seeks to break the bad habit of doctors overprescribing antibiotics, a problem that has led to the modern-day scourge of untreatable superbugs in hospitals. In this study, every time a doctor enters a new antibiotic prescription into a patient's digital chart, he or she is prompted to offer an explanation as to why they have written the prescription–a step that heretofore was not required. By creating an environment where the actors are forced to consider the reasoning behind their actions, the study hopes that good behavior will prevail.

The conclusions of both studies will not be known before year's end at the earliest. Given the optimistic hypotheses, will it be disappointing if the calendars don't improve patient habits? "Yes, absolutely," says Shu, though with a caveat: In every study that doesn't pan out, it's still possible that the general principle was right, but the implementation was wrong. If the calendars don't work out, perhaps some sort of innovative game that turns daily medication into a playful competition.

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