Tag Archives: nudge

Doctors prescribing social capital?

Flickr photo by carf

I wrote earlier about some insurers using social capital in making decisions of whom to insure.

That post and a story sent to me by Lew Feldstein about doctors prescribing outdoor time got me thinking about doctors and social capital.  In the same way as doctors ask questions of patients around smoking, exercise, diet, etc., why shouldn’t doctors also ask patients to fill out a short survey about social capital activities they engage in:  number of confidants, how many of their neighbors’ first names they know, how often they go to friends’ houses or entertain others in their home, etc.?

These data could be used for 3 purposes:

1) to track real changes in the patient over time:  e.g., if a patient used to report 2 confidants and now reports zero it would be a chance for the doctor to find out what had triggered this (a friend moving, serious arguments, a close friend dying, etc.) that might help identify patients at risk of being socially isolated or going through stressful times.

2) to benchmark against others of the patients’ education, race and age.  In larger practices, or if this information was aggregated anonymously by affiliated hospitals, the computer could help patients understand the degree to which they far less involved in community or other associations or less trusting than comparable others nationwide or in their area.  If one was significantly below what others were, the doctor might want to bring this to the patient’s attention:  “did you know that most others like you are far more active in their community?”  or “did you know that most others like you volunteer much more their community?”  “This is something that has clear health impacts;  would you like more information about how to get more involved?”

3) to prescribe social capital “treatments”.  We’re far more used to a doctor prescribing an antibiotic or an aspirin than recommending that a patient get actively involved in a group (on a topic he/she cares about).  And some social capital deficits are more easily treated than others — it’s hard to suddenly develop a confidant.  But doctors might note to patients that there are real health consequences of being socially isolated and being socially and civicly uninvolved: i.e., getting sick more often and recuperating more slowly.  If acquiring a confidant in the next year is not a doable goal, maybe deciding which of ones’ friends have the potential to be confidants and taking some steps to start to deepen these relationships might be doable over the next 6-12 months.   Patients might agree to certain steps they want to take and put them on a card in a sealed and addressed letter that gets sent to them in 4 months.  Nudges can also be used to help people keep promises (through ongoing social groups that hold their members accountable for their promises, checks that go to disliked groups if commitments are broken, etc.).

And as to why?  Doctors might point out that they would rather be prescribing social capital now than prescribing hypertension drugs five years down the road.

[Read related story in NY Times about prescribing outdoor time: "Head Out for a Daily Dose of Green Space" (Jane Brody, 11/30, 10]

Social Capital Nudges [UPDATED 3/27/13]

In Cass Sunstein and Richard Thaler‘s wonderful book Nudge (2008), they note that individuals’ choices can be influenced by countless factors that people are unaware of (where food is positioned in a cafeteria or a grocery store, what the default settings are on an iPhone, whether programs like retirement contributions are opt-out or opt-in, etc.).  The authors advocate libertarian paternalism: that American leaders be choice architects, trying to arrange society so that Americans maximize good outcomes, but enabling Americans to opt out of these arrangements if they disagree.

Reading the book made me wonder how “choice architects” trying to maximize social capital (social interaction) or civic engagement in society would arrange affairs.

1) Physical space: Architects, as Nudge points out, often are choice architects.  Architects can influence anything from how comfortable we are in our homes or communities to how efficiently we move, to how much we interact.  On the latter, think about front porches or stoops, walkable streets, vibrant public squares, or farmers’ markets as only a few examples of this.  The Forum at Harvard Kennedy School (where public and private leaders come to give talks) was designed based on the Roman Forum and Greek agorae.  It has little nooks along staircases that take you to higher floors, maximizing the chances for interacting, encountering others and conversing.  Of course there are limits to this, as can be seen in “Social Capital and New Urbanism: Leading a Civic Horse to Water?

2) Asking people their intentions in advanceNudge points out that asking people about their intentions (“priming”), increases their chance of doing so.  See this earlier blog post about asking people of their intention to vote to increase voting.   One can also increase the likelihood of voting by having them draw a map of how to get from their home to their voting location.  One wonders what other civic actions we could effectively prime: volunteering, attending a public meeting that discussed town affairs, joining a group, attending a block party, etc.

3) Social norming:  I’ve written about this earlier, but publicizing that most people do things differently than individuals expect can nudge people toward the actual norm. For example, administrators  found that describing the actual infrequency of  college binge drinking (lower than what most college students had believed), lowered the rate of binge drinking further among those who were binge drinking. What are the opportunities to capitalize on this for civic engagement.  We could observe that 40% of Americans attend a house of worship weekly or more frequently and close to three quarters attend at least monthly. We could tell Americans that 62 million fellow Americans volunteer, contributing 8 billion hours of volunteer service worth $162 billion.  And there are undoubtedly other facts we should bring to their attention to increase civic behavior.  [One does have to worry that the folks who are doing a civic behavior far more than the average may be induced to lower their behavior.]  [For an article on social norming, see Tina Rosenberg, 'The Destructive Influence of Imaginary Peers", New York Times, 3/27/13]

Another example of this is OPower that is trying to induce people to use less electricity by pointing out how energy conscious their neighbors are.

4) Offer rewards for civic behavior?  We might provide a deduction on health insurance rates for those participating in community groups (a la Samaritan Ministries’ self-insurance or discounts for health club memberships). Similarly, neighborhood stores might offer discounts or coupons for students engaged in regular community service.  Tax deductions are likely more controversial.

5) Civility check: Sunstein/Thaler recommend in Nudge an invention that detects an uncivil e-mail that a user is considering sending and asks the user if he/she is willing to have a 12 hour cooling off period and see if he/she still wants to send the message as is.  [This is reminiscent of Google Mail Goggles which was set up to avoid people sending embarrassing e-mails when drunk.]

6) Get civic commitments up front: Nudge highlights the effectiveness of getting individuals to commit to take action and depositing monthly checks with a third party.  For every month that this commitment is not honored, a group reviled by this individual gets a contribution.  So for example, an advocate of women’s right to choose would deposit checks with this third party made out to the National Right to Life.  She would  vow to attend a book group every month or conversely to attend a church committee’s meetings each month.  Any month that she did attend, her check for that month would be ripped up.  Any month that she didn’t attend, her check would be sent to the NRL.

7) Using groups to reinforce promises:  Many studies have found that commitments made to groups are more likely to be honored.  That is why AlAnon or Weight Loss Groups or Self-Help groups have groups at their core.  We should pursue opportunities like the New Year’s Nudge to encourage people to stick to commitments and might have a Pledge Day where people pledged to take certain pro-civic or pro-social capital activities over the next year.

8) Hanging around other civic types: In James Fowler’s  and Nick Christakis’ Connected, they detail how many social practices are spread through social networks (drinking, depression, obesity, etc.).  It appears from their research that hanging around others who are civic works in the same way;  part of this effect may be the “social norming” effect described earlier, that being around lots of civicly active people changes one’s reference group for citizenship in the same was as being surrounded by overweight people changes one’s sense of how heavy or thin one is.

9) Behavioral placement.  Public health advocates like Jay Winsten were very successful in getting television shows to popularize behavior like “designated drivers.”  More recently, television programs have interwoven wellness behaviors (like exercise or eating right) into show themes.  These may be more effective since a viewer observes a character that the viewer likes or respect undertaking these behaviors.  (Note: it may not be advisable to have Homer Simpson displaying the civic behavior you want to encourage.)

10) metering people’s health and happiness benefits from civic engagement.  Not sure that the studies of the links between social capital and health and social capital and happiness are finely enough calibrated, but it is clear that people alter their behavior in response to more immediate feedback (e.g., the instantaneous MPG feedback on Toyota Priuses or on some GPS devices, the smart meter readouts in some homes of how much electricity they are using instantaneously).  What if there were an iPhone app where you daily plugged in your amount of socializing, volunteering, attendance at public meetings  on town affairs and club going? The iPhone app would generate an instantaneous readout with a face with differing expressions of how well you were doing (with a scowl showing the most displeasure and a smile showing the most) or a stylized body that looked healthier or less healthy depending on your habits.  [A Brazilian bar had an interesting experiment to make people aware of the hidden costs of drunk driving.]

11) Positive deviance: Learn from outliers so others can do the same.  We might do more studies of places that are unusually civic (like Minnesota) to understand what it is that they do differently from communities where there is far less civic behavior and whether nudges could help spur people towards the positively deviant (e.g. very civic community).

12) Setting up defaults.  Here is a graphic on how best to choose a default (not focused on civic engagement).  I haven’t thought of good ideas of how defaults could be used to boost civic engagement, but I’m sure this could be used more.

13) Take advantage of fact that people are  more willing to increase their civic behavior in the future. Sunstein and Thaler capitalize on research that shows that people give more when asked to make a donation in the future than if asked to make it today; they propose a project called “Give More Tomorrow“.  I haven’t seen any research on this but one wonders whether “Volunteer More Tomorrow” or “Coach Little League Tomorrow” or other civic or community engagement  would show similar patterns.

14) Publicize non-civic behavior.  “In a 2005 study, Alan Gerber of Yale got Michigan voters to increase their turnout an amazing 8.6% with a single peer-pressure mailer that listed the previous voting records of their neighbors and noted that a follow-up would be sent indicating who voted this time. (The Obama [presidential] campaign actually priced out a similar mailer but decided not to risk a backlash.)” (From Nudge Blog)

We welcome your thoughts about what nudges might have the biggest impact on increasing social capital or civic engagement/volunteering.   Sunstein and Thaler note that nudges are most helpful where: a) the consequences of bad decisions are delayed (true for many social capital decisions); b) the decision is complex or confusing; c) where you face overwhelming number of choices (true of how we spend our free time); d) where people would benefit from greater feedback from their decisions (true of many social capital decisions); and e) where such decisions are infrequent.

Read  long interview with Thaler here (Fall 2009 Yale School of Management), BBC interview (2009), a To The Point roundtable and Firedoglake conversation.

See “Cass Sunstein Wants to Nudge Us” (NYT Magazine section, 5/16/10)

Read the Nudge Blog.