The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review

In this systematic literature review, we identify evidence on the effectiveness of nudges in improving the self-management of adults with chronic diseases and derive policy recommendations. We included empirical studies of any design published up to April 12^th, 2018. We synthesized the results of the studies narratively by comparing statistical significance and direction of different nudge types’ effects on primary study outcomes. Lastly, we categorized the nudges according to their degree of manipulation and transparency.We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects. However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g., glycemic control), found that nudges had a significant positive effect for one intervention arm.In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders, feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges. Accordingly, they can generally be recommended to policymakers.     

Nudge: a new and better way to improve health?

Nudging, or libertarian paternalism, is presented as a new and ethically justified way of improving people's health. It has proved influential and is currently taken up by the governments in the US, the UK and France. One may question the claim that the approach is new, in any case it has many similarities with the idea of “making healthy choices easier”. Whether the approach is better from an ethical perspective depends on the ethical principles one holds. From a paternalistic perspective there could be no objections, but from a libertarian, there are several. Contrary to what the authors state, libertarian paternalism is an oxymoron.     

Government interventions to aid choice: Help to self-help or paternalism?

A random sample of Danish respondents was asked in which aspects of every-day life they find it more difficult to adhere to behavioural patterns that they believe are best for them and their family. Individuals report high degrees of lack of self-control in specific areas of everyday life, suggesting that individuals are not consistently exhibiting utility optimising behaviour, a finding that accords with behavioural economics and the expected prevalence of irrational behaviour. We observe greater self-perceived self-control problems amongst individuals from the lower economic strata. Thus, to the extent that self-control relates to environmental factors, there is justification for introducing government interventions targeting such factors to improve equity in health and to increase utility levels amongst those with lower incomes and lower levels of education. Further, the public's preferences for a range of government interventions targeting different facets of life-style were elicited. Individuals who were the target of interventions were less supportive of these interventions. Individuals in the target group whose self-perceived self-control was low tended to be more supportive, but still less so than those who were not targeted. Since support was shown to come mainly from those not targeted by the intervention, and especially from those who feel in control of their lives, our results indicate that the interventions cannot be justified on the grounds of libertarianism (help to self-help).     

Nudging in screening: Literature review and ethical guidance

Objectives

Nudging is the purposeful alteration of choices presented to people that aims to make them choose in predicted ways. While nudging has been used to assure high uptake and good outcome of screening programs, it has been criticized for being paternalistic, undermining free choice, and shared decision making. Accordingly, the objective of this study is to explore a) nudging strategies identified in screening, b) arguments for and against nudging; and on basis of this, to c) suggest a tentative conclusion on how to handle nudging in screening.

Clinical evaluation of an electronic hand hygiene monitoring system

BackgroundWe aimed to test the accuracy of an electronic hand hygiene monitoring system (EHHMS) during daily clinical activities in different wards and with varying health care professions.MethodsThe accuracy of an EHHMS (Sani Nudge) was assessed during real clinical conditions by comparing events registered by two observers in parallel with events registered by the EHHMS. The events were categorized as true-positive, false-positive, and false-negative registrations. Sensitivity and positive predictive value (PPV) were calculated.ResultsA total of 103 events performed by 25 health care workers (9 doctors, 11 nurses, and 5 cleaning assistants) were included in the analyses. The EHHMS had a sensitivity of 100% and a PPV of 100% when measuring alcohol-based hand rub. When looking at the hand hygiene opportunities of all health care workers combined taking place in the patient rooms and working rooms, the sensitivity was 75% and the PPV 95%. For doctors’ and nurses’ taking care of patients in their beds the EHHMS had a sensitivity of 100% and a PPV of 94%.ConclusionsThe objective accuracy measures demonstrate that this EHHMS can capture hand hygiene behavior under clinical conditions in different settings with clinical health care workers but show less accuracy with cleaning assistants.     

Development,internal reliability and preliminary construct validity of the Dutch Dietary Intention Evaluation Tool for In-patients (DIETI)

Background and aimsDiet is important in prevention and management of non-communicable disease and in particular, cardiovascular disease. Recently, more hospitals gear towards healthier dietary policies, however, a tool to assess the effect of these interventions in patient populations is currently lacking. The Theory of Planned Behavior (TPB) is generally used to assess health-related behavior and offers a framework for development of questionnaires. In this study, we aim to evaluate the reliability, internal consistency and preliminary construct validity of the newly developed Dietary Intention Evaluation Tool for In-hospital patients (DIETI) which is based on the TPB.Methods and resultsAn expert panel constructed the item list of the DIETI. A total of 312 patients admitted to the cardiology ward filled out the DIETI. Explanatory- and confirmatory factor analysis showed that our tool adequately discerns five TPB-consistent factors regarding a healthy diet in hospitalized patients. (N = 312, for the CFA model χ² = 313.072 (df = 160, p < 0.001, CFI = 0.939, RMSEA = 0.058). Subsequent analysis of reliability showed satisfactory to strong internal consistency of the questionnaire as a whole and all subscales (Cronbach's alpha for the subscales ranging between 0.65 and 0.88).ConclusionsWe conclude that the DIETI is an internally reliable tool to assess behavioral intentions regarding a healthy diet of in-hospital patients. Thus, this questionnaire can be used to evaluate the effect of dietary interventions aimed at hospitalized patients.