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Preventing Chronic Disease | Behavioral Economics: “Nudging” Underserved Populations to Be Screened for Cancer - CDC

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Preventing Chronic Disease | Behavioral Economics: “Nudging” Underserved Populations to Be Screened for Cancer - CDC



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Behavioral Economics: “Nudging” Underserved Populations to Be Screened for Cancer

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Jason Q. Purnell, PhD, MPH; Tess Thompson, MPH, MPhil; Matthew W. Kreuter, PhD; Timothy D. McBride, PhD

Suggested citation for this article: Purnell JQ, Thompson T, Kreuter MW, McBride TD. Behavioral Economics: “Nudging” Underserved Populations to Be Screened for Cancer. Prev Chronic Dis 2015;12:140346. DOI: http://dx.doi.org/10.5888/pcd12.140346External Web Site Icon.
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Abstract

Persistent disparities in cancer screening by race/ethnicity and socioeconomic status require innovative prevention tools and techniques. Behavioral economics provides tools to potentially reduce disparities by informing strategies and systems to increase prevention of breast, cervical, and colorectal cancers. With an emphasis on the predictable, but sometimes flawed, mental shortcuts (heuristics) people use to make decisions, behavioral economics offers insights that practitioners can use to enhance evidence-based cancer screening interventions that rely on judgments about the probability of developing and detecting cancer, decisions about competing screening options, and the optimal presentation of complex choices (choice architecture). In the area of judgment, we describe ways practitioners can use the availability and representativeness of heuristics and the tendency toward unrealistic optimism to increase perceptions of risk and highlight benefits of screening. We describe how several behavioral economic principles involved in decision-making can influence screening attitudes, including how framing and context effects can be manipulated to highlight personally salient features of cancer screening tests. Finally, we offer suggestions about ways practitioners can apply principles related to choice architecture to health care systems in which cancer screening takes place. These recommendations include the use of incentives to increase screening, introduction of default options, appropriate feedback throughout the decision-making and behavior completion process, and clear presentation of complex choices, particularly in the context of colorectal cancer screening. We conclude by noting gaps in knowledge and propose future research questions to guide this promising area of research and practice.
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Introduction

Low-income, minority, and uninsured people in the United States are disproportionately affected by illness and death from cancer and have lower rates of participation in recommended screenings (1,2). This article explores how insights from behavioral economics may reduce these disparities by providing tools to increase screening for breast, colorectal, and cervical cancer.
Breast, colorectal, and cervical cancer affect hundreds of thousands of Americans each year, and there is an evidence base for both supporting screening behavior and administering screening for all 3 of these cancer sites (3). The US Preventive Services Task Force (USPSTF) recommends that women receive screening mammography every 2 years from age 50 through 74 (3). For colorectal cancer, the USPSTF recommends screening for adults aged 50 to 75 using colonoscopy, sigmoidoscopy, or fecal occult blood testing (FOBT) (4). The availability of several screening methods with different recommended intervals adds to the complexity of a patient’s decision to be screened for colorectal cancer. For cervical cancer, the USPSTF recommends screening for women aged 21 to 65 by Papanicolaou (Pap) test every 3 years; women aged 30 to 65 may now choose a longer screening interval by combining cytology and testing for human papilloma virus (HPV) every 5 years (5). As part of Healthy People 2020, the US Department of Health and Human Services has set ambitious screening targets (compliance of 70.5% for colorectal cancer screening recommendations, 93.0% for cervical cancer, and 81.1% for breast cancer). However, underserved populations continue to be screened at lower rates (1,6).
Reaching the Healthy People 2020 goals in the face of persistent disparities requires new strategies for promoting screening tests. Three concepts from behavioral economics — judgment, decision-making, and choice architecture — can enhance existing evidence-based screening strategies by providing new insights into the behavior of patients and clinicians and suggesting new tools and techniques to promote screening.

Acknowledgments

The authors received no financial support for the work described in this article.
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Author Information

Corresponding Author: Jason Q. Purnell, PhD, MPH, Assistant Professor The Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130. Telephone: 314-935-3738. E-mail: jpurnell@wustl.edu.
Author Affiliations: Tess Thompson, Matthew W. Kreuter, Timothy D. McBride, Washington University in St. Louis, St. Louis, Missouri.
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