Changing behaviours in public health - to nudge or to shove

This briefing for councillors and officers explains how behavioural change interventions – or nudge theory as it is dubbed – can help local authorities fulfil their public health responsibilities.

Prevention, it is often said, is better than cure. If people didn’t smoke, drank less, had better diets and exercised more, the burden of disease would be reduced. But what is the role of the state in persuading people to alter their lifestyles?

The traditional approach dictates that in cases where something causes serious harm, such as drug use, restricting choice or even an outright ban is appropriate. However, where it is less clear cut, the argument goes, the state should leave it to individual choice. But this ignores the fact that there is a variety of ways in between that behaviour can be influenced from encouraging and incentivising people through to subtly guiding choice in a certain direction. This can include enticing people to take up activities or using subliminal marketing.

For example, stressing social norms can encourage people to change behaviour because they want to be alike. Alternatively it can involve making an environment less conducive to someone making an unhealthy choice. An example of this would be making salad a default option as a side instead of chips or placing clear signs to steps rather than escalators. This is known as behavioural change and there has been growing interest in the issue among policy-makers across the world - and not just solely in terms of health. The choices people make can have a profound impact in a host of other areas from education to crime as well.

Much of the debate stems from the 2008 book ‘Nudge: Improving Decision about Health, Wealth and Happiness,’ which was written by US academics Richard Thaler and Cass Sunstein. Their theory is that libertarianism and paternalism do not have to conflict and that the state can – and should – act as a guiding hand, “nudging” citizens in the right direction. But the term nudge probably does not do justice to the full range of interventions that can influence behaviour. The spectrum has been set by the Nuffield Council on Bioethics in its “ladder of intervention”. 

The fact there is such a wide range of approaches is reflected by the other terms that have started being used to describe interventions other than nudges. Techniques like direct incentives, such as vouchers in return for healthy behaviour, are being labelled hugs, while the tougher measures that restrict choice, like restricting takeaways from schools, are shoves. Bans, such as the restriction on smoking in public places, are simply known as smacks.

Local Government Association, October 2013

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