Report on Behavioral Economics for Sustainable Public Health Outcomes

Introduction: Aligning Public Health with Sustainable Development Goals

The rising global incidence of preventable chronic diseases, which account for over 60 percent of all deaths, presents a significant obstacle to achieving United Nations Sustainable Development Goal 3 (SDG 3: Good Health and Well-being). In the United States, 90 percent of the $4.5 trillion annual healthcare expenditure is directed at chronic and mental health conditions. This report details how behavioral economics offers scalable and sustainable interventions to address this crisis. Drawing on the work of physician-economist Kevin Volpp, this analysis outlines strategies that leverage behavioral insights to improve population health, directly contributing to SDG 3 and related goals concerning poverty (SDG 1), hunger (SDG 2), inequality (SDG 10), and global partnerships (SDG 17).

Leveraging Behavioral Science for SDG 3: Good Health and Well-being

Behavioral economics provides a framework for designing interventions that “nudge” populations toward healthier decisions, preserving autonomy while improving outcomes. This approach is critical for addressing Target 3.4 of SDG 3, which aims to reduce premature mortality from non-communicable diseases through prevention and treatment.

Core Intervention Strategies

Dr. Volpp and his colleagues at the Center for Health Incentives and Behavioral Economics (CHIBE) utilize several key behavioral tools:

• Financial Incentives: Programs providing financial rewards for health-promoting behaviors, such as smoking cessation.
• Social Norms: Using peer comparisons and social influence to guide behavior, such as reducing unnecessary antibiotic prescriptions.
• Choice Architecture: Structuring environments to make healthier choices easier and more intuitive.
• Gamification: Incorporating game-like elements to increase engagement with health programs.

Application of Interventions Across Health Domains

Individual and System-Level Health Improvements

Behavioral interventions have demonstrated success in addressing public health problems where individual choice plays a significant role. These applications directly support the achievement of multiple SDGs.

1. Promoting Healthy Lifestyles (SDG 3):
   • Smoking Cessation: A study with General Electric employees found that behaviorally informed financial incentives tripled long-term smoking cessation rates. This model was replicated with CVS Health employees and later adopted by GE for its 152,000 U.S. employees.
   • Physical Activity and Medication Adherence: Interventions are designed to make it easier for individuals to engage in physical activity and adhere to prescribed medication regimens, which is fundamental to managing chronic diseases.
   • Reducing Distracted Driving: A recent study demonstrated that behavioral interventions can decrease handheld phone use while driving, reducing crash risk and contributing to Target 3.6 (halve deaths and injuries from road traffic accidents).
2. Improving Nutrition and Food Security (SDG 2 & SDG 3):
   • The “Health Care by Food” initiative, an American Heart Association project, advances “food is medicine” programs to prevent and manage diet-related diseases. This directly addresses SDG 2 (Zero Hunger) by improving access to nutritious food and SDG 3 by preventing non-communicable diseases.
   • Research on taxes on sugar-sweetened beverages has shown a significant decrease in consumption, a system-level intervention that promotes healthier diets.
3. Enhancing Global Health and Reducing Inequalities (SDG 1, SDG 10, SDG 17):
   • CHIBE’s global research demonstrates the adaptability of behavioral interventions. This work embodies SDG 17 (Partnerships for the Goals) by collaborating with international partners.
   • South Africa: Text messaging leveraging the “fresh start” effect is used to encourage people living with HIV to return to care.
   • Uganda: Research is exploring incentives for adherence to tuberculosis preventative therapy and reduced alcohol use.
   • India: A successful diabetes prevention program is being adapted and scaled.
   • Low- and Middle-Income Countries: A study on cash transfer programs found they were associated with a 20 percent reduction in mortality for women and an 8 percent reduction for children under five, linking health interventions directly to SDG 1 (No Poverty) and SDG 10 (Reduced Inequalities).

Implementation, Scalability, and Measurement

Challenges in Real-World Application

A primary challenge is the “voltage drop,” where the effectiveness of an intervention decreases when moved from a controlled research setting to a large-scale, real-world implementation. Ensuring that interventions are effective and equitable for all populations, thereby supporting SDG 10, requires careful planning.

Strategies for Sustainable and Equitable Scaling

To overcome these challenges and ensure long-term viability, the following strategies are employed:

1. Forming Aligned Partnerships (SDG 17): Collaborating with organizations that share research interests and have the capacity for large-scale testing.
2. Utilizing Human-Centered Design: Designing programs that are inherently engaging for participants from the outset.
3. Conducting Rigorous Testing: Using a combination of tests to assess both efficacy (in trial participants) and effectiveness (among all offered the program).
4. Ensuring Transparency and Replicability: Maintaining methodological rigor and transparency to allow for successful replication of studies.

Measuring Success

The success of a behavioral intervention is measured against several key metrics that align with the principles of sustainable healthcare systems:

• Does the intervention improve patient health outcomes?
• Is the intervention cost-effective?
• Does it reduce the workload of clinicians and staff?
• Does it make it easier for the healthcare system to function?

An example is a semi-automated pharmacist referral system for statin prescriptions, which doubled appropriate prescribing while reducing clinician workload. Another program for colonoscopy preparation, scaled to 20,000 patients, increased show rates by 6 percent while easing the burden on clinical staff.

Technological Platforms as Enablers of a Sustainable Health Agenda

The Penn Way to Health (W2H) Platform

The Penn Way to Health (W2H) platform serves as a critical technological infrastructure for implementing and scaling behavioral change interventions. By providing a flexible and automated system, W2H facilitates the collaboration and reach necessary to advance the SDGs.

• Scope: The platform has supported approximately 450 programs and currently supports 163 active initiatives, reaching nearly 2.2 million participants across all 50 U.S. states.
• Collaboration (SDG 17): Research teams from over 15 universities have used the platform, fostering a collaborative environment for developing evidence-based health solutions.
• Impact: W2H has been instrumental in studies that have improved patient outcomes, reduced hospital readmissions and mortality, and decreased burdens on care teams, demonstrating a scalable model for achieving SDG 3.

Analysis of SDGs, Targets, and Indicators

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being
   • The article’s central theme is improving public health outcomes through behavioral economics. It directly addresses issues like preventable deaths, chronic diseases, mental health, medication adherence, vaccination rates, smoking, and distracted driving, all of which are core components of SDG 3. The text states that “preventable chronic diseases account for more than 60 percent of all deaths” globally and discusses interventions to combat these health challenges.
2. SDG 2: Zero Hunger
   • The article discusses nutrition-related health issues and interventions. The mention of the “‘food is medicine’ interventions that can treat, manage, and prevent diet-related diseases” and the finding that “taxes on sugar-sweetened beverages significantly decrease consumption” directly connect to improving nutrition, which is a key aspect of SDG 2, particularly its focus on ending all forms of malnutrition.
3. SDG 1: No Poverty
   • The article references a study on the impact of social protection systems in low- and middle-income countries. It notes that “cash transfer programs were associated with a 20 percent reduction in mortality for women and an 8 percent reduction in mortality for children younger than 5 years old,” linking directly to poverty reduction strategies and their health co-benefits.
4. SDG 10: Reduced Inequalities
   • The article touches upon health equity by mentioning efforts to “promote health for all” and improve outcomes “across a range of urban and rural populations.” The discussion of cash transfer programs reducing mortality in low- and middle-income countries and the goal of “improving representativeness in clinical trials” also point towards reducing health inequalities.
5. SDG 17: Partnerships for the Goals
   • The article emphasizes the importance of collaboration. It highlights “strong, aligned research partnerships,” the work of the Penn Way to Health (W2H) platform supporting “teams from more than 15 universities,” and international research in countries like “Singapore, India, Peru, Uganda, and South Africa.” This collaborative approach is the essence of SDG 17.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
   • The article is heavily focused on this target, discussing the rising toll of “preventable chronic diseases,” which are non-communicable, and the high healthcare costs associated with them. Interventions aimed at improving nutrition, increasing physical activity, and ensuring medication adherence for chronic conditions directly support this target.
2. Target 3.a: Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate.
   • The article provides a specific example of a successful intervention that “found a tripling of long-term smoking cessation rates” among employees at General Electric and CVS Health, directly aligning with the goal of tobacco control.
3. Target 3.6: By 2020, halve the number of global deaths and injuries from road traffic accidents.
   • The article mentions a study demonstrating how “behavioral interventions can decrease handheld phone use while driving, which, if scaled, could reduce distracted driving and crash risk in the population.” This directly addresses a major cause of road traffic accidents.
4. Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.
   • The article describes global health research targeting specific communicable diseases, such as using text messaging “to encourage people living with HIV to return to care in South Africa” and studying incentives for “adherence to tuberculosis preventative therapy” in Uganda.
5. Target 2.2: By 2030, end all forms of malnutrition.
   • The “food is medicine” initiative aims to “prevent diet-related diseases,” and interventions like taxes on sugary drinks are designed to “nudge people to choose healthier food options.” These efforts contribute to ending malnutrition, which includes overnutrition and diet-related non-communicable diseases.
6. Target 1.3: Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable.
   • The article cites research showing that “cash transfer programs were associated with a 20 percent reduction in mortality for women and an 8 percent reduction in mortality for children younger than 5 years old in low- and middle-income countries.” These programs are a form of social protection system.
7. Target 17.17: Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships.
   • The article describes numerous partnerships, such as the American Heart Association’s Health Care by Food initiative, research with corporations like General Electric and CVS Health, and the W2H platform’s collaboration with over 15 universities, exemplifying the multi-stakeholder partnerships this target promotes.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Smoking cessation rate: This is an explicit indicator of success. The article states that an intervention led to a “tripling of long-term smoking cessation rates.” This measures progress towards Target 3.a.
2. Rate of handheld phone use while driving: The article mentions a study that “demonstrated how behavioral interventions can decrease handheld phone use while driving,” serving as a direct indicator for reducing road risks under Target 3.6.
3. Rate of appropriate statin prescribing: This is a specific metric used to measure the success of an intervention. The article notes a “doubling in appropriate statin prescribing,” which is an indicator for managing chronic diseases under Target 3.4.
4. Patient engagement/show rates: The article measures the success of a colonoscopy preparation program by tracking show rates, noting a “28 percent increase in show rates” in a pilot and a “6 percent increase in show rates” when scaled. This can be an indicator of access to and utilization of health services for prevention under Target 3.4.
5. Mortality rates for women and children: The article explicitly mentions a “20 percent reduction in mortality for women and an 8 percent reduction in mortality for children younger than 5 years old” as an outcome of cash transfer programs, serving as a powerful indicator for Target 1.3.
6. Rate of patient return-to-care for HIV: The research in South Africa aims to “encourage people living with HIV to return to care,” making the rate of return a key indicator for progress on Target 3.3.
7. Consumption of sugar-sweetened beverages: The article mentions that taxes on these beverages “significantly decrease consumption,” making consumption levels a measurable indicator for nutritional improvements under Target 2.2.
8. Number of collaborative programs and participants: The W2H platform’s success is quantified by the number of programs it supports (“163 active research and clinical programs”) and the number of people it reaches (“nearly 2.2 million participants”), which are indicators for the scale of partnerships under Target 17.17.

Summary Table

4. SDGs, Targets, and Indicators

Source: theregreview.org