75 per cent of trained clinicians were proficient (Hall et al., 2015). Thus, when
developing complex interventions it is critical to develop and evaluate quality training
programmes to ensure that intervention facilitators are competent to deliver the
intervention, as designed, in practice contexts (such as schools or clinics). Only in this
way can intervention design be translated into improved health promotion and health
care delivery.
Governments are interested in effective behaviour change interventions, including
those that could improve public health and reduce expenditure on health services. Both
the UK and US governments were influenced by a book by Thaler and Sunstein (2008)
describing how ‘NUDGE’s could be used to change behaviour. Both governments
set up teams to develop and evaluate NUDGE interventions. What are NUDGE
interventions? ‘NUDGE’ is an unusual acronym because, for example, the ‘N’ stands
for incentives, that is, use of reinforcement to shape behavioural responses. Decades of
work have shown that reinforcement, including use of financial incentives can change
behaviour patterns. For example, if people can be persuaded to deposit savings, which
they know they will subsequently lose if they fail to meet weight loss targets they lose
more weight (Volpp et al., 2008). Similarly, if pregnant women are paid to abstain from
smoking they are more successful. In one study smoking cessation follow-up at 12 weeks
post-partum found that 24 per cent of those receiving financial incentives had been
successful compared to only 3 per cent in the control group (Heil et al., 2008).
Governments cannot pay everyone to improve their health-related behaviour patterns
so the key research question here is, can reinforcement-based interventions initiate
psychological changes that bolster intrinsic motivation and, through practice, develop
skills and habits that allow behaviour change to be sustained (through impulsive
regulation) – after incentives are removed. If so, such interventions have considerable
potential but, if not, they are unlikely to have sustainable effects on public health. Further
research is needed on the sustainability of incentive-based intervention but it seems
unlikely that use of incentives is an effective way of motivating change and development
in children (Kunz and Pfaff, 2002; Deci, Koestner and Ryan, 1999).
The ‘D’ in NUDGE stands for ‘default’. This refers to the construction of systems
that encourage the least effort option. For example, when subscription to a service is
automatically renewed or tax is automatically deducted. Such systems make it easier
for people to act as required by removing the costs of decision-making and action. There
is evidence that such default opt-in, or assumed consent systems could benefit public
health. Johnson and Goldstein (2003) argue that, in relation to organ donation, opt-in
systems impose physical, cognitive and emotional costs on those wishing to donate
organs and that these barriers reduce organ donation levels. They show that, in the UK,
which uses an opt-in system, approximately 17 per cent of people donate their organs
after death while in a range of European countries with assumed consent systems the
figure is more than 99 per cent. It is likely, therefore, that legislation in the UK could
increase organ donation dramatically. Note that this would be an intervention operating
at the national level in the social ecological model (see Figure 9.2).
Use of reinforcement, including financial incentives and the construction of default
opt-in systems are quite distinct approaches to encouraging population-level behaviour
change. So NUDGEs include a variety of intervention types drawing on a range of
change techniques and regulatory processes. Thaler and Sunstein (2008) characterize
the interventions that they are interested in as altering ‘choice architecture... without
214 MOTIVATION AND BEHAVIOUR