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There is ample evidence of the power of social influence on pro-environmental behaviors. Beliefs about the conservation behavior of others (descriptive normative beliefs) have a strong positive correlation with one's own conservation actions. However, this relationship has not been investigated much further in terms of possible moderators or involved mechanisms of information processing. The present study examines two potential moderators and draws links to underlying processing mechanisms. We hypothesized that personal involvement with conservation issues and beliefs about other's approval of conservation (injunctive normative beliefs) would moderate the relationship between descriptive normative beliefs and conservation behavior. The sample consisted of 1604 California residents that were recruited through random digit telephone dialing. Results showed that both injunctive normative beliefs and personal involvement moderated the relationship between descriptive normative beliefs and conservation behavior. High personal involvement weakened the relationship, whereas high injunctive normative beliefs strengthened it. We conclude from these findings that descriptive normative beliefs influence conservation behavior through a rather nonconscious, peripheral route of information processing, while personal involvement motivates a more elaborate, central route of information processing. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

We examined 3,046,538 acute respiratory infection (ARI) encounters with 6,103 national telehealth physicians from January 2019 to October 2021. The antibiotic prescribing rates were 44% for all ARIs; 46% were antibiotic appropriate; 65% were potentially appropriate; 19% resulted from inappropriate diagnoses; and 10% were related to coronavirus disease 2019 (COVID-19) diagnosis.

Background: Effective strategies are needed to curtail overuse that may lead to harm., Objective: To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients., Design: 18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753)., Setting: 60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022., Participants: 371 primary care clinicians and their older adult patients from participating practices., Intervention: Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability., Measurements: Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A 1c (HbA 1c ) less than 7%., Results: At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA 1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20])., Limitation: A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation., Conclusion: Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes., Primary Funding Source: National Institute on Aging., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2183.

Importance: Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed., Objective: To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery., Design, Setting, and Participants: This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription., Interventions: In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention., Main Outcome and Measures: The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months., Results: There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions., Conclusions and Relevance: In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse., Trial Registration: ClinicalTrials.gov NCT05070338.

Background: The Financial Incentives for Weight Reduction (FIReWoRk) clinical trial showed that financial incentive weight-loss strategies designed using behavioral economics were more effective than provision of weight-management resources only. We now evaluate cost-effectiveness., Methods: Cost-effectiveness analysis of a multisite randomized trial enrolling 668 participants with obesity living in low-income neighborhoods. Participants were randomized to (1) goal-directed incentives (targeting behavioral goals), (2) outcome-based incentives (targeting weight-loss), and (3) resources only, which were provided to all participants and included a 1-year commercial weight-loss program membership, wearable activity monitor, food journal, and digital scale. We assessed program costs, time costs, quality of life, weight, and incremental cost-effectiveness in dollars-per-kilogram lost., Results: Mean program costs at 12 months, based on weight loss program attendance, physical activity participation, food diary use, self-monitoring of weight, and incentive payments was $1271 in the goal-directed group, $1194 in the outcome-based group, and $834 in the resources-only group (difference, $437 [95% CI, 398 to 462] and $360 [95% CI, 341-363] for goal-directed or outcome-based vs resources-only, respectively; difference, $77 [95% CI, 58-130] for goal-directed vs outcome-based group). Quality of life did not differ significantly between the groups, but weight loss was substantially greater in the incentive groups (difference, 2.34 kg [95% CI, 0.53-4.14] and 1.79 kg [95% CI, -0.14 to 3.72] for goal-directed or outcome-based vs resources only, respectively; difference, 0.54 kg [95% CI, -1.29 to 2.38] for goal-directed vs outcome-based). Cost-effectiveness of incentive strategies based on program costs was $189/kg lost in the goal-directed group (95% CI, $124/kg to $383/kg) and $186/kg lost in the outcome-based group (95% CI, $113/kg to $530/kg)., Conclusions: Goal-directed and outcome-based financial incentives were cost-effective strategies for helping low-income individuals with obesity lose weight. Their incremental cost per kilogram lost were comparable to other weight loss interventions., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Prior work has demonstrated that personalized letters are effective at reducing opioid and benzodiazepine prescribing, but it is unclear whether If/when-then planning prompts would enhance this effect. We conducted a decedent-clustered trial which randomized 541 clinicians in Los Angeles County to receive a standard (n = 284), or comparator (n = 257) version of a letter with If/when-then prompts. We found a significant 12.85% (6.83%, 18.49%) and 8.32% (2.34%, 13.93%) decrease in the primary outcomes morphine (MME) and diazepam milligram equivalents (DME), respectively. This study confirms the benefit of planning prompts, and repeat letter exposure among clinicians with poor patient outcomes. Limitations include lack of generalizability and small sample size. Clinicaltrials.gov registration: NCT03856593., (© 2024. The Author(s).)

When two people coincidentally have something in common (such as a name or birthday), they tend to like each other more and are thus more likely to offer help and comply with requests. This dynamic can have important legal and ethical consequences whenever these incidental similarities give rise to unfair favoritism. Using a large-scale, longitudinal natural experiment, covering nearly 200,000 annual earnings forecasts over more than 25 y, we show that when a CEO and a securities analyst share a first name, the analyst's financial forecast is more accurate. We offer evidence that name matching improves forecast accuracy due to CEOs privately sharing pertinent information with name-matched analysts. Additionally, we show that this effect is especially pronounced among CEO-analyst pairs who share an uncommon first name. Our research thus demonstrates how incidental similarities can give way to special treatment. Whereas most investigations of the effects of similarity consider only one-shot interactions, we use a longitudinal dataset to show that the effect of name matching diminishes over time with more interactions between CEOs and analysts. We also point to the findings of an experiment suggesting that favoritism born of sharing a name may evade straightforward regulation in part due to people's perception that name similarity would exert little influence on them. Taken together, our work offers insight into when private disclosures are likely to be made. Our results suggest that the effectiveness of regulatory policies can be significantly impacted by psychological factors shaping the context in which they are implemented., Competing Interests: Competing interests statement:The authors declare no competing interest.

Importance: Interventions that improve clinician performance through feedback should not contribute to job dissatisfaction or staff turnover. Measurement of job satisfaction may help identify interventions that lead to this undesirable consequence., Objective: To evaluate whether mean job satisfaction was less than the margin of clinical significance among clinicians who received social norm feedback (peer comparison) compared with clinicians who did not., Design, Setting, and Participants: This secondary, preregistered, noninferiority analysis of a cluster randomized trial compared 3 interventions to reduce inappropriate antibiotic prescribing in a 2 × 2 × 2 factorial design from November 1, 2011, to April 1, 2014. A total of 248 clinicians were enrolled from 47 clinics. The sample size for this analysis was determined by the number of nonmissing job satisfaction scores from the original enrolled sample, which was 201 clinicians from 43 clinics. Data analysis was performed from October 12 to April 13, 2022., Interventions: Feedback comparing individual clinician performance to top-performing peers, delivered in monthly emails (peer comparison)., Main Outcomes and Measures: The primary outcome was a response to the following statement: "Overall, I am satisfied with my current job." Responses ranged from 1 (strongly disagree) to 5 (strongly agree)., Results: A total of 201 clinicians (response rate, 81%) from 43 of the 47 clinics (91%) provided a survey response about job satisfaction. Clinicians were primarily female (n = 129 [64%]) and board certified in internal medicine (n = 126 [63%]), with a mean (SD) age of 48 (10) years. The clinic-clustered difference in mean job satisfaction was greater than -0.32 (β = 0.11; 95% CI, -0.19 to 0.42; P = .46). Therefore, the preregistered null hypothesis that peer comparison is inferior by resulting in at least a 1-point decrease in job satisfaction by 1 in 3 clinicians was rejected. The secondary null hypothesis that job satisfaction was similar among clinicians randomized to social norm feedback was not able to be rejected. The effect size did not change when controlling for other trial interventions (t = 0.08; P = .94), and no interaction effects were observed., Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, peer comparison did not lead to lower job satisfaction. Features that may have protected against dissatisfaction include clinicians' agency over the performance measure, privacy of individual performance, and allowing all clinicians to achieve top performance., Trial Registration: ClinicalTrials.gov Identifiers: NCT05575115 and NCT01454947.

Background: Unnecessary testing and treatment of common conditions in older adults can lead to significant morbidity and mortality. The primary objective of this study was to develop and pilot test a set of clinical decision support (CDS) alerts informed by social psychology to address overuse in three areas related to ambulatory care of older adults., Methods: We developed three electronic health record (EHR) CDS alerts to address overuse and pilot tested them from January 17, 2019 to July 17, 2019. We enrolled 14 primary care physicians from three practices within a large health system who cared for adults aged 65 years and older. Three measures of overuse applied to patients meeting the following criteria: ordering of prostate-specific antigen (PSA) for prostate cancer screening in adult men aged 76 years and older, ordering of urinalysis or urine cultures (UA or UC) for non-specific reasons to identify bacteriuria in women aged 65 years and older, and overtreatment of diabetes with insulin or oral hypoglycemic medications in adults aged at 75 years and older (DM). Clinicians received CDS alerts when criteria for any of the three overuse measures were met. We then surveyed clinicians to evaluate their experience with the CDS alerts., Results: The number of clinical encounters that triggered CDS alerts was 19 for PSA, 48 for UA/UC and 128 for DM. For PSA encounters, 4 (21%) orders were not performed after the alert. In the UA/UC encounters 29 (60%) orders were not performed after the alert. For the DM encounters, 21 (34%) had diabetes therapy reduced following the alert. Survey respondents indicated that the alerts were clinically accurate and sometimes led them to change their clinical action., Conclusions: These CDS alerts were feasible to implement and may minimize unnecessary testing and treatment of common conditions in older adults., Competing Interests: Declaration of Competing Interest Dr. Persell receives research support from Omron Healthcare and previously received research support from Pfizer, Inc. He is a consultant QuiO Technologies and the RAND Corporation. After the completion of the research presented in this paper, Dr. Friedberg became a paid employee of Blue Cross Blue Shield of Massachusetts., (Copyright © 2022. Published by Elsevier B.V.)

Importance: Financial incentives for weight management may increase use of evidence-based strategies while addressing obesity-related economic disparities in low-income populations., Objective: To examine the effects of 2 financial incentive strategies developed using behavioral economic theory when added to provision of weight management resources., Design, Setting, and Participants: Three-group, randomized clinical trial conducted from November 2017 to May 2021 at 3 hospital-based clinics in New York City, New York, and Los Angeles, California. A total of 1280 adults with obesity living in low-income neighborhoods were invited to participate, and 668 were enrolled., Interventions: Participants were randomly assigned to goal-directed incentives, outcome-based incentives, or a resources-only group. The resources-only group participants were given a 1-year commercial weight-loss program membership, self-monitoring tools (digital scale, food journal, and physical activity monitor), health education, and monthly one-on-one check-in visits. The goal-directed group included resources and linked financial incentives to evidence-based weight-loss behaviors. The outcome-based arm included resources and linked financial incentives to percentage of weight loss. Participants in the incentive groups could earn up to $750., Main Outcomes and Measures: Proportion of patients achieving 5% or greater weight loss at 6 months., Results: The mean (SD) age of the 668 participants enrolled was 47.7 (12.4) years; 541 (81.0%) were women, 485 (72.6%) were Hispanic, and 99 (14.8%) were Black. The mean (SD) weight at enrollment was 98.96 (20.54) kg, and the mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 37.95 (6.55). At 6 months, the adjusted proportion of patients who lost at least 5% of baseline weight was 22.1% in the resources-only group, 39.0% in the goal-directed group, and 49.1% in the outcome-based incentive group (difference, 10.08 percentage points [95% CI, 1.31-18.85] for outcome based vs goal directed; difference, 27.03 percentage points [95% CI, 18.20-35.86] and 16.95 percentage points [95% CI, 8.18-25.72] for outcome based or goal directed vs resources only, respectively). However, mean percentage of weight loss was similar in the incentive arms. Mean earned incentives was $440.44 in the goal-directed group and $303.56 in the outcome-based group, but incentives did not improve financial well-being., Conclusions and Relevance: In this randomized clinical trial, outcome-based and goal-directed financial incentives were similarly effective, and both strategies were more effective than providing resources only for clinically significant weight loss in low-income populations with obesity. Future studies should evaluate cost-effectiveness and long-term outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT03157713.

Background: The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record., Methods: Teladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1-7% absolute differences in antibiotic prescribing among groups., Discussion: Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use., Clinicaltrials: gov: NCT05138874., (Copyright © 2022. Published by Elsevier Inc.)

Background: Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms., Objective: To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing., Design: We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019., Participants: Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot., Main Measures: Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease., Interventions: Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both., Key Results: Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%)., Conclusions: EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing., (© 2021. The Author(s) under exclusive licence to Society of General Internal Medicine.)

Background: Requiring accountable justifications-visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert-has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts., Methods: We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications., Results: There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for "anxiety" or "acute pain"); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., "risks and benefits discussed"). Most accountable justifications (65%) were of uncertain clinical appropriateness., Conclusion: Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making., Competing Interests: S.D.P. receives research support from Omron Healthcare and previously received research support from Pfizer, Inc. He is a consultant at QuiO Technologies and the RAND Corporation. All other authors report no competing interests., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed., Objective: To test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance., Design: Cluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers.", Main Measures: The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building., Key Results: Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p<.05), educational value (1.86, 1.17-2.96) and relationship building (1.63, 1.13-2.35) (both p<.01)., Conclusions: The pandemic has shed light on clinicians' commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists' performance can be measured and improved with feedback using aspirational norms., Trial Registration: clinicaltrials.gov NCT03784950., (© 2021. Society of General Internal Medicine.)

Encouraging vaccination is a pressing policy problem. To assess whether text-based reminders can encourage pharmacy vaccination and what kinds of messages work best, we conducted a megastudy. We randomly assigned 689,693 Walmart pharmacy patients to receive one of 22 different text reminders using a variety of different behavioral science principles to nudge flu vaccination or to a business-as-usual control condition that received no messages. We found that the reminder texts that we tested increased pharmacy vaccination rates by an average of 2.0 percentage points, or 6.8%, over a 3-mo follow-up period. The most-effective messages reminded patients that a flu shot was waiting for them and delivered reminders on multiple days. The top-performing intervention included two texts delivered 3 d apart and communicated to patients that a vaccine was "waiting for you." Neither experts nor lay people anticipated that this would be the best-performing treatment, underscoring the value of simultaneously testing many different nudges in a highly powered megastudy., Competing Interests: Competing interest statement: K.G.V. is a part-owner of VAL Health, a behavioral economics consulting firm., (Copyright © 2022 the Author(s). Published by PNAS.)

Background: High levels of opioid prescribing in the United States has resulted in an alarming trend in opioid-related harms. The objective of Trial 2 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-2) is to dampen the intensity and frequency of opioid prescribing in accordance with the Centers for Disease Control and Prevention recommendation to "go low and slow". We aim to accomplish this by notifying clinicians of harmful patient outcomes, which we expect to increase the mental availability of risks associated with opioid use., Methods: The trial is multi-site. Random assignment determines if prescribers to persons who suffer an opioid overdose (fatal or nonfatal) learn of this event (intervention) or practice usual care (control). Clinicians in the intervention group receive a letter notifying them of their patient's overdose. The primary outcome is the change in clinician weekly milligram morphine equivalent (MME) prescribed in a 6-month period before and after receiving the letter. Additional outcomes are the change in the proportion of patients prescribed at least 50 daily MME and in the proportion of patients referred to medication assisted treatment. Group differences in these outcomes will be compared using an intent-to-treat difference-in-differences framework with a mixed-effects regression model to estimate clinician MME., Discussion: The AESOPS-2 trial will provide new knowledge about whether increasing prescribers' awareness of patients' opioid-related overdoses leads to a reduction in opioid prescribing. Additionally, this trial may better inform how to reduce opioid use disorder and opioid overdoses by lowering population exposure to these drugs., Trial Registration: ClinicalTrials.gov: NCT04758637., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Overtesting and treatment of older patients is common and may lead to harms. The Choosing Wisely campaign has provided recommendations to reduce overtesting and overtreatment of older adults. Behavioral economics-informed interventions embedded within the electronic health record (EHR) have been shown to reduce overuse in several areas. Our objective is to conduct a parallel arm, pragmatic cluster-randomized trial to evaluate the effectiveness of behavioral-economics-informed clinical decision support (CDS) interventions previously piloted in primary care clinics and designed to reduce overtesting and overtreatment in older adults., Methods/design: This trial has two parallel arms: clinician education alone vs. clinician education plus behavioral-economics-informed CDS. There are three co-primary outcomes for this trial: (1) prostate-specific antigen (PSA) screening in older men, (2) urine testing for non-specific reasons in older women, and (3) overtreatment of diabetes in older adults. All eligible primary care clinics from a large regional health system were randomized using a modified constrained randomization process and their attributed clinicians were included. Clinicians were recruited to complete a survey and educational module. We randomized 60 primary care clinics with 374 primary care clinicians and achieved adequate balance between the study arms for prespecified constrained variables. Baseline annual overuse rates for the three co-primary outcomes were 25%, 23%, and 17% for the PSA, urine, and diabetes measures, respectively., Discussion: This trial is evaluating behavioral-economics-informed EHR-embedded interventions to reduce overuse of specific tests and treatments for older adults. The study will evaluate the effectiveness and safety of these interventions., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory., Methods and Analysis: This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings., Ethics and Dissemination: The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country., Trial Registration Number: ClinicalTrials.gov identifier: NCT04104256., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite widespread national, state, and local guidelines for COVID-19 prevention, including social distancing and mask orders, many people continue to not adhere to recommendations, including congregating in groups for non-essential activities, putting themselves and others at risk. A social psychological perspective can be used to understand reasons for lack of adherence to policies and methods for increasing adherence based on successes from other behavior change campaigns. This manuscript seeks to describe some of the social psychological research that may be relevant to COVID-19 prevention and behavior change, describe how these theories have been previously applied in various domains to change behavior, and provide examples of how these approaches might be similarly applied to control the pandemic. We provide concrete examples of actions that can be taken based on social psychological research that might help to increase adherence to COVID-19 recommendations and improve prevention and control of the virus., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice., Methods: AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects., Discussion: The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Cardiovascular disease (CVD) is a major cause of morbidity among people living with HIV (PLWH). Statins can safely and effectively reduce CVD risk in PLWH, but evidence-based statin therapy is under-prescribed in PLWH. Developed using an implementation science framework, INcreasing Statin Prescribing in HIV Behavioral Economics REsearch (INSPIRE) is a stepped-wedge cluster randomized trial that addresses organization-, clinician- and patient-level barriers to statin uptake in Los Angeles community health clinics serving racially and ethnically diverse PLWH. After assessing knowledge about statins and barriers to clinician prescribing and patient uptake, we will design, implement and measure the effectiveness of (1) educational interventions targeting leadership, clinicians, and patients, followed by (2) behavioral economics-informed clinician feedback on statin uptake. In addition, we will assess implementation outcomes, including changes in clinician acceptability of statin prescribing for PLWH, clinician acceptability of the education and feedback interventions, and cost of implementation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Colorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality in the United States. Although various interventions have improved screening rates, they often require abundant resources and can be difficult to implement. Social psychology and behavioral economics principles offer an opportunity for low-cost and easy-to-implement strategies but are less common in clinical settings., Methods: We randomized 2,000 patients aged 50-75 years eligible for CRC screening to one of the 2 mailed interventions: a previously used text-based letter describing and offering fecal immunochemical testing (FIT) and colonoscopy (usual care arm); or a letter leveraging social psychology and behavioral economics principles (e.g., implied scarcity and choice architecture), minimal text, and multiple images to offer FIT and colonoscopy (intervention arm). We compared total screening uptake, FIT uptake, and colonoscopy uptake at 1-month intervals in each group., Results: There were 1,882 patients included in the final analysis. The mean age was 69.3 years, and baseline characteristics in the 2 groups were similar. Screening completion at 26 weeks was 19.5% in the usual care arm (16.3% FIT vs 3.2% colonoscopy, P < 0.01) and 24.1% in the intervention arm (22.1% FIT vs 2.0% colonoscopy, P < 0.01) (P = 0.02)., Discussion: Among primary care patients aged 50-75 years in an academic setting, mailed CRC outreach employing social psychology and behavioral economics principles led to a higher participation in CRC screening than usual care mailed outreach., Translational Impact: Mailed interventions to increase CRC screening should incorporate social psychology and behavioral economics principles to improve participation.

Background: Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations., Objective: To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients., Design: Randomized controlled trial., Participants: Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers., Intervention: Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy., Main Measures: Primary outcomes: percentage achieving systolic BP (SBP) < 140 mmHg, percentage achieving diastolic BP (DBP) < 90 mmHg, and changes in SBP and DBP, all after 6 months. Priority secondary outcomes were SBP < 140 mmHg, DBP < 90 mmHg, and BP change at 12 months, 6 months after the intervention ended., Key Results: After 6 months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP < 140 mmHg (adjusted odds ratio (AOR) 2.53 (1.13-5.70)), 79.8% vs 70.1% for DBP < 90 mmHg (AOR 2.50 (0.84-7.44)), and 53.6% vs 40.2% for achieving both targets (AOR 2.04 (0.92-4.52)). However, at 12 months, the groups did not differ significantly in these 3 measures: 39.5% vs 35.0% for SBP (AOR 1.20 (0.51-2.83)), 68.4% vs 75.0% for DBP (AOR 0.70 (0.24-2.09)), and 35.5% vs 33.8% for both (AOR 1.03 (0.44-2.42)). Change in absolute SBP and DBP did not differ significantly between the groups at 6 or 12 months. Exploratory post hoc analysis revealed intervention benefit only occurred among individuals whose providers intensified their regimens, but not among those with intensification but no intervention., Conclusions: The intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit., Trial Registration: NCT01402453; http://clinicaltrials.gov/show/NCT01402453.

Introduction: Obesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals' utilisation of evidence-based behavioural strategies while addressing obesity-related economic disparities in low-income populations. Trials have focused on testing incentives contingent on achieving weight loss outcomes. However, based on social cognitive and self-determination theories, providing incentives for achieving intermediate behavioural goals may be more sustainable than incentivising outcomes if they enhance an individual's skills and self-efficacy for maintaining long-term weight loss. The objective of this paper is to describe the rationale and design of the Financial Incentives foR Weight Reduction study, a randomised controlled trial to test the comparative effectiveness and cost-effectiveness of two financial incentive strategies for weight loss (goal directed vs outcome based) among low-income adults with obesity, as well as compared with the provision of health behaviour change resources alone., Methods and Analysis: We are recruiting 795 adults, aged 18-70 years with a body mass index ≥30 kg/m 2 , from three primary care clinics serving residents of socioeconomically disadvantaged neighbourhoods in New York City and Los Angeles. All participants receive a 1-year commercial weight loss programme membership, self-monitoring tools (bathroom scale, food journal and Fitbit Alta HR), health education and monthly check-in visits. In addition to these resources, those in the two intervention groups can earn up to $750 over 6 months for: (1) participating in an intensive weight management programme, self-monitoring weight and diet and meeting physical activity guidelines (goal-directed arm); or (2) a ≥1.5% to ≥5% reduction in baseline weight (outcome-based arm). To maximise incentive efficacy, we incorporate concepts from behavioural economics, including immediacy of payments and framing feedback to elicit regret aversion. We will use generalised mixed effect models for repeated measures to examine intervention effects on weight at 6, 9 and 12 months., Ethics and Dissemination: Human research protection committees at New York University School of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine and Olive-View-UCLA Medical Center granted ethics approval. We will disseminate the results of this research via peer-reviewed publications, conference presentations and meetings with stakeholders., Trial Registration Number: NCT03157713., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The influence of social norms on behavior has been a longstanding storyline within social psychology. Our 2007 Psychological Science publication presented a new rendition of this classic telling. The reported field experiment showed that social norms could be leveraged to promote residential energy conservation, but importantly, the descriptive norm was shown to increase consumption for low-consuming households. This potential destructive effect of social norms was eliminated with the addition of an injunctive message of social approval for using less energy. The article is among the 30 most-cited articles across all APS publications, which we attribute to our methodology, which measured real behavior in a large-scale field experiment and to several circumstances associated with the timing of the work. The article coincided with the explosion of social media, the emergence of behavioral economics, and a heightened level of concern about climate change. These contemporaneous activities set the stage for our work and for its high degree of citation.

This article reviews research from several behavioral disciplines to derive strategies for prompting people to perform behaviors that are individually costly and provide negligible individual or social benefits but are meaningful when performed by a large number of individuals. Whereas the term social influence encompasses all the ways in which people influence other people, social mobilization refers specifically to principles that can be used to influence a large number of individuals to participate in such activities. The motivational force of social mobilization is amplified by the fact that others benefit from the encouraged behaviors, and its overall impact is enhanced by the fact that people are embedded within social networks. This article may be useful to those interested in the provision of public goods, collective action, and prosocial behavior, and we give special attention to field experiments on election participation, environmentally sustainable behaviors, and charitable giving.

Intergroup relations research has largely focused on relations between members of dominant groups and members of disadvantaged groups. The small body of work examining intraminority intergroup relations, or relations between members of different disadvantaged groups, reveals that salient experiences of ingroup discrimination promote positive relations between groups that share a dimension of identity (e.g., 2 different racial minority groups) and negative relations between groups that do not share a dimension of identity (e.g., a racial minority group and a sexual minority group). In the present work, we propose that shared experiences of discrimination between groups that do not share an identity dimension can be used as a lever to facilitate positive intraminority intergroup relations. Five experiments examining relations among 4 different disadvantaged groups supported this hypothesis. Both blatant (Experiments 1 and 3) and subtle (Experiments 2, 3, and 4) connections to shared experiences of discrimination, or inducing a similarity-seeking mindset in the context of discrimination faced by one's ingroup (Experiment 5), increased support for policies benefiting the outgroup (Experiments 1, 2, and 4) and reduced intergroup bias (Experiments 3, 4, and 5). Taken together, these experiments provide converging evidence that highlighting shared experiences of discrimination can improve intergroup outcomes between stigmatized groups across dimensions of social identity. Implications of these findings for intraminority intergroup relations are discussed. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Background: Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial., Methods: Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined., Results: We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44-0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54-0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53-0.995)., Conclusions: We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects., Trial Registration: ClinicalTrials.gov: NCT01454960 .

Importance: Interventions based on behavioral science might reduce inappropriate antibiotic prescribing., Objective: To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections., Design, Setting, and Participants: Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded., Interventions: Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of "top performers" (those with the lowest inappropriate prescribing rates)., Main Outcomes and Measures: Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians., Results: There were 14,753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, -11.0%) for control practices; from 22.1% to 6.1% (absolute difference, -16.0%) for suggested alternatives (difference in differences, -5.0% [95% CI, -7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, -18.1%) for accountable justification (difference in differences, -7.0% [95% CI, -9.1% to -2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, -16.3%) for peer comparison (difference in differences, -5.2% [95% CI, -6.9% to -1.6%]; P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions., Conclusions and Relevance: Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections., Trial Registration: clinicaltrials.gov Identifier: NCT01454947.

Background: Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse., Objective: The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers., Participants: We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51% response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting., Design: The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition., Main Measures: The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics., Key Results: Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95% CI: 2.9 to 20.1%; p = .008)., Conclusions: Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians' ability to prescribe what they believe is best for their patients.

A great deal of psychological research has investigated the influence of perspective taking on individuals, indicating that perspective taking increases the extent to which people like, feel a sense of self-other overlap with, and help those whose perspective they take. However, previous investigations of the topic have been limited to the study of the perspective taker, rather than the individual whose perspective has been taken. The purpose of the current work is to begin to fill this large gap in the literature by examining the consequences of believing that another individual is taking one's perspective, a phenomenon we refer to as perceived perspective taking. Over a series of 6 experiments, we demonstrate that perceiving that one's perspective has been taken confers many of the same interpersonal benefits as taking another's perspective. Specifically, our data suggest that believing that another person has successfully taken one's perspective results in an increased liking for, a greater sense of self-other overlap with, and more help provided to that person. Consistent with predictions, we find that one's self-other overlap with the perspective taker and the amount of empathy one perceives the perspective taker to feel operate in tandem to mediate the link between perceived perspective taking and liking for the perspective taker. Further, a mediational path from perceived perspective taking to helping behavior through liking is supported. Future directions are discussed, along with implications for theory and application in domains such as intergroup relations, conflict resolution, and political campaigning.

Importance: "Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice., Objective: To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs)., Design, Setting, and Participants: Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention)., Interventions: The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs., Main Outcomes and Measures: Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status., Results: Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time., Conclusions and Relevance: Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts., Trial Registration: clinicaltrials.gov identifier: NCT01767064.

Background: Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians., Methods/design: The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider's rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease., Discussion: The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics., Trials Registration: ClinicalTrials.gov: NCT01454947.

Despite a revolution in therapeutics, the ability to control chronic diseases remains elusive. We present here a conceptual model of the potential role of behavioral tools in chronic disease control. Clinicians implicitly accept the assumption that patients will act rationally to maximize their self-interest. However, patients may not always be the rational actors that we imagine. Major behavioral barriers to optimal health behavior include patients' fear of threats to health, unwillingness to think about problems when risks are known or data are ambiguous, the discounting of risks that are far in the future, failure to act due to lack of motivation, insufficient confidence in the ability to overcome a health problem, and inattention due to pressures of everyday life. Financial incentives can stimulate initiation of health-promoting behaviors by reducing or eliminating financial barriers, but may not produce long-term behavior change without additional interventions. Strategies have been developed by behavioral economists and social psychologists to address each of these barriers to better decision-making. These include: labeling positive behaviors in ways consistent with patient life goals and priorities; greater focus on more immediate risks of chronic diseases; intermediate subgoals as steps to a large health goal; and implementation of specific plans as to when, where, and how an action will be taken. Such strategies hold promise for improving health behaviors and disease control, but most have not been studied in medical settings. The effectiveness of these approaches should be evaluated for their potential as tools for the clinician.

How do arousal-inducing contexts, such as frightening or romantic television programs, influence the effectiveness of basic persuasion heuristics? Different predictions are made by three theoretical models: A general arousal model predicts that arousal should increase effectiveness of heuristics; an affective valence model predicts that effectiveness should depend on whether the context elicits positive or negative affect; an evolutionary model predicts that persuasiveness should depend on both the specific emotion that is elicited and the content of the particular heuristic. Three experiments examined how fear-inducing versus romantic contexts influenced the effectiveness of two widely used heuristics-social proof (e.g., "most popular") and scarcity (e.g., "limited edition"). Results supported predictions from an evolutionary model, showing that fear can lead scarcity appeals to be counter-persuasive, and that romantic desire can lead social proof appeals to be counter-persuasive. The findings highlight how an evolutionary theoretical approach can lead to novel theoretical and practical marketing insights.

Acts of self-control may deplete an individual's self-regulatory resources. But what are the consequences of perceiving other people's use of self-control? Mentally simulating the actions of others has been found to elicit psychological effects consistent with the actual performance of those actions. Here, we consider how simulating versus merely perceiving the use of willpower can affect self-control abilities. In Study 1, participants who simulated the perspective of a person exercising self-control exhibited less restraint over spending on consumer products than did other participants. In Study 2, participants who took the perspective of a person using self-control exerted less willpower on an unrelated lexical generation task than did participants who took the perspective of a person who did not use self-control. Conversely, participants who merely read about another person's self-control exerted more willpower than did those who read about actions not requiring self-control. These findings suggest that the actions of other people may either deplete or boost one's own self-control, depending on whether one mentally simulates those actions or merely perceives them.

Despite a long tradition of effectiveness in laboratory tests, normative messages have had mixed success in changing behavior in field contexts, with some studies showing boomerang effects. To test a theoretical account of this inconsistency, we conducted a field experiment in which normative messages were used to promote household energy conservation. As predicted, a descriptive normative message detailing average neighborhood usage produced either desirable energy savings or the undesirable boomerang effect, depending on whether households were already consuming at a low or high rate. Also as predicted, adding an injunctive message (conveying social approval or disapproval) eliminated the boomerang effect. The results offer an explanation for the mixed success of persuasive appeals based on social norms and suggest how such appeals should be properly crafted.

Self-perception theory posits that people sometimes infer their own attributes by observing their freely chosen actions. The authors hypothesized that in addition, people sometimes infer their own attributes by observing the freely chosen actions of others with whom they feel a sense of merged identity--almost as if they had observed themselves performing the acts. Before observing an actor's behavior, participants were led to feel a sense of merged identity with the actor through perspective-taking instructions (Study 1) or through feedback indicating that their brainwave patterns overlapped substantially with those of the actor (Studies 2-4). As predicted, participants incorporated attributes relevant to an actor's behavior into their own self-concepts, but only when they were led to feel a sense of merged identity with the actor and only when the actor's behavior seemed freely chosen. These changes in relevant self-perceptions led participants to change their own behaviors accordingly. Implications of these vicarious self-perception processes for conformity, perspective-taking, and the long-term development of the self-concept are discussed., (2007 APA, all rights reserved)

Three experiments examined how 2 fundamental social motives--self-protection and mate attraction--influenced conformity. A self-protective goal increased conformity for both men and women. In contrast, the effects of a romantic goal depended on sex, causing women to conform more to others' preferences while engendering nonconformity in men. Men motivated to attract a mate were particularly likely to nonconform when (a) nonconformity made them unique (but not merely a member of a small minority) and when (b) the topic was subjective versus objective, meaning that nonconformists could not be revealed to be incorrect. These findings fit with a functional evolutionary model of motivation and behavior, and they indicate that fundamental motives such as self-protection and mate attraction can stimulate specific forms of conformity or nonconformity for strategic self-presentation.

This review covers recent developments in the social influence literature, focusing primarily on compliance and conformity research published between 1997 and 2002. The principles and processes underlying a target's susceptibility to outside influences are considered in light of three goals fundamental to rewarding human functioning. Specifically, targets are motivated to form accurate perceptions of reality and react accordingly, to develop and preserve meaningful social relationships, and to maintain a favorable self-concept. Consistent with the current movement in compliance and conformity research, this review emphasizes the ways in which these goals interact with external forces to engender social influence processes that are subtle, indirect, and outside of awareness.