Advertisement

Encouraging Mammograms Using Behavioral Economics: A Randomized Controlled Trial in Chile

  • Fabián Duarte
    Correspondence
    Correspondence: Fabián Duarte, PhD, Economics Department, University of Chile, Diagonal Paraguay 257, Santiago 8330015, Chile.
    Affiliations
    Economics Department, University of Chile and Millennium Nucleus in Social Development, Santiago, Chile
    Search for articles by this author

      Highlights

      • Women face psychological and material barriers in taking advantage of free mammograms.
      • The use of free mammography increased 167% on average owing to interventions designed to address these barriers.
      • This research provides a framework for understanding the low rates of free mammography use and a potential channel for improvement.

      Abstract

      Objectives

      This article illustrates the effect of a direct mail campaign that used insights from behavioral economics and psychology to increase the number of free mammograms in Chilean women aged 50 years or older.

      Methods

      We hypothesized 4 barriers in obtaining a mammogram based on previous literature and focus group analysis. A behavioral economic approach providing incentives was used to help overcome these barriers. We accessed a unique data set, which comprised 12 000 women 50 years old or older, with private health insurance who have not had a mammogram for 24 or more months. We conducted a randomized controlled trial with 8 treatments, each involving a specific combination of messages.

      Results

      The intervention overall led to a 167% increase in the use of free mammograms, a 1.13% to 3.03% average increase from the control to treatment groups, respectively. Regarding barriers, we found that all messages were effective, with a slightly larger and persistent effect for the less complex ones in terms of information. This finding illustrates the benefits of keeping the message simple.

      Conclusions

      Finally, these results suggest a successful public policy for increasing use of free mammography programs. Moreover, they are potentially transferable because the study considered decision-making heuristics that are not specific to one culture or social context.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal

      Subscribe:

      Subscribe to Value in Health
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Jemal A.
        • Bray F.
        • Center M.M.
        • Ferlay J.
        • Ward E.
        • Forman D.
        Global cancer statistics.
        CA Cancer J Clin. 2011; 61: 69-90
        • Puschel K.
        • Thompson B.
        Mammogram screening in Chile: using mixed methods to implement health policy planning at the primary care level.
        Breast. 2011; 20 suppl 2: S40-S45
        • Bleyer A.
        • Welch H.G.
        Effect of three decades of screening mammography on breast-cancer incidence.
        N Engl J Med. 2012; 367: 1998-2005
        • Gigerenzer G.
        Making sense of health statistics.
        Bull World Health Organ. 2009; 87: 567
        • Kerlikowske K.
        • Grady D.
        • Rubin S.M.
        • Sandrock C.
        • Ernster V.L.
        Efficacy of screening mammography. A meta-analysis.
        JAMA. 1995; 273: 149-154
        • Nystrom L.
        • Rutqvist L.E.
        • Wall S.
        • et al.
        Breast cancer screening with mammography: overview of Swedish randomised trials.
        Lancet. 1993; 341: 973-978
        • Urban N.
        • Anderson G.L.
        • Peacock S.
        Mammography screening: how important is cost as a barrier to use?.
        Am J Public Health. 1994; 84: 50-55
        • Mandelblatt J.S.
        • Cronin K.A.
        • Bailey S.
        • et al.
        Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms.
        Ann Intern Med. 2009; 151: 738-747
        • Weedon-Fekjær H.
        • Romundstad P.R.
        • Vatten L.J.
        Modern mammography screening and breast cancer mortality: population study.
        BMJ. 2014; 348: g3701
      1. Ministerio de Desarrollo Social y Familia (MIDEPLAN). Santiago, Chile: MIDEPLAN. CASEN 2017: Encuesta de caracterización socioeconómica nacional. http://observatorio.ministeriodesarrollosocial.gob.cl/encuesta-casen-2017. Accessed December 15, 2020.

        • Puschel K.
        • Coronado G.
        • Soto G.
        • et al.
        Strategies for increasing mammography screening in primary care in Chile: results of a randomized clinical trial.
        Cancer Epidemiol Biomarkers Prev. 2010; 19: 2254-2261
        • Sullivan P.S.
        • Lansky A.
        • Drake A.
        • HITS-2000 Investigators
        Failure to return for HIV test results among persons at high risk for HIV infection: results from a multistate interview project.
        J Acquir Immune Defic Syndr. 2004; 35: 511-518
        • O’Donoghue T.
        • Rabin M.
        Doing it now or later.
        Am Econ Rev. 1999; 89: 103-124
        • Madrian B.C.
        • Shea D.F.
        The power of suggestion: inertia in 401(k) participation and savings behavior.
        Q J Econ. 2001; 116: 1149-1187
        • Slovic P.
        • Finucane M.L.
        • Peters E.
        • MacGregor D.G.
        The affect heuristic.
        in: Gilovich T. Griffin D. Kahneman D. Heuristics and Biases: the Psychology of Intuitive Judgment. Cambridge University Press, New York2002: 397-420
        • Iyengar S.S.
        • Lepper M.R.
        When choice is demotivating: can one desire too much of a good thing?.
        J Pers Soc Psychol. 2000; 79: 995-1006
        • Meissner H.I.
        • Smith R.A.
        • Rimer B.K.
        • et al.
        Promoting cancer screening: learning from experience.
        Cancer. 2004; 101: 1107-1117
        • Slater J.S.
        • Henly G.A.
        • Ha C.N.
        • et al.
        Effect of direct mail as a population-based strategy to increase mammography use among low-income underinsured women ages 40 to 64 years.
        Cancer Epidemiol Biomarkers Prev. 2005; 14: 2346-2352
        • Sohl S.J.
        • Moyer A.
        Tailored interventions to promote mammography screening: a meta-analytic review.
        Prev Med. 2007; 45: 252-261
        • Püschel K.
        • Thompson B.
        • Coronado G.
        • Gonzalez K.
        • Rain C.
        • Rivera S.
        ‘If I feel something wrong, then I will get a mammogram’: understanding barriers and facilitators for mammography screening among Chilean women.
        Fam Pract. 2010; 27: 85-92
        • Golman R.
        • Hagmann D.
        • Loewenstein G.
        Information avoidance.
        J Econ Lit. 2017; 55: 96-135
        • Pop-Eleches C.
        • Thirumurthy H.
        • Habyarimana J.P.
        • et al.
        Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
        AIDS. 2011; 25: 825-834
        • Karlan D.
        • McConnell M.
        • Mullainathan S.
        • Zinman J.
        Getting to the top of mind: how reminders increase saving.
        Manag Sci. 2016; 62: 3393-3411
        • Luoto J.
        • Levine D.
        • Albert J.
        • Luby S.
        Nudging to use: achieving safe water behaviors in Kenya and Bangladesh.
        J Dev Econ. 2014; 110: 13-21
        • Kahneman D.
        • Tversky A.
        On the interpretation of intuitive probability: a reply to Jonathan Cohen.
        Cognition. 1979; 7: 409-411
        • Legler J.
        • Meissner H.I.
        • Coyne C.
        • Breen N.
        • Chollette V.
        • Rimer B.K.
        The effectiveness of interventions to promote mammography among women with historically lower rates of screening.
        Cancer Epidemiol Biomarkers Prev. 2002; 11: 59-71
        • Cialdini R.B.
        Influence: the Psychology of Persuasion.
        HarperCollins Publishers Inc, New York2007
        • Elder J.P.
        • Ayala G.X.
        • Harris S.
        Theories and intervention approaches to health-behavior change in primary care.
        Am J Prev Med. 1999; 17: 275-284
        • Angrist J.D.
        • Imbens G.W.
        • Rubin D.B.
        Identification of causal effects using instrumental variables.
        J Am Stat Assoc. 1996; 91: 444-455
        • Ministerio de Economía, Fomento y Turismo, Servicio Nacional de Turismo (SERNATUR)
        Medición y comportamiento del turismo interno.
        • van Hout B.A.
        • Al M.J.
        • Gordon G.S.
        • Rutten F.F.
        Costs, effects and C/E-ratios alongside a clinical trial.
        Health Econ. 1994; 3: 309-319
        • Johannesson M.
        • Meltzer D.
        Some reflections on cost-effectiveness analysis.
        Health Econ. 1998; 7: 1-7