Heuristics and decision-making: What are the effects on women going through menopause?

The human mind has evolved to make decisions and draw the most plausible conclusions regardless of the quality of the available information.
The decision-making process is influenced by heuristics, or cognitive shortcuts, that can have a significant effect on adherence when relevant information is limited.
Understanding heuristics can significantly help us to understand patients’ adherence and support them in taking their medication as prescribed through the process of “nudging.”

As described in the previous articles in this series, the mind has two systems of thinking. System 1 is immediate and spontaneous, System 2 is reflective and conscious. System 1 governs our immediate, impulsive reactions and is responsible for 95%¹ of the decisions we make; it is driven by heuristics (i.e., cognitive shortcuts), which make it faster, less taxing, and more prone to error. System 2 requires cognitive effort² and is used less frequently than System 1. In this article, we describe some of the heuristics that have important implications for patient behaviors, including adherence.

People make decisions even when relevant information is unavailable

Behavioral science has demonstrated that the human mind reacts to its environment as best it can in the moment while expending the least mental effort possible. System 1 runs this process, functioning automatically and effortlessly. System 1 generates a rapid response, which is very useful when we need to immediately get out of harm’s way, but in many cases, such information is insufficient for making a rational decision about the issue at hand. Even in situations where relevant information is limited, System 1 continues to draw conclusions and make decisions using mental proxies based on experience and prior learning. These cognitive shortcuts, or heuristics, significantly influence attitudes and behaviors, including adherence.

Understanding patient adherence behavior requires an understanding of these cognitive heuristics

Understanding these heuristics, or rules-of-thumb, can allow a prescriber to better understand how people make their judgements regarding their medication adherence and in which way these judgements are biased. Among others, these heuristics include the following:

Anchoring. This heuristic is a tendency to make decisions with respect to a reference point.³ Consider the following experiment: three groups of people are asked how much they would be willing to donate to a charity via the following questions:
- How much would you consider giving to charity, for example, $5?
- How much would you consider giving to charity? (No anchor provided.)
- How much would you consider giving to charity, for example, $400?

The researchers found that people were willing to give, respectively, $20 when anchored at $5, $64 with no anchor, and $143 when anchored at $400.³ Simply put, the participants were strongly influenced by the initial amount that was proposed. This heuristic is often used in negotiation, but it can also be readily applied in healthcare settings.

In a recent dermatological study on a monthly injectable treatment, a group of patients (the intervention group) was asked to rank their desire to take a daily injection for psoriasis. The incorporation of “daily” was used as an anchor, as patients were then asked if they would be willing to take a monthly injection. The results revealed that the patients anchored with the suggestion of daily injections were over three times more willing to start a monthly injection treatment when compared to the control group that received no anchoring.⁴ This rationale may be applied to women undergoing menopause: if they are informed about standard treatment practices (i.e., given an anchor point), they may be more likely to adhere to new therapies.

Availability (Salience). Humans assess the probability of an outcome based on the ease with which they can imagine a given outcome rather the actual probability of a given outcome⁵. For example, someone who has recently seen images of an earthquake in a movie may be more likely to overestimate the probability of an earthquake. This heuristic implies that a person who has visualized or experienced an earthquake will be keener to buy earthquake insurance; however, it also implies that once the memory of the earthquake disappears, the effect on purchasing behavior will also disappear.5 The same principle can be applied to women undergoing menopausal treatment: A woman who has recently suffered from severe symptoms (hot flashes, sweating, cognitive troubles) is likely to be more adherent to a treatment, but her medication adherence is also more likely to decrease over time if her symptoms disappear.

A recent study of patients with HIV showed that the percentage of patients with mean adherence rates of 90% or greater increased from 31.1% to 48.3% for those who had recently received positive feedback (salient information) about the HIV medication from other patients.6 Providing positive examples of other women undergoing therapy for menopause, preferably with a similar profile, may increase their probability of beginning treatment

Loss Aversion/Endowment. People generally feel sadder about losing something than they feel when they gain the same thing.⁷ For example, losing $100 is typically more painful in intensity than is the joy of being given $100. Richard Thaler uses the example of a group of students who were split into two sub-groups. One sub-group received a mug with the university insignia, and the other did not. After that, each student was asked at what price they would consider buying (or selling) the mug. The sellers of the mug valued it at twice as much as the buyers. How can this heuristic be exploited in the case of adherence? A physician can stress that every time medication is taken or the patient engages in positive behavior such as exercise, she is improving her health, and that by abandoning such behaviors, she will be lose or detract from the progress she has made.

Using System 1 heuristics to “nudge” patients toward better adherence

In their 2008 book Nudge, Nobel Prize winner Richard Thaler and Holberg Prize winner Cass Sunstein further explain their theory of decision-making, making the case for what they call “libertarian paternalism.”⁸ They argue that most people are not experts in the many domains that affect their day- to-day lives, and when confronted with a choice, cannot spontaneously make the best decisions. For example, when offered a large number of health insurance policies, how do novices in the market decide which one best fits their needs? It is possible to help people optimize their decision-making by presenting options in a manner that makes the best options more likely to be chosen—in other words, to “nudge” System 1’s spontaneity into making the best choice. Given the primacy of System 1 heuristics in decision-making, the value of being able to influence it in the area of health and disease management is clear.

Nudging techniques are not meant to eliminate choice. If people want to reflect on a decision rationally and employ their System 2 thinking, they can always override their System 1 processes. As Thaler and Sunstein explain, choice (Thaler and Sunstein call it choice architecture) can be presented in such a way that patients still have absolute freedom to decide among their options, but the most beneficial choices become more likely for those who choose to rely on System ¹⁸.

Consider decisions surrounding human organ donation. Having human organs readily available at hospitals can save countless lives, yet organ donation remains a difficult issue to address in many societies, making organ availability scarce. In Austria, the government applied the following nudge technique: The default option for Austrians is to donate organs automatically should the criteria for donation be satisfied. Austrians can always opt out of this program, but as a result of this nudge, 99% of Austrians consent to organ donation. By comparison, neighboring Germany has not employed this default consent to donation, and the rate of organ donation is only 12%.⁹ In other words, Austria has an opt-out program, whereas Germany has an opt-in program. Recognizing the utility of System 1 default bias has helped Austrians to substantially increase the availability of organs in the country and to save more lives.

Authorities increasingly use opt-in/opt-out nudging techniques to shape public policy. They use nudge approaches to enroll workers in pension schemes and healthcare plans—they have even used it to decrease mortality rates on dangerous highways. Several countries, including the UK, the USA, and Germany, have even created nudge units within their governments10.

On one hand, heuristics drive decisions and behavior, including decisions to start new treatments and remain adherent to those that patients have already initiated. On the other hand, they may also prevent people from beginning treatments, especially if they are associated with something potentially dangerous. For example, in the case of women’s menopausal hormone therapy, as we have mentioned in previous articles, women can have preconceived ideas about the supposed risks involved. The ease with which these notions come to mind drive the availability heuristic and strongly influence their decisions of whether or not to initiate treatment.

Breaking this heuristic and substituting it with another availability heuristic (such as showing patients examples of happy patients undergoing treatment for menopause) requires time. Doctors can initiate discussions about potential treatments with women who are in the early stages of menopause, thus introducing favorable notions early in the process. This is the kind of nudging that could improve women’s quality of life.

Activating menopause patients to improve adherence

References

Jordanov P. Thinking fast? Slow down. Neurofied blog. December, 2018, Accessed August 20, 2020. https://neurofied.com/thinking-fast-slow-down/
Kahneman D., Lazy Controller. In Thinking fast and slow. New York, Farrar, Straus, and Giroux; 2011:58-75, https://libro.eb20.net/Reader/rdr.aspx?b=714626, Accessed September 16, 2020
Kahneman D., Anchors. In Thinking fast and slow. New York, Farrar, Straus, and Giroux; 2011:184-199, https://libro.eb20.net/Reader/rdr.aspx?b=714626, Accessed September 16, 2020
Oussedik, E, Cardwell LA, & Patel NU. An anchoring-based intervention to increase patient willingness to use injectable medication in psoriasis. JAMA Dermatology; 2017; 153(9): pp. 932-934.
Kahneman D., Availability, Emotion, Risk. In Thinking fast and slow. Farrar, Straus, and Giroux; 2011:200-199, https://libro.eb20.net/Reader/rdr.aspx?b=714626, Accessed September 16, 2020
Linnemayr, S & Stecher, C. Behavioral economics matters for HIV research: The impact of behavioral biases on adherence to antiretrovirals (ARVs). AIDS & Behavior; 2015; 19(11): pp. 2069-2075.
Kahneman D., Answering easier questions, In Thinking fast and slow. Farrar, Straus, and Giroux; 2011:151-165, https://libro.eb20.net/Reader/rdr.aspx?b=714626, Accessed September 16, 2020
Thaler R, & Sunstein C. Introduction. In Nudge, improving decisions about health, wealth and happiness. New Haven, Yale University Press; 2008: 827, https://libro.eb20.net/Reader/rdr.aspx?b=1037044, Accessed September 16, 2020
Johnson, E., Goldstein, D. (2003). Medicine. Do defaults save lives?. Science, 302. 1338-9.
Zeina A., “Nudge units” – where they came from and what they can do, October 2017, Blog, World Bank, Accessed September 16, 2020, https://blogs.worldbank.org/developmenttalk/nudge-units-where-they-came-and-what-they- can-do