Recently the Demography Library staff sat down with Alison Buttenheim. Alison is an Associate Professor of Nursing and Health Policy, a Research Associate of both the Population Studies Center and the Population Aging Research Center, as well as the Interim Director of the Penn Center for Health Incentives & Behavioral Economics.
SHANNON: What projects are you working on right now?
Alison: We’re in the final year of an R01 in Peru applying behavioral economics to improve household participation in a vector control campaign for Chagas disease. The goal was to get households to agree to have their home sprayed with insecticide. Mike Levy and I developed a set of interventions, ran a big 5,000 household trial and we just published the results – unfortunately, null results.
Theoretically these interventions made a lot of sense given the behavioral barriers we identified. One of the papers we're working on now is about possible “motivation crowd out” for our lottery interventions. Ministries of Health and other implementers can get pretty nervous about financial incentives like lotteries because they worry that if we pay people to participate in one public health interventions, they're going to want payments for all interventions. So we’re testing to see if households who received the lottery were later reluctant to participate in other related and unrelated public health activities.
I also work on vaccine acceptance and vaccine refusal in the U.S. In a current R01 study we are evaluating the impact of a recent policy change in California that eliminated nonmedical exemptions for school entry vaccine mandates. My team is assessing whether parents shift to more homeschooling when nonmedical exemptions are eliminated. It turns out tracking down the homeschooling numbers from multiple data streams is really challenging. We think it will be the first decent estimate of the homeschool population in California.
Through Penn’s Center for Health Incentives and Behavioral Economics (which I’m currently directing during Kevin Volpp’s sabbatical) I'm also focusing on two different studies for smoking cessation for low-income pregnant women. We want to reduce smoking during pregnancy as much as possible because it's very expensive and has very poor health outcomes for mom and baby. There is strong evidence that financial incentives work best of all the interventions we have and, yet, no Medicaid program offers a program like this.
NYKIA: That sounds exciting! What motivates you to do what you do?
Alison: I'm a very practical, pragmatic person – a public health throwback. I'm less motivated by scientific and theoretical questions and more motivated by the challenge of “can we move the needle?” on a specific behavior or a health outcome.
"We think financial incentives, designed and delivered in the right way, can shift people’s perceptions of the costs and benefits of a given behavior."
NYKIA: Could you say a little bit more about what the implications of your research are?
Alison: I'm very interested right now in the design of interventions, and how to tailor and target them. I think the field needs to think more strategically about how to match intervention design ideas to the behavioral bottlenecks that people are facing. With the pregnant moms, for example: we know quitting smoking is hard, but we're trying to understand, in a very nuanced way, for this specific population, what gets in the way of their quitting? Their lives are very stressful—we can’t necessarily change that, but we can think creatively about strategies and intervention designs that in the moment help them pivot away from that next cigarette.
NYKIA: Why do you think that the financial incentives didn't work in Peru, but why do you think they will work with the low income women in the U.S.?
Alison: That’s a great question. We think financial incentives, designed and delivered in the right way, can shift people’s perceptions of the costs and benefits of a given behavior. For the Chagas disease campaign in Peru, the perceived hassle costs of the behavior (moving furniture, waiting around all day, having smelly insecticide dripping down your walls) were really high, while the perceived benefits (preventing a disease that didn’t feel very risky or likely) didn’t seem high at all. Our lottery incentive didn’t change that equation enough.
With smoking cessation, it's actually weird that incentives, in general, work. The incentives we offer for cessation are usually way less than the smoker will save by not buying cigarettes. You shouldn't need the financial incentive because you're already paying yourself a lot by quitting. But it turns out that this extra incentive is really salient and really motivating. It feels like compensation for this very hard thing that you have to do. It can focus your effort to overcome craving in the moment. And we can structure the incentives to be even more powerful. For example, we can say, okay, every time you come to your prenatal appointment and you can demonstrate that you haven’t smoked in the past couple of days, you'll get $60, and you can do that up to 10 times. That's pretty motivating. Even more motivating though is to say, we've set up a virtual account for you with $600 in it, and every time you come in and you can’t demonstrate that you haven’t smoked, we’ll take $60 out of the account. It’s the same amount of money. You can earn $600 total either way, but when we “endow” you with that money up front, you're even more motivated not to lose it because it feels like it's yours already. Behavioral economists refer to that effect as prospect theory or the endowment effect.
NYKIA: Are there a lot of psychologists involved in behavioral economics?
Alison: Yes, in fact they often question why it’s called behavioral economics! A lot of it looks suspiciously like social and cognitive psychology. Economists consider behavioral economics a branch of economics because it has to do with people making strategic choices about constrained resources. It’s “behavioral” in contrast to neoclassical economics that says people operate with full information and make rational choices based on expected utility. Behavioral economists recognize that the human brain really doesn’t work that way.
NYKIA: Can you tell us more about your career path?
Alison: Short version: History major in undergrad, healthcare management consulting, applied to nursing school to become a midwife, didn’t get in, went to Stanford Business School for an MBA instead. After b-school I decided what I really wanted to do was global maternal child health and population research. I didn't even know what degree that should be – I had never heard of demography as an academic discipline. I was very fortunate that Anne Pebley at UCLA encouraged me to do a PhD in public health with her and participate in UCLA’s T32 demography training program. Then I went to Princeton’s Office of Population Research for a postdoc with Noreen Goldman, and then came to Penn as a Robert Wood Johnson Foundation Health and Society Scholar in 2009 and joined the School of Nursing as an assistant professor in 2011.
NYKIA: Tell us something most people would not know about you.
Alison: I'm a beekeeper! My hive is at a community garden at the Eastern State Penitentiary. I poke around in the hive a couple times a year to steal some honey, but mostly I just leave them alone and hope that they make it through the winter.