1. The art of SNAP decisions and the science of well-being as they apply to health Paul Dolan Imperial College Business School

2. The beginning and the end What affects well-being and what effects does it have? What affects behaviour and what effects does it have? And we need to join them up

3. Priming money Being primed with cash (e.g. as screensaver or scrambled sentence task) makes people Less helpful Donate less Sit further apart Does it make them more likely to favour financial incentives?

4. Prof. Daniel Kahneman, Oct 2008 “One of the things that we have been exercising over for decades is the relative impact of internal factors as against environmental factors in the control of behaviour...... It turns out that the environmental effects on behaviour are a lot stronger than most people expect.”

5. The essence of behaviour change Beliefs, habits, goals Change the person Financial, psychological Change the incentives SNAP decisions Change the situation

6. The art of SNAP decision making Salience Norms Affect Primin g We attend to novelty and simplicity We take cues from what others do We behave according to our feelings We respond subconsciously to stimuli

7. The essence of well-being Wanting – preference satisfaction Needing – objective lists Liking – mental states Subjective well-being (SWB)

8. Problems with preferences S alience – attention and focussing illusion N orms – what is the ‘right’ answer? A ffect – feelings drive responses P riming – responses affected by arbitrary cues = Miswanting

9. Rethinking valuation Rather than ask people what matters to them, elicit SWB and allow regression analysis to do it for us Most of what we know about SWB comes from global assessments of life satisfaction And mostly from the BHPS

10. Valuing health states SF-6D dimension SG LS Pain.167 [1].034 [5] Mental health.128 [2].159 [1] Physical functioning.111 [3].071 [3] Vitality.091 [4].089 [2] Social functioning.087 [5].002 [6] Role limitations.050 [6].039 [4]

11. Problems with life satisfaction S alience – may not focus on what really matters and we don’t go around thinking about life satisfaction N orms – responses relative to others or self over time A ffect – not clear how much this should play a part P riming – affected by not-so-relevant cues = Misevaluating

12. Other more direct measures of SWB Moment-to-moment ‘pleasure’ Plus moment, episode or local ‘reward’ Plus spontaneous thoughts and mind-wandering Can we measure the frequency and intensity of these pop-ups and what effect do they have?

13. Thoughts about health 1200 on-line and phone in the US (Rand) Overall mood yesterday Frequency and intensity of thoughts about health, work, finances and family yesterday EQ-5D and TTO Second variant with EQ-5D and TTO first »Plus ‘top-down’ and ‘bottom-up’ TTO

14. Dependent variable: TTO(I)(II)(III)(IV)(V) eqm20.0080.0130.002 0.010 eqm3-0.018-0.0020.011-0.008-0.018 eqs2-0.001-0.015-0.020-0.013-0.009 eqs3-0.119-0.166-0.183-0.169-0.157 equ2-0.061*-0.063*-0.065*-0.060*-0.047 equ30.1820.1680.1410.151*0.169 eqp2-0.029 -0.040*-0.032*-0.029 eqp30.1890.1770.1640.1840.186* eqa2-0.001 0.0070.038*0.043* eqa30.257*0.243*0.258*0.322*0.319* eqn3-0.440*-0.422*-0.415*-0.412*-0.393* Random TTO-0.073*-0.074* Age0.011* 0.010* Age 2 0.000* Average ‘happiness’ yesterday0.0150.013 Average ‘sadness’ yesterday-0.013-0.007 low frequency and positive thoughts0.040 high frequency and positive thoughts0.035 low frequency and negative thoughts-0.030 high frequency and negative thoughts -0.076* Constant0.920*1.016*0.724*0.688* 0.664* R2R2 0.070.090.11 0.12 Observations1173

15. Issues Focussing attention in TTO on health problems means that thoughts about health are likely to show up But thoughts about health matter before and after TTO Could do TTO to remove any problems at all if so inclined Need to understand how thoughts and feelings affect the flow of well-being without/before focussing on activities A QALY approach requires duration-weighting Is this still possible?

16. The beginning and the end What affects well-being and what effects does it have? What affects behaviour and what effects does it have? And we need to join them up

17. Thank you