We researchers love unintended consequences; well-intentioned actions that backfire. Unintended consequences refer to any effect that is different to the intended effect. Backfires refer to an effect opposite to that which was intended.

A recent BMJQS editorial gives very useful lists of unintended consequences and backfires in the social world in general and in healthcare in particular.[1]

There are some lovely examples of backfires in the social world. For example, three randomised controlled trials show that exposing juvenile offenders to prisons actually increases crime rates.

Another well-known example is the effect of fining parents for arriving late to pick up the children from nursery; this intervention increases late arrivals. An example not included, but covered in a past issue of the CLAHRC WM News Blog, concerns the effect of community groups for male youths at risk of antisocial behaviour, which increases the risk of criminal activity.[2]

In healthcare, numerous studies have shown that trying to decrease hospitalisation by identifying people at high risk before they seek health care, has the opposite to the intended effect. An example that I did not know about concerns provision of free condoms for sex workers. This can actually increase the risk of sexually transmitted infections by creating a premium for unprotected sex. An example that I love concerns providing a financial reward on production of dead cobras to counteract the scourge of snake bite in India.[3] This encouraged the breeding of cobras in order to elicit the reward. The hapless cobras were subsequently released following withdrawal of the failed initiative! It also turns out that disclosing conflicts of interest perversely increases the bias it is supposed to counteract. The ARC WM Director declares no conflict of interest!

Richard Lilford, ARC WM Director

References:

1. Shojania KG. Are increases in emergency use and hospitalisation always a bad thing? Reflections on unintended consequences and apparent backfires. BMJ Qual Saf. 2019; 28(9): 687-92.
2. Lilford RJ. Adverse Effects of Well-Intentioned Interventions to Improve Outcomes in Adolescence. NIHR CLAHRC West Midlands News Blog. 15 January 2016.
3. Freakonomcs. The Cobra Effect (Ep. 96): Full Transcript. Freakonomics Podcast. 11 October 2012.