Friday, July 18, 2008

Habits and Behavior Change

Here is an interesting article from the New York Times on the use of advertising techniques to encourage positive behavior change in developing countries, specifically Ghana.

Nowadays, behavior change modification is the key to most successful international public health campaigns. For example, Uganda has seen one of the most successful HIV prevalence declines worldwide due to policies that focuses on behavior change- faithfulness and partner reduction.

Of course, the key is to figure out what appraoch to use to bring about the change desired. My father went to a lecture where an engineer spoke about the installation of a water pump in a village somewhere in Africa (can't remember the country). In spite of having good equipment and training the community, the water pump fell into disrepair and was useless. In this situation, something was missing, a spark to make the community incorporate postivie behavior into their daily routines.

The article talks about Ghana and one campaign to get people to use soap after the using the bathroom. It turns out that most Ghanians wash their hands after using the bathroom- just not with soap. Like so many places in the developing world, diarrhea and other illness transmitted this way are seens as just a part of life. So how to convince people to use soap as part of their after-bathroom routine? Interesting, the team conducting the study found that people used soap when they felt dirty- after cooking, working with the land, etc. The answer was to transmit the idea that using the bathroom was just as dirty. The campaign was successful- subsequent studies found that 41% more people reported handwashing with soap after using the bathroom as part of their hygiene routine.

The techniques used to encourage this change came directly from the advertising world. The approach has been criticized because it uses commerical avenues to promote a common good. But if the end result is healthier people, then there's not much that I can complain about.


Kate said...


The same research is just as valuable in the developed world - for all our money, we still manage to sicken and kill a huge number of people from contaminated foods & water. I'm actually been reading a lot of papers on consumer behaviour, perceptions and methods of education/prevention in relation to food safety. Which includes hand washing! You'd be amazed how many people don't wash their hands before preparing food etc.

That said, behaviour change is only of worth when people have the ability to change their behaviour. And in many developing countries, poverty is a huge limitation. Hand washing isn't going to be such a big help if the washing water is contaminated. And all the ads in the world won't help a woman who has no way to make money besides prostitution. I think we'd do a lot more for HIV/AIDS by bringing people out of poverty than everything else combined. Which means giving women access to comprehensive reproductive health services - not just access to condoms.

Also, it's worth noting that association does not mean causation. Only a case-control trial can prove causation - and that's not possible in most of these situations. I certainly think the programs did play a big part, but there are tons of confounders in there. Not least the fact that there are different strains of HIV and each strain is evolving. So Uganada could have been, in part, the beneficiary of a strain that was decreasing in infectivity.

Leslie said...

You're right, Kate. Poverty plays a huge part in the decisions that people make. For me, what was interesting about the hand washing case was that people were already washing their hands for somethings so there was really no additional cost involved. Of course, it would be interesting to see the effects of this type of campaign on communities where the soap-using habit didn't previously exist.

Kate said...

The hand-washing thing is really interesting, especially considering that it's not a majority habit in much of the developed world. I'd love to see research comparing people's motivation to hand wash - is it cultural, influenced by education, by parental teaching, education, lack of other sanitation options etc.? Perhaps we could learn from Africa about getting people to hand wash - we have a lot more sanitation issues in the developed world than we admit.

I'm also curious about whether the use of soap counter-balances any pathogens in the water. Is it risky to encourage hand-washing if people might continue it without soap when the water may be contaminated?

I forgot today, but on Monday, I'll have to look and see what the estimations are for % handwashing in the US and Canada.