Exchange in Behavior Change

Making consumers feel, instead of do

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One of the most often expressed grievances related to the COVID-19 pandemic has been around wearing face masks. Everyone is made aware of its importance when stepping out. We can thank the hundreds of videos, posters (digital and offline), social media content, and articles on the subject. Not wearing a face mask outside today could mean instant scrutiny, even mockery or humiliation. Sometimes I wonder how many wear face masks to protect their health and that of others, and how many wear face masks because ‘everybody else is doing it’ or it is ‘cool’ or ‘popular’ or ‘this one is branded and oh so pretty’. Of course, this is not to say there is only one motivation at play here, or that one is better than the other. It just is an excellent example of how simple awareness-raising of the health benefits is not enough – motivation comes from a combination of individual and social factors as well as knowledge.  

Social marketing’s impact

In the context of social marketing, we briefly discussed the idea of ‘exchange’ in our blog post by social marketing expert Rowena Merritt, “It Makes Me Smile,” posted a fortnight back. We explained how, if the goal is to change a behavior, offer something in return. While most of us might think of cash incentives or gift vouchers as rewards, the exchange is often non-monetary, such as making someone feel unique, or creating a sense of control or ownership. At Sight and Life, we think about whom we are serving and what could be a compelling exchange for our target audience. 

Research is important

Let us look at the Eat More, Eat Better campaign* launched in Rajasthan – a state in Northern India – in 2018. The project aimed to improve food access and food choices for pregnant and lactating women (PLW), whose calorie intake was 40% below doctors’ recommendations. However, we quickly realized that we needed to do more than raise awareness; we needed to offer an exchange that our audience valued. To help us do this, we used social marketing techniques and tools and conducted in-depth formative research. 

The findings helped identify critical insights to develop a behavior change strategy, the most notable being:
  A. The kitchen was generally the mother-in-law’s domain, and she associated eating more with being indulgent, greedy or lazy. This perception was not relaxed even for her pregnant or lactating daughter-in-law!
  B. The husband tried to balance patriarchal norms with being more emotionally available to his wife. For instance, he would occasionally smuggle in goodies or fruits for his wife to eat.
  C. Snacking, rather than the three meals, carried greater permission for the PLW as it did not lead to territorial clashes in the kitchen and was also something that was not frowned upon by the mother-in-law.

Based on these findings, the social marketing project focused on introducing a new behavior – nutritive snacking for PLW. The habit of snacking was accepted and already practiced, making it a more natural behavior to change. PLW were provided a specially designed snack box that she could use when away from the kitchen and a small treat pouch that she could use to carry snacks in her sari.  The baby was dubbed a ‘Champion’ that would fill both the mother and father with pride and parents were encouraged to do what is best for their ‘Champion’. Fathers were also asked to sign a pledge to support the nutritional needs of their wives and babies actively. And the exchange? The PLW felt special and cared for by her husband and empowered when it came to looking after herself and her baby. 

This is a graphic for the Eat More, Eat Better campaign paying a tribute to the region’s unique Rajput painting style. It shows a husband urging his wife to eat more and calling her the mother of the ‘Champion’.

Another good example is our work in the 2017 Karnataka WASH (Water, Sanitation and Hygiene) behavior change project. As part of the larger objective to improve nutritional status among school-going children, Sight and Life worked with PATH and Karuna Trust on a strategy to prevent loss of nutrients among children by aiming to influence motivations regarding several behaviors:
  A. Washing hands with soap at key times, including before meals, after using the toilet, after play, and after handling garbage
  B. Drinking water from safe sources only
  C. Rejecting open defecation or urination
  D. Flushing the toilet with water after use
  E. Keeping their school tidy and free of garbage
  F. Eating vegetables and healthy snacks

The formative research delved into the physical, social-normative, and biological factors that drove eating and hygiene practices in school. The team conducted a combination of ethnographic interviews and focus group discussions exploring codes related to hygiene, sanitation, and social influence. Based on this information, the team designed a phased strategy where they tried to make the behavior changes as fun, easy, and as popular (the social norm) as they could by deploying the following:
  A. Physical cues – for example, rhymes and short messages, relevant signboards, installing a tippy tap, soap for handwashing and buckets and jugs made available in toilets (making it easy)
  B. Games – specially crafted games and someone entrusted with the responsibility of owning these games (making it fun)
  C. Role modeling – each class elected a role model, who would then encourage his/her classmates to adopt health behaviors (making it popular) 
  D. Helper crews – specifically created to ensure all tasks were fulfilled (making it fun, easy and popular!) 

In 2017 Sight and Life’s intern, Shannon King, worked in India to research the implementation of these school-based nutrition and WASH intervention strategies to develop healthy eating habits while improving hygiene and sanitation behaviors.

It is interesting to see how the ‘fun’ element was given great importance, and rightly so since the target audience was young children. The rhymes and games helped children identify ideal WASH behaviors; watching role models encourage the same outside of playtime helped build good habits. Rhymes and games acted as an essential feel-good factor and led to a higher recall for a topic that runs the risk of being regarded as boring and irrelevant by many children. 

Knowledge is key

Figuring out the exchange is an engaging journey, one which requires exploring the individual and society, the motivations at play, and the broader environment they are all delicately balanced within. This summer, Sight and Life is holding a three-day online course with the SSPH Lugano Summer School, “Generating Demand for better public health goods and services: A systems and consumer-centered approach”. The course will look at how to create demand for healthy products and healthy behaviors (and we will also talk about exchange). Further details regarding enrollment can be found here. We look forward to (virtually) meeting you there!

* The formative research for the Eat More, Eat Better campaign was completed by Eva Monterrosa, former Sight and Life Senior Research Manager.

The Social Marketing of Micronutrient Powder in Sudan

Applying Formative Research to Design Social Marketing Strategies

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In this backstory we explore the article, ‘The Social Marketing of Micronutrient Powder in Sudan – Generating consumer insights to address micronutrient deficiencies’ written by Yana Manyuk in the Sight and Life magazine, Focus on Food Culture edition. Yana Manyuk is the Program & Policy Officer, Behavior Change Communications, for the World Food Programme (WFP) Regional Bureau for the Middle East, North Africa, Central Asia & Eastern Europe.

In 2013, the introduction of MNP was originally piloted in three localities of Sudan’s Red Sea state in 2013 by the Sudanese Ministry of Health, in collaboration with the World Food Programme. The research allowed an understanding of the consumer experience which was essential for reshaping program services and communication activities to fit beneficiary requirements.

After graciously accepting an interview with Sight and Life, Yana shared her experience and insight on the formative research she conducted in Sudan to gain consumer insights in order to design social marketing strategies that would generate demand for micronutrient powders (MNP). 

Ms Manyuk told Sight and Life she believes nutrition cannot be taken as a stand-alone subject, but one that takes into consideration underlying behavioral and socio-cultural perspectives.

Sight and Life magazine (SAL): What inspired you to choose this topic, and how did collect your data?

Yana Manyuk (YM): The WFP that distributing fortified flour at that point was facing quite low uptake. The Sudanese government, together with WFP, had already agreed on a decision to change the program design, as it required more effort from beneficiaries to collect and grind flour, and also to use the product. A decision had already had been made to change fortified flour to single-dose sachets. So, instead of coming to the centre and picking up a heavy bag full of flour, recipients could pick up a small sachet. They would still receive food; however, they could now use the food they received how they wanted, and could use the sachet how they wanted – for example when their children were eating separate food.

I was then brought on board to carry out formative research to see what we would need to do. The initial idea was to see what we needed to do to ensure the new program design and sachets would be accepted. Of course, we could have taken lots of angles to this research, such as looking into what packaging, color or design people preferred, and we could have simply researched the branding. But what was really important for me was knowing that the introduction of a new product into a community – especially a product that was a novelty for people – requires more than colorful branding to be accepted. It was essential to take a systems approach, and look at what needed to be improved from the beginning of providing the service – servicing the product, marketing, communicating, and using the product. So our research focused on the entire social marketing process, and the gaps and strengths of service provision, as well as the  marketing.  I was inspired by the desire to understand how to make the entire programme better, not just how we could make the product look and feel nicer.

SAL: How typical is social marketing in the development sector?

YM: The difference between our research and research you very commonly find around topics of introducing MNP, or introducing any new service or behaviour in the developing sector, is quite focused on the product or the service itself, as well as the barriers associated with that specific product or service. This is instead of taking the consumer of that service or product in the round, and really trying to get under the consumer’s skin, and discover the hooks in the lives of the people that we can use to market our service and product. Sometimes these hooks have nothing to do the qualities that we as nutritionists attribute to a product or service.

Scientifically, MNP is supposed to prevent anemia, which has certain symptoms and causes. If we had conducted research to understand whether or not people know what anemia is, what causes it has, and what symptoms, we would have found out that actually knowledge around anemia is pretty low. Our conclusion would have been: ‘Okay, we need to educate people about anemia, what it is, and why its important to prevent it.’ But that would not have told us one important thing: People care about anemia. So, is informing them going to help us gain acceptance of product, or do we have to understand what people really care about in their community? How do they frame issues about health? What symptoms do they associate with diseases? And then we need to explain in a language which people speak, and using symptoms they know.

I’m not saying it’s not important for people to watch out for symptoms of certain diseases. Some of the most successful education nutrition programmes take people’s own perspectives and understandings into account. For example, a Kenyan non-governmental organisation (NGO) designed a campaign around breast cancer prevention and self-examination … They were dealing with a quite illiterate population, so they took nuts and beans from what was available locally, and created a string of different-sized beans and nuts so that women could feel what a possible tumour could feel like – instead of explaining in medical language what it means to have cancer.

It’s very practical to use local materials. People are all about teaching, feeling, hearing, and  smelling, so what makes our research approach different is that we took the audience as the centre of our research. We took a step back from the thing we wanted to promote, and tried to understand what was important to people and their lives. It helped us immensely to brand MNP around those little nudges that would trigger people to accept the product.

SAL: I hear that you have a master’s in social marketing, Yana. How often do you find people with your skill-set in the sector where you work? 

YM: I think that my social marketing degree has significantly contributed to the ways in which I think today.  Many of these may be unconventional, in that I step back and look at the entire system of issues, from the side of supplying certain services, products, or behaviors to the demand side. But I also think the few programs that look at health and social marketing today – and I have been asked to be a lecturer on a distance social marketing programs – may be lacking a little bit of technical nutritional understanding. What’s important is that public health and nutrition degrees today integrate courses on behavioral economics, on marketing. I feel nutrition has been increasingly medicalized in the developing world. As a result, we have somewhat lost that human touch, and the socio cultural drivers of what is causing many of these problems. So a degree or course on these disciplines can be very, very helpful. But we don’t find many people with this degree. We are a rare breed!

SAL: If people wanted to learn more about social marketing, where could they go? Is there a website or distance learning course they might take?

YM: A number of universities offer social marketing courses. But the social marketing sphere is  still quite small in terms of places where to go. The annual World Social Marketing conference 2017 was in Arlington and, as far as I know, this was the first time UNICEF was represented there by the global director of their communications for developme[U2] nt department. This was a big deal, as the social marketing sphere is still quite dominated by actors from the developed world, addressing problems such as overweight, obesity, smoking, HIV, drug prevention, and so on.

The UK is very strong in the social marketing field. The National Social Marketing Centre in London started off as an NGO, and is now a consulting firm. It provides free online resources on the social marketing planning providers, plus some foods. The University of Brighton, UK, offers a social marketing programme, as does King’s College, London.

Different discussions about behavioral change communication (BCC) are taking place globally. BCC puts communication at the centre, and is all about designing communication strategies. Meanwhile, social marketing looks at understanding problems, and finding solutions which can be of a different nature. They can, but don’t have to, include communication and education, ways of redesigning an environment. It also looks at putting up control mechanisms. Thus, at policy levels, if we look at banning smoking, these are all technically tools that are the outcome of thoroughly-done social marketing research that understands the barriers, behaviors, and chief benefits.

From my heart, I wish to see more actors in this field who put one and one together, and include an understanding of people’s behaviors in their nutrition analyses, instead of adding these topics as an afterthought. We need to realize today that, in societies that are being increasingly diverse, globalized, and complex in terms of the industrialization of food systems marketing, we cannot take nutrition as a stand-alone subject. We have to look at the underlying behavioral and socio-cultural perspectives. I hope nutrition degrees not only educate people about nutrition, but help us understand why people do what they do.