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.

An Eye-Opening Research Experience through India

Learning Along the Way

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Hello, my name is Shannon King and I am working with Sight and Life as an intern while completing my Masters of Science in Public Health with a focus in human nutrition at Johns Hopkins Bloomberg School of Public Health.

The Assignment in India

During the late summer of 2017, I spent 2 months in India where I was working with our local partner, Karuna Trust, to conduct research on the implementation of the PATH “Feeding the Future through Fortified Rice Program”. Within this intervention Sight and Life has designed three school-based nutrition and WASH strategies to develop healthy eating habits while improving hygiene and sanitation behaviours. The intervention uses peer role modeling and cues to action; games and helper crews; and problem-based learning within the school environment to promote behaviour and attitude change.

The study required visiting 50 schools in four different areas of Karnataka in order to understand how the program is being implemented. Our observations allowed for us to examine to what extent each school had executed program activities- such as having soap available for the students, and how the program materials are being used around the school. Further, in-depth discussions with the implementing teachers provided detailed descriptions of how the program is being used and their experiences thus far.

Impact of my Experience

Overall, it was an incredible experience allowing me to engage first-hand in the entire research process from protocol design, to ethics review, data collection, and data analysis. As a graduate student, I have had the opportunity to work on studies in the past; however, this was the first time I have been given ownership of a study and the ability to work on it from initiation to conclusion. It has been very rewarding to work through each step of the process and overcome all the associated challenges and roadblocks.

During my time in the field, I found it fascinating to see a wide range of implementation processes used in the schools despite the fact that each school was provided with the same program materials and instructions. As researchers, a better understanding of the factors influencing implementation allows us to develop programs in a manner that will optimize delivery.

While the research did not involve any formal data collection from the school children, I will always cherish the moments I was able to engage and play with them. The opportunities were few and far between, however, at one school we arrived early and the teachers were having lunch so the facilitators and myself played one of the nutrition and WASH games with the children. Despite needing a translator to help facilitate the process, it was an hour filled with laughter and joy. It was also an incredible opportunity to see the program in action and how much the children were enjoying to learn.

Working through Barriers

The biggest challenge, and the most eye-opening experience of the trip, was working as a young female researcher. In several different contexts and settings, comments and suggestions made by females were treated less seriously than those put forward by males. Or sometimes women’s opinions were simply ignored, and it was eye-opening and aggravating to experience. Witnessing an individual’s esteem being judged primarily on their gender and seniority is quite the contrast to a working environment where your capabilities are judged primarily on your education, experiences and work ethic. It provided me with an even stronger appreciation of the efforts made to promote gender equality. India has an incredible, young female population with the potential to be strong leaders and change-makers, if given the opportunity.  

Lastly, this experience highlighted the need for implementation research to better understand how the nutrition community can optimize the delivery of nutrition interventions rather than purely conducting before-and-after data collection to assess the success of a program. I look forward to sharing the results with both project partners, in the hopes of allowing for mid-course corrections to improve program implementation, and sharing the findings with the greater research community to help build the literature base of implementation research in nutrition.

Enjoy this gallery of pictures showcasing my visit to Indian schools.

Photo credits: Prachi Katre

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