harnessing the power of emotional drivers to promote behaviour change

Harnessing the power of emotional drivers to promote behaviour change Eff orts to address malnutrition, maternal and child mortality, and other global health priorities are heavily relia

Harnessing the power of emotional drivers to promote

behaviour change

Eff orts to address malnutrition, maternal and child

mortality, and other global health priorities are heavily

reliant on behaviour change, including adoption and

correct use of health technology, and following treatment

recommendations.1,2 One long-standing concern is

the limited eff ectiveness of many behaviour change

interventions, even when exposure to intervention

activities is adequate, and activities are implemented

with high fi delity.3 A second concern is low coverage

of proven behaviour change interventions, under

conditions of routine programme implementation.2

Those people who are not reached might be the poorest

or most vulnerable, and therefore the ones who stand to

gain the most from the intervention.4

Target of emotional drivers such as affi liation

(social inclusion), nurture, and disgust, has been

identifi ed as one way to increase the eff ectiveness

of behaviour change interventions,5 with disgust

considered appropriate specifi cally for promoting

avoidance of sources of infection.6 The investigation

by Katie Greenland and colleagues7 of a behaviour

change intervention for diarrhoea control in Zambia

represents an attempt to operationalise this concept

of harnessing emotional drivers to increase uptake

of desired behaviours under routine conditions The

authors categorise their trial as a proof of concept, and

lay out their theory of change to demonstrate how

intervention activities bring about changes in protective

and treatment-related health behaviours

The intervention promotes four very diff erent

behaviours Intervention uptake goals vary, from

establishing a new and permanent habit (handwashing

with soap), to a temporary habit (exclusive

breastfeeding), to the immediate response to a sick child

(preparation of oral rehydration salt solution and zinc

treatment for childhood diarrhoea) Furthermore, the

emotional drivers the intervention aims to encourage

might apply to the four behaviours in diff erent ways.1

Implicit in the authors’ theory of change is a concern

for intervention fi delity, “the degree to which an

intervention is delivered as intended”.3 Kim and

colleagues8 identify four aspects of implementation

fi delity that warrant attention in a community based

study: adherence, dosage and exposure, quality of delivery, and participant responsiveness Greenland and colleagues7 assert that their study “demonstrate[ed]

that a model based on emotional drivers may prompt change in exclusive breastfeeding behaviour”

Using disgust for promotion of handwashing as one example, Greenland and colleagues do not present

evidence that the change agents (Komboni housewives)

received training or guidelines on how to create feelings

of disgust when interacting with the community, or followed these guidelines (adherence) Dosage and exposure to activities eliciting feelings of disgust are not presented, nor do we learn if people actually felt disgusted when exposed to these activities (participant responsiveness) Further, we question whether the change agents operationalised disgust to a suffi cient degree as so to elicit a behavioural response The concept

of suffi cient quantities is crucial for interventions targeting emotions such as disgust Nicholson and colleagues9 indicate that it is not necessarily an individual’s tendency (propensity) to feel disgusted that leads to eff ects on behaviour, but rather the degree (sensitivity) to which that disgust is felt Greenland and colleagues present no data on intervention fi delity in this paper, so we cannot judge if this study constitutes

a fair test of the eff ectiveness of emotional drivers in increasing uptake of these four behaviours When we fail

to observe changes in behaviour, we are not in a position

to know if the problem lies with the limited technical

eff ectiveness of the intervention, or insuffi cient exposure to intervention activities for change to occur.4

The low coverage achieved in this study is another major concern High coverage promotes equity, and evidence shows that rapid increases in coverage of maternal and child health interventions bring about gains in equity.10 Greenland and colleagues compare clusters with high exposure and low exposure, and note better results for some indicators in the high exposure clusters We do not learn if there were pre-existing diff erentials in wealth, education or access

to information between the high-exposure and low-exposure clusters If such diff erentials do exist, then they may explain the better results in the high exposure

See Articles page e966

clusters Reaching the poorest and the marginalised, and delivering behaviour change interventions with high quality and intervention fi delity, is a crucial challenge for the fi eld of implementation science, particularly in low-density rural populations in Africa.2

Target of emotional drivers of preventive and treatment behaviours is a promising avenue for increasing the

eff ectiveness of behaviour change interventions.5,6

More research is needed on how to best operationalise interventions based on emotional drivers in routine programmatic settings, how to measure the diff erent aspects of intervention fi delity in community-based interventions,3,8 and how to achieve high coverage and quality among the poorest and most vulnerable members

of a population

Furthermore, future research should examine whether diff erent emotional drivers warrant eff ort and emphasis within the intervention package, depending on the specifi c behaviours promoted and their characteristics:

habitual versus occasional, and preventive versus treatment-related

Peter J Winch, Elizabeth D Thomas

Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins; and Bloomberg School of Public Health, Baltimore, MD 21205, USA

pwinch@jhu.edu

We declare no competing interests.

Copyright © The Author(s) Published by Elsevier Ltd This is an Open Access article under the CC BY-NC-ND license.

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