Mbrella is a charitable organization devoted to helping impoverished Kenyan families buy health insurance. Mbrella connects donors with Kenyan mothers and employs a number of behavioral interventions meant to help the mother gain enough financial stability to be able to eventually, over time afford insurance for the family on her own. One such intervention is the Mbrella Calendar, which was designed with the help of CAH to leverage a number of behavioral insights. The calendar is meant to help Kenyan mothers overcome barriers such as lack of social support, an environment designed with temptation and instant gratification at its core, and the basic difficulty of keeping track of one’s progress, which can all derail good intentions.

View the Mbrella Calendar Here

In designing the calendar, we first wanted to tackle issues of social support. In order to do this, we sought to engender a sense of collective responsibility within the family. Typically, mothers are in charge of healthcare for the household, but fathers tend to be in charge of finances. Rather than putting all of the responsibility on one member of the family, we wanted the family to see itself as a group reaching towards a collective goal. At the very top of the calendar, we have “Team [family surname]’s Savings Calendar” written, where the family will write in their name. This is designed to encourage family members to think of this as a goal that the family will be pursuing as a unit. Also, at the top of the calendar, there is a story that outlines a hypothetical family’s savings journey with Mbrella – which demonstrates the importance of having the entire family save for health insurance.

Typically, mothers are in charge of healthcare for the household, but fathers tend to be in charge of finances.

The next design feature leverages prior work demonstrating that developing concrete plans leads to a higher likelihood of goal achievement. We have included boxes over the days of the week so that families can choose on which days they intend to save. Underneath the calendar itself, we have instructions for how to save for insurance using the mobile M-TIBA wallet (including the relevant account and phone numbers needed to save), and a way to keep track of savings using the calendar. Even something as simple as forgetting the account number can act as a significant barrier to action, so it is important to provide easily accessible reminders.

Finally, at the bottom of the calendar we have a gamified savings system that helps families track savings each month while also providing an element of fun. Football (soccer) is a very popular sport in Kenya, so we thought creating a tracking system that mimicked a football match could help to involve the children in the savings process. Hopefully, by involving the children, we can reinforce the value of saving for health insurance for the parents, and provide a model of savings behavior for those children as they grow up. Families are given a sheet of stickers with football stickers for each month that they need to save. One sticker represents 10 Kenyan Shilling. Each time they save, they add a football (or multiple footballs if they save more than 10 Shilling at a time) to the football field to track their progress from one end of the field to the goal. Along the way, we have added “defenders” that need to be avoided, which are pictures of temptations (e.g., clothes, fast food, soda) that Kenyans have reported wanting to cut down on to reduce spending.

On the sticker sheet, we have photos of each temptation, with a corresponding number of footballs that each temptation would cost. This should help members think in terms of health insurance savings when dealing with temptation. Reaching the goal means that a family has successfully saved for a month. If the family fails to reach their goal for a month, they will be given a fresh start when they flip the calendar to the next page. Fresh starts can provide a renewed motivation towards a goal, focusing them on the future rather than the past. Finally, whereas the football field acts as a short time-scale tracker and is meant to be the primary area of focus for the family, the sticker sheet also acts as a tracker towards the ultimate goal, as individuals can determine how far they need to go to reach their final goal by counting the number of stickers left on the sheet.

When it comes to helping families save for health insurance, Mbrella wants each of its interventions to tackle as many potential barriers as possible. The Mbrella calendar epitomizes this approach by providing solutions for socio-cultural and individual barriers. Whereas the calendar seeks to solve a number of problems, no one intervention can do it all. This is why Mbrella is rolling out several behavioral interventions over time which will be integrated with the calendar to help support the savings system set up by the calendar and tackle issues not accounted for by the calendar intervention. If you are interested in finding out more about the behavioral interventions being used by Mbrella, or if you like the idea of supporting families as they work towards being able to buy insurance on their own, please visit the Mbrella site.

Jonathan Corbin is a Senior Behavioral Researcher at the Center for Advanced Hindsight at Duke University, an applied behavioral science research lab that helps people be happier, healthier, and wealthier. You can reach him at jonathan.corbin@duke.edu

Is your organization in any other way interested in health research with CAH? Contact Jan Willem Lindemans, Principal, at jan.lindemans@duke.edu.

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Nina doing a presentation for our partner on workplace health

For most jobs, meetings are a very familiar ritual. You walk in the meeting room, sit down, open your laptop and try to concentrate on the issues at hand for the next 30 minutes to an hour. The average worker spends around 6-hours a week sitting in meetings whereas senior managers can spend as much as 23 hours per week in meetings (Rogelberg, Scott, & Kello, 2007). That is a lot of time spent sitting and trying to focus one’s attention!

Judson doing behavioral mapping

During the World Team’s month long trip to Amsterdam and Nairobi, we spent a lot of time in (very productive!) meetings, and along the way found some new, exciting ways to engage in healthy, yet efficient meetings. Who knew that meetings could actually be healthy? Our partnerships are located around the world. We are currently working in the Netherlands, Kenya and Nigeria, and making an effort to personally visit all partners twice a year. During the month of July, we spent a week and a half in Amsterdam, and the rest of the month in Nairobi.

During our time in Amsterdam, we held a big mid-year presentation with each of our partners: Zilveren Kruis, the Joep Lange Institute, the PharmAccess Foundation and CarePay. We updated them on our work in 2019 so far, including progress of projects, results, learnings, and plans for the coming months. These big presentations were followed by insightful discussions, such as our partner steering committee meetings, where we were able to dive deeper into specific projects.

Nina and Jonathan discussing strategy with an Amsterdam collaborator

Overall, our meetings were extremely productive, and not at all redundant. What was the secret ingredient? We came to realize that different meeting types require different meeting formats. For larger groups, conference rooms might be most suitable, while for small one-on-one chats a walking meeting might be best. Being outside, feeling the fresh air, really helped us stay focused, while at the same time, getting some exercise. However, being active and healthy is not confined to the outdoor space. During our conference room meetings, we made the conscious choice to stand up now and then, and to stretch our legs while engaging in discussions. Spending too many hours sitting is hazardous, so changing your posture frequently helps reduce the risk for obesity, diabetes, cardiovascular disease and deep-vein thrombosis. This prompted a more serious discussion on how to encourage standing meetings, which led to new projects aimed at getting people moving during meetings. We are very excited to be studying this topic in more detail during the coming months.

Hypertension/diabetes patient group

In addition to the physical positives that came from our partner meetings, we also aligned on many other project goals for the coming six months. For example, we spoke a great deal about our partners’ non-communicable disease (NCD) work currently taking place in Kenya. These discussions led to a series of very interesting and eye-opening meetings once we arrived in Nairobi. During our time there, we attended an NCD screening at a local employer, a meeting of NCD patients at a clinic, and a meeting with our partner’s agents who enroll individuals into the NCD program. Each of these meetings gave us deeper insights into the complex issues surrounding NCDs, and inspired new ideas for interventions to improve the screening and enrollment process, including: 1) using a sticker as a social proof/pressure device for employer screenings, similar to an “I voted” sticker, 2) simplifying the current NCD app to reduce confusion and friction, and 3) focusing on specific, singular unhealthy behaviors that individuals can work on to improve their health and NCD status. We hope that our partners will test some of these interventions in the coming months, so stay tuned!

Jan Willem helping with measuring blood pressure

Jan Willem experiencing “fear of the finger prick”

As you can see, (the right kind of) meetings can be a great source of productivity and creativity. Finding and employing the right meeting format, and focusing the right people on the right topics, can make meetings not only constructive, but also fun! We hope to continue to test and use these insights in our partner work, as well as our own work at CAH. So if you visit CAH soon and see everyone just standing around, it means we’re really working hard!

The World team post glorious combat – Judson and Jonathan’s team won

Are you interested in the partnership on workplace health? Contact Nina, Partnership Lead, at nina.bartmann@duke.edu. 

Are you interested in the partnership on healthcare in Africa? Contact Judson, Partnership Lead, at judson.bonick@duke.edu. 

Is your organization in any other way interested in CAH World? Contact Jan Willem Lindemans, Principal, at jan.lindemans@duke.edu.

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I fell in love with behavioral science when I was exposed to Dan’s research as a teenager. Since then, working at the Center for Advanced Hindsight had been my dream. Lucky for me, I was able to secure my dream job just a few months after graduation. I made the move from Upstate New York to Durham, North Carolina with little idea of what was in store for me on the other side.

It took me nearly a year to get over the oh-my-god-I-work-at-Dan-Ariely’s-lab jitters. Everyone I met seemed so intelligent and fascinating, and I remember thinking to myself What can I possibly add to this? Is there anything I could say that they don’t already know? Two years later, I can tell you that some of the most uniquely brilliant minds I have ever met – from academics, to statistics wizards, to policy makers – I met in my time at the center.

Playing mini-golf with the World Team

I can tell you firsthand, most of these people are actually very friendly and approachable, despite their intimidating brains and professional air.

I also traveled internationally for the first time while working at the Center. My work took me to both Europe and Africa, and I am extremely grateful to have had such experiences. Getting to experience different cultures was eye-opening to say the least.

Meeting with our Dutch partner in Amsterdam

Community Health Volunteer training in Nairobi

Through the blood, sweat, and tears, I learned a lot in my time at the Center. Some of the most notable things I learned are:

1. Information does not change behavior. The list of misguided attempts to give people all the facts about their decisions in a particular domain is miles long. Take it from an actual behavioral scientist, with knowledge of the biases that affect human behavior – knowing about these biases does not automatically make you more rational. A friend once said something to the effect of “behavioral scientists are late just as often as everyone else. The only difference is that when they finally arrive, they look at each other knowingly and say, ‘planning fallacy.’”

Behavioral scientists may be more understanding of mistakes than other folk, but they are just as likely to make those same mistakes themselves (unless they employ clever nudges on themselves, which many of us do). My colleagues and I often use pre-commitment devices to ensure that they do what they set out to to. For instance, I have legitimately had someone approach me asking me to publicly shame them on our work Slack channel if they did not review an article by a certain date and time.

2. Almost nothing is as simple as it seems. I have spent a large portion of my time at the Center studying charitable giving. On the surface, you might think that this is a pretty straightforward topic. Au contraire – people don’t just give money to charitable causes out of the goodness of their hearts (at least not all of them). Some are looking for that warm fuzzy feeling that comes from doing good, some give in order to quell feelings of guilt or empathy, and others are simply hoping to appear like good people.

In light of this information, you might think that one should cover all of these bases when soliciting donations (and you’d be wrong). It turns out that giving people mixed reasons to give actually decreases their intention to give. Therefore, when designing a giving campaign, it is best to speak with experts, or at least read up on what others have done, before moving forward with your plan.

3. Lack of accountability and lack of planning are failure’s best friends. I have learned this through personal experience, and through a thorough examination of implementation intention research. People often intend to perform healthy or productive behaviors like jogging or writing a manuscript, but have trouble actually implementing this. Writing down an implementation intention such as “when it is [time/day of the week], I will [perform a specific behavior]” can actually make people more likely to do what they set out to do. Without these specific plans, you can easily put off getting in shape or writing that manuscript for months without making any progress.

I am grateful for the time I’ve spent working at the center and wouldn’t trade it for anything. And, to my World team friends: habana haba, hujaza kibaba (1)!

Ciara Lutz was a researcher at the Center for Advanced Hindsight at Duke University, an applied behavioral science research lab that helps people be happier, healthier, and wealthier. You can reach her at ciarahlutz@gmail.com.

1. This Swahili saying is our informal team moto, and means something like “If you save little by little, you’ll fill the whole piggy bank”.

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If you’re a policy maker launching a new program, then you might have to consider how to get your target audience to take up and engage with the program. That is, you’re pondering how to encourage a new behavior. Oftentimes, the challenge is that even when the target audience says that a program is desirable, people’s actions often don’t reflect their intentions.

When new programs struggle to catch on, it might appear that it is because they failed to convince people of the merits of program, or because they failed to provide enough information. However, we question whether in some cases, the problem is actually a lack of fluency rather than a lack of information or desire.

To answer this question, the CAH World team partnered with the PharmAccess Foundation, who conducted a randomized controlled trial of a CAH-developed intervention in Kenya. Participants included 220 new and expecting mothers who were being enrolled into a subsidized health insurance program. In this program, each mother was given one year of free health insurance for her and her family, but could extend the health cover for a second year if she saved a total of 3,000 Kenyan Shillings (KSh) (about $30) within one year. Savings were made in M-TIBA* which is a digital wallet similar to Venmo or Paypal, but exclusively for healthcare transactions.

The intervention

The intervention involved helping participants to practice depositing money into M-TIBA during on-boarding. Mothers randomly assigned to the treatment group practiced making four deposits. After each deposit, an onboarding agent instructed the participant to notice a confirmation SMS sent to their phone and provided positive reinforcement, e.g., “nice job, you’re remembering how to save on your own!” Participants were randomly assigned to receive the practice intervention or not, but all participants were given the same explanation and information about how to make a deposit. Other manipulations included the size of the total amount deposited and whether the money the participant used to deposit was the participant’s own money, or was “gifted” money.

Results

Overall, the practice intervention nearly doubled savings behavior. Within 3 months of the intervention, the proportion of individuals who made 1+ deposits increased from 24% to 46%, and the total average amount saved increased from KSh 64 ($0.64) to KSh 138 ($1.38).

Interestingly, the practice intervention was found to be even more effective when participants deposited their own money versus gifted money. Mothers who practiced by depositing their own money saved an average of KSh 174, while those who practiced by depositing gifted money saved KSh 113 (excluding any money saved on the day of on-boarding). There was something particularly motivating about choosing to invest one’s own resources in the practice.

What could explain this?

We think effects such as the self-herding bias or the sunk cost fallacy may have played a role here. Still, it’s worth pointing out how the result runs counter to what we’d expect if humans were perfectly rational. Those who used their own money to make the practice deposits are immediately “poorer” compared to those who used gifted money. That is, the group that used their own money voluntarily “spent” some of their available money. The group that used gifted money didn’t spend any of their available money. Given this, you would expect the “poorer” group to save less than the group who hadn’t spent any money yet. Yet, here we see the opposite: spending money on savings leads to even more savings.

Why was the practice intervention effective?

It seems that practicing increased fluency in the steps of depositing as well as confidence in being able to save. At the end of the onboarding interaction, participants were asked if they could recall the account number required to make a deposit in M-TIBA. Those who did not practice making deposits recalled this number accurately 55% of the time compared to 93% of those who practiced. A similar difference was found between the two groups’ confidence that they could meet their savings goal.

This study has important implications for policy makers who are considering how to encourage users or citizens to adopt a new behavior. While ensuring users have adequate information and a desire to perform the behavior is important, we argue that these aren’t enough. This experiment illuminates one way in which a program can help users become fluent and confident in a desired behavior. Importantly, the evidence shows that this intervention can have a significant impact.

Are you interested in this partnership? Contact Matt Bodien, Joep Lange Institute Partnership Lead, at matt.bodien@duke.edu.

Is your organization interested in CAH Global? Contact Jan Lindemans, Principal of CAH Global, at jan.lindemans@duke.edu.

* M-TIBA is a digital savings platform developed and operated by the PharmAccess Foundation and CarePay International, and supported by the Joep Lange Institute. All organizations are partners of the Center for Advanced Hindsight.

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Discussions about health insurance reform have recently occupied brilliant minds around the world. Last month, Ting Jiang, Principal of the global team, gave a talk about the role of behavioral technology in health insurance innovation and reform at the China International Health Insurance & Health Financing Innovation Forum in Shanghai. Ting described behavioral tech as akin to financial technology (fintech), which refers to new technology that seeks to improve and automate financial services. “Behavioral tech,” on the other hand, can be used to refer to new technology that improves and automates human participation (i.e., behavioral uptake) in products, services, and programs.

She stated that systematic application of behavioral tech could be the next breakthrough of innovation in healthcare, and an opportunity that one should not miss. She pointed out that the emphasis of any public debate so far is too much on who is paying and how to increase the ability to pay, and too little on how to reduce cost by using policies and infrastructural supports to promote health. The cumulative cost of chronic disease in middle- and low-income countries is expected to increase to $11.2 trillion by 2030. Speeding up the development of new medicines and medical treatment needs to go hand in hand with the development of behavioral treatment to curb the rapid increase of chronic diseases caused mainly by lifestyle choices. In other words, unlocking human potential to prevent unnecessary illness can and will help save healthcare.

For more on behavioral tech and product examples of behavioral tech created by our own lab, be on the lookout for Ting’s blog post in next month’s newsletter. And if you think behavioral uptake is one of your core challenges, get in touch with one of the CAH principals! There’s a chance we could help you apply behavioral tech to solve your problem.

Ting Jiang is Principal of Global at the Center for Advanced Hindsight at Duke University, an applied behavioral science research lab that helps people be happier, healthier, and wealthier. You can reach her at t.jiang@duke.edu

Ciara Lutz is a researcher at the Center for Advanced Hindsight at Duke University, an applied behavioral science research lab that helps people be happier, healthier, and wealthier. You can reach her at ciara.lutz@duke.edu

The post Can Behavioral Tech Help Save Healthcare? appeared first on Center for Advanced Hindsight.

The World Health Organization estimated that over 150,000 Kenyan children died from preventable causes in 2011 alone. One reason is that people simply cannot afford to get treatment for themselves or their children, particularly those living in the slums. A simple cough can quickly become pneumonia if untreated. When faced with a seemingly minor illness, parents making less than $1.50 a day have to make tough decisions between basic necessities like food, shelter, and medical care. Saving for health can be difficult, but life-saving.

M-TIBA is a free health savings wallet that is stored on a mobile phone. A Kenyan can sign up for M-TIBA and then save as little as 10 cents at a time, but this money can only be used for health expenses. If the individual saves one dollar in a month, then M-TIBA provides a bonus of 50 cents. The goal is to save little by little so that when a health issue arises, the individual can dip into the M-TIBA wallet to pay for medical care.

Unfortunately, while enrollment in M-TIBA has been high (over one million users since its start in May 2016), savings rates have been low. Most users have never saved in their health wallets. The Center for Advanced Hindsight’s Global Health and Development Team has worked with its partners, the PharmAccess Foundation and CarePay, to increase savings in these health wallets.

The Power of Anchoring

People are often influenced by the first piece of information that is offered (the “anchor”) when making decisions. They then base subsequent decisions on this anchor. For example, imagine a person sees a phone that costs $1,000 on a website. They are now anchored to this amount. Thus, if the person sees that the phone is selling for $900 a week later, she would think that this is a great deal.

The global team applied the insight of anchoring to the case of M-TIBA, hypothesizing that people are anchored to saving one dollar, since M-TIBA heavily promotes the bonus of 50 cents for a dollar saved. This amount might be too high, as the average Kenyan living in the slums of Nairobi makes less than $1.50 per day. If a person does not readily have one dollar to save, then this might be a barrier for depositing at all. A lower anchor might increase the number of users depositing by lowering that barrier. CAH and its partners decided to test this idea via text messages. M-TIBA users were sent two different text messages – one with an anchor of 10 cents and one with an anchor of one dollar:

1. “Save 100 KSh in M-TIBA, and unlock 50 KSh bonus this month.”
2. “Save as little as 10 KSh in M-TIBA, and unlock 50 KSh bonus if you save at least 100 KSh this month.”

As we hypothesized, the lower anchor increased the percentage of people saving: 3.4% saved in the 100 KSh (one dollar) anchor group while 4.8% saved in the 10 KSh (10 cent) anchor group. The lower anchor also increased the percentage of repeat savers from 0.6% to 1.1%. However, the lower anchor led to a lower amount of savings for those who actually saved: the most frequent deposit amount was 10 KSh in the low anchor group versus 100 KSh in the high anchor group. In addition, the median amount saved was 50 KSh in the low anchor group, compared with 100 KSh in the high anchor group.

Implications

These results illustrate the potentially powerful impact anchoring can have on saving. When considering any new product or intervention, one should pay special attention to the following:

• Anchors can encourage or discourage people to save, so thought should be given to the initial amount that is asked. If it’s too high, people won’t save. If it’s too low, people may not save as much as they can. If possible, a test should be conducted to determine the optimal amount.
• Anchors will also have an effect on the number of times people save, so it is important to find the balance between the number of user deposits and the amount saved.
• Different anchors may be more appropriate for different objectives. A lower anchor may be more useful to get people to begin using a product or intervention, whereas a higher anchor may be better to increase savings among those already engaged.

Anchors offer a great tool for savings programs to increase engagement. In the case of M-TIBA, lowering the anchor provided a substantial increase in the number of savers, which is important considering the lack of even one-time depositors in the program. An increase in saving for health by those who are most vulnerable to health shocks provides a concrete way to lower the number of preventable deaths in Kenya. If a child gets sick, a parent who saved in M-TIBA little by little is more likely to immediately take the child to a clinic for treatment, so the cough never becomes pneumonia. The smallest change in the framing of the reminder can save lives.

Judson Bonick is a Senior Behavioral Researcher with the Global Team at The Center for Advanced Hindsight at Duke University.

Ting Jiang is Principal of Global Health and Development at The Center for Advanced Hindsight at Duke University, an applied behavioral science research lab that helps people be happier, healthier, and wealthier.

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Global team members Ting Jiang, Jan Willem Lindemans, and Rebecca Kelley attended the 8th Games for Health Europe conference in Eindhoven, the Netherlands between October 8-9. The largest conference on games for health in Europe, it brings together medical professionals, academics, and game developers from the field of applied health games to discuss using game technologies to improve health and the delivery of healthcare.

Ting Jiang, Principal of CAH’s Global Health and Development team, gave the opening keynote about the important role that behavioral science can play in creating more impactful games and gamification features, especially for health-related behavioral change. In her talk, Ting used the example of designing a game aimed at increasing medication adherence and explained that a behavioral diagnosis is necessary to determine the extent to which non-adherence is caused by: lack of intention vs. intention-behavior gap, social vs. individual factors, and system II (deliberative) vs. system I (automatic) thinking.

(Photo: “Happy Money” game playtest in Kibera)

Ting noted that applying behavioral science tools early in the game development process leads to more accurate identification and measurement of behavioral change progress and permits experimentation aimed at identifying the most effective game components. She also gave examples of games developed by CAH, including the board game “Happy Money,” which is designed to help individuals with low income make better daily spending and saving decisions, in order to reduce deaths from lack of health financing for curable diseases. “Bill Thrill,” a cashier training game funded by the Joep Lange Institute, is another example of how games can be used to promote effective behavioral change. After identifying a core behavioral barrier of health clinic cashiers shying away from the use of a new digital transaction platform, the team gamified this real-life challenge to improve cashiers billing skills and increase their professional pride, with the aim of increasing behavioral uptake of the new platform and self-efficacy.

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With urban migration on the rise, cities are not only facing an increased influx of people, but they also have to find solutions to many of its consequences: lack of infrastructure, housing shortage and massive amounts of unclean water. For the urban poor, having access to drinking water cannot be equated with access to safe drinking water. On a yearly basis, around 300,000 children worldwide die because of water-borne illnesses.

Splash, a global nonprofit, is committed to creating safe water, sanitation, and hygiene (WASH) programs for school children across India, South East Asia and Africa by supplying handwashing stations  and clean water fountains educating children on hygiene behaviors and driving policy and infrastructure changes in schools, orphanages and local governments.

In October 2017, Splash convened its first of two Behavior Change Summits. Together with other experts, Ting Jiang, Principal of CAH’s Global Health and Development team, and David Neal, Executive in Residence, provided ideas on behavior-based interventions that would maximize Splash’s impact.

Our team contributed to two main ideas to improve the rate of students washing their hands with soap after using the toilet. First developed by Robert Dreibelbis, the team  built on the idea of painting colorful footsteps on bathroom floors that lead children from the toilet to the handwashing stations. Kids like to play, and colorful footsteps are a fun way to get them to walk to the handwashing stations. The footsteps also provide an immediate visual cue to remind kids to wash, thus helping to overcome the “intention behavior gap.”

Second, inspired by the Kenyan handwashing station Mrembro, CAH suggested the addition of mirrors above handwashing stations. Though they are not prevalent in many households, mirrors are an exciting object that attracts the attention of many children. Once drawn to the mirror by curiosity, they will remember to wash their hands. Repeating this behavior of going to the toilet and being drawn to the handwashing station by either footsteps or the mirror, will eventually instill a ritual of handwashing behavior in the children.  This idea builds on the concept of a “Trojan horse” – that is, a product feature that is intrinsically rewarding (the mirror) and triggers people to interact with a product, where they are then more likely to perform the real, intended behavior (washing their hands).

Based on CAH’s contribution to the experimental design, both the footsteps and the mirror idea were field-tested in the months to follow the summit.

Nina Bartmann, Behavioral Researcher at CAH, and David Neal, Executive in Residence at CAH, attended the second Behavior Change Summit in July 2018, at which Splash presented preliminary results from Addis Ababa, Ethiopia. According to this pilot, the mirror intervention increased the percentage of students who washed both hands with water and soap after using the toilet from 25% to 62%, where as the footsteps only increase handwashing behavior from 27% to 29%. However, certain logistical challenges may have limited the impact of the painted footsteps (finding local paint products that could sustain heavy foot-traffic in the school environment).

Lastly, over the course of both Behavior Change Summits, CAH also contributed to Splash’s overall Behavior Change Strategy. In particular, we focused on how to address the intention-behavior gap and how to incorporate habit change into their model. The intention-behavior gap is a common phenomenon where one has an intention to act (e.g., to wash their hands regularly) but tends to forget or be disrupted in following through on that intention.

The results presented at the second Behavior Change Summit speak for itself: Splash is not only successfully delivering hardware that allows for handwashing, but is also able to influence children’s behavior by incorporating behavioral science principles. We are confident that through the use of evidence-based interventions we can effectively change behavior that would further prevent death caused by water-borne illnesses.

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Together with the Joep Lange Institute and the Amsterdam Health and Technology Institute (AHTI), the Global team hosted a workshop titled “A healthier, wealthier Africa: Behavioural science, digital innovation, and beyond” on August 8th, at Strathmore University.

The workshop speakers brought a range of experiences in entrepreneurship, academia, experimental design, and change leadership to talks and a panel exploring what behaviorally informed-solutions for financial inclusion, wellness, and poverty alleviation can look like now and in the future.

The event built on increasing recognition of the importance of embedding behavioural science into designing for impact, and was an example of how international partnerships are approaching conversations around innovations in fighting poverty and healthcare financing.

Dan Ariely commented about this event:

“In general we make lots of attempts to try and get people to behave in a way that is in their own long term best interests, but when we make these attempts without understanding the true nature of human behaviour, these attempts are very likely to fail. This is the same for human beings across the world, from East Africa to Europe or the US. What behavioural economics gives us is a true foundation to understanding what really drives behaviour. With plans for Universal Health Coverage, Kenya is at an important juncture in making progress toward health and wellness. When we create interventions with behavioural economics incorporated, we are much more likely to succeed, so I’m excited about the conversations happening in Nairobi and across the continent, now and into the future.”

The following are 4 key takeaways from the presentations:

• Behavioral Science has the potential to bridge the intention-behavior gap.

Principal of Global Health and Development, Ting Jiang, gave examples of how behavioral science can save lives by enabling practitioners to make more accurate problem diagnoses and apply BE informed interventions that bridge the gap between intention and behavior.

• Digital Innovation can help improve the mental health of a population

With lack of access, price, and stigma as the leading roadblocks to accessing mental health services in Kenya, Alex Royea gave an excellent presentation on how Amka Life is using bots to make mental health services more accessible. You can read more on this from his presentation:  Using Bots and Tech to Scale Mental Health Solutions.

• Experimental design is extremely important to Behavioral Science

David Clarance painted a clear picture of the importance of testing Behavioral Science solutions based on previous research. You can read more on this from his presentation: Experiment Design in Practice.

• Implementing sustainable healthcare solutions in action

Access Afya runs low-cost, affordable clinics within Nairobi tailored for the global mass market. The organization also sells health subscriptions to factories and schools. On the other hand, ahti supports entrepreneurs, both start-ups and scale-ups, to generate solutions for better health, care, and costs by providing hands-on mentorship and access to their extensive network of healthcare institutions. You can read more on these in Melissa Menke’s and Laurens Van Hoorn’s presentations.

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This question is important for those promoting giving in part because of a human bias – the fundamental attribution error (i.e., over-attributing intentions to others’ behavior; assuming that people actively chose not to give rather than assuming that they intended to, but never got around to it). This human bias might lead us to focus too much on increasing the intention to give without paying sufficient attention to the intention-behavior gap in giving. As a result, we could end up effectively wasting the intention to give, and ignoring the importance of helping people actually implement the act of giving. The good news is, especially for those dedicated to promoting doing good, the pitfall of under-estimating individuals’ willingness to give and over-estimating the success of their acting on their good intentions, lends itself to some great opportunities to promote giving.

When we examine our own giving behavior, we may soon discover that we are more generous in our intention to give than in our actual giving behavior. In other words, like many of our intentions, such as attempting to exercise more or eat less, we often don’t do it as much as we say we’d like to, even in the domain of charitable giving – while Americans give 3% of their income on average, they believe that one should give 6%. In addition, research conducted by CAH’s own Ari Kagan and Nick Fitz found that 85% of people reported not giving as much as they would’ve liked. In fact, they wanted to give 2.5 times more, on average. Who would’ve thought?

Needless to say, it’s easier to recognize the intention-behavior gap in behaviors that benefit ourselves, like cutting down on late-night snacks, than behaviors that benefit others (at least for those economists who still deeply believe that humans are self-regarding by nature). And let’s admit it, the intention-behavior gap is probably smaller in giving than in living healthily. Nevertheless, the gap is there. Increasingly more research shows that giving has a positive impact on happiness, and that people generally report giving less than they intended to.

Are there reasons to assume that the giving behavior is deterred by implementation barriers besides monetary constraints? Here are two examples of potential barriers:

Forgetfulness

Sometimes, we simply forget to donate. It’s hard for us to keep track of all the things we intend to do, and we end up focusing on urgent tasks, while postponing those that don’t have strict deadlines – charitable donation is no exception. Indirect evidence of this is that many people end up donating close to the end of the year for tax exemption reasons, but not before. We sometimes forget about our good intentions, and only remember them when we are prompted by the holidays and end-of-the-year tax exemption or fundraising campaigns. But with many other deadlines to meet at the end of the year, it’s easy for the deadline of giving to be moved to the bottom of the priority list, even though it may be on top of our mind, and we end up only partially meeting our donation goals.

Choice Overload

The tendency to experience “choice overload” is illustrated by a well-known study in behavioral economics conducted by Iyengar and Lepper. In this experiment, shoppers were either exposed to a display of 24 jams or a display of 8 jams. They were free to test and/or purchase as many as they liked. Although more people stopped to look at the 24-jam display, shoppers were one-tenth as likely to buy as people who saw the 8-jam display. Choice overload also affects the charitable giving industry. There are over 1 million registered charities in the U.S. alone, serving myriad causes. As illustrated in the jam study example, even though we often believe that more choice is better, this is not the case. In the presence of so many choices, we procrastinate, fearing that we won’t be making a good decision or pick the right charities.

Remedies to bridge the intention-behavior gap in giving

Fortunately, there are remedies to combat the behavioral barriers underlying the intention-behavior gap of charitable giving. For instance, to combat forgetfulness, it would be useful to introduce charitable appeals when donors are likely to have the time and energy to respond right away (think lunchtime, weekends, or after-work hours) so that they don’t forget later. In addition, when we get a chance to email potential donors, instead of appealing to their motive to give as usual, consider sending just a gentle reminder of their intent to give instead.

To combat choice overload and help prospective donors choose which charities to support, direct potential donors to sites like GiveWell, which keep a ranking of the most effective charities, and offer to allocate users’ donations to the most effective causes. Narrowing down donors’ choices makes giving relatively hassle-free and may galvanize more people to action.

Lastly, recognizing the intention-behavior gap in giving doesn’t mean that there is no room for increasing the intention to give – there are definitely barriers that affect donors’ intention to give. We will dive further into these in our next post.

Giving money to charity is one thing that most of us can probably agree is a good thing. But, like many of our intentions to be healthier and happier, we often don’t do it as much as we say we’d like to. Though Americans give more money to charitable causes than people in most other countries, we still give less, on average, than we think we should.

The key takeaway is that there are ample opportunities to promote giving through bridging potential donors’ intention-behavior gap. In doing so, we can avoid wasting the good intention inherent in humans, as well as the good intention many charitable organizations work hard to create.

References

Croson, R., Handy, F., & Shang, J. (2009). Keeping up with the Joneses: The relationship of perceived social norms, social information, and charitable giving. Nonprofit Management & Leadership, 19(4). doi: 10.1002/nml.232

Davis, K., Kim, A., & Warren, A. (2016). Is there a $250 billion gap in charitable giving in the US? Retrieved from: http://www.ideas42.org/blog/250-billion-gap-charitable-giving-u-s/

Dunn, E. W., Aknin, L. B., & Norton, M. I. (2008). Spending money on others promotes happiness. Science, 319, 1687-1688.

Iyengar, S. S., & Lepper, M. R. (2000). When choice is demotivating: Can one desire too much of a good thing? Journal of Personality and Social Psychology, 79(6), 995-1006.

doi: 10.1037//0022-3514.79.6.995

Philanthropy Roundtable. (n.d.). Statistics on US Generosity. Retrieved from: http://www.philanthropyroundtable.org/almanac/statistics/

Ross, L. (1977). The intuitive psychologist and his shortcomings: Distortions in the attribution process. Advances in Experimental Psychology, 10, 173-220. https://doi.org/10.1016/S0065-2601(08)60357-3

Sheeran, P., & Webb, T. L. (2016). The intention-behavior gap. Social and Personality Psychology Compass, 10(9), 503-518. doi: 10.1111/spc3.12265

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