Harnessing the power of emotional drivers to promote behaviour change
Authors: Peter J Winch, Elizabeth D Thomas
Journal: The Lancet Global Health (2016)

Efforts 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.1Briscoe C Aboud F Behaviour change communication targeting four health behaviours in developing countries: a review of change techniques.Soc Sci Med. 2012; 75: 612-621Crossref PubMed Scopus (97) Google Scholar, 2Elder JP Pequegnat W Ahmed S et al.Caregiver behavior change for child survival and development in low- and middle-income countries: an examination of the evidence.J Health Commun. 2014; 19: 25-66Crossref PubMed Scopus (19) Google Scholar One long-standing concern is the limited effectiveness of many behaviour change interventions, even when exposure to intervention activities is adequate, and activities are implemented with high fidelity.3Breitenstein SM Gross D Garvey CA Hill C Fogg L Resnick B Implementation fidelity in community-based interventions.Res Nurs Health. 2010; 33: 164-173PubMed Google Scholar A second concern is low coverage of proven behaviour change interventions, under conditions of routine programme implementation.2Elder JP Pequegnat W Ahmed S et al.Caregiver behavior change for child survival and development in low- and middle-income countries: an examination of the evidence.J Health Commun. 2014; 19: 25-66Crossref PubMed Scopus (19) Google Scholar 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.4Luby SP Is targeting access to sanitation enough?.Lancet Glob Health. 2014; 2: e619-e620Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Target of emotional drivers such as affiliation (social inclusion), nurture, and disgust, has been identified as one way to increase the effectiveness of behaviour change interventions,5Aunger R Curtis V The anatomy of motivation: an evolutionary-ecological approach.Biol Theor. 2013; 8: 49-63Crossref Scopus (58) Google Scholar with disgust considered appropriate specifically for promoting avoidance of sources of infection.6Curtis V de Barra M Aunger R Disgust as an adaptive system for disease avoidance behaviour.Philos Trans R Soc Lond B Biol Sci. 2011; 366: 389Crossref PubMed Scopus (428) Google Scholar The investigation by Katie Greenland and colleagues7Greenland K Chipungu J Curtis V et al.Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: Cluster Randomised Trial.Lancet Glob Health. 2016; 4: e966-e977Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar 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 different 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 different ways.1Briscoe C Aboud F Behaviour change communication targeting four health behaviours in developing countries: a review of change techniques.Soc Sci Med. 2012; 75: 612-621Crossref PubMed Scopus (97) Google Scholar Implicit in the authors' theory of change is a concern for intervention fidelity, “the degree to which an intervention is delivered as intended”.3Breitenstein SM Gross D Garvey CA Hill C Fogg L Resnick B Implementation fidelity in community-based interventions.Res Nurs Health. 2010; 33: 164-173PubMed Google Scholar Kim and colleagues8Kim SS Ali D Kennedy A et al.Assessing implementation fidelity of a community-based infant and young child feeding intervention in Ethiopia identifies delivery challenges that limit reach to communities: a mixed-method process evaluation study.BMC Public Health. 2015; 15: 316Crossref PubMed Scopus (46) Google Scholar identify four aspects of implementation fidelity that warrant attention in a community based study: adherence, dosage and exposure, quality of delivery, and participant responsiveness. Greenland and colleagues7Greenland K Chipungu J Curtis V et al.Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: Cluster Randomised Trial.Lancet Glob Health. 2016; 4: e966-e977Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar 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 sufficient degree as so to elicit a behavioural response. The concept of sufficient quantities is crucial for interventions targeting emotions such as disgust. Nicholson and colleagues9Nicholson E Barnes-Holmes D Developing an implicit measure of disgust propensity and disgust sensitivity: examining the role of implicit disgust propensity and sensitivity in obsessive-compulsive tendencies.J Behav Ther Exp Psychiatry. 2012; 43: 922-930Crossref PubMed Scopus (69) Google Scholar indicate that it is not necessarily an individual's tendency (propensity) to feel disgusted that leads to effects on behaviour, but rather the degree (sensitivity) to which that disgust is felt. Greenland and colleagues present no data on intervention fidelity in this paper, so we cannot judge if this study constitutes a fair test of the effectiveness 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 effectiveness of the intervention, or insufficient exposure to intervention activities for change to occur.4Luby SP Is targeting access to sanitation enough?.Lancet Glob Health. 2014; 2: e619-e620Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar 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.10Victora CG Barros AJD Axelson H et al.How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.Lancet. 2012; 380: 1149-1156Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar 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 differentials in wealth, education or access to information between the high-exposure and low-exposure clusters. If such differentials do exist, then they may explain the better results in the high exposure clusters. Reaching the poorest and the marginalised, and delivering behaviour change interventions with high quality and intervention fidelity, is a crucial challenge for the field of implementation science, particularly in low-density rural populations in Africa.2Elder JP Pequegnat W Ahmed S et al.Caregiver behavior change for child survival and development in low- and middle-income countries: an examination of the evidence.J Health Commun. 2014; 19: 25-66Crossref PubMed Scopus (19) Google Scholar Target of emotional drivers of preventive and treatment behaviours is a promising avenue for increasing the effectiveness of behaviour change interventions.5Aunger R Curtis V The anatomy of motivation: an evolutionary-ecological approach.Biol Theor. 2013; 8: 49-63Crossref Scopus (58) Google Scholar, 6Curtis V de Barra M Aunger R Disgust as an adaptive system for disease avoidance behaviour.Philos Trans R Soc Lond B Biol Sci. 2011; 366: 389Crossref PubMed Scopus (428) Google Scholar More research is needed on how to best operationalise interventions based on emotional drivers in routine programmatic settings, how to measure the different aspects of intervention fidelity in community-based interventions,3Breitenstein SM Gross D Garvey CA Hill C Fogg L Resnick B Implementation fidelity in community-based interventions.Res Nurs Health. 2010; 33: 164-173PubMed Google Scholar, 8Kim SS Ali D Kennedy A et al.Assessing implementation fidelity of a community-based infant and young child feeding intervention in Ethiopia identifies delivery challenges that limit reach to communities: a mixed-method process evaluation study.BMC Public Health. 2015; 15: 316Crossref PubMed Scopus (46) Google Scholar and how to achieve high coverage and quality among the poorest and most vulnerable members of a population. Furthermore, future research should examine whether different emotional drivers warrant effort and emphasis within the intervention package, depending on the specific behaviours promoted and their characteristics: habitual versus occasional, and preventive versus treatment-related. We declare no competing interests. Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: a cluster randomised trialThe intervention may have improved exclusive breastfeeding (assessed by self-reporting), but intervention effects were diluted in clusters with low exposure. Complex caregiver practices can improve through interventions built around human motives, but these must be implemented more intensely. Full-Text PDF Open AccessHarnessing the power of emotional drivers to promote behaviour change – Authors' ReplyI thank Peter Winch and Elizabeth Thomas for their thoughtful letter1 concerning our trial2 in The Lancet Global Health and for highlighting the profound challenges associated with changing multiple behaviours in public health interventions. To improve the effectiveness of public health strategies, we need more innovative behaviour change interventions that undergo rigorous evaluation3,4 and more debate about what works, what doesn't, and why. It is thus vital that reports of trial outcomes be accompanied by detailed exploration of the reasons for the outcomes in the study context. Full-Text PDF Open Access