Behavioural Nudges for better health and hygiene practices in rural Bangladesh (Part 1)
THE PROTOTYPING PROCESS
In January 2021, Jeeon and BRAC SIL jointly took an initiative under the Hygiene Behaviour Change Coalition (HBCC) to test out a series of nudges in rural Bangladesh to improve the health and hygiene practices (especially with regards to covid-19) of the rural populace. As the first-point-of-care for over 70% of the country’s population, informal health providers like village doctors, pharmacists/chemists, etc. hold tremendous influence over their communities and clientele when it comes to health information and advice and present a prime opportunity to affect health and hygiene behaviour. As such, we prototyped and tested out a series of “nudges” that leverage pharmacies and medicine shops to promote healthy behaviours with regards to (a) hand hygiene, (b) mask use and respiratory hygiene, and (c) social distancing.
WHAT ARE NUDGES?
While the idea of nudges have been around for some time, it was popularised in recent times by Richard Thaler and Cass Sunstein in their 2008 book Nudge: Improving Decisions About Health, Wealth, and Happiness. The following excerpt from their book explains it well:
A nudge, […] is any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates. Putting fruit at eye level counts as a nudge. Banning junk food does not.
Reference: Thaler, Richard, and Cass Sunstein (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. Penguin Books.
DESIGN PHASE
The Nudge prototyping exercise started on the 22nd of November 2020 with an organisation wide idea generation week within Jeeon. The week was kicked off with a primer on nudges which included a brief theoretical discussion and a much longer conversation around 10 examples of successful nudges across the world. Everyone was then given a couple of days to come up with ideas for nudges that we may test out. Field staff were especially encouraged to participate. They were also instructed to speak to pharmacies and village doctors first so as to incorporate any ideas that may be suggested by our target group.
We curated over 50 ideas which were then shortlisted to 13 ideas (based on a scored evaluation of novelty, feasibility, and our ability to successfully execute and evaluate). These 13 ideas were then further narrowed down to the top 5 ideas which were then fleshed out with operational details and discussed with pharmacists and village doctors through (a) our field staff and a (b) one day field research visit from the head office. Based on the findings, the ideas were once again iterated after which we created the communication materials. Once again the designs were verified in the field through our field staff and minor iterations were made to the language and designs. During this time, we also presented the designs to the BRAC team and incorporated their feedback into the designs. The prototype designs were finalised on 28 Dec 2020 and after printing and couriering the materials to our test site, field implementation began on the 3rd of January 2021 in the Netrokana and Sherpur.
The final designs of the nudge prototypes are given below
Objective: Making general people (customers) in a pharmacy maintain social distancing while purchasing drugs or getting treatment.
Idea 1: Have ribbons with decals indicating the standing position for customers in front of the shop to encourage social distancing between customers as they wait in line.
Objective: Educating customers on how to wear a mask effectively by providing a timely message
Idea 2: Provide guidelines on proper mask usage along with the mask so that a wearer sees the message just before putting on the mask. Each mask will be inside a printed envelope for sale. The envelope will be printed with the 6 messages on how to wear the mask correctly. If this succeeds, this messaging may be printed inside the mask for cost effectiveness.
Objective: Reminding general people to wash their hands when they enter their houses and to wear a mask and maintain social distancing when they go out of their houses.
Idea 3: Posters for Pharmacist to give to customers put at the entryway to their homes and remind residents about (a) hand-washing before entering house and (b) social distancing and (c) mask user when leaving the house.
Objective: Provide relevant hygiene messages to people at the right time (while travelling or just after having reached home) so as to maximise the chances of acting upon the message.
Idea 4: Print hygiene messages on the packets/envelopes in which customers carry their purchased medicines home so that they are exposed the to message at the right time (while travelling or just after having reached home)
Objective: Using the space around a pharmacy to deliver positively and negatively reinforcing messaging on mask use.
Idea 5: Behavior reinforcement messages painted on mirrors that are placed strategically on opposing sides of the counter at the pharmacy. The pharmacist will be instructed to request customers to stand on the relevant side of the counter depending on whether they are wearing a mask or not.
Of these 5 prototypes, we found success with 3 of them. The table below summarises our results.
