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The need for behaviour change programmes

VAL CURTIS: Hi there. My name is Val Curtis, and I’m director of the Environmental Health Group at the London School of Hygiene and Tropical Medicine. And I work mostly on trying to change people’s behaviour, whether it’s for public health, for exercise, for nutrition, or indeed for vector control. So I’m sure you’ll agree with me, getting people to change their behaviour is extremely easy. All you have to do is say, well, sleep under a bed net and you won’t get malaria. Wash your hands with soap, you won’t get sick. So if I said to you, you should eat less, it’s better for your health, or you should exercise more, you’ll do it, right? Because we all know it’s good for us.
Well, unfortunately, it’s not that simple. Education is not necessarily the best way to get people to change behaviour. The sort of approaches that you’ll be used to seeing in vector control, where we load people with information, they may help, but they’re hardly likely to get people to change behaviour. Why not? Well, everybody has their reasons why they don’t do what they know is good for them. For example, it might be too hot to sleep under a net. Maybe I get sick occasionally, but malaria, nah. And even if I do get it, it doesn’t really matter.
If I instal a bed net, maybe– gosh, that’s a hell of a lot of extra work I’m going to have to do to clean the net and mend it when it gets torn, for example. Maybe the net– maybe my kids sleep on the floor, and a net doesn’t work sleeping on the floor. There’s nowhere to tuck it in, for example. Or maybe you’re just not paying any attention to me as I’m telling you to sleep under a bed net, because I’ve heard it all before. It’s boring. There’s nothing surprising about what you’re telling me. And I’m not going to change my behaviour. So what I wanted to introduce to you is an approach which we call behaviour centred design.
It’s a systematic approach to getting people to change their behaviour. So if you think about it, what we’re trying to do is change the state of the world, for example, trying to get people to avoid the diseases that are caused by vectors. That is going to involve changing a lot of behaviour by a lot of people. How are we going to do that? Well, all of those people who need to change their behaviour, somehow we’ve got to get into their brains. Make them feel that this is something they want to get up in the morning and do. How are we going to do that? Well, we can’t do it directly. We can’t plug ourselves into their brains.
All we can do is change the world around them by changing the information that they get, or changing indeed the behaviour setting in which they are. So maybe we need to get involved with what they do at bed time. What is happening? Who’s playing what role? On what stage? With what props? Following what social norms? Using what competency? Those are all the factors that keep our routine behaviour on rails and make it very hard to disrupt it. So we need to understand those things.
If we can understand all those things, then maybe, if we’re very clever, we can design an intervention that will change the environment, that will make people want to change their behaviour, which will mean they will change their behaviour, which means we will conquer disease or whatever it is that we’re trying to achieve through a behaviour change programme. So that all sounds very logical, very simple. Well, of course, how are we going to actually do that? Well, we need to know a lot more about environments, brains, and behaviour to do that. How are we going to do that? We’ve got a simple process which we call the ABCDE of behaviour centred design. A is assess.
We need to know everything that people already know about how to change behaviour, programmes that have been successful in the past. But mostly, we won’t find all the answers in the literature and in experts. We need to go to the field and do the build step. That is, we need to find out exactly what these environments are, find out what people’s evening routines are before they go to bed, and describe the setting in which those take place. With those, we can build a theory of change, which will help us design an intervention that will allow this cascade of events to happen.
And what we do is we work with commercial creative agencies because we aren’t creative enough to come up with approaches that really work, approaches that are surprising enough to get people’s attention, tell them something they don’t know, approaches that revalue, make the behaviour that we want people to do so valuable that they actually want to do it, something they really care about, and feel emotionally that they want to do it. And something that makes it easy for them to perform the behaviour. Now, if we can do all that, deliver an intervention that does that, and evaluate it, we can find out whether it’s really worked to change behaviour.
And that information goes back into the next cycle of assess and build. So OK, that’s quite a lot for a very short presentation. Three things I want you to remember, three key things. If we can surprise people, if we can make the behaviour something that they really value, and care about, want to do, and if we make it easy, so that the behaviour can be performed, then we stand a good chance of changing behaviour. So let me just give you some examples that I’ve pulled out from a troll of the Internet of surprising reevaluating and performance enhancing interventions in the domain of mosquito control. Surprise, reevaluation, performance.
Here’s an ad campaign for an insect repellent. Look at the picture for a minute. Is it surprising? It’s certainly puzzling. Does it get your attention? You’re going, hang on a minute, there should be a child here. Where’s the child gone? And then you read the slogan, switch to invisible mode. You stop and think about it for a while, and you think, hang on a minute. What is this telling me? Aha, it must be about the mosquito repellent is making me invisible to mosquitoes. So at least an ad that’s distracting and attention grabbing, maybe get us to change our behaviour. What about reevaluation? Well luckily, there’s a toolkit of values we can use to apply to our interventions.
There’s 15 human motives. We all fear accidents. We all are disgusted by things that might make a sick. We all get hungry when we haven’t eaten for a while. We all like to be in a comfortable environment. We all, at least most of us, depending what age we are, have a healthy proclivity for the opposite sex or whatever. We all want to create a world that’s better, in which we can love our partners, in which we can nurture our children, in which we can get all the stuff we want so that we can make the environment a better place to do all of this stuff in.
And so that we can be attractive, so that we can get mates, et cetera. We all want to have the best status we can achieve so that gives us power to achieve the things we want to achieve in our life. Most of us care deeply about a world that is more just and we’ll fight for it. And most of us want to improve our brains as well. We’re curious. If your scientists like me, this is one thing that drives you. And we want to play with things. We want to find out how they work so that we can use them another time.
So we all have motives that make our bodies work better, that make our world work better for us, and make our brains work better for us. So we can use these motives. How can we use these for mosquito repellents, for example? So here’s an ad for a product that gives you smoother skin and at the same time it has a repellent in it. What happens? It makes you more attractive because your skin is so smooth that even mosquitoes skid about out on it. What about this one? This is talking to doctors. And it’s saying to the doctors, release your patients from malaria.
And if you look, you see it’s made up of disgusting, horrible, handcuffs made out of lots, and lots, and lots of mosquitoes. So we’re talking here about comfort, about giving your patients a better world that’s without malaria. And here’s another intervention, somewhat surprising because you see an insect on the top of a– you see a large insect on top of an ad, which is not something you would normally see. Is it fear? Is it nurture? I think what this is mostly– it says comfort here, but this is mostly here’s a way of protecting your child from the sickness that’s caused by insects. The third one is performance. Let’s make it easy.
Let’s have products that make it possible for people to avoid disease more easily. So a button you put on a child. A mosquito repellent that you roll on and you can carry around with you. A set off clothes that are attractive and at the same time, they keep your kids safe from malaria. What can we conclude? We want to get people to change their behaviour. First of all, we need to understand that behaviour. And we do that by assessing a building. And then we work with creative folk to come up with interventions that bring to life those ideas of surprise, reevaluation, and performance. We’re not talking about education. We’re talking, people mostly know what they need to do.
We have to move them. And we do that through motives, through emotion. And like I said, there’s three things– there’s one thing I want you to take away, is these three things. An intervention should be surprising, not boring, get people’s attention, and tell them something they don’t know. It should revalue– make people want to do it because of motives and emotions. And it should make it easier. So we should think more about the products and the environment in which people behave, and see if we can modify and disrupt those, so that people actually take up those behaviours. If you want more materials on behaviour centred design and other approaches to changing behaviour, there’s a lot of stuff on our website.
And if you follow me on Twitter, you’ll find I keep talking about these issues. So great talking to you today. Thanks very much. Goodbye.

Changing peoples’ behaviour surrounding vectors (such as usage of bed nets and application of topical repellents) is a vital aspect in the control of vector borne diseases. Professor Val Curtis is the Director of the Environmental Health Group at LSHTM, a multidisciplinary group researching hygiene, sanitation and water (WASH). Trained in engineering, epidemiology and anthropology, she studies human behaviour from an evolutionary perspective.

Professor Curtis will discuss behaviour change programmes, the need for them, and the challenges they face.

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