Saving Lives By Closing the Intention-Action Gap

This is the third article in a three-part series about applying behavioral science in the context of international development, with a focus on the ways good intentions can go amiss, the pitfalls of misperceptions, and lessons from designing and implementing interventions in the field. Click here to read part one and part two.

I, Crawford, have a number of prolapsed discs in my back. I could tell you all the reasons why I must do the ten physio exercises every day and how they are proven to be good for me. But guess what? That doesn’t mean the physio gets done.

We all know we should be doing all manner of things—from doing our physio to getting daily exercise to flossing our teeth. Ask most people why they should do any of the above and they’ll almost certainly cite all the textbook proven reasons, like me—yet still struggle to do them. Behavioral scientists call this the intention-behavior or intention-action gap—when we have every intention of doing something with the knowledge and understanding of why to back it up, yet somehow it never happens.

Failing to close the gap between intention and action is frustrating at best. For Crawford’s back, it’s painful. But for sanitation and health behaviors, it can be fatal.

Failing to close the gap between intention and action is frustrating at best. For sanitation and health behaviors, it can be fatal.

Treating drinking water and proper hand-washing are two examples. We have the technology, understand the importance of it, but people still fail to follow through. This is particularly the case in developing parts of the world, where infrastructure around water and sewer systems is often lacking. Two recent interventions show how a behaviorally-informed approach can help close the intention-action gap for these two behaviors—improving health and saving lives.

Clean water using behavior-led design

One of the most important priorities in developing countries is access to safe drinking water. Yet, around the world, over 785 million people lack such access, putting them at risk of contracting a number of waterborne diseases, such as cholera, numerous worm diseases, typhoid, and dysentery. Making drinking water safe can also help prevent diarrhea, which is a leading cause of death among children under five years of age.

One of the simplest and cost-effective ways to ensure safe drinking water is by encouraging communities to treat their water with chlorine. The most common approach to chlorination in areas without piped water infrastructure is to offer small bottles of chlorine for sale or sometimes even for free to households. However, only around 10 percent of households regularly use them. Adoption tends to be poor as people forget to use them or aren’t sure how to use them—a classic example of the intention-action gap.

A few years ago, a team from Innovations for Poverty Action led by behavioral scientist Michael Kremer took a behavioral approach in order to devise a solution. The two barriers outlined above each signal a way to design for this problem. First, an effective solution would need to help communities embed chlorine use into their daily habitual routines. Second, the chlorine needed to be much easier and simpler for people to use than the existing bottles provided to households.

Through their work, they discovered that one of the most effective ways to promote use of chlorine purification was to install a dispenser at the local community water source—tying into the new purification behavior to the well-embedded routine of collecting water. Research into how to build a new habit consistently shows that one of the most crucial elements is a stable context or environment in which to embed the new behavior. A second finding is that integrating a new behavior into an existing habitual routine, sometimes called ‘piggybacking’, can be extremely effective.

The positioning of the dispenser at the local community tap also had further influences on behavior; it created an immediate social reward for using chlorine. Later iterations of the design also made it more salient. A bright blue dispenser provided a daily visual reminder to treat water at the point of collection, helping to make it something that was easily remembered rather than easily forgotten. The location of the dispenser also made it the most effective for treatment because the required agitation and wait time for chlorine-treated water are at least partially accomplished automatically during people’s walk home from the water point. And the sometimes off-putting smell is also gone by the time they get home.

One final, but significant design feature is that a single unit of chlorine dispensed from the unit (the default) is enough to treat the standard water container in the community. Villagers place their bucket or jerrican under the dispenser and turn the valve once to dispense a correctly measured amount of diluted chlorine. This makes it even easier to use, removing any need for calculating and measuring and solves the second barrier highlighted above, as some households were unsure how to use the bottles of chlorine they were given.

An initial randomized controlled trial in Western Kenya found that 50 to 61 percent of households with access to the public dispensers adopted the water treatment, compared with only 6 to 14 percent in the control group—an impact which was sustained over the course of two years from the installation of the dispensers. The organization Evidence Action has since been scaling up this solution, installing more than 27,000 dispensers across Kenya, Malawi, and Uganda, providing access to clean water for 4 million people. Usage rates are comparable to the initial trial, at over 50 percent—a considerable success.

Clean hands from “super mothers”

Equally important to health and sanitation as safe drinking water is hand-washing with soap. Many organizations have tended to provide information and education via mass media campaigns. These campaigns generally assume that building knowledge and changing attitudes is enough to spur behavior change in communities where there is next to no practice of hand-washing with soap. Yet these initiatives rarely have any long-lasting effect. The knowledge and understanding may have improved, but the action is still missing.

However, recent behaviorally-focused interventions, designed to overcome the intention-behavior gap, have had more promising impacts.

The SuperAmma campaign (meaning “super mother”) was a project aimed at reducing child mortality caused by diarrheal diseases in a region of rural India, by improving hand-washing with soap. Funded by The Wellcome Trust it was designed and implemented by a team at the London School of Hygiene and Tropical Medicine a few years ago.

Hand-washing with soap was almost non-existent in villages in this region in southern India: only around one to two percent of the population washed their hands with soap at the four key occasions recognized as key to improving health—before eating, after defecation (themselves and cleaning up a child), and before preparing food. In fact, the proportion of soap use at any time hands were washed was only one in five.

Image: SuperAmma Campaign

Hand-washing with soap is a habitual behavior that is ingrained at a young age by the main carer—typically the mother of the child in these societies. Given this, the team decided to focus on the mother as a mechanism for behavior change in the household and wider community. Mothers want to nurture their children as well as they can, and it is also expected of them by society and is something on which they can be judged. The campaign decided to tap into these motivating factors to help improve hand-washing.

They outlined the following statement as the central message to be communicated to the target population of mothers:

“Very good mothers—SuperMothers—are those who instill hygienic habits, particularly hand-washing with soap, in their offspring, e.g. via calling them ‘good manners’ which relates back to the feeling of disgust.”

The campaign centered around the emotive idea of nurture, motivating mothers to encourage hand-washing in their family as part of children’s good manners and a good upbringing, a behavior that any good mother promotes in her children.

This was a radically different approach to imparting hygiene knowledge to a community, yet had a strong impact. Six months after the campaign ran, people were washing their hands more often—over 37 percent of key times for hand-washing now involved hand-washing with soap. By age group, among schoolchildren, rates had increased from 32 to 51 percent, among women from 10 to 28 percent and men from 13 to 31 percent. Significantly, the cost of the intervention was just $1000 per village, much lower than most health interventions.

By shaping the design of an intervention to make it as user-friendly as possible or finding more emotive draws to do the behavior, the usual behavioral barriers can be more easily overcome, narrowing the intention-action gap. When it comes to clean water and proper sanitation, closing that gap means preventing disease and saving lives.