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The challenge of behavior change

Blog Post3 min read

Today's blog post is a double-header. First up is a video sent to me by Michael Geruso, a health economics professor at UT Austin and a member of rice's board of directors. It was made by the Rockefeller Foundation around 1910 or so to promote their hookworm eradication efforts. It's not a talkie, but it speaks loudly about how long people have been working hard on the problem of fecal pathogens.

I have also been thinking about a recent research paper by Rema Hanna, Esther Duflo, and Michael Greenstone. They report a randomized controlled trial of a program to promote use of improved cooking stoves in Orissa, India, a poor state. Smoke from burning traditional solid fuels like wood or cow dung is terrible for the health of the women cooking and their children who are often nearby.

Many social programs, therefore, have distributed and promoted improved, healthier cook stoves throughout the developing world. The economist authors of this study dialogue extensively in their paper with medical and epidemiological studies, which have generally found large effects on health of improved stoves, when tested in carefully controlled conditions.

Four years out from the stoves’ initial distribution, however, this study finds no health benefits. But there is no paradox here: people simply weren’t using the stoves. Many never did, others used them alongside traditional stoves, and many more did not maintain their new stoves or fix them when, like everything does, they needed routine repairs.

The authors' conclusions are worth quoting at length: “This study shows that relatively inexpensive stoves, used under real world conditions, had limited long-run impacts. The stoves reduced smoke exposure for the primary cook in the household in the first year of the study, but after normal use, they subsequently had no discernible effect on exposure. The declining effect appears to be the result of stove breakages combined with insufficient investments in maintenance, reductions in the number of meals cooked with good stoves, and inappropriate use. We found no observable effects on health, even in the early years. While households overwhelmingly claimed that the stoves used less wood, fuel use remained unchanged, and if anything, somewhat increased. The lack of obvious benefits may explain why households were not interested in using the stoves optimally.

“More broadly, this study illustrates that it is critical to allow for household behavior when evaluating health and environmental technologies. Laboratory and laboratory-style field studies are important for understanding the best case scenario for a technology. However, all technologies must ultimately be used by humans who reveal their valuations through their usage and maintenance decisions."

What is striking about this conclusion is how readily it could also apply to latrines: they are great for children’s health if people use them, but not if they don’t, and all too often that is the case. The real challenge is often behavior change, and this is not easy.

These days, many economists – myself included – are fascinated by what might be possible for smart social programs to accomplish by using insights from psychology or behavioral economics. This is the “nudge” agenda: that little psychological tweaks – like making signing up for being an organ donor the default, or putting fruit near the cash register instead of candy – can help us do things that are good for us, and that in some sense we really want ourselves to do. Indeed, proponents call the idea “libertarian paternalism” because it is supposed to help people promote their own best interests, often as they would themselves recognize them.

But I am not immediately thinking of any examples of such psychological “light touches” that substantially shifted people towards doing something that they really don’t want to do. [Behavioral economist readers, am I missing something? Perhaps some forms of tax policy?] Certainly people can be manipulated and induced by a variety of less light means to change their behavior. But can we “nudge” people to do something that they are pretty sure is a bad idea? If people don’t use free improved stoves because they think the old way is better, if people think that defecating in the open is good for their health, is there a shortcut to the hard work of changing their minds?

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r.i.c.e. is a non-profit research organization focused on health and well-being in India. Our core focus is on children in rural north India. Our research studies health care at the start of life, sanitation, air pollution, maternal health, social inequality, and other dimensions of population-level social wellbeing.

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