How to Get People Addicted to a Good Habit
Reshmaan Hussam and colleagues used
experimental interventions to determine if people could be persuaded to develop
a healthy habit. Potentially at stake: the lives of more than a million children.
years ago, Reshmaan respiratory infections.
Major health organizations have poured a lot of
money into handwashing education campaigns in the developing world, but to
little avail. Even when made aware of the importance of a simple activity, and
even when provided with free supplies, people continue to wash their hands
without soap—if they wash their hands at all.
“If you look at these public health initiatives, you see that
they are often a complicated combination of interventions: songs and dances
and plays and free soap and water dispensers,” says Hussam, an assistant
professor at Harvard Business School whose research lies at the intersection of
development, behavioral, and health economics. “Which means that when these
initiatives don’t work, nobody can say why.”
When Hussam and her fellow researchers conducted their initial
survey of several thousand rural households in West Bengal, India, they
discovered that people don’t wash their hands with soap for the same reason
most of us don’t run three miles every morning or drink eight glasses of water
every day, despite our doctors lecturing us on the benefits of cardiovascular
exercise and hydration. It’s not that we are uninformed, unable, or lazy. It’s
that we’re just not in the habit.
With that in mind, the researchers designed a field study to
understand whether handwashing with soap was indeed a habit-forming behavior,
whether people recognized it as such, whether it was possible to induce the
habit with experimental interventions, and whether the habit would continue
after the interventions ceased.
The field experiment was based on the theory of “rational
addiction.” Developed by economists Gary Becker and Kevin Murphy, the theory
posits that addictions are not necessarily irrational. Rather, people often
willingly engage in a particular behavior, despite knowing that it will
increase their desire to engage in that behavior in the future (i.e. become
“addicted”). As “rational addicts,” people can weigh the costs and benefits of
their current behavior taking into consideration its implications for the
future, and still choose to engage.
One way to test whether people are in fact “rational” about
their addictions, Hussam says,is by looking at how changes in the future cost
of the behavior affect them today. For example, if a rational addict learns
that taxes on cigarettes are going to double in six months, she may be less
likely to take up smoking today.
Hussam remains agnostic on whether the behavior of addicts (to
cigarettes, drugs, or alcohol, for example) can be fully understood by the
theory of rational addiction—“a theory that fails to explain why addicts often
regret their behavior or regard it as a mistake,” she says. But she found the
framework, which has historically been applied only to harmful behaviors, was
useful to shift into the language of positive habits.
“Habits, after all, are like a lesser form of addiction: The
more you engage in the past, the more likely you are to engage today,” she
says. “And if that’s the case, do people recognize—are they ’rational’
about—the habitual nature of good behaviors? If they aren’t, it could explain
the underinvestment in behaviors like handwashing with soap that we see. If they
are rational, it can affect the design of interventions and incentives that
policymakers can offer to encourage positive habit formation.”
The team’s experiment and findings are detailed in the paper Habit
Formation and Rational Addiction: A Field Experiment in Handwashing,
authored by Hussam; Atonu Rabbani, an associate professor at the University of
Dhaka; Giovanni Reggiani, then a doctoral student at MIT and now a consultant
at The Boston Consulting Group; and Natalia Rigol, a postdoctoral fellow at Harvard’s
T.H. Chan School of Public Health.
The handwashing experiment
In partnership with engineers at the MIT Media Lab, the
researchers designed a simple wall-mounted soap dispenser with a time-stamped
sensor hidden inside. The sensor allowed the team to determine not only how
often people were washing their hands, but also whether they were doing so
before dinnertime, critical to an effective intervention. (The idea for the
hidden sensors came from a scene in Jurassic World in which one of
the characters smuggles dinosaur embryos in a jury-rigged can of Barbasol
shaving cream.) The data gave the researchers the ability to tease apart
behavioral mechanisms in a way that earlier work (which often used self-reports
or surveyor observations of hand hygiene) could not do.
The researchers were also mindful about which type of soap to
use in the dispensers. Through pilot tests, they found that people preferred
foam, for example. “They didn’t feel as clean when the soap wasn’t foamy,”
Hussam says.
And because all people in the experiment ate meals with their
hands, they were turned off by heavily perfumed soap, which interfered with the
taste of their food. So the experiment avoided strongly scented soap. That
said, “we preserved some scent, as the olfactory system is a powerful sensory
source of both memory and pleasure and thus easily embedded into the habit
loop,” the researchers explain in the paper.
The experiment included 3,763 young children and their parents
in 2,943 households across 105 villages in the Birbhum District of West Bengal,
where women traditionally manage both cooking and childcare. A survey showed
that 79 percent of mothers in the sample could articulate, without being
prompted, that the purpose of soap is to kill germs. But while more than 96
percent reported rinsing their hands with water before cooking and eating, only
8 percent said they used soap before cooking and only 14 percent before eating.
(Hussam contends that these low numbers are almost certainly overestimates, as
they were self-reported.) Some 57 percent of the respondents reported that they
didn’t wash their hands with soap simply because “Obhyash nai,” which means “I
do not have the habit,” Hussam says.
Monitoring vs. offering incentives
The researchers randomly divided the villages into “monitoring”
and “incentive” villages, taking two approaches to inducing the handwashing
habit. In each experiment, there was a randomly selected control group of
households that did not receive a soap dispenser; altogether, 1,400 of the
2,943 households received dispensers.
“The monitoring experiment tried to understand the beginnings of
social norm formation: whether third-party observation through active tracking
by surveyors of handwashing behavior could increase handwashing rates, and
whether the behavior could become a habit even after the monitoring stopped,”
Hussam explains.
Among the 1,400 households that received a soap dispenser, one
group was told their handwashing would be tracked from the get-go, and that
they would receive feedback reports on their soap usage patterns. Another group
was told their behavior would be tracked in a few months, enabling a precise
test of rational habit formation—whether people would start washing their hands
now if they knew that the “value” of handwashing would increase in the future.
And another group was not told that soap use would be tracked.
The incentive experiment “tried to price a household’s value of
handwashing and forward-looking behavior,” Hussam says—in other words, whether
financial incentives could increase handwashing rates, and whether those
households would keep using soap even after the incentives stopped. In one
incentive group, people learned that they would receive one ticket for each day
they washed their hands; the tickets could be accumulated and cashed in for
various goods and gifts in a prize catalog. In another group, people learned
that they initially would receive one ticket each day for washing their hands
with soap, but that in two months they would begin receiving triple the number
of tickets for every day they used the dispenser. The final group received the
same incentive boost two months into the experiment, but it was a happy
surprise: The group had no prior knowledge of the triple-ticket future.
“The difference … is a measure of rational habit formation,”
Hussam explains. “While one household is anticipating a change in future value
of the behavior, the other household is not; if the first household behaves
differently than their counterpart in the present, they must recognize that handwashing
today increases their own likelihood of handwashing in the future.”
A clean victory
The results showed that both monitoring and monetary incentives
led to substantial increases in handwashing with soap.
Households were 23 percent more likely to use soap if they knew
they were being monitored. And some 70 percent of ticket-receiving households
used their soap dispensers regularly throughout the experiment, compared with
30 percent of households that received the dispensers without incentives.
Importantly, the effects continued even after the households
stopped receiving tickets and monitoring reports, suggesting that handwashing
with soap was indeed a developable habit.
More importantly, the experiment resulted in healthier children
in households that received a soap dispenser, with a 20 percent decrease in
acute respiratory infections and a 30 to 40 percent decrease in loose stools on
any given day, compared with children whose households did not have soap
dispensers. Moreover, the children with soap dispensers ended up weighing more
and even growing taller. “For an intervention of only eight months, that really
surprised us,” Hussam says.
But while it appeared that handwashing was indeed a habitual
behavior, were people “rational” about it? Indeed they were, based on the
results of the monitoring experiment.
“Our results are consistent with the key predictions of the
rational addiction model, expanding its relevance to settings beyond what are
usually considered ‘addictive’ behaviors,” the researchers write.
In the incentives group, the promise of triple tickets didn’t
affect behavior much, but, as Hussam notes, that may have been because the
single tickets were already enough to get the children their most coveted
prize: a school backpack. “Basically, we found that getting one ticket versus
getting no tickets had huge effects, while going from one to three did little,”
she says.
But in the monitoring group, handwashing rates increased
significantly and immediately, not only for those who were monitored but also
for those who were simply told to anticipate that their behavior would be
tracked at a later date. “Simply knowing that handwashing will be more valuable
in the future (because your behavior will be tracked so there’s a higher cost
to shirking) makes people wash more today,” Hussam says.
This, Hussam hopes, is the primary takeaway of the study. While
the experiment focused on a specific behavior in/among a specific area of
India, the findings may prove valuable to anyone who is trying to develop a
healthy addiction—whether it be an addiction to treating contaminated drinking
water and using mosquito nets in the developing world, or an addiction to
exercising every day and flossing every night in the developed world.
“Wherever we go, habits define much of what we do,” Hussam says.
“This work can help us understand how to design interventions that help us
cultivate the good ones.”
by Carmen Nobel
https://hbswk.hbs.edu/item/how-to-get-people-addicted-to-a-good-habit?cid=spmailing-18706809-WK%20Newsletter%2001-31-2018%20(1)-January%2031,%202018
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