The Carrot and the Stick: Public Health and Behavioral Change
By Fiorenzo Conte
Many of the current public health interventions are premised on the condition that people have to change their behavior in order for such interventions to be effective. Let’s take the example of malaria. The Rolling Back Malaria Partnership – a global framework for coordinated action against malaria – puts weightage on convincing and educating people to change their behaviors: for instance, individuals have to acquire and properly use bed nets and pregnant women are expected to adhere to intermittent preventive therapy with anti malarial drugs. For this reason a fundamental part of health policies is to package messages which can prompt people to change their behaviors. The social marketing approached, pioneered by Population Services International, represents one such attempt and utilizes marketing strategies to make health behaviors, such as the use of bed nets, more appealing for people.
However, if change in behavior is to be promoted, an important element needs to be taken into consideration: social control. In his research about HIV/AIDS professor Tim Allen has stressed the importance of putting in place social enforcement mechanisms if behavioral changes has to take place. Reason being that poor people are rarely in a position to freely chose their behaviors. He argues for example that an important role in driving down HIV infections in Uganda has been played by the tight control that the local councils, patrilineal hierarchies and religious leaders were able to exercise on the social and sexual lives of young people in the community. By so doing these authorities were able to ensure that abstinence and condoms use were effectively practiced and not only left on paper. In other words, new behaviors were promoted but at the same time change in practices was enforced.
The problem with social control mechanisms is that they are difficult to be implemented in a top down fashion because they are at risk of backfiring. For that reason NGOs or international organizations often stay away from this issue. To be successful and acceptable by the population these mechanism needs to be owned and implement by the communities. A success story in the fight against malaria in a Senegalese village shows how this can be done.
In the village of Thienaba, Senegal, a group of women came together to put an end to malaria infections in the community. Part of their strategy was to distribute nets to each households and educate them on the proper use. However, education was not enough. The women, in collaboration with village’s chief, visited each household at dawn to verify that bed nets were used. Those households found not compliant were fined and the money were pooled together for an emergency fund to be used for transportation of people in need of malaria treatment. This multipronged approach, which included also the sanitation of potential breeding grounds for mosquitoes, resulted in a drastic reduction of malaria cases from 3,500 to nearly zero.
In sum, behavioral change only rarely happens because of information alone. Mechanisms that can enforce the compliance to new practices need to be integrated in any public health intervention which seriously seek to incentivize people to change their behaviors – be that the use of bed nets or the disposal of human waste. The story from Senegal points out that the involvement of the community is essential for these social control mechanisms to work.
 “AIDS and evidence: Interrogating some Ugandan myths”, T Allen, Journal of Biosocial Science, 2006