Can Peer Pressure Save Lives?

by Helen Coster

When we hear that someone succumbed to peer pressure or conformed to group expectations, we are inclined to think about it in negative terms. We imagine a young person smoking his first cigarette or an adult parroting the consensus of her community. We know that these social forces can cause people to act in ways that are harmful to themselves and others; but every day we are discovering more ways that they can be harnessed to solve problems in health, education and other areas. This is crucial. For decades, development organizations have spent billions of dollars developing medicines, installing wells, or building clinics or schools that people have not fully used, if they have used them at all.

Providing the right tools to fix a problem is only part of a solution, and often the easy part. Changing behavior is much tougher. Consider water. Impure water can cause diarrhea, which kills 760,000 children under 5 each year. To curb transmission of waterborne diseases, many governments and donors focus on building wells and other water sources, but one big problem is that water is often recontaminated when people transport and store it. There is a relatively simple solution to this problem: chlorine.

Social norms have so much sway that it’s possible to get people to change their behavior simply by telling them what the norm is.

It’s not expensive. In Kenya, for instance, the cost of chlorine for a family of five is about one cent per day. Despite the fact that it would save many lives, and reduce illness, most people do not use it to treat their water. One organization, Innovations for Poverty Action (IPA), based in New Haven, Conn., applied behavioral science to the problem. They developed a new chlorine dispenser with a convenient delivery system and a valve calibrated to release a set dose, making it simple to treat a 20-liter container of water.

But they also went further: They installed the dispensers at communal water sources, where neighbors could see one another using it, and feel pressure to follow suit. They enlisted a community member to be a “promoter,” whose job is to refill the chlorine tank each month, teach the community about the importance of chlorine, and report problems to the local health ministry.

The combination of a convenient, free device and social pressure to use it changed people’s behavior. In a randomized control trial, IPA found that two years after installing the dispenser, 61 percent of sampled households had chlorine in their water, compared to less than 15 percent of households in the control group.

“If you accept the basic framework that we make decisions to maximize our happiness, there are two parts that incorporate other people,” said Dean Karlan, a Yale economics professor who is the founder of IPA. “One part is that our happiness isn’t just a function of what we eat, drink and consume: it’s also our image to others, and our reputation. The second way that people influence decisions is through their information networks. I get information from friends, and that information will affect the decisions I make. [Many public health] interventions are using those levers: They’re using peers to send information.”

“You need opinion leaders in a community to do something, which gets other people to mimic that behavior,” added Jeremy Hand, who ran IPA’s safe water program. “The other driver is the idea of peer pressure: if you know that you’re being observed, and the community accepts this behavior as healthy, that peer pressure factor can be a big driver of adoption.”

In many parts of the developing world, behavioral economists are attacking problems including poverty, malnutrition and familial violence, by applying these basic insights — particularly the realization that a primary force governing how we behave is how other people behave. We imitate those we respect. We turn to trustworthy sources for information. We conform to what’s considered normal. And when we feel that someone is watching, we’re more likely to do the right thing — whether it’s putting the trash in the bin or avoiding that parking spot reserved for disabled people.

When a problem is inextricably linked to behavior change, it’s essential to make the solution both convenient to practice, and something that can be socially reinforced.

Social norms have so much sway that it’s possible to get people to change their behavior simply by telling them what the norm is. This has been demonstrated by Opower, a Virginia-based company that has gotten its customers to cut their energy consumption by roughly two percent simply by telling people how their bills compare to their neighbors. Similarly, Tina Rosenberg has reported in this column about how this approach has been used to combat binge drinking at Northern Illinois University. Students there drank heavily at parties — but they believed that binge drinking was more widespread than it really was. School officials built a campaign around the message that “most students drink moderately.” It cut binge drinking by nearly half over 10 years. It is one of many examples showing that social norm campaigns work.

Positive social pressure has been a central part of the effort to eradicate Guinea worm disease, which is transmitted through dirty, stagnant water that incapacitates its victims. (It’s a heinous disease: Waterborne larvae mate and grow inside a person’s abdomen, reaching as long as three feet, before emerging from the body through a lesion on the skin, causing excruciating pain.)

The only way to prevent Guinea worm disease is to convince people to stop drinking contaminated water. Health workers figured out part of that challenge when they devised an inexpensive, cloth pipe filter that they distributed free throughout Sudan and other parts of Africa. But they struck epidemiological gold with a simple behavioral tweak: adding nylon cords to the pipes, so that people could wear them around their necks. Volunteers spread the message that contaminating water is an unneighborly act. Local leaders began wearing the filters, which over time became a symbol of good judgment and respect for the community’s health, according to Dr. Donald Hopkins, the vice president of health programs at The Carter Center. Based in part on these efforts, Guinea worm disease is close to being eradicated.

When a problem is inextricably linked to behavior change, it’s essential to make the solution both convenient to practice, and something that can be socially reinforced. In Liberia, for example, 60 percent of women are pregnant by age 19. How do you effectively teach young people about protected sex and contraceptives so that it changes their actions? That’s a problem that Population Services International has been struggling with for years, said Reid Moorsmith, its representative for Liberia.

One shift it has made is delivering its training programs inside youth clubs, and holding “Clinic Celebration Days,” where H.I.V. testing and contraceptives are provided on the spot. There is a significant difference in bringing the clinic to the participants. Not only is it simple, but young people can watch their peers, friends and family members choosing to get tested or obtain contraceptives. According to Moorsmith, 59 percent of the 6,300 women who had participated in Clinic Celebration Days were getting family planning services, compared to 19 percent nationwide.

Many health solutions are simple — or, at least, they seem like they should be. Breast-feeding, for instance, helps build immunity against childhood killers like diarrhea and pneumonia, and it doesn’t cost anything. But while the practice is common, in many developing countries women don’t breast-feed exclusively for six months, which the World Health Organization recommends. Mothers will often feed their babies dried milk mixed with water, or just water — which is frequently contaminated.

Historically, health officials have tried to inform, or sometimes, scare people into adopting a healthy behavior. While it’s important for people to understand risks and causes of illnesses, when it comes to changing behavior, it is often more effective to lead with a message that is clear and aspirational.

So, in Bangladesh, health workers from Save the Children drew attention to happy, fat babies  and their breast-feeding mothers  to encourage other women to nurse during their child’s first six months. The health workers organized birthday parties for 6-month-old babies who had been exclusively breast-fed, and invited the whole community so they could showcase the health benefits and teach other mothers about infant nutrition. Researchers believe that when mothers see the other women breast-feeding, they’re more likely to follow suit. Save the Children reports that after five years of this program, the rate of exclusive breast-feeding had increased from 29 percent to 64 percent.

Positive social pressure can be applied in countless other ways — to increase rates of vaccination, get people to shift to clean cook stoves or to encourage them to educate daughters. When people make these choices, they’re acting on deep human impulses: to be accepted and liked by others, to imitate those we respect, and to connect and fit in with our peers. The stakes are high. Governments and development programs have spent billions of dollars to make lifesaving interventions available around the world. But often people have passed them by. By using the knowledge we have today about what it takes to change behavior, we stand to save many lives.

This article originally appeared in [https://opinionator.blogs.nytimes.com/2014/05/14/peer-pressure-can-be-a-lifesaver/] and belongs to the creators.