Making doctors wash hands

This article first appeared in The Hindu on 24th April, 2020

Ignaz Philipp Semmelweis, a Hungarian-born doctor came to Vienna in 1846 to work at the city’s General Hospital. Dr. Semmelweis noticed that women delivered by doctors had three times higher mortality rate than women delivered by midwives. He spotted a link between the lack of hygiene of the doctors and the mortality rate of the mothers. After he initiated a mandatory hand-washing policy, the mortality rate for women delivered by doctors fell from 18 percent to about 1 percent. Despite such a brilliant outcome, the idea of hand washing was rejected by the medical community. Doctors were offended by the suggestion that they could be causing infections. Semmelweis’s practice earned widespread acceptance only two decades after his death, when Louis Pasteur, of pasteurization fame, raised awareness of pathogens.

From 1850s to 2020, hand washing has been advocated as a simple way of reducing the risk of infection. But even after 170 years, studies find that doctors still do not wash their hands often. A systematic review of studies on compliance with hand hygiene in hospitals, done by researchers Vicki Erasmus et al, found that only 32% of doctors and 48% of nurses wash their hands between seeing patients. Another study by researcher Didier Pittet, an infection control expert with the University of Geneva Hospitals, Switzerland found that compliance rates for hand washing amongst doctors and nurses was only 57 percent, and years of awareness programs urging doctors to wash up or use disinfectant gels have had little effect. A study of hand hygiene compliance amongst Indian doctors by researchers S. K. Ansari et al, found only 49% of doctors and 56% of nurses washed their hands with soap between patients.

If India needs to contain the spread of Covid-19, everybody ought to be washing our hands, especially doctors and nurses. But how can we change their hand washing behaviour?

The traditional approach of changing behaviour is to educate doctors and nurses on the importance of hand washing. It seems like the rational and logical thing to do, but even though doctors and nurses know that they should be washing their hands, they forget to do so. That’s why we need to apply behavioural design. Behavioural design is about creating subconscious nudges right at the moment where the desired action is to be performed, in our case where hand washing needs to happen.

Behavioural scientists piloted a low-cost experiment in rural schools in Bangladesh where behavioural design nudges were used to guide hand washing with soap after toilet use. Hand washing stations were built in visible and easy‐to‐reach locations, brightly colored paths were painted from toilets to the hand washing station, and footprints and handprints were painted on the path and at the hand washing station. Hand washing with soap after using the toilet went from 4% before these behavioural design nudges nudges were created, to 74% six weeks after they were introduced. No other hygiene education was communicated as part of the study.

Similarly, in hospitals where wash basins and hand sanitizers are placed, stickers of brightly colored footsteps should be placed so that doctors and nurses get attracted by them, which subconsciously directs them to the wash basin or the hand sanitizer. Such behavioural design nudges influence doctors and nurses to wash their hands with soap or sanitizer without making a conscious decision to do so. Hand washing is often done as a relatively subconscious habitual action, and can be easily triggered by contextual cues, so hand washing lends itself well to such behavioural design nudging. An experiment done at the Gentofte Hospital in Denmark has found that hand sanitizer usage increased from 3% to 67% when the hand sanitizer was placed in a prominent location with bright signage that caught people’s attention. Not bad for such a simple and low cost intervention.

Creating social bonds while physical distancing

This article first appeared in Mint on 6th April 2020

Till a few weeks ago almost nobody in the world knew what social distancing meant. But since the spread of Covid-19, the term ‘social distancing’ has gone viral too. It implies steps that need to be taken to prevent the spread of coronavirus by maintaining a physical distance between people and reducing the number of times people come into close contact with each other. It involves keeping a distance of six feet from others and avoiding gathering together in large groups. It is critical in curbing the spread of the virus and must be followed as far as humanly possible.

But the term ‘social distancing’ means to avoid being social. That’s unnatural for most humans. Humans are a social and emotional beings. We survive and thrive being social. Children are attached to their parents. Grandparents love spending time with grandchildren. Siblings are emotionally close to each other. We all have friends who are our life supports. In India, house helps are like extended family. But now because of Covid-19 we suddenly need to follow social distancing from the people who are always there for us precisely in times like these. It goes against human nature. That makes using the term ‘social distancing’ inappropriate.

Matthew Liebermann, a social neuroscientist, has conducted several studies on how our brains processes social pain. He finds that to the brain, social pain feels a lot like physical pain. The more rejected the participant felt, the more activity there was in the part of the brain, that processes the distress of physical pain. What’s surprising is that studies show that drugs that treat physical pain, like paracetemol, can also reduce emotional pain like social rejection, because similar brain circuitry is engaged when we feel physical pain. That’s perhaps why we express social pain in terms of physical pain, like “she broke my heart”, “he hurt my feelings”. Social pain is real pain. Social pain is associated with decreased cognitive functioning, increased aggression and engagement in self-defeating behaviors, like excessive risk taking and procrastination. So its safe to assume that social distancing in today’s times must be causing real pain too.

Over the past few days we’ve been seeing people in various countries come out in their balconies and sing songs, play music and cheer the people who have been dedicating their time, risking their lives serving patients and delivering essential supplies. Prime Minister Narendra Modi has addressed the nation twice requesting we all stand in solidarity. It may not mean much for people who can easily take care of themselves during these times. But for the rest of us, his aim is to boost morale, because levels of stress and anxiety are rising. We humans don’t like uncertainty. We don’t know how long it may take for the vaccine to be made available for most of our population. We don’t like being caged in our little homes away from our social bonds. These times call for social bonding, not social distancing. Thankfully social bonding is possible today because of being able to stay connected over voice and video calling. We can talk to each other about how we are feeling, what we cooked, the jokes our children are cracking, the dreams we’re getting at night and details about the quarrels between couples.

On March 20, the World Health Organization officially changed its language. “We’re changing to say ‘physical distancing,’ and that’s on purpose because we want people to still remain connected,” said WHO epidemiologist Maria Van Kerkhove. Language matters. Just like how ‘climate change’ is now refered to as ‘climate crisis’ by media, ‘social distancing’ needs to be refered to as ‘physical distancing’. So start exercising physical distancing and social bonding, because this pandemic is going to last quite some time.

Get rid of that tricky habit of touching your face

This article first appeared in Mint as an opinion editorial on 31st March 2020.

Few days back Dr. Sara Cody, director of the Santa Clara County’s Public Health Department, US was speaking at a press conference about a simple, yet vital, way on how people can stop coronavirus from spreading: Don’t touch your face. “Today, start working on not touching your face — because one main way viruses spread is when you touch your own mouth, nose, or eyes,” Dr. Cody, said at the press conference. Less than a minute later, Dr. Cody brought her hand to her mouth and licked her finger to turn a page in her notes.

It’s not just Dr. Cody, millions have the habit of touching their tongue before turning the page of a document, especially the elders, who are at the highest risk of catching coronavirus. This is just one of the instances of touching a part of the face. The bigger problem is that almost every human being in the world has a habit of touching their face, including me and probably you too. A study by scientists in New South Wales, Australia, Kwok, Gralton and McLaws, found that on average people touch their faces 23 times an hour. What makes this behaviour tricky is that it’s a habit.

Habits are automatic behaviours that are done sub-consciously. They are actions that we perform frequently on auto-pilot. That’s precisely why they go unnoticed. This makes habits tricky because we aren’t even aware of it. Honestly this is the first time, being a behavioural scientist, that I’m even thinking about touching my face. I must be doing it all the time everyday without any realization whatsoever. But now we’re finding that coronavirus can spread easily, by touching surfaces that may be infected with the virus, and then touching any part of the face like mouth, nose or eyes – where the body’s mucous membranes are vulnerable to infection. That’s bringing up our habit of touching our face and making us aware of it. But even after being aware of it, I can’t help touching my face.

Ironically, the more you want to consciously avoid something, the more you think about it. So the more one thinks about not touching the face, the more it makes you want to touch your face. You are probably wanting to touch your face right now. That’s because you’ve been momentarily made conscious of your face, eyes, nose and mouth. This simple fact makes you want to touch it, perhaps as simple as scratch your cheeks a little or adjust your eyebrows or itch your nose. The other reason is psychological reactance. People cannot resist indulging in precisely what they’ve been told to avoid. It’s like being on a diet. When people are on particular diets and forbidden to eat certain foods, it makes them want to eat those foods even more.

Touching the face is an instinctive response. A recent study by behavioural scientists Mueller, Martin and Grunwald show that face touching is involved with coping with stress, regulating emotions and stimulating memory. Other researchers have established it’s an instinct we share with monkeys and apes. Gorillas, orangutans and chimpanzees all exhibit similar face-touching behaviour. But what can we humans do to prevent touching our faces and prevent getting infected this way by coronavirus?

Washing hands is the need of the hour. But we also need to use our hands often to open doors, press lift buttons, use keyboards, drink from glasses, use pens, open and shut taps, and a hundred other things that  we don’t think about. How often can one wash hands or even use the hand sanitizer. It can be overwhelming if we have to wash hands after touching everything. I’m not recommending we don’t do it. I’m simply saying that it’s not practical to keep washing hands after each and every interaction.

Keeping our hands away from our face requires a lot of willpower. But willpower has been shown in behavioural science studies to always be limited in supply. Willpower works temporarily in the moment when one is conscious but wears out quickly as we slip back into doing things subconscious i.e. habits. Willpower is a bit like our muscles. The stronger our muscles are, the more we can work them out. But eventually they tire out. Similarly, the stronger our willpower is the more we can work them out but eventually we tire out. So willpower is not a dependable way of avoiding to touch our faces, while touching our face is going to be unavoidable.

That’s why we need to rely on behavioural design to help us not touch our face. Behavioural design is about tweaking our environment, right at the time and place our behaviour takes place, to achieve the desired action. For example, to reduce the quantity of food intake, instead of relying on willpower, if we reduce the size of the plate we eat from as well as the size of the spoon, we’re likely to eat less. Similarly, to avoid touching our face with our hands, we could try keeping a clean tissue at a close distance. By using clean disposable tissue we could prevent our bare hands from touching our eyes, nose and mouth. You can use a small portion instead of one whole piece to conserve paper. Small things make a big difference.

The limitations of asking questions in research

Researchers ask people for their opinion about their product, packaging or concepts to pick insights about their appeal, and get wonderful feedback that is sincere, detailed, and emphatic but has little relation to the truth.

We wrote about ‘Why focus groups cannot be relied’ earlier on the blog. Here’s another perspective – impression management. Impression management is one of a diverse array of forces that influence our truthfulness. Here’s a behavioural science study in which White college students were asked to state their level of agreement (ranging from ‘strongly disagree’ to ‘strongly agree’) with the following two statements:

  1. It is a bad idea for Blacks and Whites to marry each other.
  2. Black people are generally not as smart as Whites.

Half the participants who were asked these questions received them the Black researchers and other half from White researchers. All participants were assured that the answers would be confidential.

When the questioner was Black, the participants’ responses were noticeably more Black-favorable than when the questioner was White. The impression management effect occurred without the subjects being aware that their answers had been influenced by the race of the questioner.

Impression management produces flawed, inaccurate responses to many questions, not just race related. That’s why we don’t ask people questions or conduct surveys or focus groups. We rely on the knowledge of the human brain, cognitive neuroscience, behavioural economics and thousands of proven experiments conducted by behavioural scientists on human behaviour, to create Behavioural Design solutions that make the impact.

Source: J.B McConahey, B.B. Hardee & V. Batts – Has racism declined in America? It depends on who is asking and what is asked – Journal of Conflict Resolution 25, 563-579. (1981)

Honesty: such a lonely word

Honestly, how many of us are honest all the time? We would like to believe we are honest, good, wonderful, moral people but at the same time we also would like to benefit from cheating if it helps us economically. But can both happen together? Can we cheat a little and yet think of ourselves as wonderful honest people. Apparently the answer is Yes.

Says Dan Ariely, “Due to our flexible cognitive ability, and due to the fact that we can rationalize things very quickly, as long as we cheat just a little bit, we can both benefit from cheating, just a little bit, and we can still view our self as honorable people.” And that’s he calls the fudge factor.

Once Dan ran an interesting experiment in which he gave people a sheet of paper with 20 simple math problems to be solved in five minutes and paid them $1 per correct answer. At the end of the 5 min people counted how many ones they got correctly, shredded the sheet of paper, announced how many questions they got correctly and got paid accordingly. What the people in this experiment didn’t know is that the shredder only shred the sides of the page. Dan found that people solve 4 problems, but they report to be solving 6. And most of the people cheated. He tried the experiment with 25 cents, 50 cents, $2, $5, $10 but the results were similar – lots of people cheated a little.

In another experiment Dan went to UCLA, and asked about 500 students to try and recall the Ten Commandments. None of them could recall all Ten Commandments. But after getting them to try and recall the Ten Commandments he gave them the same math task. And the result was – zero cheating. Regardless of whether one was religious or an atheist, nobody cheated.

Just thinking about morality seems to shrink our fudge factor, gets us to be a bit more careful about our own behavior and therefore allows us to be more honest.

Dan also tried a secular version of the experiment. He edited one sentence to the beginning of the test. “I understand that this short survey falls under the MIT or Yale honor code – Signature.” What happened? People signed, they did the test, they shredded, no cheating whatsoever. And no cheating whatsoever despite the fact that neither MIT nor Yale actually had an honor code.

Source: Dishonesty of Honest People – A Theory of Self-Concept Maintenance – Nina Mazar, On Amir and Dan Ariely – Journal of Marketing Research, Vol. 45, No. 6, pp. 633-644 – 2008

Should a company offer job applicants money to NOT take up the job?

Yes if it wants to induce cognitive dissonance – the feeling you get when behaviour and belief don’t match. Like when you gorge on that sizzling brownie with ice-cream and chocolate sauce when you know it’s going to make you put on. But then you say what the hell ‘Life is an ice-cream, enjoy it before it melts.’ Here’s an interesting way a company uses the same principle of cognitive dissonance to meet its hiring goals, by paying applicants to NOT take up the job. This complicated phenomenon is best explained by behavioural scientist Dan Ariely…

“There’s this interesting company called Zappos. Zappos is a shoe company. One of the interesting things about Zappos, is the hiring process.

They bring people in for training and train them for around a week. At the end of this training, they say to people, we would love for you to be part of the Zappos family. But this is not the right place for everybody. And if this is not the right place for you, we don’t think this is something good for you. And therefore, we will pay you to NOT take the job.

They started by offering people $500. They increased it to $2000 and then increased it to $4000. Think about it. What a crazy idea. You come, you do a week of training. At the end of week of training they say we’ll pay you $4000 not to take the job. Now these are not highly paid people, these are people who are going to get paid $12, 14, 15 an hour to do customer service on the phone.

Why would Zappos pay people not to take the job? There are basically two reasons. The first reason – you actually don’t want the people who don’t like their jobs so much to be around because not only are they not going to do a good job, they’re going to pollute other people. And Zappos is a fantastic customer service company.

The second thing has to do with cognitive dissonance. Cognitive dissonance is about the fact that if we behave one way but don’t believe in the same way, this creates a tension, what Leon Festinger called dissonance.

Can we change what we’ve done? No. We’ve done it already. Maybe we can change what we believe. And that actually happens quite a lot. You behave a certain way, and then you shift your belief to, to fit with that.

So what happened to Zappos? You have these $4,000. Now, it’s not as if Zappos is telling you, you know what, for the rest of your life every morning you could wake up and decide if you want to take the money or stay on the job. No, no. You have 48 hours. And if the end of 48 hours you decide not to take the money, you wake up every morning for the rest of your career at Zappos and you’ll tell yourself, I could have gotten $4000 but I decided to work at Zappos. That means that if I say no to this offer, then I am buying in. And because of that, you go to work much more excited.

Only 2% of Zappos trainees take the money and leave. Often they are the same people the trainers already had doubts about.”

Do you suffer from the money illusion?

In a study by Kahneman, Knetsch and Thaler, subjects were asked to judge the fairness of pay cuts and pay increases, in a company located in a community with substantial unemployment. One group of subjects was told that there was no inflation in the community and was asked whether a 7 percent wage cut was “fair.” A majority, 62 percent, judged the action to be unfair. Another group was told that there was 12 percent inflation and was asked to judge the perceived fairness of a 5 percent raise. Here, only 22 percent thought the action was unfair. Similar results suggesting this money illusion have been reported by Shafir, Diamond, and Tversky.

People fail to notice how inflation eats up savings, people fail to notice how inflation eats up returns, people fail to notice convenience fees on air tickets, people fail to notice fees on mutual funds, people fail to notice brokerage on stocks bought and sold, the list goes on.

Do you suffer from the money illusion too?

Sources:

Daniel Kahneman, Jack L. Knetsch and Richard Thaler – Fairness as a Constraint on Profit Seeking: Entitlements in the Market – The American Economic Review Vol. 76, No. 4, pp. 728-741 (Sep, 1986)

Eldar Shafir, Peter Diamond Amos Tversky – Money Illusion – The Quarterly Journal of Economics, Volume 112, Issue 2, Pages 341–374 (May 1997)

How to get people to stop littering?

Let’s explore few ways in which one could reduce littering:

1. You could fine people for littering.

2. You could place CCTVs in the area.

3. You could incentivize people for using garbage bins.

4. You could create a social stigma for people who litter.

5. You could make throwing stuff in bins fun.

6. You could use social proof to indicate that a high percentage of people use the bin.

But behavioural scientists did something better in the 2011 Copenhagen study that reduced littering by 46%.

They placed green footprints on the ground, pointing the way to the nearest garbage bin. Simple, low cost, effective Behavioural Design.

India, though is a different story. Usually there are no trash bins in public places, because the trash bins get stolen by people who sell it to make some money, even though they are fixed to the ground with screws. Everything in India has re-sale value.

So Briefcase has created a Behavioural Design solution in the form of non-stealable, waste-segregated, long-lasting, low cost, low maintenance, all weather, endorsable trash bins. But unfortunately, the local government authorities here in Mumbai – the officers from BMC, aren’t interested because of apathy. How can we change their behaviour? Can you help us?

Source: http://www.inudgeyou.com/green-nudge-nudging-litter-into-the-bin/

Do you spend enough time analyzing the problem?

I used to hear the words ‘the client wants it yesterday’ a lot when I used to be in advertising. And for various reasons people in advertising succumbed to the pressure. This in turn led to clients crunching the timelines even shorter as years passed, while the ad industry diligently kept working harder at keeping deadlines, lowering the quality of strategic thinking, thereby positioning ad agencies as short-term ad campaign makers.

Though you may not be from the ad industry you may find yourself in a similar situation. Unfortunately, the temptation in such time-pressured situations is to use habitual responses to get started on the solution immediately. Since problem-construction feels like a waste of time, it’s the phase that gets sacrificed most often. In reality, it is the most important part of the creative process.

In the classic study on creative preparation conducted by behavioural scientists Jacob W. Getzels and Mihaly Csikszentmihalyi, they asked art students to create a still-life painting of an object, which was later evaluated professionally. The study found that students judged to have created the best work were those who spent the longest preparing – thinking about the object itself and how they were going to use it. When Mihaly returned to the same people 7 and 18 years later, he found that it was these measures of problem identification and construction that predicted the artists’ long-term success. Even 18 years later, artists who spent longer constructing the problem were more successful.

Says Jeremy Dean of www.psyblog.co.uk, “The choices made in the early stages have a massive impact later. That’s why spending longer thinking about the problem before you dive in is likely to lead to higher levels of creativity in the final product. Fools rush in where the more creative dare to tread.”

Needless to say, deadlines are part and parcel of constraints in any commercial work. Constraints bring out the best in us, but we need to give ourselves adequate time to analyze the problem well enough. That’s why before identifying the Behavioural Design principles to be applied to the challenge, we spend a substantial amount of time analyzing the product and customer data and map out the customer journey, whether the customer is a consumer, employee, investor or simply put, the user.

Source: Jacob W. Getzels and Mihaly Csikszentmihalyi – The creative vision: A longitudinal study of problem finding in art – Wiley New York 1976

S.M. Rostan – Problem finding, problem solving and cognitive controls: An empirical investigation of critically acclaimed productivity – Creative research journal 7, no. 2 (1994): 97-110

Behavioural Design for Urban Planning

We were happy to be invited to speak at Milano Arch Week 2019 on applying Behavioural Design to urban planning or as they liked to refer to it ‘Urban Regeneration’. We are happy that architects are opening up to our practice of Behavioural Design to build cities that work for people living in it and to use architecture to modify public behaviour.

Our talk included Behavioural Design examples from my Instagram feed. Some of the examples we referred to were the Ballot Bin that gets cigarette smokers to stub their cigarette buds at the Ballot Bin because they are motivated to vote for their choice, whether the choice is about your favourite football player or some other topical question. We were asked about Bleep horn reduction system as a Behavioural Design nudge to reduce drivers’ honking. We spoke about how the Bureau of Energy Efficiency (BEE) in India has made it mandatory for appliances to come with star ratings and how it’s nudging people to choose higher star rated appliances so that people can save money and in doing so also consume lower power and contribute towards climate crisis in a positive manner. Some of the other examples we spoke about were Behavioural Design nudges to reduce overspeeding, getting people to – use trash bins in the outdoor, use sanitizers in hospitals, use stairs instead of escalators, and many more. If you’re curious to know more, click here.

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