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.

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?


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)

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, “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 Employee engagement at Nasscom

It was fun speaking on applying Behavioural Design to improve employee engagement at Nasscom Technology & Leadership Forum on 21st Feb 2019 at Grand Hyatt, Mumbai. I spoke about few high-impact low-cost Behavioural Design nudges, based on experiments in behavioural science, that demonstrate how employee engagement and experience can be improved at the workplace. Given that employee engagement is at abysmally low levels at a lot of companies, it’s high time to apply behavioural science to transform processes like appraisals, feedback, learning, rewards, recognition, productivity, collaboration amongst other experiences to improve employees’ performance and happiness. The Behavioural Design nudges shared raised a good amount of smiles and curiosity. There were inquiries to deliver talks at different companies and do projects to change employee behaviour. Let’s see which of them happen. After all Behavioural Design is about improving conversions.

Behavioural Design for safer public spaces (Mint)

Behavioural Design for public spaces

This article first appeared in Mint on 24th Sep, 2018.

Recently it was reported that a 9W 697 Mumbai-Jaipur flight was turned back to Mumbai after take off as, during the climb the crew forgot to select the bleed switch to maintain cabin pressure. This resulted in the oxygen masks dropping. Thirty out of 166 passengers experienced nose and ear bleeding, some also complained of headache.

Aviation safety experts say such an incident was “extremely rare” as turning on the bleed switch is part of a check-list that pilots are expected to mandatorily adhere to. If turning on a switch that regulated cabin pressure is part of standard protocol, how could the pilots make such a simple, common-sensical error. And more importantly how can such errors be avoided in the future?

Traditional thinking suggests increasing the training of the pilots so that it makes them better and thereby avoid such errors. But training is not a full-proof method of ensuring human errors don’t get repeated. That’s because as long as humans need to rely on their memory to ensure the cabin pressure switch is turned on, errors are bound to happen. Sure check lists work. But that’s still a manual method of ensuring that the switch is turned on. And after repeatedly performing the tasks on the checklists over multiple flights, checklists themselves become routine habitual tasks done without much thinking. Also given that there are multiple tasks pilots need to perform in the 3-4 minutes after taking off, the chance of errors happening during those critical moments becomes high.

So instead of the pilot having to rely on their memory or routine check-lists, the answer to avoid such human errors lies in implementing simple behavioural design nudges. For example, if there was a continuous audio-visual reminder that the bleed switch had not been turned on, it would draw the pilot’s attention and it would be highly likely they would have turned it on. Such an audio-visual reminder was not present in this kind of an older generation of aircraft, and therefore the chance of human error increased.

The Japanese have a term for such error-proofing – poka yoke. This Japanese word means mistake proofing of equipment or processes to make them safe and reliable. These are simple, yet effective behavioural design features that make it almost impossible for errors to occur. The aim of error-proofing is to remove the need for people to think about the products or processes they are using. Some examples of behaviourally designed products used in everyday life are the microwave oven that doesn’t work until the door is shut or washing machines that start only when the door is shut and remains shut till the cycle is over. Elevator doors now have sensors that cause them to not close when there is an obstruction. This prevents injury to someone trying to enter as the doors are closing.

Human behaviour cannot be trusted to be as reliable as a machine. In fact, human behaviour is far from perfect. Yes, the people who operate expensive and complicated machines may be the best trained, but human errors in the form of simple error, lapse of judgment or failure to exercise due diligence are inevitable. According to Boeing, in the early days of flight, approximately 80 percent of accidents were caused by the machine and 20 percent were caused by human error. Today that statistic has reversed. Approximately 80 percent of airplane accidents are due to human error (pilots, air traffic controllers, mechanics, etc.) and 20 percent are due to machine (equipment) failures.

Another instance of how systems could be made safe by applying behavioural design is of airplane emergency evacuations. During the emergency landing of the Emirates flight EK521 at the Dubai airport in 2016, passengers were running to get their bags from the overhead cabins, instead of evacuating the plane. Only when the airplane staff began yelling at them to leave their bags and run, did the passengers finally pay heed to their calls and evacuate. Just a few minutes after the evacuation, the plane caught fire. It was a near miss situation. Had even a few passengers waited to get their bags from the overhead cabins, many of them would have got engulfed in fire. Again the natural instinct to correct such a situation would be to train people to evacuate and get them to listen to the flight’s safety instructions. But behavioural science studies have proven that such efforts are time-consuming, money-draining, unscalable and most importantly ineffective at changing human behaviour. In such an emergency situation, if the overhead cabins were automatically locked, with a label “Locked due to emergency”, passengers would not waste time trying to open them. That would in turn get passengers to behave in the desired manner and evacuate faster.

Sometimes behavioural design nudges are intuitive. Other times they are counter-intuitive. In a fire-drill experiment by behavioural scientist Daniel Pink, he found that placing an obstacle like pillar in the middle of a doorway got people to exit a hall 18% faster than without the pillar. The pillar was an obstacle but it split up people into two streams at the exit. That got people to use each side of the door, which in turn made the flow of people exiting the hall a lot smoother and faster. When the pillar wasn’t there to separate them at the exit, people bottle-necked at the door making the exit slower. Likewise, behavioural design could go a long way to design safer buildings, machines and systems and reduce human errors.

Smart water bottle experiment (incl. video)


The Smart Water Bottle Experiment

Drinking water is essential to human health. The amount one should drink varies from person to person based on gender, age, height, weight, physical activity, sweat levels, metabolism level, body temperature, humidity levels, external temperature, altitude, quantity and quality of food intake, quantity and quality of other fluids’ intake and host of other details. When you don’t get enough water, every cell of your body is affected. You lose a lot of electrolytes, including sodium, potassium and chloride, which are essential to your body’s functions. Pretty much all of your cellular communications revolve around sodium and potassium, including muscle contractions and action potentials. Fatigue, lethargy, headaches, inability to focus, dizziness and lack of strength are all signs of dehydration. Nature has given us a powerful alert system – thirst. But in our busy chaotic lives we often ignore it and forget to drink water.



Behavioural Design vs awareness

There is enough information about why we should drink more water, yet most people feel they don’t drink enough. Education doesn’t change behaviour.

Behavioural change requires a different approach. Drinking water regularly is a good habit. Habits are essentially automatic in nature, where one does not consciously think about the action. In other words, habits are auto-pilot behaviours. For a behaviour to become a habit, it requires three things to come together – trigger, action and reward. When the loop gets completed, the habit sets into place. For example, over a period of time we have gotten used to waking up in the morning (trigger), brushing our teeth (action) and feeling fresh (reward). To create good habits, initially conscious effort is required. However, we humans are lazy, so the lesser the effort to get the habit started, the better. Eg. We forget to drink water during the day. So if there’s a trigger like a reminder from the water bottle, we’re likely to drink water. Over time the action of opening the water bottle because of the reminder can become auto-pilot i.e. become a habit. This approach led us to create a water bottle that glowed and beeped that gently nudged people to drink water 16% more.


The Experiment

We chose to do an experiment in an office of one of our corporate clients. The administration department of that company would keep filled-water-bottles on the desk of each employee every morning and refill it once every evening. So we bought the same type of water bottles for our experiment so as to not draw any suspicion amongst participants. And we created two versions of caps. In the first version of the cap, we fitted a chip which recorded the number of times the water bottle was opened. In the second version of the cap, we fitted a chip which recorded the number of times the water bottle was opened and in addition, the cap now glowed and beeped once after every two hours of the water bottle being opened. If the bottle wasn’t opened, then the cap would glow and beep after an hour. When the water bottle was opened, the cap would sense it and stop glowing. In both versions the chip was hidden inside the caps.

Creating prototypes of both versions of water bottle caps took longer and was costlier than we expected (planning fallacy). We could only produce a total of 70 water bottle caps over more than a year. Thirty-five pieces of each version – first version with recording chip without glow and beep and second version with recording chip with glow and beep. Because of being able to produce 70 water bottle caps we chose to randomly select thirty-five participants from the office employees who wished to participate in our experiment.

In week 1 we gave them our similar looking water bottles with the first version of the cap with recording chip hidden in it. In week 2 we replaced the caps with the second version of the cap with the recording chip with the glow and beep. We accounted for data from Monday morning to Friday night in both weeks. We then compared the data of how many times the water bottle was opened with the numbers of hours the employees had spent in office on each day of Week 1 (no glow and beep) and Week 2 (glow and beep). Had we been able to conduct the experiment amongst a larger set of sample, we would have chosen the typical control group and treatment group, but due to the above mentioned capacity, time and money constraints we did a before-and-after format for this experiment.


The Results

In week 2 employees opened the water bottles 16% more than in week 1. It means the employees were not sufficiently hydrated with regular water bottles even though they were kept on their desk right in front of their eyes. The simple Behavioural Design of glow and beep water bottle caps got employees to drink 16% more frequently than without the Behavioural Design nudge.


Frequently asked questions

Q. How much water does one need?

A. Scientific studies are inconclusive on the amount of water required by an adult. Some say its 3 litres. Some say 2.5 litres. Some (Mayo clinic) say for men its 3 litres and for women its 2.2 litres. But fact is that calculating how much water you need depends upon your gender, age, height, weight, physical activity, sweat levels, metabolism level, body temperature, humidity levels, temperature, altitude, quantity and quality of food intake, quantity and quality of other fluids intake and host of other reasons. It’s extremely difficult to calculate real time hydration levels accurately.

Q. Why didn’t we create a bottle that could calculate how much water each individual person needed?

A. To do that we’d need to know people’s gender, age, height, weight, physical activity, sweat levels, metabolism level, body temperature, humidity levels, temperature, altitude, quantity and quality of food intake, quantity and quality of other fluids intake and host of other details. It’s extremely difficult to calculate real time hydration levels accurately. Sensors and software that can capture all of the above seamlessly are very expensive as of date. Measuring only some of the inputs would lead to an inaccurate result that would be misleading. So we used a simple rule of thumb of drinking water every two hours to stay hydrated.

Q. What’s the best way to judge whether you are hydrated or dehydrated?

A. The most scientific and simplest way to judge whether you are hydrated or dehydrated is to look at the colour of your urine. If your urine is crystal clear it means you’re probably drinking too much water. If its light or mild yellow it means your drinking an adequate amount of water. If its proper yellow or darker it means you need to drink more water. If its brown you need to visit a doctor.



Mild Dehydration Affects Mood in Healthy Young Women – Lawrence E. Armstrong, Matthew S. Ganio, Douglas J. Casa, Elaine C. Lee, Brendon P. McDermott, Jennifer F. Klau, Liliana Jimenez, Laurent Le Bellego, Emmanuel Chevillotte and Harris R. Lieberman – The Journal of Nutrition – 21 December, 2011.

Mild dehydration impairs cognitive performance and mood of men – Matthew S. Ganioa, Lawrence E. Armstronga, Douglas J. Casaa, Brendon P. McDermotta, Elaine C. Lee, Linda M. Yamamotoa, Stefania Marzano, Rebecca M. Lopez, Liliana Jimenez, Laurent Le Bellego, Emmanuel Chevillotte and Harris R. Lieberman – British Journal of Nutrition – Volume 106 / Issue 10 / November 2011, pp 1535-1543

Lawrence E. Armstrong – an international expert on hydration who has conducted research in the field for more than 20 years (professor of physiology in UConn’s Department of Kinesiology in the Neag School of Education)

Potential loss can make us behave irrationally

Potential loss can make us behave irrationally

There are many instances where a perceived loss makes us behave irrationally. Here’s one of the many stories – of Captain Jacob Van Zanten – in connection to loss aversion.

Captain Van Zanten was regarded as one of the most experienced and accomplished pilots in the world. He was head of KLM’s safety program, known for his attention to detail, methodical approach and a spotless record. He even featured in KLM’s ad which said KLM – the people who made punctuality possible.

On one flight en route from Amsterdam to Las Palmas airport in Canary Islands, Spain, Van Zanten got an urgent message that a terrorist bomb had exploded at the Las Palmas airport. He was now made to land at nearby Tenerife’s tiny airport along with many other re-directed flights.

He safely parked the plane. But he wanted to take off before the mandatory rest period got underway, because there was no replacement crew at Tenerife, the airline would have to find passengers a place to stay, the delay would initiate a cascade of flight cancellations throughout KLM and he of course had thoughts about his own reputation on line.

Two hours had already passed by. So Van Zanten decided to refuel at Tenerife thinking that he would shave an hour off the turnaround at Las Palmas. But soon thereafter, word came from Las Palmas that the airport had finally reopened. But it was too late to stop the refuel.

Finally just when it looked like he could take off, a thick layer of fog descended upon the runway – visibility dropped to just 300m. Nevertheless he revved up the engines and lurched down the runway. When the co-pilot alerted him that they didn’t get ATC clearance, he hit the brakes and asked him to get the approval. The co-pilot received the airway clearance but not the takeoff clearance. Completely out of character, Van Zanten again turned the throttle to full power and roared down the runway.

To his nightmare he saw a Pan Am 747 parked across the runway while he was approaching full speed. He managed to pull the aircraft’s nose desperately, but the underside of the fuselage ripped through the top of Pan Am. The KLM plane burst into flames killing all crew and passengers, 584 in all, including Van Zanten.

The aeronautical community was stunned. The experts concluded that it wasn’t a mechanical failure or terrorist attack. Pan Am missed a taxiway turnoff and wasn’t supposed to be on the runway. Because of the fog Van Zanten couldn’t see Pan Am. Pan Am pilot couldn’t see KLM. The under staffed tower controllers couldn’t see either. But why did a seasoned pilot, the head of safety at KLM make such a rash and irresponsible decision?

The best explanation the investigators came up with was that Van Zanten was feeling frustrated. But how could he cast aside every bit of training and protocol when the stakes were so high?

Turns out the investigators were right. We’re all susceptible to a tendency to go to great lengths to avoid possible losses. We’re loss averse. Van Zanten’s desire to avoid a delay started small. But as the delay grew longer, the potential loss seemed almost inevitable. He got so focused on avoiding the loss, that he tuned out of his common sense and years of training.

As Columbia business school professor, Eric Johnson says, “the more meaningful a potential loss is, the more loss averse we become. In other words, the more there is on line, the easier it is to get swept into an irrational decision.”


Employee performance and happiness talk (Gartner)

Employee performance and happiness talk (Gartner)

Our latest talk was on applying behavioural science for improving employee performance and happiness at the Gartner Symposium ITXPO, Goa for India’s Top 300 CIOs.

Behavioural science experiments on employee performance and happiness show that businesses often operate in ways that are not aligned to principles of human psychology, leading to engagement and motivation levels that are disappointing.

For example, when performance appraisals are done annually, employees are also given feedback on improvement and learning. But behavioural science shows that the focus of employees at that stage is on earning, while learning shuts down. Companies can benefit to a great extent if the ‘scope of improvement’ conversation is done as a separate exercise at a separate time than the performance review and appraisal.

The talk covered behavioural science findings on rewards, recognition, incentives – monetary, non-monetary, experiential; performance appraisal, feedback, teams, collaboration, workplace design, change management, productivity, culture and core values.

Like we always do, the talk focussed on simple but innovative and practical Behavioural Design nudges that could make a big difference in employee performance and happiness.