For Entrepreneurs9/12/16

Four behavior change lessons from a low tech solution

Rock Health

Maria May, Senior Programme Manager, BRAC Social Innovation Lab and Richard Cash, Senior Lecturer, Harvard T.H. Chan School of Public Health and Visiting Professor, James P. Grant School of Public Health, BRAC University


Of the staggering 165,000 consumer health apps, two-thirds focus on improving wellness by supporting exercise, healthy diet, and other lifestyle habits. Meanwhile, $2B in funding filled digital health company coffers in the first half of 2016. Yet life expectancy is still stagnant and healthcare costs continue to rise. Digital health has money, scale, and innovation—so where are the widespread impacts on consumer behavior? Part of the problem lies with what people do—or rather, don’t do. For instance, though about 12% of Americans now have purchased health wearables, over half abandoned them within six months of purchase.

By understanding how motivation, habits, and psychology shape behavior, innovators can find clever ways to help people switch to new routines. While digital health has come a long way, we looked at learnings of innovators in other health environments to what lessons might be useful for health tech entrepreneurs. Some of the best insights came from developing countries, which have focused on building health systems that rely on the cheapest and most easily available tools. One such story came out of Bangladesh, from an NGO we work with, BRAC.

In the 1980s, Bangladesh-based BRAC found a way to diagnose and treat tuberculosis—at that time the leading cause of death in adults—with few doctors, virtually no technology, and a limited brick-and-mortar infrastructure. For Bangladesh’s 80 million people, there were just 50 hospitals that could treat tuberculosis, and that was only when they had medications on hand.

Tuberculosis is completely curable as long as a patient takes the medication daily for six months. BRAC realized most people could not afford to journey to the hospital to take tests and collect medications, so they decided to bring the health system to patients’ doorsteps. They sent community health workers to conduct home visits, asking if anyone had a cough or nighttime fever (common symptoms of tuberculosis). Community sputum collection centers were set up occasionally for sample testing. After confirming the diagnosis, people began treatment at home with medications provided for free by the government, under daily supervision of a local community health worker.

These steps were the easy part: when people feel bad, they are usually willing to take steps to feel better. The most difficult challenge was getting patients to adhere to daily medication routines for many months, particularly when they’d start feeling better within weeks. But failure to complete the full six-month course meant the disease could become resistant to the drugs and come back in a more lethal form.

So BRAC devised a simple system through which they now treat over 70,000 patients annually: a bond. Before starting treatment, the patient put down a small deposit, equivalent to an average week’s wages. The deposit was only refunded if the patient completed the treatment, creating a powerful nudge to finish. Before they introduced the bond, only 60% of patients completed treatment; today, the success rate is 94%.

Changing behaviors isn’t impossible, but it is hard. We offer these four key design principles that have proven helpful to us for those working on digital solutions.

  1. People want a one-stop shop. For instance, “9-1-1” is so widely used because it provides a single phone number for any emergency. What’s less helpful is a product that can only solve some problems, and expects the user to figure out how to navigate without assistance. A good app should be like the community health worker—the trusted go-to for anything health-related, and consistently, reliably helpful. An app needs to be easy enough to be useful and convenient enough to become a habit.
  2. Make the connections. CareMore’s CEO Sachin Jain recently called technology an “enabler,” highly effective only when integrated into a much larger system of care. Similarly, a community health worker clearly can’t do everything on her own, but she has a health system with laboratories, doctors, and a medical supply chain behind her that enables her to be extremely effective—and doesn’t function without her. The best apps will integrate into a much more holistic system, be it medical or personal, to the point that the user values the app’s connectivity as one of its primary benefits.
  3. Tap into their emotions. Ever yelled at Siri when she was particularly unhelpful? People are emotional and need personal interactions, especially around sensitive issues like health. Many organizations find that patients listen to community health workers not because of their technical knowledge, but because they are sympathetic, compassionate, and nice. Consequently, community health workers had a lot of social influence and were able to affect client behavior. Similarly, apps need to build a strong “relationship” with their users. Take for example, the SMS-based financial advisory platform Juntos, a completely automated information service, which receives many “Merry Christmas” messages from customers who want to share the holiday cheer with a trusted “friend.”
  4. Don’t spare the rod. Accountability is critical to changing long-term behaviors. Even the most dynamic community health worker struggles to get patients to complete their full regimen of medication; it took BRAC adding a bond to the program to really solidify the full behavioral change model. When a person’s reputation or money is on the line, they are inherently more motivated to follow through. Apps can add teeth to their design in various ways, for example, through social community challenges (Fitbit and LoseIt!) or monetary commitments (DietBet and Stickk). Make users feel invested, and don’t let them get off the hook easily.

Ultimately, technology provides a powerful new tool to shape behaviors for the better, but its potential relies on our ability to figure out how to best put it to use. Providers faced with extreme constraints have identified creative and simple no-tech ways to influence health behaviors through understanding human behavior—we hope their learnings will be useful to digital health innovators building better high-tech solutions.