The first two sessions of the symposium set the scene for the behaviour change challenge and showed the science and practical applications that can be used to achieve behaviour change. However, it is also apparent that behaviour change cannot be achieved in isolation. Changing population behaviour in regards to diet and nutrition, lifestyle, hygiene and sustainability is difficult and complex. One of the most challenging parts of this process is reaching the entire breadth of the population. This step requires scaling up efforts and sharing expertise, which can better be achieved through private–public partnerships. As such, this session commenced with the presentation of two success stories in behaviour change for better health, which were both derived within a scientific framework. Professor Ibrahim Elmadfa and Dr Gerda Feunekes presented on a sodium reduction strategy, and Dr Val Curtis and Dr Myriam Sidibe presented on a global handwashing campaign. The session concluded with Dr Marti van Liere discussing the need for collaborations between industry, governments, the private sector and nongovernmental organisations in order to create effective behaviour change.
New approaches to sodium reduction: International Union of Nutritional Sciences and Unilever collaboration Professor Ibrahim Elmadfa and Dr Gerda Feunekes
Unilever and the International Union of Nutritional Sciences (IUNS) participate in a formal partnership aimed at reducing NCD, with a current focus on increasing demand for sodium-reduced foods, and generally lowering sodium intake. Sodium intakes around the globe are on average two to three times higher than that recommended by the World Health Organization and other health authorities . Overconsumption of sodium is a major contributor to cardiovascular disease as it progressively raises blood pressure levels with age. Globally, an estimated 49% of coronary heart disease events and 62% of strokes can be attributed to elevated blood pressure . In countries where effective sodium-reduction programmes were implemented, the prevalence of blood pressure and cardiovascular diseases decreased in parallel .
In industrialised countries, most of the sodium intake is derived from processed foods and restaurant foods. In developing countries, sodium is mainly added during food preservation and preparation, either as salt, seasonings or sauces. As taste preferences for salty foods are often linked to traditional food preservation and preparation, there is an opportunity for food industries to apply modern technology to help people reduce their sodium intake. However, general awareness on the need to reduce sodium intake is low and, furthermore, even if people are interested in reducing their sodium intake they need to be motivated to gradually adjust their salt preference by actively choosing sodium-reduced foods.
In light of this, in 2012 Unilever and the IUNS organised a series of six sodium-reduction behaviour change workshops with local public health experts and other relevant stakeholders, to generate ideas and actionable strategies to support behaviour change initiatives to reduce sodium intake amongst the general population. These workshops were conducted in Germany/ Austria, Hungary, South Africa, China, India and Brazil. Given the limited information available on this topic, a series of studies were performed to generate quantitative information on barriers and triggers for sodium reduction, as well as preferred sources and channels for promoting sodium reduction, as input for the workshops.
Based on two pilot workshops in the UK and the Netherlands, Unilever developed a format for the behaviour change workshops. The setup of the single-day workshops includes a ‘step in the shoes of consumers’ role-play exercise, where workshop participants first role-play a specific consumer in a focus group to work through a series of questions on salt by guessing how consumers would answer and experience such questions. Workshop participants then watch an actual focus group discussion of general consumers to see what the consumer reactions and experiences really were. Through engaging in such an exercise, participants generally grow to accept that education alone is not enough to drive consumer choice. This activity was then followed by a split-group structured brainstorm exercise, using Unilever’s Five Levers for Change (explained in the previous section), aimed at developing ideas for new sodium-reduction approaches. A cartoonist is present to help capture ideas and campaigns. The workshops are then concluded with a mediated session where the brainstorm ideas are shared, and concrete actions are captured.
The research studies consisted of consumer cohort studies in each of the aforementioned countries. Within each country a population representative sample of 1,000 adults (aged 18 to 65) filled out an online questionnaire, which was adapted to local language, foods and habits. The overall results revealed that, although salt reduction was an important topic and relevant to health, the majority of the respondents believed their sodium intake was satisfactory and they were not thinking of, or planning to, reduce their sodium intake. Interestingly, South Africa and China were relatively advanced in terms of awareness of recommendations and intentions to reduce sodium intake, probably linked to recent local communication on the need to reduce sodium intake. Other key insights from the survey were that the perceived importance of low-salt food choices grew with an advanced stage of behaviour change awareness, and that people felt that they themselves were responsible for their salt intake, independent of the stage of change. Full results on each of the local surveys were provided as input to the local IUNS behaviour change workshops.
The completed workshops were reported as successful by the IUNS and Unilever representatives. These workshops, lead by IUNS, helped to engage public health stakeholders, ranging from nutrition experts to consumer organisations and food industry representatives, in jointly developing exciting behaviour change approaches in the area of salt reduction. They were only a first step of a local sodium-reduction journey, which will require follow-up meetings for implementing and upscaling of the agreed consumer-focused salt-reduction approaches. At a global level, output from the surveys and workshops will be used to identify common themes around the world, and cluster countries where similar approaches could work. Combining an increased availability of sodium-reduced foods with generic, public health-type campaigns and motivational, branded campaigns will increase consumer awareness on the need to reduce sodium intakes and will motivate consumers to try more sodium-reduced foods, while gradually adjusting their taste preference.
Driving handwashing habit change at scale: one billion by 2015 Or Valerie Curtis and Dr Myriam Sidibe
Whilst many people in the developed world worry about overconsumption, at the same time there remains a silent emergency of underconsumption in many developing countries. Two out of five people on the planet still have no toilet, and some four out of five people still do not wash their hands with soap at key moments . As a result, three-quarters of a million children lose their lives to diarrhoeal disease before they reach the age of 5 . Soap is an affordable and readily available technology that could cut the diarrhoea risk almost by one-half [46, 47] and could also prevent respiratory infections . Although present in almost every home in developing countries , soap is still not used for handwashing at key times, especially after contact with faecal material and before feeding children. In this presentation we describe a body of work that combines new approaches to behaviour change with the market power and reach of Lifebuoy, a major soap brand, to bring handwashing with soap to the billions that need it most.
The importance of motives
In the field of health promotion, theories of behaviour abound. Health psychologists have most often used the Theory of Planned Behaviour , the Health Belief Model  or the Health Action Process Approach . These theories are based on the assumption that behaviour is cognitive, conscious and calculated to produce rational outcomes. However, most behaviour is not under rational control but is driven by motives that cause people to seek out and secure the things they need to survive and reproduce effectively. These needs include food, mates, social bonds and social justice (Aunger R, Curtis V, manuscript submitted), and do not include health.
If rational appeals to behave in healthier ways are of limited use and there is no health motive, then how should we design handwashing campaigns? First, we must better understand the drivers of handwashing behaviour; and second, we need to translate our understanding into effective large-scale programmes.
Motivations behind handwashing
Studies of handwashing were carried out in over 12 mainly developing countries using the lens of the Evo–Eco model . We used methods such as structured observation, behaviour trials, the elicitation of daily routines, video ethnography, projective techniques using stories and pictures and Internet-based questionnaires. One important finding was that, although there is some variation from country to country and from setting to setting, many of the basic drivers of handwashing behaviour were the same.
Habit was the most important psychological determinant of handwashing behaviour . Behaviour trials showed that handwashing would only happen habitually if it was incorporated into the daily routine. This required preparing facilities and using place and previous activity to cue the behaviour. Many different motives for handwashing were explored, including status (high-class people/celebrities wash their hands) and attraction (your husband loves clean hands). However, the most effective were disgust (invisible contamination on your hands can only be removed with soap), nurture (your child will thank you/love you for the care you took to keep his/her hands clean) and affiliation (doing what everyone else is doing). Disgust has been shown to be effective in encouraging handwashing in a number of studies [54, 55]. Also well established is the fact that affiliation is a key motive: changing local norms can do much to change behaviour . The formative research brought to light the importance that mothers and schools attached to teaching children good manners, and that this might be employed in changing societal norms around handwashing.
Unilever’s Lifebuoy brand has committed to getting a billion people washing hands with soap by the year 2015. The results of the global formative research, along with local research and the Unilever Five Levers for Change, helped to provide the components of the current campaigns, which have already reached 48 million people in 2011 in countries including Indonesia, India, Vietnam, Bangladesh, Pakistan, Malaysia, Kenya and Ghana.
To ensure uniform delivery of the programme across so many countries, Lifebuoy developed five non-negotiables – core principles of the campaigns that came from theory and evidence and were to be adapted to local conditions. These non-negotiables were as follows:
♦ Disgust: in the interaction with the school children, in order to show that the use of soap is important, the Glo-Germ demonstration shows children that there is invisible contamination on their hands – this provides a visceral emotional experience that is more powerful than a lecture about germs.
♦ Nurture (mother and child interaction): mothers are encouraged to enforce the handwashing habit at home contributing to their perception of being a good mum – for new mums, the creative work is based on the idea that ‘Your child trusts your hands the most’,
♦ Affiliation (positive reinforcement): Lifebuoy created ‘the school of five’ where kids want to join the group, aided by a well-respected and loved celebrity.
♦ Habit (21-day practice): making soap use in the five occasions into a new habit means encouraging mothers and children to do the same – to repeat behaviours again and again in the same settings until they stick.
♦ Pledging and creating new norms: mothers and children take pledges in front of others whose opinions matter – making handwashing good manners and therefore socially desirable.
Whilst we increasingly understand the drivers of healthy behaviour, such as handwashing, huge challenges still remain in implementation. We know that approaches such as those described above can be effective at the small and medium scale [57, 58]. However, with multiple millions of people still to reach, the priority now has to be finding ways of making such interventions as cheap as possible, and to anchor them into the education and health systems of every country. Every mother and every teacher should be entrenching the habit of handwashing with soap in their charges. Only then will handwashing become a norm for the majority of the population, and children in every country in all walks of life will be protected from fatal infectious illness.
Importance of collaborations in changing behaviour Dr Marti van Liere
The Global Alliance for Improved Nutrition works with both public and private-sector partners to improve the accessibility and affordability of appropriately fortified foods in developing countries. The Global Alliance for Improved Nutrition has just celebrated its 10-year anniversary in mid-2012 and is now reaching over 660 million people with nutritious, fortified food products – such as iodised salt, vegetable oil enriched with vitamin A, or fortified complementary foods for babies 6 to 24 months old. As the Global Alliance for Improved Nutrition brought these high-quality fortified products to the market, they realised that consumer behaviour needed to be influenced so that they start choosing and using fortified food products.
Traditionally, infant feeding behaviour change campaigns, inspired by the World Health Organization infant feeding guidelines [59, 60], have been executed by the health sector. Although projects have demonstrated an impact of interventions on behaviour and even nutritional status, there are not enough examples of well-documented, large-scale programmes that have successfully improved feeding practices in children 6 to 23 months old and have resulted in improved health outcomes at national level. Campaigns often transmit multiple, complex messages to illiterate mothers – leaving it to her to figure out how to find the time to breastfeed or the financial means to prepare a diverse diet especially for the baby. These messages ignore the reality of globalisation, urbanisation and modernisation: many of these mothers, although poor, are having long working days in rural and urban settings; they may have a cell phone but do not grow fresh produce in their own home garden or may not be able to access it at an affordable price at the wet market or supermarket. Mothers and caregivers not only wish for their children to be healthy and grow up well, they are also consumers, looking for convenience, making their choices based on the available products and information.
The public health sector can learn from commercial marketing to become more effective in driving the desired behaviour change. Where public health focuses on the needs of people for better health, hygiene and nutrition, translating this into well-intended knowledge messages, marketers understand that human behaviour is also driven by the wants of consumers, the more immediate benefits one can get out of life. Advertisement is based on behavioural psychology insights that trigger a consumer to purchase a product not because she/he needs it for a rational reason, but because she/he wants it for an emotional reason. Often this approach is more impactful and effective than a knowledge-based awareness-raising campaign.
Technological solutions to improve health, such as water purifiers, medication or fortified foods, will not have the desired health impact if there is no or limited uptake by the targeted users. Alliances such as Water and Sanitation for the Urban Poor, Scaling Up Nutrition and the CEO Water Mandate have recognised the value of multi-stakeholder collaboration, including the private sector, to scale-up impact in health, nutrition or environment at a country level.
Public health and nutrition experts should tap into the strengths of the commercial private sector, to achieve sustainable impact on a large scale in improving infant feeding behaviour and nutritional outcomes.
In multi-stakeholder collaborations, each stakeholder brings its own strengths to the table: academics lend credibility to the messages and provide the scientific evidence base; industry brings expertise in innovation, production, distribution and marketing; and public health services and nongovernmental organisations understand the needs of the poorest and have the capacity to reach the most vulnerable target groups. Policy-makers and regulatory authorities are also important players, establishing regulatory standards and marketing guidelines that allow or inhibit claims that are presumed to influence purchasing behaviour. The user or consumer should be central, as she/he is the person that will take an informed decision to make use or not of an innovation. Consumers are not just passive receivers but are key drivers of change, which is why not only their needs but, foremost, their wants should be central to all stakeholders.
Partnerships between the public and private sectors are not without challenges. One of the main hurdles is the negative perception of the business benefit by those working in the public sector: why should nongovernmental organisations or governments support companies to market their products and help them make profit? There is a thin line between demand creation for a product category or a generic habit (promotion of consumption of iodised salt) and the advertisement and promotion of a branded commercial product (use of a specific salt brand). From a business perspective, however, it makes sense that investments in a partnership are expected to bring a benefit and contribute to the business key performance indicators, such as brand equity, supply-chain efficiencies or product penetration or sales. Collaborations or partnerships are hard work and require adequate time and energy investment.
They can only work if the main principles are trust, transparency and equity. Success factors include the definition of a clear roadmap with shared goals and transparency about the individual goals (including business objectives), and measurable key performance indicators for each partner. Roles and responsibilities of each partner should be spelled out at the start. Partners must discuss a common communication framework including, if appropriate, guidelines for use of logo and branding. Many public-sector organisations have strict rules regarding non-endorsement of products or brands. Appointing a designated focal point is important, as is frequent and open communication, but senior leadership support is even more crucial. Only then will the partnership be allowed sufficient time and resources to develop and deliver.
Changing behaviour for better health requires passionate and creative marketers applying their skills and competencies to solve complex changes in behaviour to improve health and nutrition of underprivileged target groups. This change of behaviour also requires passionate and committed public health experts to create access to appropriate solutions and choices through multiple channels, and to empower vulnerable target groups to make informed decisions based on their own needs and wants.
There is no easy or quick fix to changing behaviour for better health or better nutrition, but the potential of achieving impact at scale through public–private sector collaborations makes the investment worthwhile.