Behavioral economics does not offer a magic formula for improving decision-making by women, households, and health providers. However, it does offer insights about why and how our choices are influenced by social norms and pressure. Social Norms Theory, first used to address college student alcohol use (Perkins & Berkowitz, 1986), focuses on the environment and interpersonal influences to change behavior, rather than focusing on the individual.
Social norms interventions have long been harnessed by the behavior change community as a tool for improving decision-making. For example, the telenovelas of Miguel Sabido in Mexico in the 1970s and radio soap operas in Tanzania in the 1990s portrayed the benefits of contraception and smaller families as positive individual and social goods (Rogers et al., 1999). In this sense, media can be used to correct false beliefs about social norms—for example, providing accurate statistics on regional family size, or condom use. They can also be used to provide information about how an individual’s behavior compares to that of peers. Knowing what our peers and community members are doing or thinking can have a strong effect on our own decisions. A woman might overestimate the likelihood that her husband disapproves of contraceptive use; however, information about other husbands in her community might encourage her to engage in communication.
Like the commitment devices described earlier, we can harness social pressure by creating “social commitments.” These are public statements of intention, which leverage social sanctions to reinforce follow-through on a decision. In some cases, social commitment has been shown to reinforce beneficial decision-making, particularly in the context of savings. In an analysis of seventy rotating savings and credit organizations (Roscas), this savings approach was found to be popular and successful—despite its inherent riskiness and inflexibility. Women participate primarily because Roscas provide a socially-enforced commitment to save (Gugerty, 2007).
Investigating further, Karlan (2007) finds that individuals with stronger social connections to others in their Rosca, or savings group, end up with higher savings and higher repayment rates. Social commitment devices are a combination of the commitment devices discussed in the previous section and the social pressure described here. They have been applied to health decision-making in the context of savings: in Kenya, individuals were invited to make deposits into savings account labeled for health expenditures. Those investing in a group setting saved more— and invested more in preventive health—compared with those making deposits on their own (Dupas & Robinson, 2013).
|Berhane Hewan: Social Commitment + Incentives|
|A quasi-experimental evaluation of Berhane Hewan, a program aimed at delaying marriage and empowering adolescent girls in Ethiopia, successfully increased educational attainment and delayed marriage among 10-14 year olds. It also increased the use of family planning services among sexually active and married adolescents (15-19 year olds). The program included a public commitment by parents and their daughters to delay marriage for at least the duration of the two-year program. Families were told they would receive a goat upon successful completion of the program, to incentivize participation and offset financial costs of delaying marriage (Erulkar & Muthengi, 2009).|
To our knowledge, there has been no other research testing the effectiveness of social commitment related to reproductive health decision-making; this is an area for further research.
Harnessing strong norms
Susceptibility to social pressure can be used to design interventions that counter harmful social norms. For example, policymakers can design and support positive social norms related to contraceptives, enabling individuals to act in line with their own preferences. A policymaker might change the reference point for contraception within her community, signaling that those who adopt contraceptives are responsible and desire to improve family well-being—which is in direct opposition to the more pervasive belief that contraception is a practice of sexually promiscuous, irresponsible people.
|PRACHAR: Pro-Social Pressure|
|In Bihar, India an intervention has been developed to prevent child marriage and increase child spacing. The program, PRACHAR, has a component aimed at influencing community and family members and instigating pro-social pressure to delay marriage. It targets youth aged 15-19 years, as well as their parents and communities. The interventions include training of unmarried adolescents, home visits with parents-in-law, and community education. A retrospective study, with random cluster sampling of participants and a control group, suggests that PRACHAR delayed age at marriage and first birth. It also may have increased the use of contraceptives to delay second pregnancy, including among the most economically disadvantaged groups (Daniel & Nanda, 2012).|
In other areas of public preventive health, especially in the context of risky behaviors, the reinforcement of positive social norms is a promising tool for improving individual decision-making (DeJong et al., 2006). And failing to change harmful norms can result in perpetuation of false information or wrong beliefs. In a study in the US, college students were shown to routinely overestimate the drug and alcohol use and risky sexual behavior of their peers (Martens et al., 2006)—and the researchers in this study found a positive association between these perceived norms, and students’ actual behavior.
|Social Norms and Energy Use|
|In a randomized natural field experiment, a US company called OPOWER sent letters to utility customers comparing their electricity use to that of their neighbors. The program reduced energy consumption by 2 percent, which is equivalent to the effect of approximately a 16 percent increase in energy prices. Effects were greatest on households with the highest initial energy consumption (Allcott, 2011).|
Policymakers can also harness persuasion and altruism to encourage pro-social behaviors (e.g. healthier, safer, more socially conscious behavior) by providing messages about what is normal among peers, and how individual decisions affect equity within the community. For example, in the context of natural resources, people can be pressured to reduce their own consumption, based on information about peer households’ consumption (Allcott, 2011).When misperception of social norms leads individuals to make undesirable choices—particularly choices that harm others—a policymaker can correct the misperception, since knowing what others actually do seems to have a stronger effect on what people actually do.
Accountability through Feedback and Social Pressure
Another important application of social pressure is to generate accountability, which can motivate improved service delivery among health providers or teachers. Creating simple (and anonymous) client feedback mechanisms can help providers feel more accountable to their patients, for the quality of services delivered (Tavrow, 2010).
Efforts to improve accountability more broadly can involve holding public officials responsible to the communities nearest them. This is typically achieved by revealing strategic information about a public official’s performance, which elicits a response of pressure within the community. One experiment in Uganda focused on holding public authorities accountable for the provision of essential services to vulnerable populations. This study (Björkman & Svensson, 2009), corroborated by cross-sectional and qualitative case study evidence (Papp, Gogoi & Campbell, 2012; George, 2003; Murthy & Klugman, 2004; Berlan & Shiffman, 2012), suggests that interventions like citizen report cards, which equip communities to hold officials and providers accountable, can increase utilization of services, and in some cases increase quality.