Using behavioral insights in public health programming - NDPHS

Using behavioral insights in public health programming

28 March, 2023

Often, when people know how to behave healthily, they choose not to do so. For example, people who know how to eat healthily may choose an unhealthy option. Or people who know effective treatment instructions for a medical problem may choose not to follow them. This is because behaviors are driven by multiple socioeconomic and cultural factors. Public health professionals’ education or training do not necessarily change behaviors alone.

Healthy behaviors are triggered by different factors

Behavioral Insights (BI) can help us to change persistent unhealthy behaviors. Firstly, it can be used to explore factors that affect health behaviors and secondly these can be used to improve the outcomes of health policies, services, and communication. Theories from social and behavioral sciences can be used to identify both positive and negative triggers for the behavior. Theoretical Domains Framework (TDF) is one of these theories. It includes 14 domains that explain behavior including knowledge, skills, social and professional roles, social influences, beliefs in consequences, beliefs in capabilities, psychological processes, emotions, optimism, intention, goal, behavioral regulation, emotions, environmental factors, and resources. It has been used to understand various behaviors including alcohol use, antibiotic use, and the uptake of vaccines and ARVs, among others (Rosario et al 2021; Lohiniva et al 2020; Bell et al 2021).

Cultural context matters

Behavior triggers are often context-specific, making it important to explore them in time and place. There are individual differences between us as well as many demographic and cultural factors that shape our perceptions and beliefs. For example, for decades, anthropologists have been studying hygiene by determining how dirt and contamination are understood in different subcultures which, as a result, influence hygiene behaviors (Kleinman 1987; Curtis 2007). Years ago, I was conducting formative research on motivators for hand hygiene among patients in a low-resource country. I learned that among the local nursing staff, patients were perceived as “contaminated,” which triggered the need to wash their hands, not only when they had visible dirt or an odor, but also when dealing with patients who spoke in a loud voice or had an unfriendly attitude towards the staff. Quiet and polite patients did not trigger the need to wash their hands. The findings were used to help inform a communication campaign that emphasized the risk of infection from various types of patients.  We tend to think that cultural concepts and practices are barriers to healthier behaviors, but my example shows that cultural concepts can actually be utilized to promote healthier behaviors. Cultural understanding feeds into the acceptability and sustainability of behavior change.

Theory-based intervention can lead to sustained behavior change

Often, public health interventions are developed based on what we think will be effective or easy to implement. However, when we follow BI as an approach, we use social and behavioral sciences theories to develop data-driven interventions to support behavior change or modification. One of these frameworks is the Behavior Change Wheel, which consists of nine behavioral interventions including coercion, education, environmental restructuring, incentivization, persuasion, restrictions, training, modeling, and enablement which include +80 different tactics to be used to change behavior (French et al 2012). For example, if the behavior is a tendency to forget the uptake of Tuberculosis medication, the appropriate intervention would be persuasion and the tactic would be the use of reminders to take the medication.

BI is an effective approach to changing health behaviors though more data are needed about behavioral triggers and what interventions change different behaviors in different settings. Our network of experts in the NDPHS is an ideal platform to explore vital health behaviors in different settings and to co-create best practices, programs, and policies for the region that are based on theories and principles of BI.


Text: Anna-Leena Lohiniva, Chair, the NDPHS Expert Group on HIV, TB&AI, Finnish Institute for Health and Welfare



Bell J, Sharma S, Malone S, Levy M, Reast J, Ciecieląg J, Gogolina S, Ansons T, Fourie S, Braz R, Little K, Hasen N. Targeting interventions for HIV testing and treatment uptake: An attitudinal and behavioural segmentation of men aged 20-34 in KwaZulu-Natal and Mpumalanga, South Africa. PLoS One. 2021 Mar 10;16(3):e0247483. doi: 10.1371/journal.pone.0247483.

Bolsewicz K, Debattista J, Vallely A, Whittaker A, Fitzgerald L. Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom. AIDS Care. 2015;27(12):1429-38. doi: 10.1080/09540121.2015.1114992. Epub 2015 Dec 7. PMID: 26641139.

Curtis VA. Dirt, disgust and disease: a natural history of hygiene. J Epidemiol Community Health. 2007 Aug;61(8):660-4. doi: 10.1136/jech.2007.062380.

 French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, Buchbinder R, Schattner P, Spike N, Grimshaw JM. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012 Apr 24;7:38. doi: 10.1186/1748-5908-7-38.

Kleinman A. Concepts and a model for the comparison of medical systems as cultural systems. Soc Sci Med (1967). 1978 Apr;12(2B):85-95. doi: 10.1016/0160-7987(78)90014-5.

Lohiniva AL, Elwali E, Abuobaida D, Abdulrahim A, Bukuluki P, Talaat M. A theory-based exploration of antibiotic use in primary healthcare in Gezira state, Sudan. Implement Sci Commun. 2021 Dec 4;2(1):132. doi: 10.1186/s43058-021-00229-3.

Rosário F, Santos MI, Angus K, Pas L, Ribeiro C, Fitzgerald N. Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework. Implement Sci. 2021 Jan 7;16(1):6. doi: 10.1186/s13012-020-01073-0.

Seidlein AH, Salloch S. Illness and disease: an empirical-ethical viewpoint. BMC Med Ethics. 2019 Jan 9;20(1):5. doi: 10.1186/s12910-018-0341-y.

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