Using behavioral economics to reduce the intention-action gap for medical male circumcision: Lessons from a pilot study in South Africa

Summary:

Medical male circumcision (MMC) is a core component of South Africas HIV prevention response. Although many men say that they intend to get circumcised, relatively few men follow through on this intention. We hypothesised that we could reduce this intention-action gap for MMC by using insights from behavioural economics. We applied behavioural principles, such as social proof and the self-generation effect, to the script used by contact centre agents and to the materials used by social mobilisers in promoting MMC. We randomly allocated contact centre agents and social mobilisers into test and control groups and trained the test groups to use the behaviourally-informed materials. We monitored results over three months and used difference-in difference analysis to analyse results. The updated scripts resulted in a 21% increase in booking through the contact centre (p< 0,05). Changes to the social mobiliser materials resulted in a 25% increase in bookings and 29% increase in actual procedures. We estimated that small changes to the scripts could result in over 30,000 additional circumcisions a year. This abstract is both research and practice-orientated and learning could be applied to improve the effectiveness of other health interventions supporting the achievement of the SDGs.

Background/Objectives

As part of South Africas HIV prevention strategy, the National Department of Health aims to circumcise an additional 2.5 million men aged 15-49 by 2022. Men are mobilised for medical male circumcision (MMC) through mass media campaigns directing them to a contact centre where a booking for MMC is made, or through social mobilisers who make the booking directly. Despite high levels of circumcision intention, the number of men following through is low. We hypothesised that by applying behavioural economics to the conversations between men considering circumcision and contact centre agents or social mobilisers, we could reduce this intention-action gap.

Description Of Intervention And/or Methods/Design

We listened to calls made by men considering MMC to the contact centre. We also conducted narrative interviews with men in eThekwini and observed their interactions with social mobilisers promoting MMC. We identified where insights from behavioural economics could be incorporated into the contact centre script and social mobiliser materials to improve the persuasiveness of conversations. Using historical performance of booking men for circumcision, we randomly allocated contact centre agents and social mobilisers into test and control groups. The test groups were trained to use the behaviourally-informed materials. The materials included insights from behavioural economics such as social proof, the self-generation effect, and appeals to authority. We used difference-in-difference analysis to assess the change in MMC bookings and procedures over time. Data were analysed in Stata version 14.

Results/Lessons Learned

The updated scripts resulted in a 21% increase in booking through the contact centre (p< 0,05). Changes to the social mobiliser materials resulted in a 25% increase in bookings and 29% increase in actual procedures. Using historical figures as a base, including these changes in the contact centre would have resulted in an estimated 11,500 additional bookings across the year, while social mobilisation changes would have resulted in about 38 700 additional bookings and 31 500 confirmed procedures. For the contact centre, we were also able to calculate a reduction in the effective cost associated with each booking from 87 South African cents to 72 cents.

Discussion/Implications For The Field

Our pilot showed that behavioural economics is effective in improving the persuasiveness of conversations between contact centre agents and men considering MMC, and between social mobilisers and men considering MMC. We estimated that small changes to the scripts could result in over 30,000 additional circumcisions a year. What is most compelling about these results is that the small changes result in disproportionately large changes in outcomes at a relatively low-cost. This pilot study demonstrates the potential use of behavioural economics in other health programmes.

Abstract submitted by: 

Sarah Magni - Genesis Analytics

Jamie McGraw - Genesis Analytics

Samantha Booth - Genesis Analytics

Dayanud  Loykissoonlol - 

National Department of Health South Africa 

Saul Johnson - Genesis Analytics