Book Review: Join the Club, by Tina Rosenberg

Join the Club, by Tina Rosenberg, W.W. Norton and Company, 351 pages (plus bibliography and notes), 2011.

Join the Club, by Pulitzer Prize winning journalist Tina Rosenberg, is the latest in the currently vogue genre of Pop Social-Psychology/Pop Sociology. The genre, for which Rosenberg’s fellow New York Times writer Malcom Gladwell is probably the best-known populizer, typically takes a rather academic topic for which there has been recent research that either contradicts the conventional wisdom, or is profound in its societal implications.  The best works, such as Sunstein and Thaler’s Nudge or Gladwell’s Tipping Point, do both.  The journalist-author then acts as a medium, distilling the social science for the general audience, as well as forging an engaging story that can hold that audience’s attention.  Join the Club is Rosenberg’s first full foray into the genre and is highly recommended to anybody concerned with human behavior.  Though the book ultimately suffers from poor organization and the examples have all been presented with greater analytical rigor elsewhere, Rosenberg nevertheless synthesizes these stories in a new and fascinating way.

Behavioral Economics and Healthcare Study by Center for Global Development

Just saw this pop up in my inbox from the Center for Global Development, one of the best think tanks out there working on development issues.  It's a new study they're doing together with the Johns Hopkins Bloomberg School of Public Health that will be looking at how practitioners asses the potential for behavioral economics based solutions in health (click images for larger).



Here's the key lines out of the email: "Behavioral economics approaches may be particularly relevant for health policy: people around the world, regardless of their income or social status, often act in ways that don't reflect what would "rationally" be best for their health. Yet the value of its application in health policy in low and middle income countries, from the view point of practitioners, has yet to be assessed."

And from the start of the survey: "Many...policies [in low and middle-income countries] are based on traditional economic models that assume individuals will behave in a rational manner. However, evidence suggests that individuals deviate from such models. For example, individuals make decisions in the short-run which are inconsistent with their welfare over the long-term, their choices are influenced by how options are framed for them, and they often conform to a dominant social view instead of choosing what is really best for them."

The study caught my eye because it relates pretty strongly to my own work with behavior change here in Moldova.  In fact, three recent books in the behavioral economics line have essentially changed the entire way I look at human behavior and health, and convinced me that the standard economic models aren't sufficient when it comes to health systems.  (The books are Dan Ariely's Predictably Irrational, Sunstein and Thaler's Nudge, and Rosenburg's Join the Club; book reviews forthcoming.)

Behavioral economics has also played a big role in Vitality's work; the three aforementioned books in fact are at the top of our recommended reading list, which is how I first came across them.  (Vitality's founder, after all, is a labor economist by training.)

The field has been gaining a lot of attention in recent years; as Rosenburg points out in Join the Club it's related to one of the biggest public health successes of the last two decades in the U.S.: the reduction in teen smoking.  Nudge, meanwhile, was wide read by incoming Obama administration officials who had their sights set on our healthcare system.

But the CGD study reveals a very interesting fact: despite the fact that it's been getting a lot of academic attention from upper-level policy makers, behavioral economics has yet to filter its way down to tangible policy prescriptions for the development worker in the field.  I would wager that in part is due to the fact that the theory still hasn't been boiled down into programmatic suggestions, making it somewhat daunting for the average programming staff person who struggles to keep abreast of the most recent policy suggestions, let alone have time to redesign new programs from scratch.

Regardless, it will be very interesting to see the results of this study, which should provide the best look yet at the prospects of behavioralism going mainstream in development programs in the near future.

For those interested or unfamiliar with the field, here is a great TED talk by Dan Ariely that gives the basic gist of what behavioral economics is all about.  Enjoy!

Trans-theoretical Moldel of Behavior Change: Presentation

Human behavior is at the center of global health challenges today.  Whether trying to decrease smoking, increase hand washing, or advocating more balanced diets, changing a few key behaviors holds more potential to improve overall human health and wellness than just about any treatment-based solution.  Consequently, it occupies a key place in public health - the core preoccupation fueling the growth of the entire sub-field of health education.

Likewise, behavior change campaigns - or in the case of youth, often negative behavior prevention campaigns - are at the center of Peace Corps Moldova's Health Education program.  Everything we do, from classes to community initiatives, is essentially part of a broader strategy tackling the slow and difficult process of helping people to take control of their own health for the better.

Needless to say, I've spent a lot of time thinking about behavior change these past couple years (after all, it's also key to Vitality In Action Foundation's work).  I'll have some thoughts on the broader process of behavior change in a future post, but in the meantime, last month I had the pleasure to lead a 5 day In-Service Training on community-based behavior change campaigns for 33 Health Education Peace Corps Volunteers, Moldovan nurses, and community partners (social assistants and teachers).

Below is the presentation I gave on behavior change theory, primarily focused on the Trans-Theoretical/Stages of Change Model.  Contact me if you'd like to use; slides also available in Romanian.

This entry is cross-posted here to "The Vitality Blog".

Small Victories: my favorite moment of the week

My favorite moment of today happened when I was sitting next to my nurse partner, working on a plan for a health education program.  Laying open next to us was the book* where the Medical Center is required to record all of the health education activities it does, as health education is a required component of every nurse and doctors job.

The Chief Nurse poked her head in the door and started chastising my partner, "You haven't written in the book yet!"  To which my nurse partner Galena replied, "You all write, but we actually do."

SNAP.  Well said Galena.

*Most of what's written in that book is fiction.

Medical Center Success – pairwise ranking session!

My Program Manager recently asked me to lead this summer’s training sessions on medical center work for the new health volunteers.  Thus, while the events of this post took place a couple of months ago now, it constitutes one of my bigger successes here in Moldova and is something I’m thinking about a lot while preparing to teach the new volunteers.

One of the hard parts of the Health Education program is that we straddle worlds – we must work in both the highly structured educational system, and the much more fluid world of community medical centers.  Work at the school begins very quickly after arriving at site, and similar to English Education (EE) volunteers, the fruits of our labors become quickly visible.

Facilitating a needs assessment session at the med center.

At the medical centers, however, our job is much closer to that of Community Organization and Development (COD) volunteers – work at the organization goes in fits and starts depending on how busy they are and how effective we are at identifying projects they are motivated to collaborate on.  These two cultures can often be hard to bridge, with the fast pace of the school making it harder to be patient with the incremental change at the medical centers.  This is one reason I think so few healthies work at their medical centers for the entire two years of service.

As a result of the less structured environment of medical centers, the needs assessment stage is a much longer process.  Facilitating good needs assessment, in fact, is not just necessary to choosing the best health education topics, but is in of itself a key skill we need to transfer.  Good needs assessment is also the first step of any long term planning process.

After coming up short for months in trying to get my medical center to write a one year health education plan, we’d had a number of needs assessment discussions that fizzled.  I finally decided it was time to try a different approach, and reached out to my COD friend Craig.  One of the downsides of bridging programs is it doubles the number of competencies a successful volunteer needs to possess; one of the upsides of Peace Corps is that we have colleagues like Craig who bring the perspective of a different program.

As part of its heavy emphasis on local sustainability, Peace Corps teaches the PACA  approach to needs assessment, (Participatory Analysis for Community Action).  More than a set of tools, PACA is a whole philosophy that calls for empowering community members instead of the development worker to set the agenda through participatory activities.  It also includes a toolkit of creative needs assessment activities.  The results are better needs assessments and thus an increase in the number of stakeholders, which lays a stronger foundation for resulting actions.  The analysis itself helps build consensus amongst participants by demonstrating that the agreed upon needs were not a foregone conclusion.

For my medical center, Craig recommended we try an approach known as Pairwise Group Ranking,

My job, pt. III: A view of my desk is a day in my [work] life

This is the final part of a three post series introducing the work component of my life as a Health Education Specialist in Peace Corps Moldova.  The series has moved from the broad to the specific, so Part III will conclude by a look at what my work actually involves on a daily basis.  Part I is a general introduction to the public health situation in Moldova, and Part II examines my different projects at the general level.

When I started writing this series at the end of October – yeah, it’s been a long time in the making – I had just passed the point where I had been at site longer than in training, and it was really starting to show in my work life.

The soaring towers of paper accumulating on my desk are only the most visual sign that this work life is finding traction.  Those who have lived around me know me to be a crowded desk person.  Some say “crowded” is just a euphemism for “messy”, but in my opinion the difference is that there is a logic to my system.  That’s probably in the eyes of the beholder…my dad claims the same thing.  My desk hasn’t yet reached the state of his fire hazard, but then I also don’t have many bills to pay.

In what may have been an indication of concern, my host family recently put a second desk in my room.  This was one of the happiest days of my life, though they didn’t seem to understand the natural logic of the law of desk space: desk piles will expand to occupy the space available.  (On the other hand, my host family probably considered it a victory simply that these piles moved out of my bed and off the floor…)  What might concern them more is the fact that what’s going on in my head at any given moment tends to resemble my desks…  It also, however, provides a glimpse at my daily work life.

Starting our tour a desk #1, we find the computer in the dominant position. 

My job, pt. II: So what do you actually DO?

This is Part II of a three post series introducing the work component of my life as a PCV, in which we’ll look at my program’s objectives and major projects at the general level.   The series is moving from the broad to the specific; Part I is a general introduction to the public health situation in Moldova and Part III will conclude by a look at what my work involves on a daily basis.

Every Peace Corps Volunteer worldwide works in a program; here in Moldova, I work in the Health Education in Schools and Communities (HESC) program.  My formal title is Health Education Specialist – yes, even as a volunteer one gets a snappy title.  In PC Moldova parlance, I’m referred to as a “Healthy.”

As a HESC PCV my primary work focuses on building local capacity for the educative aspects of a public health program.  As I explained in my previous post, Moldova has one of the highest health care provider ratios in the world, but the concept of public and preventative health is still taking root here.  It also has a decent public education system, considering the local resources available.  But again, health education is still struggling to be integrated in an intentional and coherent manner.  The local providers, in short, aren’t yet accustomed to being educators, and the local educators aren’t yet accustomed to the specifics of health education.  I’m here to facilitate that step.

That step is broken down into two overarching goals and seven objectives:

• Goal 1: Improved Health for Youth
• Objective 1.1: Develop School Health Educators (i.e., teachers)
• Objective 1.2: Improve Students’ Learning
• Objective 1.3: Promote Peer Education in Extra-curricular Activities
• Objective 1.4: Increase Parental Involvement in Schools
• Goal 2: Improved Community Health
• Objective 2.1: Develop Community Health Educators (i.e., medical staff)
• Objective 2.2: Enhance Community Involvement in Community Activities
• Objective 2.3: Improve Use of ICT to Support Community Health and Education

My job, pt. I: Moldova’s Health Profile

I’ve been getting more questions recently about what the work side of my life actually entails.  It’s a huge topic, so I’m tackling it in three parts.  The series will move from the broad to the specific.  This is Part I, a general introduction to the public health situation in Moldova.  This article is by far the lengthiest, and if the background is boring, I won’t begrudge you for skipping it.  But it also contains the roots of the problems I struggle with daily, so it’s an important part of my work here.  Part II will look at my specific projects, and Part III will focus on what I do on a daily basis.

Moldova has what’s known as a “dual health profile,” meaning that it has elements of a health care system of a fully developed nation, but simultaneously struggles with problems typically associated with less developed countries. As an example, while Moldova has high vaccination rates and one of the highest doctor and nurse to patient ratios in the world, it also faces a high prevalence of TB, and access to safe drinking water and sanitation standards remain a pressing problem in rural areas.

Moldova is often summed up as “Europe’s poorest country.”  Obviously, this depends on a lot of definitions, but based on GDP per capita and given the broadest possible conception of Europe, only Kyrgyzstan and Tajikistan are poorer, so the general point is well taken.  Despite this fact, however, at Moldova has a higher life expectancy (by 2 to 5 years) than other significantly richer post-Soviet states.

• Life Expectancy: 68.5 years (WHO, 2007), 70.8 years (CIA World Fact Book, 2010)

On other key indicators of health such as infant and maternal mortality, Moldova is also outperforming the rest of the Eastern European WHO region (WHO 2005).

• Infant Mortality: 13.13 deaths/1000 live births (CIA World Fact Book, 2010)

Arguably, then, Moldova is doing pretty well given the context – it’s significantly below the global economic average, but nevertheless can boast health outcomes somewhat above the global average.  This fact is impressive, because wealth is a key predictor of health outcomes – though not by any stretch the only important indicator, remember the U.S. has a lower life expectancy than Bosnia and Herzegovina.  The point is, clearly systems and public policy matter too.  And “doing well given the context” isn’t much consolation to those people dying at young ages from preventable causes.