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Behavior Change

  • October 2015
2014 Jonathan Torgovnik/Reportage by Getty Images, courtesy of the Hewlett Foundation

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Individuals often engage in behaviors that may be detrimental to their long-term health and wealth. Modifying behaviors can lead to positive changes in individual lives, including improved health and economic well-being. Risky sexual behaviors may expose someone to early, unwanted pregnancy or sexually transmitted infections, both of which have lasting social and economic costs in terms of the price of care, lost earnings, and inter-generational poverty. Adolescents who are not able to attend school on a regular basis are at risk for repeating grades and for not completing primary or secondary school, which affects their long-term earning potential.  Addressing these issues in low- and middle-income countries in sub-Saharan Africa and Asia has been the focus of many development efforts, and recent behavioral interventions such as incentive programs and education campaigns show some promise.

The William and Flora Hewlett Foundation’s Population and Poverty Initiative and its partners have funded several studies that examine programs designed to change sexual behavior and promote school attendance through both information campaigns and incentive programs. Other studies have assessed changes in behavior associated with policy shifts, economic crises, or natural disasters. This body of research provides insights into strategies for creating behavioral changes that lead to improvements in long-term health and economic outcomes.

Policy Lessons

Cash incentive programs can improve school attendance among young women and reduce risky sexual behavior among both adolescent girls and adults. Providing a cash transfer linked to school attendance is effective at increasing school enrollment and improving regular attendance among adolescent girls in rural Malawi (Baird, Chirwa, & McIntosh 2010). Cash incentives, even when not linked to requirements to attend school, also lead to declines in early marriage, teenage pregnancy, sexual activity, and HIV and HSV-2 rates.  In rural Tanzania, cash incentives paid for remaining free from sexually transmitted infections (STIs) show potential in reducing risky sexual behaviors among adults ages 18-30. Safer sexual behavior has immediate positive results for individual health and wellness (Baird et al. 2012). Increasing school attendance enhances the potential for better job opportunities and higher earnings over one’s lifetime.

Increased awareness of antiretroviral therapy (ART) can lead to increased risk-taking in sexual behaviors. Both men and women adjust their sexual behavior based on their perception of risk in Mozambique, suggesting that when ART programs are scaled up, additional information campaigns should be undertaken to address changing beliefs about HIV and misconceptions about the ease of a living with HIV on ARTs (de Walque, Kazianga & Over 2011).

School-based information campaigns should consider local context when creating curriculums designed to prevent HIV. Three different strategies for educating adolescent girls on the consequences of risky sexual behaviors at schools —an information campaign, education sessions led by a teacher, and education sessions led by a consultant—produced vastly different results in different regions of Cameroon. Memorable training sessions on HIV prevention sessions do not always produce increased knowledge or less risky behavior and sometimes have perverse effects (Duflo et al. 2013).

Reducing the availability of free contraceptives may increase birth rates in poorly developed contraceptive markets. Women, particularly those who are poor, less-educated and residing in rural areas are not able to continue using modern methods of contraception when they cannot access it for free (Salas, 2013).





Conditional Cash Transfer Programs

1. Baird, Sarah, Chirwa, Ephraim & McIntosh, Craig (2010)


Conditional cash transfers to households with school age girls increases girls’ school enrollment, especially those who were not in school at the start of the program. Girls received the transfer engaged in safer sexual behaviors, showing significant declines in early marriage, teenage pregnancy, and self-reported sexual activity.

2. Baird, Sarah, Garfein, Richard S, McIntosh, Craig T & Ozler, Berk (2012)


Conditional cash transfers to households with school age girls reduced rates of HIV and HSV-2 among girls already enrolled in school at the beginning of the program. 

3. de Walque, Damien, et al. (2012)


Cash transfers conditional on negative test results for curable sexually transmitted infections reduces risky sexual behavior among adults after 12 months.  

Program Effects on Risky Sexual Behaviors

4. de Walque, Damien, Kazianga, H. & Over, Mead (2011)


Knowing about ART can lead to riskier sexual behaviors. Male risky sexual behaviors increase with the incorrect belief that ART cures AIDS, whereas female risky sexual behaviors increase with the correct belief that ART treats AIDS but does not cure it.

5. Duflo, Esther, Dupas, Pascaline, Huillery, Elise & Seban, Juliette. (2013)


Taking local context into account is critical to designing a successful HIV prevention campaign for teenage girls. Prevention messages and how they are delivered yielded different results across different areas of Cameroon.

Natural Experiments: Effects on Behavior

6. Jones, Kelly (2011)


The implementation of the Mexico City policy in Ghana results in significant increases in pregnancy, abortions, and unintended births. NGOs experience budget cuts as a result of the policy, causing them to stop rural outreach of contraceptive services. This cut in services likely increases the number of pregnancies, abortions, and unintended births among this group.

7. McKelvey, Christopher, Thomas, Duncan & Frankenberg, Elizabeth. (2012)


Very large changes in the price of contraception had little impact on its use, even among the poorest couples, which suggests that price and income are not key barriers to using contraceptives in Indonesia. Reductions in subsidies for contraception would not likely result in significant changes in usage in the overall population.

8. Salas, J.M. (2013)


Birth rates increase when free contraceptives are less available, suggesting that individuals change behavior in using contraception. Some couples are not able to pay for contraception, suggesting that some women substitute into using traditional methods, or sometimes not using any method at all when public supplies run out. 


Baird, Sarah, Chirwa, Ephraim & McIntosh, Craig. (2010). The Short-Term Impacts of a Schooling Conditional Cash Transfer Program on the Sexual Behavior of Young Women. Health Economics, 19 (1), 55-68.

Baird, Sarah, Garfein, Richard S, McIntosh, Craig T & Ozler, Berk. (2012). Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet, 379 (9823), 1320-9.

de Walque, Damien, et al. Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ open 2.1 (2012).

de Walque, Damien, Kazianga, H. & Over, Mead. (2011). Antiretroviral therapy (ART) awareness and risky sexual behaviors: evidence from Mozambique. Center for Global Development, (239).

Duflo, Esther, Dupas, Pascaline, Huillery, Elise & Seban, Juliette. (2013). Impacts of School-Based HIV Education on Reported Behavior and Knowledge of Adolescent Girls.

Jones, Kelly. (2011). Evaluating the Mexico City Policy: How US foreign policy affects fertility outcomes and child health in Ghana. International Food Policy Research Institute (IFPRI) Discussion Paper No. 01147.

McKelvey, Christopher, Thomas, Duncan & Frankenberg, Elizabeth. (2012). Fertility Regulation in an Economic Crisis. Economic Development and Cultural Change, 61 (1), 7-38.

Salas, J.M. Consequences of withdrawal: Free condoms and birth rates in the Philippines. January 1, 2013.

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