To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way. So what about just working with health-care workers, one by one, to do just that? With the BetterBirth Project, we wondered, in particular, what would happen if we hired a cadre of childbirth-improvement workers to visit birth attendants and hospital leaders, show them why and how to follow a checklist of essential practices, understand their difficulties and objections, and help them practice doing things differently. In essence, we’d give them mentors.
Atul Gawande has written [a fascinating account of the difficulties faced when trying to spread ideas and change behavior]. For Gawande, behavior change is crucial because it means saving lives. After reviewing a number of medical innovations and considering why the ideas behind them did or didn’t spread, he moves on to the [BetterBirth] project and how try are approaching this problem. Their solution is effectively mentoring: spreading ideas one person at a time.
There are four aspects of the mentorship program that I’d like to briefly discuss.
Innovation is not synonymous with high technology
The first is that not all innovations are technological. Gawande gives the example of infant hypothermia.
We’re infatuated with the prospect of technological solutions to these problems—baby warmers, say… [E]ngineers have produced designs specifically for the developing world. Dr. Steven Ringer, a neonatologist and BetterBirth leader, was an adviser for a team that made a cheap, ingenious, award-winning incubator from old car parts that are commonly available and easily replaced in low-income environments. Yet it hasn’t taken off, either. “It’s in more museums than delivery rooms,” he laments.
As with most difficulties in global health care, lack of adequate technology is not the biggest problem. We already have a great warming technology: a mother’s skin. But even in high-income countries we do not consistently use it.
You can quibble with whether kangaroo care is an “innovation” or not. According to this and other changes could “save thousands of lives.” If that’s true, it certainly meets the Berkun definition of innovation: “significant positive change.”
Innovation is social
The second idea I’d like to pull out is that innovation is deeply social. New technologies and ideas spreads through people talking to one another. Here, Gawande cites the work of Everett Rogers.
Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.
The social aspect of innovation is the essence of Bruce Nussbaum’s reply to Donald Norman. While Calthorpe talks about technology and design solutions, but social solutions are often worth considering, as well.
The third point I’d like to consider is the emphasis Gawande places on understanding the context of the mentorees. He mentioned it in the quote I started this blog post with. I think it’s essential to the program that they have put together. This comes across in the story he tells about spreading the word about oral hydration as a treatment for cholera in Indian villages.
Eventually, the team hit upon using finger measures: a fistful of raw sugar plus a three-finger pinch of salt mixed in half a “seer” of water—a pint measure commonly used by villagers when buying milk and oil. Tests showed that mothers could make this with sufficient accuracy.
Without understanding the context in which the villagers lived, a much more expensive solution would have been put in place—measuring spoons with the recipe printed on them. This solution would also have been ineffective, as many of the villagers would not have been able to read the recipes.
Learning by doing
The final point I wanted to pull out was that the mentors didn’t just offer advice, but found that people learned best through doing.
The field workers soon realized that having the mothers make the solution themselves was more effective than just showing them…
Coaxing villagers to make the solution with their own hands and explain the messages in their own words, while a trainer observed and guided them, achieved far more than any public-service ad or instructional video could have done.