AUTHOR: Tom Ngaragari, Social Behaviour Change and Marketing Director

Anyone who has worked in social behaviour change (SBC) in global health for more than a few minutes knows the standard playbook: print colourful posters, run radio spots, fire off SMS blasts, and organise community workshops. We work under the assumption that if a young person knows where to find a free HIV test or a contraceptive refill, they will walk through the clinic door and get it.

And yet, we continually find ourselves asking why our clinic waiting rooms remain  empty.  A 19-year-old girl in an informal settlement in Kampala or Mombasa usually understands that prevention matters. Yet she must navigate competing realities, including financial strain from such things as travel costs and out-of-pocket expenses that must be managed without a source of income. This is compounded by  persistent judgement from peers or neighbours, bias against sexual and reproductive health services, power imbalances, limited privacy or clinical settings that make accessing care daunting. When faced with daily demands, accessing long-term care is inevitably set aside.

Two years of programmatic data across Kenya and Uganda confirmed that a lack of information is not the primary barrier. To understand what truly drives action, we applied a behavioural economics lens and evaluated our impact across two distinct settings using a mixed-methods approach.

• Uganda (Kampala, 2023–2025)¹: A mixed-methods endline evaluation analysing service delivery records, digital platform analytics, client exit interviews (CEIs), and in-depth qualitative interviews examining SRH, HIV, PrEP, ART, and mental health outcomes.
• Kenya (Mombasa and Kilifi Counties, 2023–2024)²: A quasi-experimental evaluation comparing programme communities with control areas, evaluating PrEP adherence, mental health agency, self-esteem, and participatory engagement.

Moving past generic slogans and looking closely at these evaluation results taught us four vital lessons about how behavioural economics can drive service uptake:

1. Small, Immediate Value Outweighs Distant Health Warnings

Human beings are naturally wired to focus on the immediate present. We place far more weight on current needs than on distant future outcomes. Telling an adolescent girl that taking care of their health today will pay off in years to come doesn’t cover their bus fare or ease the burden of a long walk to the clinic.

When we introduced Tiko Miles—small micro-rewards earned by accessing services and redeemed for everyday household goods at local shops—our goal was to directly offset the costs of travel, time, and lost income, giving people a practical, tangible reason to prioritize their healthcare.

2. The Most Effective Nudge Is a Trusted Peer, Not a Leaflet

A billboard cannot sit with someone to talk through their worries. A mobile notification cannot offer quiet reassurance on a waiting room bench when a young woman is afraid of being judged.

Our digital platform links funding directly to four key local partners on the ground:

• Accredited healthcare providers offering confidential, subsidised clinical care.
• Neighbourhood shops enabling members to redeem Tiko Miles for essential items.
• Local peer mobilisers who build genuine trust, lead sensitive conversations, and support young women entering the system.
• Tech-enabled operations that streamline backend processes while prioritising the human relationships that build confidence to seek care.

3. Digital Interventions Risk Excluding the Most Vulnerable Without an Equity Lens

Analysing Multidimensional Poverty Index (MPI) indicators clearly demonstrated that girls facing the greatest hardship often lack reliable mobile devices, consistent connectivity, or independent mobility.

If a health model relies solely on smartphone technology, it unintentionally favours those who are already better off. To reach adolescents living in severe multidimensional poverty (an MPI score of 0.50 or higher), digital frameworks must be paired with accessible offline infrastructure. This means providing physical membership cards, doorstep outreach, and community-level registration led by local mobilisers. Technology should open doors wide, rather than creating a digital barrier. 

4. Behavioural Nudges Only Work When Healthcare is Truly Dignified

The rigorous evaluations across Uganda and Kenya provided clear evidence of how this approach moves young people from intention to actual service use. In Kampala, where we conducted a mixed-methods baseline and endline evaluation, thoughtful behavioural nudges helped young people bridge the gap to care. HIV testing uptake among participants rose from 78.5% at baseline to 94.7% at endline. Mental health check-ups increased significantly from 7.5% to 29.6%, while contraceptive use grew from 40.4% to 53.5%. We also observed marked increases in participants’ confidence to discuss condom use and seek out PrEP.

In Mombasa and Kilifi counties in Kenya, a quasi-experimental endline evaluation revealed similar positive trends where behavioural nudges were matched with practical support. Compared to control communities, participants showed an average treatment effect increase of 27.6 percentage points in PrEP awareness, a 7.3 percentage point rise in mental health agency, and a 5.8 percentage point increase in self-esteem measures.

While these results reflect real progress, they also highlighted critical systemic limitations. PrEP stigma remains deeply rooted, younger adolescents aged 15 to 19 continue to face steeper hurdles than 22-year olds, and some health facilities still fall short in guaranteeing basic privacy.

A behavioural nudge cannot compensate for an unwelcoming health provider or an unstocked pharmacy. Nudges are only effective when the care waiting on the other end is safe, confidential and respectful.

Reflections for the SBC Community

Let us stop designing programmes for how we think people should act, and start designing for how they actually live their everyday lives.

• For Evaluators: Break down programme findings using multidimensional poverty measures. Aggregate success metrics can easily obscure the complete exclusion of the most vulnerable young people.
• For Funders: Direct support toward connected data systems that link behavioural touchpoints, complete healthcare journeys, equity indicators, and ongoing community feedback.
• For Implementers: Focus on shaping the immediate environment around real decision points, for instance, easing travel burdens, addressing privacy concerns, and offering meaningful, immediate value.

Instead of focusing solely on telling girls that healthcare exists, we must dedicate our energy to removing the quiet, everyday obstacles that stand between them and the care they deserve.

1. Uganda ELMA/EJAF Endline Evaluation Report, March 2025. The report states that the endline AYP survey reached 412 participants compared with 465 at baseline, and that service access increased for HIV testing, mental health check-ups, and family planning; it also reports ART enrolment growth, HIVST confidence, PrEP confidence, and condom discussion confidence.
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2. Kenya Endline Evaluation Report. The report used a quasi-experimental design with treatment counties Mombasa/Kilifi and comparison county Kwale. The client survey included 1,874 Adolescents and Young People (AYP). ↩︎