2.4 Rituals and Extrinsic vs Intrinsic Motivators

Rituals can tap intrinsic motivators and make external motivators more impactful. The difference between an intrinsic and extrinsic motivator is simply that intrinsic motivators lack obvious external rewards like payments or public praise from others. Rather, they are done for incentives originating from within one’s self. This includes behaviors that come from personal interests, that are enjoyable, or that bring a sense of satisfaction. Extrinsic motivators are reward-driven. This is a form of operant conditioning6, where a behavior is done because it increases the likelihood of reward or reduces the risk of a punishment.

Project RISE’s viewpoint, based on reviews of previous studies, is that extrinsic motivators have been overemphasized and intrinsic motivators have rarely been examined carefully. The Project RISE emphasis on lived experience and intrinsic motivators does not, however, mean that extrinsic motivators are not important to understand as contributing to behavior and motivation in one’s role. The real world is more complicated and we would rarely find clear and persistent distinctions where some motivators were 100% intrinsic and others were 100% extrinsic; most will be a combination of both. For example, ASHAs may become CHWs because of an intrinsic drive to serve their communities and because of the need for incentive payments. But does this mean that the incentive payment is purely extrinsic? Getting paid and using the money to help support her children may also provide the ASHA with a sense of intrinsic fulfillment. When payment schedules are unreliable, this may weaken the role of the extrinsic aspects of financial incentive, but it may also weaken intrinsic feelings of motivation or the degree to which an ASHA feels the personal satisfaction of the role. This hypothetical discussion is meant only to illustrate the simple fact that these kinds of motivations are intertwined. We know enough about the role of incentive systems that they alone do not explain variation in ASHA performance and a more complete understanding of ASHA motivation, one that includes the intrinsic factors, is necessary.

Rituals are practiced for a variety of reasons but common functions include increasing adherence to a social norm, especially when the causality is elusive, and increasing social cohesiveness among community members. These aspects of ritual can help an ASHA’s sense of self-efficacy. If they are leveraged appropriately she gains respect and increases satisfaction in her role. If she is more connected to her community, then trust is higher as is adherence to the behaviors she recommends. If these things elevate her status then it becomes less acceptable to demand bribes from her or to withhold her payments. Again, these are hypothetical but illustrate ways in which ritual can reach across several behaviors and affect both intrinsic and extrinsic motivations.

2.4.1 Ritual-Based Behavior Change

Rituals arise, at least in part, from an evolved cultural function to prevent or avoid hazards. They provide normative tools for responding to many possible threats from social conflicts to pathogens. For these reasons, hygiene is heavily ritualized and rituals often play a functional role in promoting hygiene. Rituals can also help reduce stress during uncertain or dangerous times. Rituals can provide a sense of control over uncertainty by offering socially-sanctioned scripts for managing problems and avoiding recurrent risks.

In the contexts of promoting health behaviors or designing health-motivated interventions, rituals should not be viewed as obstacles to overcome, but rather key systems of insight that, if leveraged appropriately, can greatly increase the potential of behavior change initiatives.

That said, there are not many previous attempts to leverage ritual in the way Project RISE is proposing, which limits our ability to discuss the pros and cons of various approaches. However, a few recommendations for ritual based health intervention can be offered:

  • Open-mindedness: going into a behavior change study, it will not be clear beforehand if one needs to modify an existing ritual or create a new one. Sometimes the target health behavior will be central to a ritual and other times it may be adjacent. These differences will greatly affect the way that ritual enters the design process.

  • One needs to use mixed-methods data to formulate a taxonomy of ritual so they are aware of the centrality and strength of connections among health behaviors and existing rituals. Most rituals are intended to avoid risk and promote health, but there may be cases when an existing belief or practice runs counter to a biomedical recommendation. Changing a behavior that is either not ritualized or is peripheral to a ritual context will require different tools from one that is strictly adhered to and central to a ritual.

  • If designing a ritual, note that rituals help promote repetition, ownable cues, and the construction of meaning.

    • Practice and repeated motion help instill adherence and regularity of a practice. Rituals can help reinforce a desired behavior that must be practiced regularly. In an intervention study with hand-washing, supervising children to actively practice the correct hand-washing technique was effective in increasing the behavior and improving health outcomes (Monse et al. 2013).

    • Behaviors can be motivated by the desire for either the presence of positive cues or the absence of negative cues, so behavior change can be achieved by making these cues more explicit. For example, hand-washing interventions can be more successful when the cue of removing germs (usually invisible and non-explicit) is made more obvious through products that make hands smell and feel more clean after washing or through media campaigns that illustrate how germs are removed during the washing process (Neal et al. 2015).

    • Even when behaviors are ritualized or so ingrained that they become automatic, encouraging CHWs to make the target behaviors personally meaningful is important for sustaining the behavior and promoting the behavior to others to establish new social norms. This method has been successfully implemented in India in past work, when behavior change around hand-washing behavior was achieved by facilitating mothers to understand hand-washing as being an integral part of being a “good mother.” In this intervention, mothers had regular meetings and were encouraged to share tips with one another to effectively encourage hand-washing with their children (Nicholson et al. 2014).

Take-Home Messages: The Role of Ritual

  • Rituals are socially stipulated normative behaviors that affect both health behaviors and the project-relevant motivational factors of trust, social cohesion, perceived self-value.
  • Rituals are everywhere. They are part of all cultures and societies and they encompass many varieties of behavior, including every day actions related to health, medicine, and other quotidian factors.
  • Rituals have great potential for intervention design; this might include designing a new ritual, modifying an existing ritual, or leveraging an existing non-health-related ritual in ways that motivate health behavior.
  • The best ways to use ritual as a tool to increase motivation or alter health behaviors are not yet known, because it hasn’t been tried before, but Project RISE has design principles to help guide such efforts.


Monse, Bella, Habib Benzian, Ella Naliponguit, Vincente Belizario, Alexander Schratz, and Wim van Palenstein Helderman. 2013. “The Fit for School Health Outcome Study - a Longitudinal Survey to Assess Health Impacts of an Integrated School Health Programme in the Philippines.” BMC Public Health 13 (March): 256. https://doi.org/10.1186/1471-2458-13-256.
Neal, David, Jelena Vujcic, Orlando Hernandex, and Wendy Wood. 2015. The Global Handwashing Partnership. Washplus. USAID.
Nicholson, Julie A., Mojgan Naeeni, Michael Hoptroff, Jane R. Matheson, Anthony J. Roberts, David Taylor, Myriam Sidibe, Anthony J. Weir, Satyawan G. Damle, and Richard L. Wright. 2014. “An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities.” Tropical Medicine & International Health 19 (3): 284–92. https://doi.org/10.1111/tmi.12254.

  1. Recall the classic textbook psychology lessons about Pavlov training his dog to associate food with the sound of a bell. This was training using extrinsic motivation and it led to the formulation or awareness of operant conditioning as a psychological phenomenon.↩︎