Using a Behavioral Economics approach to improve fever case management in Nigeria

Summary:

Provider adherence to malaria rapid diagnostic test (RDT) results for treatment decisions is a major challenge in Nigeria. Formative research by USAID/Breakthrough ACTION found that providers have perceptions of time scarcity which caused them to focus on seeing as many clients as possible; have misconceptions about the reliability of RDTs and felt their clinical judgment was more accurate; overestimated the probability of malaria compared to other potential causes of fever; and turn-around-time for obtaining test results was a challenge in larger facilities. Behavioral mapping and co-design process were used to develop 5 client and provider behavioral prototypes, which were designed and user-tested to address cognitive biases. The prototypes are undergoing 12-week feasibility pilot in 12 clinics and hospitals across three states. Group discussions are used to address providers' misconceptions about RDTs, while testing stations at/near waiting areas assures clients with fever are tested before consultation. Simplified pediatric evaluation form based on integrated management of childhood illness uses active choice prompts to nudge providers into conducting differential diagnoses. Health talks and counseling tools help clients understand the benefits of testing and compliance to treatment. Performance tracking posters and supervision visits provide facilities with monthly feedback. Results of the pilot will be measured using service statistics, client exit interviews, meetings with facility staff, and provider surveys to understand users' satisfaction with the designs, challenges around feasibility of implementation, and identify early indications of changes in provider behavior. Data will be available in January 2020 and presented.

Background/Objectives

Provider adherence to malaria rapid diagnostic test (RDT) results for treatment decisions is a major challenge in Nigeria. When encountering patients with fever, providers may not follow case-management guidelines, leading to misdiagnoses and over-prescription of antimalarial. Formative assessment found providers have perceptions of time scarcity which caused them to focus on seeing as many clients as possible; have misconceptions about the reliability of RDT and overestimate the probability of malaria compared to other causes of fever; feel their clinical judgment was more accurate than RDTs and turnaround-time for obtaining test results was a challenge in larger facilities.

Description Of Intervention And/or Methods/Design

A behavioral mapping and co-design process were used to develop five behavioral interventions designed to address the cognitive biases found in the formative assessment. The interventions are simultaneously undergoing a 12-week feasibility pilot in 12 primary and secondary health facilities in three states. Group discussions are used to address misconceptions about RDTs, while testing stations at/near waiting areas ensure the timely availability of malaria RDT results, for providers to review during instead of after consultations. A simplified pediatric evaluation form based on the integrated management of childhood illness (IMCI) uses active choice prompts to nudge providers into conducting differential diagnoses. Health talks and counseling tools were provided to facilitate client understanding of appropriate fever management and acceptance of changes to services and test results. A performance tracking poster as well as supervision visits provide facilities with monthly performance feedback.

Results/Lessons Learned

The pilot commenced in mid-October 2019. Early anecdotal results of the pilot are quite positive. All pilot facilities have set-up a test before consultation desk and have fully adopted the concept. Providers have given positive feedback regarding shorter wait times for patients and consultation time for the providers which has reduced their workload. Providers in Primary Health Care facilities have indicated that the pediatric evaluation form has improved differential diagnosis and management of childhood illnesses in their health facilities. Early results from data validation and supportive supervision activities shows a reduction in ACTs issued for non-positive malaria cases when compared with earlier periods. The overall quality of data reporting has improved significantly across pilot facilities. Community leaders have given positive feedback regarding their satisfaction with the changes made in the facilities. Full results from pilot testing will be available in January 2020 and reported at the summit.

Discussion/Implications For The Field

The feasibility assessment includes provider surveys, client exit interviews, service statistics and group discussions to understand provider and client satisfaction with the designs, challenges around the feasibility of implementation, and identify early indications of changes in provider attitudes and behavior. The assessment will shed light on how behavioral approaches may affect change in fever case management practices at the individual (provider) and facility level. Presenting these findings to the SBC community will help to initiate the dialogue around identifying promising interventions and how they may be adapted for different contexts, facility settings, and providers prior to larger-scale implementation.

Abstract submitted by:

Bolatito Aiyenigba

Faraz Haqqi - Ideas42

Angela Acosta - JHU

Jose Tchofa - USAID

Foyeke  Oyedokun-Adebagbo  - USAID

Ian Tweedie - JHU