Ideas42

En este artículo analizamos casi dos décadas de evidencia sobre intervenciones basadas en ciencias del comportamiento, o nudges, dirigidas a mejorar los resultados educativos en Estados Unidos, y proponemos un marco conceptual para explicar la notable heterogeneidad en su efectividad. En línea con el concepto de sesgo aditivo presentado por Adams et al. (2021), identificamos que muchas de estas intervenciones no reducen la cantidad de tareas para los estudiantes y sus familias, sino que añaden elementos adicionales, aumentando la carga cognitiva necesaria para completarlas. A su vez, encontramos que las intervenciones que disminuyen la carga cognitiva impuesta a los estudiantes y sus familias suelen ser las más efectivas, incluso cuando implican la adición de nuevos elementos.

Hypertension increases the risk of myocardial infarction and strokes, but adherence to antihypertensive medications remains suboptimal. Increasing medication adherence may help prevent hypertension-related disability and death. To estimate the effect of incorporating behavioral science principles in mailed communications intended to increase hypertension medication adherence. This randomized clinical trial was conducted from August 18 to December 31, 2023, at Humana, a large health insurance provider, and included Medicare Advantage beneficiaries aged 65 to 80 years who were taking hypertension medications with adherence rates of 60% to 85%. Data were extracted for the as-treated analysis on April 14, 2024. Study participants were randomized in equal proportions to 1 of 7 groups: 6 received mailed communications that incorporated combinations of behavioral science principles, and 1 received no mailing (control, or usual care condition). The specific principles included were social norming (the mailing noted that more Humana beneficiaries each year were improving their medication adherence scores), messenger effects (the mailing signatory was a pharmacist), and processing fluency (the mailing incorporated a visual circle metaphor indicating current and complete adherence to prompt "closing the ring"). The first mailing contained the participant's baseline refill score, and a second mailing noted any changes in the participant's refill score after 60 days. The primary outcome was end-of-year hypertension medication adherence calculated from pharmacy claims data using the proportion of days covered (PDC) metric (having medication available for 1 target hypertension drug, as measured through prescription claims, counted as adherent on a given day). A secondary outcome was the proportion of study participants with end-of-year PDC of 80% or greater. The study participants (n = 64 290) had a mean (SD) age of 71.4 (4.1) years, and 54.1% were female. Mean (SD) end-of-year adherence in the control group was 0.81 (0.12) and was no different in any of the intervention arms (absolute mean difference compared with control was 0.00 [95% CI, -0.01 to 0.01]). The proportion of participants with an end-of-year PDC greater than 80% also did not differ significantly between the control group (6587 of 9183 [71.7%]) and any of the intervention arms (range, 6467 of 9180 [70.4%] to 6598 of 9177 [71.9%]). In this randomized clinical trial, use of social norms, messenger effects, and processing fluency in mailed communications did not significantly increase hypertension medication adherence. Further research is needed to identify tactics to effectively increase adherence. ClinicalTrials.gov Identifier: NCT06066541.

Insights from behavioural science can inform a wide range of solutions including policy reforms, infrastructure changes, process reengineering, communications, devices and others. Its application in global health has, however, often focused on narrowly defined issues with linear theories of change that are relatively straightforward to study. Using behavioural science to examine ‘upstream’ actors in complex health systems holds promise as a complementary and underused approach to improving health systems. Behavioural scientists have missed opportunities to tackle systemic issues and the field of health systems strengthening rarely accounts for human behaviour at the macrolevel of health systems. We present a framework, developed by experts from a range of disciplinary backgrounds in global health and behavioural science that guides (1) the distillation of a health system challenge into concrete, addressable behaviours (specific actors and accompanying actions) and (2) the investigation of contextual factors that influence each behaviour.

High-risk medications like benzodiazepines, sedative hypnotics, and antipsychotics are commonly prescribed for hospitalized older adults, despite guidelines recommending avoidance. Prior interventions have not fully addressed how physicians make such prescribing decisions, particularly when experiencing stress or cognitive overload. Simulation training may help improve prescribing decision-making but has not been evaluated for overprescribing. In this two-arm pragmatic trial, we randomized 40 first-year medical resident physicians (i.e., interns) on inpatient general medicine services at an academic medical center to either intervention (a 40-minute immersive simulation training) or control (online educational training) groups. The primary outcome was the number of new benzodiazepine, sedative hypnotic, or antipsychotic orders for treatment-naïve older adults during hospitalization. Secondary outcomes included the same outcome by all providers, being discharged on one of the medications, and orders for related or control medications. Outcomes were measured using electronic health record data over each intern's service period (~2 weeks). Outcomes were evaluated using generalized estimating equations, adjusting for clustering. In total, 522 treatment-naïve older adult patients were included in analyses. Over follow-up, interns prescribed ≥1 high-risk medication for 13 (4.9%) intervention patients and 13 (5.0%) control patients. The intervention led to no difference in the number of new prescriptions (Rate Ratio [RR]: 0.85, 95%CI: 0.31-2.35) versus control and no difference in secondary outcomes. In secondary analyses, intervention interns wrote significantly fewer "as-needed" ("PRN") order types for the high-risk medications (RR: 0.29, 95%CI: 0.08-0.99), and instead tended to write more "one-time" orders than control interns, though this difference was not statistically significant (RR: 2.20, 95%CI: 0.60-7.99). Although this simulation intervention did not impact total high-risk prescribing for hospitalized older adults, it did influence how the interns prescribed, resulting in fewer PRN orders, suggesting possibly greater ownership of care. Future interventions should consider this insight and implementation lessons raised. Clinicaltrials.gov(NCT04668248).

There is growing interest in how best to leverage cash transfers to foster positive impact on children in beneficiary households. We evaluate the effects of interventions based on behavioral science on measures of early childhood socio-cognitive development (and related household-level outcomes) for children from households receiving cash transfers in Madagascar using a multi-arm cluster-randomized trial, where communities were randomized into arms, with 77 communities in each arm and approximately 950 and 1200 households sampled at baseline and midline, respectively. Three behavioral interventions (a ‘Mother Leaders’ group, either by itself or augmented with a ‘self-affirmation’ or a ‘plan-making’ nudge) are layered onto a child-focused cash transfer program targeting the rural poor in Madagascar with children aged 0–6. Approximately 18 months into the implementation of these interventions, we find evidence that households in the behaviorally enhanced arms undertake more desirable parenting behaviors, interact more with their children, prepare more (and more diverse) meals at home, and report lower food insecurity than households that received only cash, and children in these arms perform better than children from households in the cash-only arm on several measures of socio-cognitive development including language learning and social skills. This is promising evidence that behavioral interventions can add significant value to cash transfer programs that aim to improve human development outcomes. (AEARCTR-0000957).

IntroductionMedication adherence for patients with chronic conditions such as gout, a debilitating form of arthritis that requires daily medication to prevent flares, is a costly problem. Existing interventions to improve medication adherence have only been moderately effective. Habit formation theory is a promising strategy to improve adherence. The cue-reward-repetition principle posits that habits are formed by repeatedly completing an activity after the same cue and having the action rewarded every time. Over time, cues become increasingly important whereas rewards become less salient because the action becomes automatic. Leveraging the cue-reward-repetition principle could improve adherence to daily gout medications.Methods and analysisThis three-arm parallel randomised controlled trial tests an adaptive intervention that leverages the repetition cue-reward principle. The trial will began recruitment in August 2021 in Boston, Massachusetts, USA. Eligible patients are adults with gout who have been prescribed a daily oral medication for gout and whose most recent uric acid is above 6 mg/dL. Participants will be randomised to one of three arms and given electronic pill bottles. In the two intervention arms, participants will select a daily activity to link to their medication-taking (cue) and a charity to which money will be donated every time they take their medication (reward). Participants in Arm 1 will receive reminder texts about their cue and their charity reward amount will be US$0.50 per day of medication taken. Arm 2 will be adaptive; participants will receive a US$0.25 per adherent-day and no reminder texts. If their adherence is <75% 6 weeks postrandomisation, their reward will increase to US$0.50 per adherent-day and they will receive reminder texts. The primary outcome is adherence to gout medications over 18 weeks.Ethics and disseminationThis trial has ethical approval in the USA. Results will be published in a publicly accessible peer-reviewed journal.Trial registration number NCT04776161

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants' backgrounds, and contextual factors, estimated the intervention's effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics -the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives.Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants’ backgrounds, and contextual factors, estimated the intervention’s effect on discontinuation rates.Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey.Conclusion: The use of two tools informed by behavioral economics —the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.