A behavioral design approach to improving a Chagas disease vector control campaign in Peru.

BACKGROUND: Individual behavior change is a critical ingredient in efforts to improve global health. Central to the focus on behavior has been a growing understanding of how the human brain makes decisions, from motivations and mindsets to unconscious biases and cognitive shortcuts. Recent work in the field of behavioral economics and related fields has contributed to a rich menu of insights and principles that can be engineered into global health programs to increase impact and reach. However, there is little research on the process of designing and testing interventions informed by behavioral insights. METHODS: In a study focused on increasing household participation in a Chagas disease vector control campaign in Arequipa, Peru, we applied Datta and Mullainathan's "behavioral design" approach to formulate and test specific interventions. In this Technical Advance article we describe the behavioral design approach in detail, including the Define, Diagnosis, Design, and Test phases. We also show how the interventions designed through the behavioral design process were adapted for a pragmatic randomized controlled field trial. RESULTS: The behavioral design framework provided a systematic methodology for defining the behavior of interest, diagnosing reasons for household reluctance or refusal to participate, designing interventions to address actionable bottlenecks, and then testing those interventions in a rigorous counterfactual context. Behavioral design offered us a broader range of strategies and approaches than are typically used in vector control campaigns. CONCLUSIONS: Careful attention to how behavioral design may affect internal and external validity of evaluations and the scalability of interventions is needed going forward. We recommend behavioral design as a useful complement to other intervention design and evaluation approaches in global health programs.

To spray or not to spray? Understanding participation in an indoor residual spray campaign in Arequipa, Peru.

Current low participation rates in vector control programmes in Arequipa, Peru complicate the control of Chagas disease. Using focus groups (n = 17 participants) and semi-structured interviews (n = 71) conducted in March and May 2013, respectively, we examined barriers to and motivators of household participation in an indoor residual spray (IRS) campaign that had taken place one year prior in Arequipa. The most common reported barriers to participation were inconvenient spray times due to work obligations, not considering the campaign to be necessary, concerns about secondary health impacts (e.g. allergic reactions to insecticides), and difficulties preparing the home for spraying (e.g. moving heavy furniture). There was also a low perception of risk for contracting Chagas disease that might affect participation. The main motivator to participate was to ensure personal health and well-being. Future IRS campaigns should incorporate more flexible hours, including weekends; provide appropriate educational messages to counter concerns about secondary health effects; incorporate peer educators to increase perceived risk to Chagas in community; obtain support from community members and leaders to build community trust and support for the campaign; and assist individuals in preparing their homes. Enhancing community trust in both the need for the campaign and its operations is key.

Increasing participation in a vector control campaign: a cluster randomised controlled evaluation of behavioural economic interventions in Peru.

OBJECTIVE: To assess the efficacy of strategies informed by behavioural economics for increasing participation in a vector control campaign, compared with current practice. DESIGN: Pragmatic cluster randomised controlled trial. SETTING: Arequipa, Peru. PARTICIPANTS: 4922 households. INTERVENTIONS: Households were randomised to one of four arms: advanced planning, leader recruitment, contingent group lotteries, or control. MAIN OUTCOME MEASURES: Participation (allowing the house to be sprayed with insecticide) during the vector control campaign. RESULTS: In intent-to-treat analyses, none of the interventions increased participation compared with control (advanced planning adjusted OR (aOR) 1.07 (95% CI 0.87 to 1.32); leader recruitment aOR 0.95 (95% CI 0.78 to 1.15); group lotteries aOR 1.12 (95% CI 0.89 to 1.39)). The interventions did not improve the efficiency of the campaign (additional minutes needed to spray house from generalised estimating equation regressions: advanced planning 1.08 (95% CI -1.02 to 3.17); leader recruitment 3.91 (95% CI 1.85 to 5.97); group lotteries 3.51 (95% CI 1.38 to 5.64)) nor did it increase the odds that houses would be sprayed in an earlier versus a later stage of the campaign cycle (advanced planning aOR 0.94 (95% CI 0.76 to 1.25); leader recruitment aOR 0.68 (95% CI 0.55 to 0.83); group lotteries aOR 1.19 (95% CI 0.96 to 1.47)). A post hoc analysis suggested that advanced planning increased odds of participation compared with control among households who had declined to participate previously (aOR 2.50 (95% CI 1.41 to 4.43)). CONCLUSIONS: Achieving high levels of household participation is crucial for many disease prevention efforts. Our trial was not successful in improving participation compared with the existing campaign. The trial highlights persistent challenges to field experiments as well as lessons about the intervention design process, particularly understanding barriers to participation through a behavioural lens. TRIAL REGISTRATION NUMBER: American Economic Association AEARCTR-0000620.