When Knowledge Is Not Enough: Applying a Behavioral Design Approach to Improve Fever Case Management in Nigeria

"[T]he feedback and perspectives shared by providers...suggested that providing information alone was unlikely to change behavior, as many of those who failed to follow guidelines already understood the requirement to test for malaria before treating clients."

In Nigeria, there is a risk that healthcare providers may overdiagnose and overtreat malaria. This article describes Breakthrough ACTION's initiative to improve fever case management in Nigeria by encouraging providers to conduct malaria parasitological tests for every patient presenting with fever or a history of fever, to provide malaria treatment only to those who test positive for malaria, and to assess nonmalaria clients for other potential causes of fever.

To understand why providers might not test clients with fever or with a history of fever for malaria and why they might disregard test results when making treatment decisions, beginning in September 2018, Breakthrough ACTION interviewed 92 health facility staff and 56 clients at 29 hospitals and clinics in Akwa Ibom, Kebbi, and Nasarawa states in Nigeria. Findings suggested that even well-informed and well-intentioned providers can fail to adhere to the guidelines due to cognitive principles such as limited attention, tunneling, base-rate neglect, and salience.

To ensure that solutions to address these behavioural drivers of nonadherence would be appropriate and easy to follow, Breakthrough ACTION incorporated stakeholder input into every stage of their development. During a 3-day codesign workshop, participants from 19 institutions generated more than 300 initial ideas that were distilled into a package of complementary designs, each of which responded to distinct needs in the fever case management process. Their feedback was incorporated into prototype designs through an iterative revision process. The final designs prioritised approaches requiring fewer resources and limited technical capacity, as can be seen in the paper's figure.

The case management interventions were piloted in 12 public health facilities in 1 hospital and 3 primary health centres in each of the states of Akwa Ibom, Kebbi, and Nasarawa between October and December 2019. Relevant changes included the following: (i) providers at each facility participated in facilitated discussions to correct misconceptions about the reliability of malaria test kits; (ii) testing procedures were integrated into existing triage systems; (iii) treatment algorithms were integrated into medical record forms; (ov) providers were issued pictorial brochures outlining danger signs to share with clients, together with instructions for when to seek further care; and (v) a process was created for facilities to monitor their own adherence to guidelines.

Breakthrough ACTION concludes that the project highlights the potential for behavioural solutions to improve case management practices without the need for substantial additional inputs. Lessons learned included:

• Disentangling the drivers of behaviour allows for more precisely targeted solutions.
• Streamlining processes for overburdened providers can allow them to redirect their attention and efforts where they can be most impactful.
• Changing staff perceptions of workplace norms can support a holistic approach to behaviour change - e.g., by creating a shared understanding of the reliability of malaria rapid diagnostic tests.

In short: "In challenging environments, a behavioral design approach can help improve case management practices by focusing solutions on removing barriers to create an environment more conducive to all of the tasks that case management requires, equipping providers with tools to better navigate the barriers they encounter, and establishing workplace norms to support and sustain changes in provider behavior."