Inciting Healthy Behaviors: Nudge, Disrupt, Leapfrog, Reach (Round 13)

Background:

Convincing people to take simple steps for their own health should be easy. But encouraging healthy behaviors is not straightforward. Living a healthy, productive life requires individuals, families, and communities to embrace behaviors, products and services that promote well-being. Despite increasing recognition of behavioral effects on health, and increasing availability of products and services that address common health challenges, adoption of both behaviors and solutions is often slow and inequitable.

Changing behaviors involves asking:

What makes people behave differently about their health? What makes people seek out and use health services or engage in positive preventive behaviors?

Though attempts to promote healthy behaviors through education and knowledge (often targeting individuals) have fallen short, we are seeing a range of new and creative approaches drawing from fields ranging from behavioral sciences, psychology and advertising to behavioral economics. We know that people's decisions to seek services or adopt preventative behaviors are influenced by a variety of social and economic factors including: income, gender, religion, caste, age, marital status, etc. There is also growing understanding that even if we can influence "good" individual behaviors, individuals may be blocked by family or community norms, or blocked by a range of barriers such as geography, literacy, access to media and technology, and cost. We also know that successful programs take into consideration both demand-side and supply-side issues – recognizing they are interdependent and highly responsive to each other

Much health promotion work has focused on individuals and assumed simple, rational, economic decision making, ignoring that decisions are influenced by emotional processes, cognitive factors, sensitivities, and risk perception which are rooted in contexts and systems. This has led to a focus on simply providing health information and hoping that will "work" – akin to seeing only the tip of the iceberg.

The Challenge: 

We know there are many reasons people may not seek care or engage in preventative behaviors. We are seeking solutions that promote health-seeking behaviors and can make a difference in reducing morbidity and mortality and promoting healthy, productive lives. Solutions may target individuals, families, communities, health providers, or the health system. Solutions may include but are not limited to: education, campaigns, behavioral "nudges," new support and incentive systems for access to care and treatment, and models and tools to understand health-seeking behaviors, constraints, and drivers, and apply a deeper understanding of our users (customers/providers) to the design of programs, services, and products/interventions. We seek solutions that are interactive, contextual, scalable, and relevant to health systems strengthening.

We are specifically interested in work targeting: reproductive health, maternal, neonatal, and child health, nutrition, HIV, TB, polio, and vaccine delivery. Brief information is here on the challenge in each of these areas; more information can be found on our strategy pages athttp://www.gatesfoundation.org/What-We-Do. Solutions may also consider intersections between and among any of these areas. We are especially interested in solutions that support any one of the following, or a combination of these:

Reproductive Health; Maternal, Newborn, Child Health; and Adolescent Nutrition:

• Adolescent girls, their families, and communities seeking to prevent unwanted pregnancy in adolescents;
• Adolescent girls and their families seeking good nutrition and nutritional guidance for them prior to pregnancy;
• Women seeking family-planning tools and advice;
• Families and new mothers seeking prenatal, peripartum and postnatal information and care;
• Pregnant women delivering in a health facility attended by a skilled birth attendant;
• Caregivers seeking safe, appropriate and timely care for neonates and children with diarrhea, respiratory illness and fever.

HIV:

• Men and women seeking HIV prevention and protection, diagnosis, and treatment;
• Men seeking opportunities for circumcision to protect against HIV;
• In HIV, we seek an understanding of perceptions of risk, self-efficacy and incentives for behavioral changes, with the perspective of southeast Asia and sub-Saharan Africa;
• HIV and TB patients seeking new ways to improve adherence to long-term medication regimens (approaches to improve adherence to medications for those living in resources limited settings at an affordable cost, NOT new devices to monitor adherence).

TB:

• Communities with the social norm to cover coughs, and persons recognizing cough as a sign of TB and seeking early sputum testing;
• Providers recognizing chest symptoms and ordering a sputum TB test.

Immunization:

• Families fully participating in polio immunization campaigns despite knowledge gaps, low risk perception;
• Vaccinators engaging with families in a respectful way that engenders trust and improves access to children;
• Communities creating a social norm that requires all children to be protected from polio and other vaccine-preventable disease;
• Mothers seeking immunizations for themselves and/or their children;
• Caregivers being aware of the benefits of immunization and ensuring that the children they care for are fully immunized;
• Communities engaging in the planning and delivery of immunization services, including outreach to hard to access communities.

We are interested in:

• New solutions for influencing people to behave differently in relationship to their health (preventative and treatment seeking);
• Solutions may involve deepening understanding (moving towards proof of concept), and/or experimentation, and/or evaluating promising ongoing programs;
• Solutions may target gaps in knowledge, gaps in delivery systems to meet demand for care, or bottlenecks blocking those with knowledge and demand from seeking services (cost, stigma, taboos, distance, etc.);
• Solutions or platforms that can be applied to or support a range of the health areas mentioned above.

We hope to see work that recognizes:

• There is a range of health care options available (self-care, traditional, public / private);
• Health promotion work often focuses on appropriate behavior for when people are not well. This is obviously essential, but so too is promoting preventative and anticipatory health;
• Decisions are influenced by a range of socio-economic and cultural factors, can be individual or collective, and are shaped by the accessibility and quality of health services available;
• Health seeking happens over time and in interactive ways; it is a continuum with decisions being made at various points;
• Health decisions are dependent on both demand-side and supply-side issues and that addressing supply side parameters may directly influence behaviors as well;
• Innovations may involve building on, disrupting, or adapting existing systems. Successful proposals will describe how their solution would work within existing health systems or what change would need to occur within health systems for their solution to be effective;
• Innovations that are based on technology or ICT platforms should have substance to explain what makes it novel for the context of the problem and the priority audience and not assume that a technology platform alone is innovative.

Priority will be given to scalable solutions that:

Address current inequities in health seeking behaviors, and prioritize marginalized populations, considering specifically those marginalized by their economic status, race, ethnicity, religion, age, marital status, gender, caste, sexuality, profession, location, literacy or lack thereof, and access to media and communications. To be considered, ideas must constitute transformative rather than incremental improvements in health seeking behavior solutions and be low cost. We define low cost as interventions targeted for populations with individuals living on less than $1 per day, deliverable, and scalable in low- and middle-income countries. Proposals must (i) have a testable hypothesis, (ii) include an associated plan for how the idea would be tested or validated, and (iii) yield interpretable and unambiguous data in Phase I, in order to be considered for Phase II funding.

We will not consider funding for:

• Ideas that are not directly relevant to low and middle income countries;
• Projects that don't clearly consider the current context of available health services/systems;
• Ideas that simply translate traditional approaches to an ICT platform (mobile, tablet or web-based tools and aids);
• Interventions that require our long-term financial support;
• Diagnostics, assays or tests that do not drive health seeking behaviors;
• Educational programs or campaigns without clearly articulated, measurable behavior outcomes or the ability to be taken to scale;
• Ideas for which proof of concept cannot be demonstrated within the scope of the GCE Phase 1 award ($100k over 18 months);
• Approaches that repeat conventional solutions without novel application;
• Basic research not directly linked to influencing health-seeking behaviors or measurable outcomes and focused purely on research tools for researchers and implementers;
• Ideas that do not address at least one of these specific areas: reproductive health; maternal, neonatal, and child health; nutrition; HIV; TB; polio; and vaccine delivery;
• Approaches that present unacceptable ethical or safety risks;
• Projects earmarking foundation funds for lobbying activity (e.g., attempts to influence legislation or legislative action) or efforts to influence political campaigns for public office.

Background on Challenge Areas:

Maternal, neonatal, and child health:

In developing countries, many women deliver at home and rarely see a trained healthcare provider before or after the baby’s birth. Skilled providers in poor countries often lack access to current tools or do not use them. Approximately 50% of neonatal deaths occur on the first day of life; many of these neonates are born at home far from medical care while others die of preventable causes even though they are born in health facilities. Families may not seek care or follow medical advice. Almost two-thirds of child deaths are due to infectious causes, nearly all of which are preventable. Pneumonia, preterm birth, diarrhea, and malaria constitute the largest contributors to childhood mortality. It is estimated that nearly 50% of under-five pneumonia mortality is attributable to delayed or absent care-seeking. In low-income countries, only 43% of children under-five with symptoms of pneumonia are taken to an appropriate healthcare provider, and a significant proportion of those children receive treatment only after the disease has progressed to a severe level. Children living in rural areas, poor children, and children with poorly educated mothers are less likely to be taken to appropriate care, as compared to children from urban areas, wealthier families, and those with more educated caregivers. Early and accurate recognition of illness and timely administration of appropriate treatment by caregivers are critical elements to preventing child deaths. The Lancet child survival series of 2003 identified oral rehydration solution (ORS) as the single intervention available at that time with the greatest potential to save lives. Yet, on average between 2006 and 2011, only one third of children with diarrhea in developing countries received ORS. Current ORS use rates in the developing world are only just reaching 40%. While effective, low-cost interventions like ORS are available, efforts are needed to improve access to create demand for safe, appropriate and timely care for children with diarrhea, respiratory illness and fever.

Nutrition:

Millions of children in the developing world suffer from a range of health problems with a common root cause: undernutrition. Many children who live in poverty don’t get enough food—or the right kind of food—to support normal growth and development. The 2013 Lancet series shows that undernutrition contributes to the deaths of about 3 million children each year, or about 45% of the total child deaths. Its results stunt physical and mental growth and development, and ultimately economic productivity is lost to undernutrition. The 2013 Lancet series also highlighted the important role of adolescent and maternal nutrition in these dynamics. Stunted, underweight, and wasted children have an increased risk of death from diarrhea, pneumonia, measles, and other infectious diseases.

HIV:

More than 33 million people around the world are currently living with human immunodeficiency virus (HIV), and more than 30 million people have died from HIV-related complications since the earliest cases were detected in the 1980s. While huge progress has been made in increasing access to HIV treatment in the past decade and new HIV infections have substantially declined in some regions, the pandemic continues to outpace efforts to control it. The growth in international funding for HIV has slowed in recent years, but the demand for HIV services has not. About half of all people in need of treatment for HIV do not receive it, and more than 2 million people are newly infected each year.

TB:

With more than 8 million cases per year, the TB epidemic remains largely unabated and is increasingly becoming drug-resistant and more difficult and expensive to control. Globally, TB control programs implementing the ‘Stop TB Strategy’ have largely stalled in their existing TB control efforts. Community-based disease prevalence surveys in multiple high burden countries have repeatedly identified the serious problem of infectious patients in the communities not seeking health services, and thus not offering the health system the opportunity to diagnose and treat these sources of disease propagation. Existing TB control strategies do not account for changing the behaviors of communities and patients to seek health care for mild chest symptoms. When persons with TB eventually do seek care, providers often fail to order appropriate sputum tests to detect or exclude the disease.

Polio:

Over the past two decades, tremendous progress has been made toward the eradication of polio. Since 1988, immunization efforts have reduced the number of polio cases globally by more than 99 percent, saving more than 10 million children from paralysis. Polio remains endemic in just three countries—Nigeria, Pakistan, and Afghanistan. However, the successes achieved through an effective and safe vaccine and immunization campaigns, a global partnership, and a global mandate to eradicate polio are continually at risk. Since 2008, more than 20 countries have experienced outbreaks of polio imported from endemic countries. Efforts to reach unvaccinated children are often hampered by poor program management, parents who refuse to immunize their children, rumors and misinformation about the safety of Oral Polio Vaccine, security risks, and geographic and cultural barriers. The high cost of vaccination campaigns—US$1 billion per year worldwide—is not sustainable in the long term. Failure to eradicate this highly contagious disease could, within a decade, lead to a resurgence of as many as 200,000 new cases each year.

Vaccine delivery:

Nearly 200 countries around the globe have endorsed a shared vision—known as the Decade of Vaccines (DoV)—to extend the benefits of vaccines to every person by 2020 and thereby save more than 20 million lives. This international collaboration has generated the Global Vaccine Action Plan (GVAP), a roadmap for extending the delivery of a basic package of vaccines, making vaccines that are available in richer countries accessible in the developing world, and supporting vaccine research and development. While the eradication of polio is an important priority of the DoV, the GVAP also emphasizes creating sustainable systems and increasing access to immunization services. This will partially be achieved through supporting stronger systems, but it is also dependent on engaging individuals and communities to seek immunization services.