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Improving Tuberculosis Care with Behavior Change Technology

By Guest Writer on July 2, 2020

tb behaviour change kenya

In the last twenty years, an explosion of research in the social sciences has demonstrated that seemingly small changes in the decision environment, such as a change in the way information is framed, or a change in the default, can result in large changes in behavior.

Keheala was built from the ground-up with behavior change in-mind – the technology and functionality was selected in support of behavior change, not the other way around.

We focus on the use of such “nudges”, as they’re often called, particularly for more effectively promoting prosocial behavior. The key elements of our approach are to increase accountability, decrease plausible deniability, and communicate expectations. Specifically, adherence is re-framed as a public good, norms are established and observability around an individual’s daily adherence is increased, in an anonymous way, because people are more likely to complete an expected behavior when they know others are watching.

These are not ‘add-on’ features or post hoc modifications to the messaging, rather, these integrated principles are the reason for the platform. Technology offers tremendous benefits as we seek to reach the masses, but providing access, by itself, does not address community stigmas, burdensome treatment protocols, healthcare resource shortages or a general lack of information, motivation and support.

Our Results with Tuberculosis

The hardest part of curing tuberculosis is getting patients to take all their pills every day for at least six months. Typically, this is done through “directly observed therapy,” or D.O.T., in which patients must swallow their pills in front of a trained caretaker every day.

We recently ran a randomized control trial with 17 health care clinics in Nairobi, Kenya. 569 patients who participated in the intervention, and 535 patients in the control group who did not use the mobile digital program. Our results were impressive. Only 4 percent of the patients in the Keheala program had bad outcomes – death, failed treatment, or loss to follow up – compared to 13 percent in the control group: a 68% reduction.

To the best of our knowledge, Keheala is the only digital adherence solution that has rigorously demonstrated improved health outcomes in TB. Our results were so promising that USAID’s Development Innovation Ventures invested $600,000 in Keheala to expand its trial to over 17,000 Kenyans in eight counties.

Our Approach to TB Treatment

To achieve these aims, we utilize Keheala’s two-way mHealth platform whose key features are daily self-verification, follow-up from live supporters in the event that individuals do not verify after multiple reminders, and occasional normative, motivational messaging.

While healthcare providers can access a web-dashboard and certain reminders are sent across SMS, the majority of interactions occur across a USSD platform that is accessible from 99% of all phones, including basic feature phones, without download.

Importantly, the decision-architecture, made possible by the interplay between the real-time and interactive platform sessions, enhances the effectiveness of embedded behavioral strategies.

Next Up: Data-Driven Decision Support

Now that we have solved real-world challenges for our patients, we are able to pursue the next series of challenges enabled by access to data. For example, we have already piloted, internally, a differentiated-care product which predicts whether a patient will succeed or fail in their treatment six months later. We make this prediction with 95% accuracy today.

It can be used for decision support. Low-risk of failure patients can be given medication for longer periods of time and visit the facility less frequently while being remotely monitored and supported by Keheala.

The patients save money and time on travel and don’t need to miss work while the healthcare system can follow along remotely, focus on other patients who would benefit from additional in-person attention, all while decluttering health facilities and reducing the transmission of disease that can occur there.

These are two examples of how Keheala is working to expand healthcare access and improve treatment outcomes in resource-constrained settings but there are many more behavioral challenges throughout the patient care cascade we plan to address as well.

By Jon Rathauser and Erez Yoeli of Keheala.

Filed Under: Healthcare
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