A nudge in the right direction: Fighting tuberculosis in Moldova

02 Apr 2014

 picture with pills When people go home from the hospital, they stop taking the pills. Why this happens remains an open question. Photo: Julie Pudlowski / UNDP Moldova

Tuberculosis (TB) remains a huge challenge for the public health sector in Moldova despite the best efforts made by all involved.

Among the primary concerns is the increasing rate of the multidrug-resistant tuberculosis in the country, which are much trickier and more expensive to treat. One of the major reasons for this is the low drug adherence rate - people tend to discontinue treatment once they leave the hospital.

Treatment generally comes in two phases:

  • The first is the intensive one whereby the patient requires hospitalization for up to two months.
  • In the second phase – know as the continuation phase – the patient is released from the hospital but required to take pills daily in the presence of a medical professional. This is called directly observed treatment (DOT) and is a safe way to ensure the necessary meds are taken to fully wipe out the infection.

This is however where our problem begins: It’s when people get to go home that they STOP taking their pills.

Why this happens is an open question.

We know that people don’t stop taking drugs because they want to get sick again. Life gets in the way, they’re forgetful, maybe some receive a pension a day or two after they were supposed to refill their prescription. In the end, however, it’s their treatment – and their health – that suffers.

The question: What if ‘all’ they need to take the pills is a nudge?

And who better for our team and the Moldovan Ministry of Health to partner with to test that assumption than the Behavioural Insights Team – commonly known as the ‘Nudge Unit’.

Our mission: To understand what factors are getting in the way of patients taking their pills once they leave the hospital in order to ‘nudge’ them to continue the treatment.

Our early efforts to understand this are framed around better understanding of how the treatment process is organized.

In our research, we’ve come up with several possibilities:

  • If patients simply forget to take their pills – then a short text message to them or someone in their household might just do the trick.
  • If patients need additional motivation – incentives like cash handouts or food stamps could do the job.
  • If the main stumbling block was something physical or tangible – say, the long distance it takes to get to the doctor’s office or the expensive cost of medication - then perhaps we could design something that would minimize those costs.

A series of discussions with public health officials, doctors, NGOs and most of all the patients’ themselves revealed that it was indeed these efforts – or friction costs - that seemed to present the key problem.

As one former patient, and now partner, Valeriu said:

“As a former patient I am looking forward to project’s implementation with great enthusiasm…I am still horrified by memories of my treatment…and it is not only treatment, but other obstacles and discomfort like you need to go each day to visit doctor to get pills…it is out of place in the 21st century…if this project gets properly implemented the treatment would be much easier to follow and, thus, to complete – and this is the most important for defeating the TB.”

It made a whole lot of sense to us:

Once home, a patient has to travel back and forth to the hospital just to swallow a pill in front of a doctor. That’s expensive, time-consuming, and furthermore since side effects of the drugs include nausea and fatigue, totally exhausting…

Who wouldn’t drop out?

This helped us think through the design process for getting people to take their meds in a way that’s as simple – and frictionless – as possible.

Equipped with these insights we came up with two new ideas to do just that:

 Introduce in practice and randomly trial video observed treatment (VOT) – an alternative to the currently mandatory directly observed treatment (DOT);

Begin a randomized trial of home-based delivery of DOT.

Each of the options has its advantages and disadvantages:

Video-observed treatment would make the lives of patients more comfortable and save doctors time by easing the flow of patients. It would also allow for covering more migrant workers and perhaps even cut costs in the long term.

However, at least in the short run, it would have to be largely confined to patients in urban areas where high-speed internet access is more readily available.

On the surface, the ‘home-delivery’ option is easier – it requires no new technology and is equally applicable in urban and rural areas; though it does need continuous investment and would not be as seamless as video treatment.

All in all, neither option is a silver bullet. But if successfully implemented and evaluated, each can bring improvements in health outcomes, making patients’ lives easier, eventually saving public money, and surely providing policymakers with robust evidence of what works and what doesn’t.

Watch this space to see how it plays out…

by Alex Oprunenco

UNDP Around the world