Abstract
Nudging, a strategy that uses subtle stimuli to direct people's behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion. A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations. This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience. Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of 'what works' and 'how it works'. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC.
Highlights
In recognition of the underinvestment, global attention and commitment to address neglected tropical diseases (NTDs), the United Nations formally recognized the NTDs, a diverse group of infectious diseases that are common in low-income populations with poor access to quality health services, water, sanitation and hygiene, generally being overlooked and receiving little attention [1]
One expert provided additional premises and guidelines: a nudge is an aspect of an intentional intervention, not the intervention itself; the intervention can include both rational aspects as well as nudges at the same time; a nudge does not affect action by provision of rational reasoning; actions can include mental events; creating an opportunity does not count as a nudge; fear of social sanctions does not count as a nudge; and lastly, a nudge implemented to alter the mental or emotional state should be supported by evidence and not merely assumed
We identified a total of 33 studies that included a nudge strategy for behavior-based prevention and control of NTDs in low- and middle- income countries (LMIC)
Summary
Preventive chemotherapy, i.e. low-cost mass drug administration without individual diagnosis, is at the core of most NTD programs [3]. An integrated approach to combating NTDs in the long term is widely recommended. This implies shifting the focus away from reliance on medicines to integrated and multisectoral approaches [6]. A strategy that uses subtle stimuli to direct people’s behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion
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