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International Health

Health Systems Program

Keyword: chronic conditions

Changing ingrained attitudes, perceptions and cultural norms that lead to harmful behavior can be one of the trickiest challenges in public health. There are varying disciplines that attempt to examine why social and behavioral change can be so difficult to accomplish. One of those fields, Health Economics, examines how to design incentives to motivate people to take care of themselves. Dr. Antonio Trujillo, co-director of Health Systems Program’s Master of Health Science (MHS) in Health Economics academic program, spearheads a study in Peru that attempts to understand why people with diabetes fail to take care of themselves over and over again.

In collaboration with the Center of Excellence in Chronic Diseases (CRONICAS) in Peru, Dr. Trujillo’s study looks at the role group incentives play in promoting healthier behavior, specifically, how we can use the combination of cooperation and group monetary rewards to encourage people with diabetes to take care of themselves. Past studies have examined the use of individual monetary incentives to accomplish certain outcomes when trying to change behavior; however, individual cash rewards have increasingly been found to work short-term but not in the long run. In addition to a lack of long-term success for consistent healthy behavior, they are often infeasible and unaffordable to scale-up to larger projects and studies, and frequently face rejection from the general public who are opposed to paying individuals to take care of themselves.

This Health Systems Program project examines the viability of a mixed-incentive study that combines both group motivation and monetary reward. Using a teamwork approach, there are two participants: one patient implements the suggested lifestyle changes while their partner, designated as a “motivator,” encourages them to stick to the new regimen. If the person implementing the suggested changes makes the goal, then they both get rewarded. The aim of the design is to foster cooperation and synergies between participants. The use of social networks and personal connections establishes a more meaningful tie to the healthier routine.

Challenges to introducing behavior change over the long haul still persist and a big part of Dr. Trujillo’s work is understanding these challenges and how best to mitigate them. One such challenge touches upon one of the basic fundamentals of public health - people in many areas of the world lack the information and knowledge, access to primary care and insurance, and do not have the income to support a steady upkeep of their health. These obstacles persist across all geographic areas, and failures to take care of diabetes are similar in both the U.S. and Peru. Dr. Trujillo and the Health Systems Program wish to see gains happen across all different types of behaviors, starting with designing better programs to address chronic disease; however, in order to achieve that, it’s necessary to help people develop a habit of taking care of themselves – all around the world. 

Diabetes and other chronic conditions are not often the first thing that comes to mind when discussions around treating Syrian refugees arise. Non-communicable diseases (NCDs), such as diabetes, are often a focal point when educating those in non-conflict settings about the importance of diet and physical activity; however they don’t occupy much real estate in the humanitarian sector when it comes to funding and support.

Dr. Shannon Doocy, from the Health Systems Program’s is attempting to target NCDs and other health burdens with a new mobile health (m-Health) app in order to make strides in the field of humanitarian relief for Syrian refugees in Lebanon. Her work in Lebanon centers on developing an app to improve management of hypertension and diabetes in refugee patients from Syria, as well as Lebanese host community members.

Addressing chronic conditions is new for humanitarian agencies - money is already stretched very thin in other immediate-need areas; however, this doesn’t mean that there won’t be dire consequences for failing to take into account the impact of untreated chronic conditions. “Treatment for chronic conditions like hypertension and type II diabetes requires continuous monitoring over time and uninterrupted adherence to treatment regiments, both of which are challenging in ideal settings, but exponentially more difficult in situations of displacement,” states Emily Lyles, a Research Assistant and PhD candidate collecting data on-site in Lebanon. Dr. Doocy hopes to mitigate the additional burden that chronic conditions might bring by improving the quality of care refugees receive and the information provided to them about their chronic conditions.

The application itself, launched in collaboration with a developer from MIT, creates a print-out for patients on the status of their health care. Since refugees are constantly in transition, the print-out allows them to improve the continuity of their care while traveling or being herded from place to place. The app aims to benefit both patients, who upon receiving the print-out perceive the quality of care they are getting to be higher, and local health care providers in Lebanon who are now prompted to ask the patients about their lifestyle choices and other related health matters, thus collecting a whole spectrum of information. The suite of information makes it possible for clinicians to view patient history over time, an important factor for NCD management - especially amongst displaced patients who may be constantly on the move.

The project is not without its challenges: the Lebanese government is currently developing NCD guidelines causing approvals to take longer than anticipated and local medical providers are seeing their caseload increase during an already stressful time period, leaving little extra time during patient consultations. Together with partner organization, International Organization for Migration (IOM), the Center for Humanitarian Health is striving to address the lack of access to and high cost of health care for many refugees who at this time, need care in every form, including against the burden of chronic conditions. The consortium hopes this study will have a sustainable impact on the introduction of m-Health care for chronic conditions in the field of humanitarian relief and provide a seamless transition for mobile populations such as refugees.