GHSP: When Knowledge Is Not Enough: Applying a Behavioral Design Approach to Improve Fever Case Management in Nigeria

14 December, 2022

A few hours ago I posted a message on HIFA where I invited us to explore how guidelines can be made more accessible and how to support their use and implementation.

Serendipitously a new paper has just been published in Global Health: Science and Practice. Below are the citation, key findings and implication, abstract and a comment from me. Some important conclusions and lessons learned:

CITATION: When Knowledge Is Not Enough: Applying a Behavioral Design Approach to Improve Fever Case Management in Nigeria

Faraz Haqqi et al.

Global Health: Science and Practice December 2022,


Health care providers encounter various behavioral barriers when trying to follow case management guidelines — even those providers who are aware of proper case management protocols and intend to follow them.

Understanding that behavioral drivers varied between individuals allowed for the design of a multipronged intervention to address the combination of factors influencing provider behavior.

The intervention streamlined processes for overburdened providers, allowing them to focus their attention and efforts where they are most impactful.

In addition to correcting provider misconceptions, the solutions also created a shared understanding of the reliability of malaria rapid diagnostic tests among providers and reset expectations with respect to patient case management and facility-wide adherence to national guidelines.


In challenging environments, a behavioral design approach can help improve case management practices by focusing solutions on removing barriers to create an environment more conducive to all of the tasks that case management requires, equipping providers with tools to better navigate the barriers they encounter, and establishing workplace norms to support and sustain changes in provider behavior.


Background: We sought to encourage health care providers to adhere to national malaria case management guidelines. This requires them to conduct malaria parasite tests for every patient presenting with a fever and provide malaria treatment only to those who test positive for malaria. Our goal was to make it easier for providers to follow guidelines by addressing drivers of nonadherence uncovered through facility observations and interviews with staff and clients.

Implementation and Monitoring: The case management interventions were piloted in 12 public health facilities in Akwa Ibom, Kebbi, and Nasarawa states in Nigeria between October and December 2019. Participating facilities included 1 hospital and 3 primary health centers in each state. Relevant changes included the following: (1) providers at each facility participated in facilitated discussions to correct misconceptions about the reliability of malaria test kits; (2) testing procedures were integrated into existing triage systems; (3) treatment algorithms were integrated into medical record forms; (4) providers were issued pictorial brochures outlining danger signs to share with clients, together with instructions for when to seek further care; and (5) a process was created for facilities to monitor their own adherence to guidelines.

Lessons Learned: The lessons learned include: (1) disentangling the drivers of behavior allows for more targeted solutions, (2) solutions that streamline processes for overburdened providers allow them to redirect their attention and efforts where they can be most impactful, and (3) changing staff perceptions of workplace norms can support a holistic and sustained approach to behavior change.

COMMENT (NPW): The use of 'treatment algorithms integrated into medical record forms' seems innovative, although this approach could have disadvantages as well as advantages. The text does not describe how this was implemented, so it is hard to draw conclusions. I have asked the authors to join us.

'When knowledge is not enough' - Knowledge is never enough, of course, but it is always a prerequisite for effective care.

Best wishes, Neil

Dr Neil Pakenham-Walsh, HIFA Coordinator

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