Iron Deficiency in Young Children in the Kyrgyz Republic

Applying Insights from Behavioural Economics to the Design and Implementation of Young Children Nutrition Policy in the Kyrgyz Republic

Executive Summary

Iron deficiency anemia among children under 2 years old is a major public health problem in the Kyrgyz Republic.

Introduction

Iron deficiency anemia is widespread among young children in the Kyrgyz Republic. According to the Kyrgyz Ministry of Health nowadays every second child under 2 years old suffers from iron deficiency anemia[1]. Iron deficiency anemia is a serious public health issue in the Kyrgyz Republic. The consequences of anemia put the health and development of young children at risk, and it jeopardizes human and economic development of the country as well.

In 2009, to address the problem of iron deficiency anemia among children under 2 years old Kyrgyz Ministry of Health initiated a three year long micronutrient powder (MNP) home fortification program (hereinafter referred to as “MNP program”) as previous studies demonstrated that daily use of MNP (one sachet contains 12.5 mg iron as ferrous fumarate, zinc 5 mg, folic acid 160 mg, Vitamin A 300 mg, and Vitamin C 30 mg), results in a reduction in the prevalence of anemia among children between 6-24 months of age[2]. However, despite implementing the program to date no significant improvement in the rate of iron deficiency anemia among children in this age group has been achieved. The Demographic and Health Survey conducted in 2012 identified that the prevalence of anemia was ~55% among children between 6-24 months of age (please see Annex 1). This number has not improved since the previous Demographic and Health Survey was conducted in 1997 (please see Annex 2) and has remained at the same level until today as the National Centre forProtection of Motherhood andChildhood reported in October 2014[3].

This policy brief aims to analyze the policy intervention implemented by the Kyrgyz Ministry of Health and recommend the Ministry the ways to improve the policy intervention by means of applying insights from behavioral economics as a growing body of research suggests that “behavioral economics has a critical role to play in improving health and healthcare”[4].

Approaches and Results

Ministry of Health in cooperation with the Swiss Red Cross and UNICEF identified the MNP program to be an effective intervention for anemia prevention. The program was rolled out in three phases. First two phases were a pilot program in Talas province, where the prevalence of anemia was found to be 50.6%, which was the highest rate compared to other provinces[5], followed by the second pilot program in Naryn province based on positive results of the first pilot program. MNP was distributed free of charge to all children 6-24 months old through the governmental primary health care system. The MNP was rebranded for use in the Kyrgyz Republic to enhance its acceptance among the local population. The MNP sachets were distributed by primary health care providers to the parents when they visited a primary health care clinic. In the Kyrgyz Republic, parents of young children have a regular contact with the local health care providers, for the reasons including preventive care, immunization and treatment. Thus, these health care providers were identified as an ideal channel through which the MNP sachets could be distributed to the population.

One of the main channels of communication used to inform population of this health care policy intervention was through primary health care providers. The primary health care providers were trained on the distribution procedures for MNP and counselling parents on the use of this product. The health care providers were also trained to provide information on managing the potential side effects of MNP and counsel those parents who were reluctant to use MNP. Additionally, information on the intervention was disseminated by means of print and radio mass media.

The pilot program in Talas province was implemented successfully. The success of the pilot program also attributes to the fact that there is “a significant published evidence that MNP programs are effective for improving micronutrient intake in a control/trial setting”[6]. The next step was to scale up the MNP program to the national level and demonstrate that the MNP home fortification program is also effective in a large-scale programmatic setting. Hence, the third phase of the program included scaling up of the program at the national level. The program was implemented using same tools, which were applied in the two pilot programs.

Overall results of the entire policy intervention were reported to be positive. However, as was mentioned above the empirical evidence suggests that MNP programs are effective in improving micronutrient intake in a control/trial setting and policymakers admitted that the effectiveness of the program in a large-scale programmatic setting is yet to be researched in order to support further implementation of the policy intervention[7]. Having said that we turn to the results of the Demographic and Health survey conducted in 1997 and 2012 (prior and post policy intervention), which suggest that there has not been significant improvement in addressing and preventing iron-deficiency anemia achieved.

Based on the results of monitoring and evaluation of the two pilot programs the following key lessons learned were identified:

1. While, overall, parents were positive to the pilot MNP program and there was a relatively high degree of acceptance; however, some parents also expressed concerns about safety of the product, some parents were concerned that the product was artificial and said that they would prefer for their children to receive vitamins and minerals from food. To address parents’ skepticism and concerns an additional outreach and communication campaign was arranged;
2. Parents were failing (or forgetting) to come to the hospital for a new supply of the MNP; therefore, medical workers had to visit each home to deliver the next supply of the MNP. The monitoring report concludes that the reasons behind this problem need to be explored in greater depth and solutions to be found as frequent home visits place an additional burden on medical workers ;
3. Primary health care workers did not provide alternative options to those parents who were not willing to subscribe to the MNP program.

Recommendations

Success of a health care policy intervention greatly depends on people’s behavior. As witnessed from the MNP program, parents’ skepticism about the program, procrastination and/or forgetfulness to follow the medical prescription were among the main factors that determined the outcome of the program. Also, behavior of primary health care providers played a role in addressing the problem of iron deficiency anemia. Therefore, it is proposed to improve the program by utilizing insights from behavioral economics, which studies the effects of psychological, social, cognitive and emotional factors on decisions of individuals. Lessons from behavioral economics can be leveraged to design large-scale public health interventions and achieve policy goals[8].

The recommendations aim to address the following four main issues encountered during the policy implementation process based on the behavioral economic insights which are empirically proven to be efficient in addressing behavioral biases people demonstrate:

1. Bounded rationality;
2. Medical non-adherence;
3. Status quo bias; and
4. “Trust” heuristic.

Bounded rationality

Standard economic theory assumes that individuals have no limitations in their ability to make decisions, both in terms of their cognitive abilities and the amount of time they need to take a decision. However, in reality people have scant mental resources to make their decisions. This explains the reason why much of the information given to people is ignored when the decision is being taken, in other words people are driven by bounded rationality. Also, an existing research suggests that a patient soon forgets much of what he has been told by a physician[9].

This phenomena explains why parents were raising concerns about safety of MNP and its side effects despite the communication campaign arranged to answer all the questions. Parents had all the information, but apparently they either paid little attention to it or simply forgot the information they were provided with when they had to take the decision to use MNP.

To address this issue it is proposed to include the issuance of a so called medical “adherence” contract at the initiation of MNP treatment in the MNP policy design. This contract will serve a number of purposes, including addressing the issue of bounded rationality. The contract should include a comprehensive information about MNP, including its side effects and how to address them, information on the purpose of this medication and consequences of not taking it as prescribed, the contract should also include a schedule of MNP intake. This behavioral contract can also include a schedule of visits parents have to make to the hospital to obtain a new supply of MNP. This provision in the contract will also help to address the issue of forgetfulness.

Medical non-adherence

The failure of patients to adhere to the prescribed medication is a major problem in health care. While medication being expensive to afford may be one explanation for non-adherence; however, evidence suggests that non-adherence prevail among those patients who get their medication for free as well[10], likewise in the case of the MNP program. There might be various reasons behind this behavior[11]. In the case of MNP program we have identified the following major reason:

Procrastination/Forgetfulness. Failing to get a new supply of MNP may be explained by the fact that individuals make suboptimal decisions when they display present bias[12]. In particularly, individuals often overweight costs and benefits incurred today relative to the costs and benefits they incur tomorrow. This type of bias leads individuals to forego the benefit of a continuous use of MNP. This is explained by the fact that going to the hospital for a new supply of MNP features a present cost to parents as they have to give up their time they would spend on something else and a delayed benefit in the form of supposedly better health of their children as a result of taking MNP, that’s why parents might perpetually wait to incur this cost. Another reason is that they can also forget to comply with the doctor’s prescription.

To address the present bias issue in the form of procrastination/forgetfulness, it is recommended to make use of modern technologies, such as mobile phone text messages, that can be sent out to the parents to remind them of the need to visit a hospital to get a new supply of MNP and reiterate the importance of adhering to the doctor prescription to ensure that their children do not suffer from iron deficiency anemia and its consequences. Additionally, the text message can provide an option of home delivery should parents not be able to visit the hospital. This will address the present cost bias that parents might be putting in the time they need to spend by going to the hospital. The medical “adherence” contract discussed above will also serve as a reminder to the parents to adhere to the medical prescription.

Status quo bias

Primary health care providers gave only one default option the parents could use to ensure their children did not have iron deficiency anemia, which was the MNP program. Since the health care providers had to report to the Ministry of Health on the number of MNP sachets distributed to the population, they were reluctant to provide other options to the parents, which could also be effective in preventing iron deficiency anemia besides MNP program. The research evidence documents that “patient preferences are increasingly considered important in healthcare policy decision-making, with many stakeholders explicitly supporting and appreciating patient involvement and consideration of patient preferences”[13]. Taking this fact into consideration, it is recommended to provide parents with alternative options they could consider to prevent their children from having iron deficiency anemia. Additionally, having exhaustive information on all possible options to prevent and treat iron deficiency anemia will build trust among parents and consequently reduce the level of skepticism.

“Trust” heuristic

Healthcare greatly depends on the level of trust between patients and healthcare service providers. Therefore, it is essential to focus on how the public health communication is conducted. Healthcare workers tend to underestimate the rational resource of the patients and, as a result, provide advice about health risks caused by iron deficiency anemia without revealing to the parents the expert base that generated this advice. The reason behind this behavior is that the public is believed to have lack of knowledge as well as lack of rational capacity to rationally comprehend and evaluate the expert base from which the medical advice is generated. However, this assumption is not necessarily correct and, therefore, “if public health workers can learn to trust the rational resources of the public, then perhaps the public will reciprocate by increasing its trust in public health” [14].

Conclusion

The results of the monitoring and evaluation exercise show that the MNP program design yet needs to be worked on to improve the outreach of the program and enhance its coverage. Main issues, which undermine the acceptance of the MNP include lack of parents’ awareness of the MNP product safety, non-adherence to the medical prescription, and absence of alternative options to the MNP program. It should also be taken into account that the results of the pilot programs in a controlled/ trial setting are more positive compared to the results of a scaled-up program. Research findings show that the evidence of the effectiveness of MNP in large-scale programs is scarce[15]; therefore, it is essential to address current issues for a successful implementation of the program at the national level.

Annex 1

Annex 2

Bibliography

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1

[1] Miroshnik, M. (2014).Медики: В КР каждый второй ребенок до двух лет страдает анемией. [online] Vecherny Bishkek. Available at: http://www.vb.kg/doc/290245_mediki:_v_kr_kajdyy_vtoroy_rebenok_do_dvyh_let_stradaet_anemiey.html [Accessed 13 Nov. 2014].

[2] Home Fortification with Micronutrient Powders (MNP). (2013). Home Fortification Technical Advisory Group (HF-TAG).

[3] Miroshnik, M. (2014).Медики: В КР каждый второй ребенок до двух лет страдает анемией. [online] Vecherny Bishkek. Available at: http://www.vb.kg/doc/290245_mediki:_v_kr_kajdyy_vtoroy_rebenok_do_dvyh_let_stradaet_anemiey.html [Accessed 13 Nov. 2014].

[4] Rice, T. (2013). The Behavioral Economics of Health and Health Care.The Annual Review of Public Health, 34, p.445.

[5] Home Fortification with Micronutrient Powders (MNP). (2013). Home Fortification Technical Advisory Group (HF-TAG).

[6] Home Fortification with Micronutrient Powders (MNP). (2013). Home Fortification Technical Advisory Group (HF-TAG).

[7] Rah, J. et al, S. (2012). Program Experience with Micronutrient Powders and Current Evidence.The Journal of Nutrition.

[8] Kessler, J. and Zhang, C. (2011). Behavioral Economics and Health.Oxford Textbook of Public Health.

[9] Medscape.com, (2014).Medication Nonadherence: Why Nonadherence?. [online] Available at: http://www.medscape.com/viewarticle/409940_2 [Accessed 13 Nov. 2014].

[10] Doshi et al. (2009). Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans.PubMed.

[11] Cutler, D. and Everett, W. (2010). Thinking Outside the Pillbox — Medication Adherence as a Priority for Health Care Reform.The New England Journal of Medicine.

[12] Kessler, J. and Zhang, C. (2011). Behavioral Economics and Health.Oxford Textbook of Public Health.

[13] Boivin AC K et al. (2010). G-I-N PUBLIC:Patient and public involvement in clinical guidelines: international experiences and future perspectives. Qual Saf Health Care.

[14] Louise Cummings (2014). The “Trust” Heuristic: Arguments from Authority in Public Health, Health

Communication, 29:10, 1043-1056.

[15] Rah, J. et al, S. (2012). Program Experience with Micronutrient Powders and Current Evidence.The Journal of Nutrition.