Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-047925 on 9 August 2021. Downloaded from Behavioural insights (BI) for childhood development and effective public policies in Latin America: a survey and a randomised controlled trial Andrea A Tomio,1 Martin Dottori,1,2 Eugenia Hesse,1,2 Fernando Torrente,3 Daniel Flichtentrei,4 Agustin M Ibanez 1,2,5,6,7 To cite: Tomio AA, Dottori M, ABSTRACT Strengths and limitations of this study Hesse E, et al. Behavioural Objectives We developed (a) a survey to investigate the insights (BI) for childhood knowledge of childhood health experts on public policies ► This is the first study analysing Latin American child development and effective and behavioural insights (BI), as well as its use in Latin public policies in Latin America: health professionals’ knowledge and opinions about American and the Caribbean countries (LACs), and (b) a survey and a randomised behavioural insights (BI). an intervention (randomised controlled trial) to test the controlled trial. BMJ Open ► This study combines two quantitative methodologies influence of nudges on the effect of a simulated public 2021;11:e047925. doi:10.1136/ assessing public policy engagement: a survey and a health programme communication. bmjopen-2020-047925 randomised control trial. Participants and settings A total of 2003 LACs childhood ► The present study presents the common limitations ► Prepublication history and health professionals participated in the study through a supplemental material for this involved in survey studies, with biases coming from Hispanic online platform. paper is available online. To self- reporting methods. Primary and secondary outcomes We used regression view these files, please visit ► We focused on expert professionals’ opinions since models analysing expertise- related information, individual the journal online (http:// dx. doi. they are the relevant population to implement BI differences and location. We extracted several outcome org/ 10. 1136/ bmjopen- 2020- methods in childhood public policies. 047925). variables related to (a) ‘Public Policy Knowledge Index’ ► There is also an imbalance in the sample regarding based on the participants’ degree of knowledge on country participation. This may bias the results in Received 16 December 2020 childhood health public policies and (b) BI knowledge, terms of subtle regional differences. Accepted 20 July 2021 perceived effectiveness and usefulness of a simulated http://bmjopen.bmj.com/ public programme communication. We also analysed a ‘Behavioural Insights Knowledge Index’ (BIKI) based on participants’ performance in BI questions. extreme poverty in developing countries was Results In general, health professionals showed low BI 2 62.7%, and when low maternal schooling and knowledge (knowledge of the term BI: χ =210.29, df=1 child maltreatment were added, this propor- and p<0.001; BIKI: χ2=160.5, df=1 and p<0.001), and tion increased to 75%.4 Both expert knowl- results were modulated by different factors (age, academic formation, public policy knowledge and location). The edge and effective interventions are crucial to prevent these adverse conditions. Stan- use of BI principles for the communication of the public on September 26, 2021 by guest. Protected copyright. programme revealed higher impact and clarity ratings from dard economic models assume that people’s 5 professionals than control messages. decision- making processes are rational. Conclusions Our findings provide relevant knowledge However, research on behavioural sciences about BI in health professionals to inform governmental suggests that this approach has serious weak- and non- governmental organisations’ decision- making nesses when predicting people’s behaviour. processes related with childhood public policies and BI As such, behavioural sciences incorporate designs. insights from several disciplines, such as psychology, in the understanding of people’s © Author(s) (or their decisions.6 Behavioural insights (BI) is the employer(s)) 2021. Re- use INTRODUCTION application of those insights drawn from permitted under CC BY-NC. No commercial re- use. See rights An alarming rate of children living in Latin behavioural science that complement the set and permissions. Published by American and the Caribbean countries of traditional tools available to governments BMJ. (LACs) lags behind in comparison to chil- when designing policies and communica- For numbered affiliations see dren living in developed countries,1 2 since tions.7 According to Thaler et al5 those who end of article. they are not receiving the required stimu- apply BI are choice architects, in the sense Correspondence to lation that ensures a proper cognitive and that they create environments in order to 3 Dr Agustin M Ibanez; socio- emotional development. In 2017, the influence people’s decisions. BI are widely agustin. ibanez@ gbhi. org proportion of children at risk of stunting or applied to health settings,8 9 showing its Tomio AA, et al. BMJ Open 2021;11:e047925. doi:10.1136/bmjopen-2020-047925 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-047925 on 9 August 2021. Downloaded from usefulness in improving childhood programmes’ effec- Box 1 Predictor variables. These sections from the survey tiveness9 10 (for additional applications of BI in child- were included as predictor variables for regression models hood policy, see online supplemental references table A1). A growing number of BI- inspired initiatives have Predictor variables and questions 11–13 14–18 been directly applied to children or their parents, Sector over the last years (see online supplemental references Q: Do you work in the public or private sector? table A2). However, the use of BI for the improvement A: Public/private/both/I don’t work of health and development policies is still scarce in the Experience region.4 19 Q: How long (years) have you been working in the social development Health development specialists represent a critical field? source in promoting the implementation of effective A: Less than 2 years/between 3 and 6 years/between 6 and 10 years/ health programmes.20 21 Parents prefer receiving health more than 10 years Academic degree advice on their children from paediatric specialists rather 22 Q: What is your highest academic degree? than based on specialists from other disciplines, while A: Doctoral degree/master’s degree/medical specialisation/hospital healthcare professionals have a pivotal role influencing concurrence/university or professional degree/associate degree/bache- 23 parents on child vaccination. Senior- level public health lor’s degree/technicature/no formation in these subjects workers ascribe high degree of support for healthy public Age policies.24 Still, to the best of our knowledge, the opinion Q: How old are you? of experts and specialists on the usefulness of BI in child- A: Age (in years) hood policies has not yet been analysed. The opinion of Country/region health professionals regarding the efficiency, usefulness Q: In what country do you live? and real impact of BI in childhood development, partic- A: Country ularly in LACs, remains largely unknown. Specifically, Public Policy Knowledge Index there are no clues about how age, expertise, academic degree and expert knowledge impact the perception and (PPKI), an index based on participants’ degree of knowl- engagement with BI frameworks. This knowledge could 35 edge regarding childhood health public policies. Since help decision- makers target specific groups of profes- BI is not a widespread discipline in LACs, we predicted a sionals to improve the implementation of childhood poli- general lack of knowledge of behavioural tools from child cies. Accordingly, as our first aim, we investigated how health specialists. these factors impact the knowledge of BI and childhood Our second aim was to apply an experimental paradigm policies across experts working with children in LACs aimed at understanding whether BI can enhance health through a survey. Additionally, our second aim was to test professionals’ acceptance and interest in child develop- http://bmjopen.bmj.com/ whether applying BI in the communication of a simulated ment public programmes. Thus, within the same survey, public programme would influence experts’ appraisal of four communicational messages of a simulated public said programme. programme were developed using BI knowledge and The most common BI interventions in health settings were randomly assigned to different groups. Concerning are related to the reduction of drug prescriptions,25–27 the this second aim, we expected that the BI-based messages promotion of evidence-based decisions,28 the biases in 29 30–32 would increase the perceived clarity, impact and interest in diagnosis, the improvement of clinical performance 38–40 the policies, as described under previous BI literature. and the screening and maintenance of hand hygiene.21 33 on September 26, 2021 by guest. Protected copyright. Similarly, health professionals’ developments of BI have been investigated across LAC related to drug prescrip- METHODS 34 35 tions, public policy knowledge about ageing and clin- Research design 36 37 ical performance improvement. However, no previous This study combines a survey and a randomised controlled BI interventions have been specifically designed for trial (RCT) presented at the last section of said survey. health professionals working on childhood development. The first section of the survey remained equal for all In