Alison Buttenheim Team Gets $2 Million Peru Research Grant

Alison Buttenheim Team Gets $2 Million Peru Research Grant

Work Supports National Efforts to Control Insect-Driven Chagas Disease

A team of Penn researchers led by Alison Buttenheim has been awarded a $2 million grant from the U.S. National Institutes of Health (NIH) to conduct behavioral economics experiments aimed at increasing public response to Peru's efforts to control a serious bug-borne disease.

Alison Buttenheim, PhD, MBA, of Penn's School of Nursing and LDI Senior Fellow has been studying efforts to control Chagas disease in Peru.

An Assistant Professor in the University of Pennsylvania School of Nursing and an LDI Senior Fellow, Buttenheim, PhD, MBA, has previously studied the Peruvian public health programs that are fighting the spread of Chagas, a potentially fatal disease common throughout Latin America. The parasite that causes the illness is carried and spread to humans by a blood-sucking insect known as a Triatomine or "kissing bug" that infests homes.

Pesticide campaign
For years Peruvian officials have engaged in a vector-control campaign whose goal was to convince citizens in the city of Arequipa to volunteer to have their dwellings fumigated with Triatomine-killing pesticides. But resistance has been high and threatens to undermine the Ministry of Health's door-to-door program.

"Elimination of Chagas transmission in Peru is an attainable goal" said Buttenheim, "but to reach that goal, we have to boost campaign participation in cities likes Arequipa where transmission is still occurring."

Buttenheim and Michael Z. Levy, PhD, assistant professor of epidemiology in Penn's Perelman School of Medicine, are principal investigators on the study, which was funded as of Sept. 1.

"It's important to treat all houses on a block with a pesticide," said Buttenheim. While an acute form of Chagas can develop shortly after infection, the disease often remains latent for decades, "which makes it a very challenging disease to get people excited about preventing," she said.

8 million infected people
Chagas, which affects more than 8 million people, invades smooth muscle tissue in areas like the heart and gastrointestinal tract. There is no effective treatment; so the best prevention is to eliminate Triatomine infestation in the home to reduce the risk of bites. But the refusal rate in Arequipa the has been rising, Buttenheim said.

Blood sucking Triatomine or 'kissing' bugs carry a Chagas disease-causing parasite and infest many neighborhoods throughout Latin America.

Reluctance to treat in Arequipa comes more from wealthier communities, whose members cite objections to spraying, including lack of time and concerns over the insecticide, according to Buttenheim, who called the treatment safe for people. Typically, residents receive a one-day notice that government workers will be in the neighborhood to spray, she said.

Effective application of the pesticide requires the home resident to move all furniture and other belongings away from the walls and into the center of each room -- a disruptive and time-consuming task.

Buttenheim and Levy plan to apply novel tools from behavioral economics that have been tested in small trials and apply them for the first time on a large scale in a randomized controlled trial of three interventions in Arequipa beginning in 2015.

Lottery intervention
One intervention uses group lotteries, in which groups of six contiguous houses are eligible to win a prize such as a food basket if their lottery number is drawn and they participated in the spray campaign. If every house in the winning group has been treated, however, households will receive a bigger prize, such as a gift card for a home repair store, said Buttenheim.

The idea behind the group lottery is that people not only won't want to miss an opportunity for a prize, they also may not want to be the one who prevents their neighbors from winning the big prize.

The second intervention involves recruiting a block's opinion leaders, such as the woman who runs the daycare center or the corner store, to recruit neighbors to help the community by allowing spraying.

In the third intervention, health workers will show up two to three weeks before spraying, rather than the day before, to seek a household's commitment to schedule a treatment in advance, and then encourage the household to make a plan for the spray day. People tend to think they'll be less busy in two or three weeks than they are now, Buttenheim explained.

Behavioral economics playbook
"This is straight out of the behavioral economics playbook," which shows people are more likely to take action if they make a plan, she said. This intervention, if successful, would be very easy for campaigns to incorporate, she noted.

Researchers will compare the outcomes of the three interventions, part of a five-year study covering 1,450 households in one district.

The study may have lessons that researchers can apply in the United States, where Levy works on the bed bug problem and Buttenheim studies childhood vaccination refusal.