Nudging Georgians to self-test for HIV

Note: This article first appeared on the Caucasus Data Blog, a joint effort of CRRC Georgia and OC Media. It was written by Dustin Gilbreath, a Non-Resident Senior Fellow at CRRC-Georgia, The views presented in the article are of the author alone, and do not necessarily reflect the views of CRRC-Georgia, UNDP Georgia, Caritas Czech Republic, Tanadgoma, or The United Nations Development Programme under the Czech-UNDP Partnership for SDGs.

CRRC Georgia data suggests incentivising people to test for HIV and making tests more accessible can encourage more young people to self-test.

HIV and AIDS are highly stigmatised diseases in Georgia: a 2020 report found that half the public would not buy vegetables from someone they knew had HIV, and two in five do not think HIV-positive children should be able to attend school with other children.

This stigma stands in the way of more people being tested for HIV, a critical issue in Georgia.

While the country is on track to meet international standards for the share of HIV-positive people receiving treatment and for those receiving treatment to have viral loads suppressed, only one in three people (36%) with HIV is estimated to be aware of their HIV status.

In this context, CRRC Georgia conducted a study in partnership with Caritas Czech Republic, Tanadgoma, and UNDP in Georgia with the financial support of The United Nations Development Programme under the Czech-UNDP Partnership for SDGs to promote self-testing among young people. The tests were offered by Selftest.ge.  

The study found that running a smartphone raffle and minimising the amount of information needed to order a test made young people more willing to participate in HIV self-testing.

The method was found to be comparable in cost to some of the least expensive global interventions used to encourage people to self-test.

To reach these conclusions, the study made use of three randomised control trials (RCT) — the gold standard for scientific evidence.  RCTs randomly assign large groups of individuals to receive different interventions. By randomly assigning individuals to receive different interventions, researchers can ascertain that the only difference between the groups on average is that one received the intervention and the other did not.

In total, each randomised control trial had between 38,000 and 54,000 participants, reaching 16-22% of those aged 18–34 using Facebook in Batumi, Kutaisi, and Tbilisi.

The randomised control trials tested three messages against a basic control message. The first message attempted to assuage people’s fears of being diagnosed with HIV. The second message highlighted that the services of selftest.ge were highly confidential and sensitive to young people’s needs. The third message offered a chance to enter a raffle for an iPhone 13.

The first study found that the iPhone 13 message was more effective than the two others at getting people to click through to the order page, followed by the message which focused on user confidentiality. In contrast to expectations, the message that attempted to assuage young people’s fears about a positive test result had a negative effect — people were less likely to click this message than the neutral control message.

Despite the large scale of clickthrough achieved in the trial, few people ordered self-tests. Project team members suspected that this may have stemmed from individuals not paying full attention to the messages. Therefore, a second trial was conducted with the same messages, but adding a one-sentence highlight of the key message to the Facebook post. However, this failed to produce more orders, with only one HIV self-test order coming through during the second randomised control trial despite thousands of clicks.

In the third and final trial, the study team inferred that the order form was too detailed and complicated for users. A new and simplified order form was trialled on Facebook with the two most effective messages (focusing on anonymity and the iPhone 13 raffle).

This final study started to lead to orders, with the combination of the iPhone 13 raffle and the simplified order form leading to the most self-test orders. In terms of the cost per order, this combination of a simple order form and the iPhone 13 raffle lead to a cost per self-test order of $2.66. This compares favourably to studies conducted internationally, which have identified the cost of testing promotion in the realm of $2 to $50+. 

While the stigma associated with HIV and AIDS in Georgia is a large-scale societal problem, enabling young people to access self-testing is critical to ensuring that people living with HIV know that they have it, and in turn, can seek treatment. This study provides one viable path for actors working on the issue to address this challenge.

The full policy brief which this report is based on is available here.

This post was written within the scope of the project Behavioral insights for low uptake of HIV testing in Georgia, which is implemented by the United Nations Development Programme (UNDP) through the Challenge Fund, with the financial support of the Ministry of Foreign Affairs of the Czech Republic.

The content of this material does not necessarily represent the official views of the Ministry of Foreign Affairs of the Czech Republic, or of the United Nations, including UNDP, or UN Member States.

Nudging Marshrutka Safety

[Note: Dustin Gilbreath is a Policy Analyst at CRRC-Georgia. This article was originally published on Eurasianet. ]

Auto safety is a perennial issue across Eurasia, as the generally poor condition of highways and byways, the proliferation of haphazardly maintained vehicles and a proclivity for reckless driving mean that death is a constant part of life on the road.

Among the most hazardous forms of public transportation are the ubiquitous communal minibuses known as marshrutkas, which ferry passengers around and between cities and towns. Marshrutkas are a mixture of taxi and public bus, and, for passengers, make up in convenience what they lack in comfort. But there is also a significant risk involved in using marshrutkas because many are old and in need of repair, and they are operated by overworked, stressed-out and distracted drivers.

But there is good news for marshrutka users: an experimental project conducted in Georgia suggests that a cost-efficient monitoring program could significantly increase rider safety.

The monitoring format, developed by the Caucasus Research Resource Centers-Georgia, underwent a month-long test, starting last September 20. CRRC recruited paid observers to ride on marshrutkas and monitor the driving behavior of operators. Monitors tracked marshrutka trips in three phases. In the first, they recorded whether a group of drivers engaged in dangerous driving behaviors, including passing in places where it was illegal, and distracted driving behaviors like smoking and talking on a cell phone. This contingent formed the trial’s control group.

For the second phase, monitors followed a different group of drivers, who were told in advance that they were being observed and that if they were judged the safest driver in the survey, they would receive a fuel voucher. The drivers in the second group were also told that an anonymous monitor would at some point in the near future come back to observe their road behaviors.

The last step involved monitors returning to both the control and treatment groups unannounced to observe driving.

By comparing the results of the first phase to the second, it was possible to determine the effect of overt observation on driving patterns. Evaluating participants in the second phase to the same minibuses in the third provided insight into whether those who knew they were monitored, and were told they would be monitored again, maintained safer driving practices. Lastly, by comparing the first-phase drivers to their third-phase performances, it was possible to test for the consistency of driving behaviors by the control group.

The results of the trial indicated that a small, anonymous monitoring program could be effective in improving driver practices. While in the first round of observation, 96 percent of drivers engaged in some form of dangerous driving, among those in the second group, who were told in advance that they were being monitored, the number was 70 percent. And while 79 percent of drivers made illegal passes in first phase, 43 percent from the second group engaged in such behavior.

In the third phase, carried out several weeks after the first two phases, drivers from the second group still engaged in 14 percent fewer dangerous driving behaviors than those from the first group who had not been told in advance that they were being observed.

CRRC-Georgia’s project involved the monitoring of 360 inter-city minibus trips in a randomized control trial (RCT). RCTs are considered the gold standard in social science because they provide firm evidence of cause and effect through randomly giving a treatment to some individuals, and not others and then comparing outcomes.

While the marshrutka safety experiment raises hopes that a monitoring program could encourage changed behaviors, the evidence is not definitive. The experiment did not take weather into account, a factor that can potentially alter driving patterns. It also could not measure precisely for the possibility of contamination of the source pool, i.e. drivers who had been observed later talking about the project with colleagues, and encouraging other drivers to be more careful behind the wheel.

While the experiment was carried out in Georgia, there is no particular reason to suspect that such a policy would not work in other areas and contexts.

Monitoring projects could be conducted either by non-governmental organizations or by municipal government agencies. A government-run project would likely stand a better chance of improving safety, as drivers could be fined for hazardous driving, as well as rewarded for safe driving. This policy would likely have a greater impact since social scientists have repeatedly shown that individuals strive to avoid losses much more intensively than they seek out gains. 

[Note: Dustin Gilbreath is a Policy Analyst at CRRC-Georgia. This article was originally published on Eurasianet. The full report this article is based on is available here: http://bit.ly/2txNQRR. The data and replication code for the analysis in this article is available here: http://bit.ly/2us0tCr. The research presented in this article was funded through the East-West Management Institute’s (EWMI) Advancing CSO Capacities and Engaging Society for Sustainability (ACCESS) project, funded by the United States Agency for International Development (USAID). The content of this article is the sole responsibility of the author and does not necessarily reflects the views of USAID, the United States Government, or EWMI.]

Safer transport options for passengers: Series introduction

Complaints about minibus (marshutka) driving are common in Georgia. From excessive speeds, to erratic and distracted driving, minibus travel in Georgia is often less than safe and comfortable. But could a small change make an important difference in passenger safety and comfort? At CRRC-Georgia, we wanted to find out. Hence, CRRC-Georgia together with the Fund Partnership for Road Safety carried out the Safer Transit Options for Passengers (STOP) project within the East-West Management Institute’s (EWMI) Advancing CSO Capacities and Engaging Society for Sustainability (ACCESS) project, funded by the United States Agency for International Development (USAID). Within the project, we carried out a randomized control trial, which tested whether a small incentive – a gas voucher for safe driving – and telling minibus drivers that they would be monitored could improve marshutka driving. In the coming weeks, we will report the results of the randomized control trial and institutional analysis carried out within the project. In today’s post, we provide some background on road safety in Georgia.

According to the World Health Organization (WHO), Georgia has among the highest death rates on roadways in the wider European space.* The problem also appears to be getting worse: official figures from the Ministry of Internal Affairs of Georgia show an increasing number of deaths on Georgian roadways. From 2013 to 2016, deaths increased from 514 to 602, a 17% increase. In 2016, 6,939 accidents took place, resulting in 602 fatalities and 9,951 injuries. At a per capita rate, this amounts to approximately 162 fatalities per million citizens, over three times the EU average in 2015, the latest year in which data is available.

While estimates do not exist for Georgia for how many accidents are caused by distracted and other dangerous driving practices, they are very likely contribute to the high fatality rates on the roads in Georgia. In the study we carried out, 96% of minibus drivers in the control group observations engaged in some form of dangerous or distracted driving.

When it comes to distracted driving, studies from other contexts suggest that a distracted driver’s chances of being in an accident are four times higher. Cell phone use is associated with increased incidence of accidents among both novice and experienced drivers. Cell phones aside, other distractions such as smoking can increase the risk of traffic accidents. Importantly, commercial vehicle drivers are no exception, with increased risk of accident associated with distracted driving among commercial drivers as well.

While we know that distracted and other dangerous driving practices among Georgia’s minibus drivers are both common and likely to be leading to fatalities in Georgia, feasible and effective policies are needed to reduce the scale of traffic accidents on Georgia's roadways. In the coming posts, we put forward a number of evidence based policy recommendations that could help do just that.

*Note: This blog post previously erroneously stated that Georgia had among the worst traffic death rates in the world, based on another article. After checking a primary data source, this statistic likely refers to the fact that Georgia has among the highest death rate in wider Europe.