From Idea to Institution: the Behavioral Science Center in Nepal

The potential of behavioral science theory and interventions is often overlooked in the global public health sector. Behavioral science is the evidence-based study of how people make decisions and act in their environments, and applying these insights to policy and strategy can result in more effective behavior change interventions. The COVID-19 pandemic and vaccine introduction offered opportunities to harness the power of behavioral science for increasing vaccine uptake, particularly in low- and middle-income countries.

Applying behavioral science to immunization can help us better understand the social and behavioral barriers and enablers of vaccination and their effects at individual, community, health system, and policy levels. By leveraging tools and approaches from behavioral science, like journey mapping, we can co-design solutions with communities that respond to people’s needs and influence the root causes that drive vaccination, such as gender and social norms.

To take advantage of these underused opportunities, practitioners require increased capacity in behavior change programming, a demand that some donors and international organizations, including the World Health Organization, have already recognized. In Nepal, through the Bill & Melinda Gates Foundation-funded Behavioral Science Immunization Network project, JSI, Dhulikhel Hospital-KUSMS, and UNICEF Nepal established the Behavioral Science Center (BSC) to sustainably strengthen local capacity in applied behavioral science, with an initial focus on immunization.

The idea: taking action following a scoping exercise

After conducting a scoping exercise, we found that:

• Health programs in Nepal are using tools and theories from behavioral science, but there is limited data and knowledge sharing about its use and effectiveness.
• There is limited funding for and training on behavioral science interventions.
• Capacity development structures for behavioral science are limited to the federal level.
• Mass media and expert-driven approaches are prioritized instead of user-centered approaches.
• Targeted, behavior-centered approaches are less prioritized than blanket approaches.
• Capacity to use behavioral science and, more specifically, to apply it to immunization is limited.

Additionally, our findings revealed that there is no national approach or strategy for using behavioral science in Nepal. Participants in key informant interviews recommended the country develop a national center of excellence.

Based on these findings and in consultation with national and local stakeholders, KUSMS established the BSC in January 2022, with technical and financial support from JSI and UNICEF Nepal. The BSC, while hosted at an academic institution, has wide-ranging membership, including representatives from academia, professional societies, government departments, civil society, UN entities, and non-governmental organizations. Members are able to work together to achieve collective ownership and promote multi-sectoral collaboration.

Moving from idea to practice: opportunities to strengthen capacity

In collaboration with KUSMS and UNICEF Nepal, we conducted formative research on the behavioral and social drivers of vaccine uptake in wards across three provinces. We also held ideation workshops in two wards of Kathmandu Metropolitan City and pilot-tested solutions to overcome barriers to vaccination among under-immunized and zero-dose children.

The formative research process became an opportunity to strengthen the capacity of the KUSMS team in using models, tools, and processes related to behavioral science for immunization. In designing and conducting a rapid inquiry, the KUSMS team developed skills in using the COM-B (capability, opportunity, and motivation-behavior) model and Journey to Health and Immunization to examine barriers and enablers to vaccination that both caregivers and health workers faced. The team also used methods from anthropology and the human-centered design (HCD) process to diagnose challenges and co-create solutions.

As the team pilot tested different counseling interventions, they strengthened the capacity of health workers and female community health volunteers to use processes like HCD and to understand the value of and relevance of social and behavior change to delivering respectful care. At the same time, as BSC members shared their knowledge, they found additional capacity development opportunities. For example, members of the National Health Research Council applied a behavioral lens to formative research on institutional delivery using similar processes and tools as the KUSMS research team.

Creating demand for behavioral science in Nepal

The BSC quickly generated demand for behavioral science across government entities, immunization practitioners, and other universities in Nepal. When responding to a measles outbreak, the Ministry of Health and Population requested the BSC’s support to identify barriers to vaccine uptake and encourage vaccination in communities in Nepalgunj. Additionally, the Department of Health Services has requested that health promotion officers receive training in behavioral science approaches to improve their understanding of barriers to vaccination in their communities.

The way forward

So what’s next for the BSC? The team is in the process of finalizing and receiving accreditation for a social and behavioral science course for graduate public health students. Eight universities in Nepal have agreed to include behavioral science lessons in their curricula as part of a newly-formed Consortium of Academic Institutions for Public Health. The BSC is also supporting the incorporation of behavioral science tools to promote respectful care in the pre-service curriculum for health workers. The BSC will continue to support the government in using behavioral insights to improve immunization and other health service programming.

By: Nicole Castle, Leela Khanal (BSC Technical Lead), and Surakshya Kunwar (Dhulikhel Hospital-KUSMS)

Photos: Dhulikhel Hospital-KUSMS