McCoy, S.I., Fahey, C., Rao, A., et al. PLOS ONE (May 2017), 12(5): e0177394, doi:10.1371/journal.pone.0177394.
This study evaluated an adherence intervention that incorporated social norms and priming concepts (using associations to influence behaviors) among 405 people living with HIV in Tanzania. The patient-centered design used the primer image of a Baobab tree, “the tree of life,” which has positive cultural associations in this setting. The clinic-based component included participants placing a sticker with the words “brave” or “courageous” on a poster of the tree after successfully attending three consecutive visits—rewarding them for participating, and demonstrating that clinic attendance is a norm. The home-based interventions included a calendar with images of the tree and other positive-association images to help keep track of appointments; and a plastic pillbox, also with a small tree image, shaped like a telephone to prevent unintentional disclosure. At endline there were significant increases in staff support of treatment goals, support from other patients, and satisfaction with the clinical care received. Patients were also significantly more likely to have their questions answered by a provider and to be retained in care after six months. The authors concluded that using social norms and priming can improve the effectiveness of treatment as prevention programs and should be considered at the health system level, given the cost-effectiveness of the approach.