The proposed study is randomized controlled trial (RCT) to be conducted at HGOPY. As the hospital’s interest is in improving the quality of family planning services it provides and increasing the demand for family planning services sought at HGOPY, the unit of intervention is a client presenting with a request for family planning services. As such, individuals will be randomly assigned to the interventions being evaluated under this study, which are described below.
1. Randomly varying the prices the individual clients face by offering discounts: at the end of each counseling session, which is conducted by a nurse using a tablet-based app (which can be described as a decision-support tool or a job aid), the health provider will offer the client a discount from the regular prices charged by HGOPY for long-acting and short-acting methods (LARCs and SARCs). We aim to investigate the following questions using this intervention:
a. Is the demand for (modern) contraception among females responsive to changes in prices?
b. Is there a discontinuity in demand at “price = 0”? Is the elasticity different for adolescents vs. adults?
The prices (or discounts) for LARCs and SARCs will be independently randomized in a 5x2 factorial design.
2. Randomly varying whether the “app” recommends one method at a time vs. “status quo”
Here, we would like to test, as closely as possible, the paradigm shift in FP counseling – from discussing all methods and letting the client state the method she would like to discuss to the “app” recommending a method to discuss first – based on the information elicited from the client during the session. Therefore, we would like to randomize, initially with equal probability, between two regimes (it is possible that we test four regimes, adding two and three choices at a time):
i. Status quo: The “app” displays all MC methods (up to four) that have not been ruled out by the client or medical eligibility up to that point. The choices are presented as unranked (i.e. as if equally suitable for the client) and the nurses will be trained to provide basic information on all choices (in order of the methods displayed, which may be randomized as well) and then allow the client to indicate which method they would like to discuss. From there, the procedure is the same (go to cue card, etc. and then adopt or choose another method and repeat – until a decision is made).
N.B. The preferred ranking will be known to the researchers, i.e. the app will still rank methods, but simply not display those rankings to the nurse counselor.
ii. Top recommendation: This is how the “app” currently works: it will display the MC deemed most suitable for the client given her preferences and ask her if she would like to hear about it. If she says ‘no,’ or if she says ‘yes’ but ends up not wanting to adopt the method, the next highest ranked recommendation will be displayed and the same process will be repeated until a final decision is reached.
The experiment, with longer-term follow-up, will shed light on what form of counseling works better to improve client welfare and satisfaction, as well as reducing the likelihood of discontinuations and unintended pregnancies.
3. Randomizing between two methods when there is a tie in rank:
The “app” bases its recommendations on the clients’ preferences regarding (a) side effects, and (b) how long she’d like to wait before becoming pregnant. Methods that the client does not want to consider and that do not meet medical eligibility criteria are then eliminated from the ranked list of recommendations.
When there is a “tie” between two methods, the tie is broken using a random number generator. Experimental evidence on the acceptability of LARCs for clients presenting to adopt SARCs (or people who are not sure about the method they would like to adopt) is scant, especially in the developing world. Randomization to break ties to recommend one method ahead of another will address this issue.