Exploring Behavioral Biases in Contraceptive Decision-Making: Evidence from a Field Experiment in Urban Malawi

Last registered on September 06, 2021

Pre-Trial

Trial Information

General Information

Title
Exploring Behavioral Biases in Contraceptive Decision-Making: Evidence from a Field Experiment in Urban Malawi
RCT ID
AEARCTR-0004194
Initial registration date
May 19, 2019

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
May 20, 2019, 1:35 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Last updated
September 06, 2021, 7:43 AM EDT

Last updated is the most recent time when changes to the trial's registration were published.

Locations

Region

Primary Investigator

Affiliation
Boston University

Other Primary Investigator(s)

PI Affiliation
PI Affiliation
Dr.
PI Affiliation
Dr.

Additional Trial Information

Status
On going
Start date
2019-07-23
End date
2022-12-31
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
This study seeks to investigate some of the behavioral mechanisms that play a role in contraceptive decision-making through a field experiment, in which we manipulate the specific architectural conditions under which women are counseled on family planning. The study population is married women of reproductive age who have a need for family planning in Lilongwe, Malawi. Our approach is motivated by evidence suggesting that women’s stated and realized preferences for contraception are likely to be both malleable and highly sensitive to a range of biases. To this end, we explore how key biases are characterized through a woman’s revealed preferences and decisions about a method. We test the following two hypotheses:
1. Women’s stated preferences for and choices of contraception are sensitive to the number of method choices that are presented to them, consistent with prior evidence on choice overload. Specifically, decision-making under the presence of too many choices may either be determined heuristically, in which choices over methods are driven by key method attributes (e.g. effectiveness in preventing pregnancy, incidence of side effects, etc.) or may be avoided altogether (decision deferral).
2. Giving women the choice whether or not to involve their husbands or partners as part of the counseling process is likely to affect 1) women’s decision-making around and choice of a contraceptive method; 2) the extent to which women are able to realize their preferences for family planning.
External Link(s)

Registration Citation

Citation
Karra, Mahesh et al. 2021. "Exploring Behavioral Biases in Contraceptive Decision-Making: Evidence from a Field Experiment in Urban Malawi." AEA RCT Registry. September 06. https://doi.org/10.1257/rct.4194-2.0
Former Citation
Karra, Mahesh et al. 2021. "Exploring Behavioral Biases in Contraceptive Decision-Making: Evidence from a Field Experiment in Urban Malawi." AEA RCT Registry. September 06. https://www.socialscienceregistry.org/trials/4194/history/99154
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Experimental Details

Interventions

Intervention(s)
All participants will receive a counseling session on contraceptive methods and family planning. Following receipt of counseling, women in all treatment arms (including the control arm) will be asked to reveal their preferred choice of method. Following this elicitation, women in all arms of the study will be offered the following package of services:
1. A free taxi ride to our partner family planning clinic in Lilongwe, the Good Health Kauma Clinic, which has been previously identified as a high quality family planning clinic that provides the full range of contraceptive methods.
2. A free consultation with a family planning service provider at the Good Health Kauma Clinic.
3. Free family planning services at the Good Health Kauma Clinic.

These services have already been tested and implemented in the field as part of a recently completed family planning study in Lilongwe (NHSRC Protocol No. 16/7/1628). To increase the salience of the offer, the package of services will be time-limited for one month following the counseling session. By offering the package of three services above, which together aim to reduce the barriers to accessing family planning services at our partner clinic, we will be able to elicit a measure of demand for family planning and will also be able to observe how a woman’s demand (her final choice of method) aligns with her initially stated preferences for family planning immediately following counseling.

A follow-up survey will be conducted one month following a woman’s counseling session. Outcome data that captures a woman’s preferences and decision-making around contraception will be collected at baseline survey, pre-counseling session, post-counseling session, and at every clinic visit. In situations where women do not show up at the clinic, our enumerators will make phone calls or home visits to conduct end-line surveys with the women and ask about their preferences and decision-making around contraception.
Intervention Start Date
2019-09-23
Intervention End Date
2019-11-30

Primary Outcomes

Primary Outcomes (end points)
Our main outcomes of interest (stated preferred method of contraception immediately following counseling, intention to use or not use contraception immediately following counseling) aim to capture women's immediate stated preferences for contraceptive methods. In addition, by observing how women may seek family planning following their counseling visit, we will examine the short-run stability of their stated preferences and the extent to which these stated preferences are subsequently realized in the face of other barriers to use. Data examining the realization of women’s eventual contraceptive preferences (e.g. contraceptive uptake, eventual method choice) will be collected during clinic visits and at follow-up across the three arms.
Primary Outcomes (explanation)
Short-term outcomes: stated preferred method of contraception, intention to use or not use contraception are directly asked at the post-counseling survey.

Long-term outcomes: contraceptive uptake, and eventual method choice are either observed at the clinic if women visit the clinic; otherwise these outcomes will be collected during the follow-up phone surveys or home visits.

Secondary Outcomes

Secondary Outcomes (end points)
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
Participants taking part in this study will receive a survey will ask about their marriage, pregnancy status, fertility preferences, and views on family planning, maternal and child health, and reproductive health. Participants will then receive a second survey after two months at a local clinic, by phone, or at the participant’s home.
Experimental Design Details
As part of the trial, each woman in the study will be randomly assigned to one of three experimental arms or a control arm.
1. A control arm T0, in which women are visited by a trained family planning counselor and are presented with a free counseling session where they will receive the standard of care in family planning counseling in Malawi. The session will consist of methods being presented using a standardized flipchart that has been developed by the Malawi Ministry of Health and Reproductive Health Directorate. The flipchart lists all 15 available contraceptive methods in order of effectiveness in preventing pregnancy (most effective to least effective).
2. A treatment arm T1 in which women will be presented with the choice to invite their husbands to the counseling session. Following the invitation, women and their husbands (should they choose to invite them) will receive the standard of care family planning counseling session described above.
3. A treatment arm T2 that that aims to minimize choice overload and increase the salience of a woman’s most preferred method attribute (e.g. method effectiveness in preventing pregnancy, duration of use, ease of use, likelihood of method-related side effects, etc.). In this arm, a woman will be asked first to compare and rank method-specific attributes (e.g. does she prefer that a method have a lower incidence of side effects over a method that is more effective at preventing pregnancy?). Once a ranking of method attributes has been elicited, the counselor will identify the attribute that the woman reveals to be most important to her and will present a limited set of 5 methods that rank highest along that revealed attribute. Particular emphasis will be placed on making the order of presentation salient, in which women will be reminded and primed to consider the relative ranking of a method across the stated attribute.
4. A treatment arm T3 that provides women both with the choice to invite their husbands (treatment arm 2 above) and presents a counseling session that minimizes choice overload across the woman’s most preferred method attribute (treatment arm 3).

Following receipt of counseling, women in all treatment arms (including the control arm) will be asked to reveal their preferred choice of method. Following this elicitation, women in all arms of the study will be offered the following package of services:
1. A free taxi ride to our partner family planning clinic in Lilongwe, the Good Health Kauma Clinic, which has been previously identified as a high quality family planning clinic that provides the full range of contraceptive methods.
2. A free consultation with a family planning service provider at the Good Health Kauma Clinic.
3. Free family planning services at the Good Health Kauma Clinic.

These services have already been tested and implemented in the field as part of a recently completed family planning study in Lilongwe (NHSRC Protocol No. 16/7/1628). To increase the salience of the offer, the package of services will be time-limited for one month following the counseling session. By offering the package of three services above, which together aim to reduce the barriers to accessing family planning services at our partner clinic, we will be able to elicit a measure of demand for family planning and will also be able to observe how a woman’s demand (her final choice of method) aligns with her initially stated preferences for family planning immediately following counseling.

A follow-up survey will be conducted one month following a woman’s counseling session. Outcome data that captures a woman’s preferences and decision-making around contraception will be collected at baseline survey, pre-counseling session, post-counseling session, and at every clinic visit. In situations where women do not show up at the clinic, our enumerators will make phone calls or home visits to conduct end-line surveys with the women and ask about their preferences and decision-making around contraception.
Randomization Method
Randomization will take place after the baseline interview. We will randomize women to intervention and control arms using prepared codes in Stata such that intervention assignment is balanced according to the following baseline characteristics: neighborhood/household cluster, distance to the nearest family planning clinic, number of living children, months since last live birth, current use of family planning, age of marriage, educational attainment, and household wealth.
Randomization Unit
Units of randomization will be implemented at an individual level.
Was the treatment clustered?
No

Experiment Characteristics

Sample size: planned number of clusters
7-9 areas in Lilongwe, Malawi
Sample size: planned number of observations
The key study population is 700 married women of reproductive age in Lilongwe, Malawi. For the initial part of our study, we will recruit women who: 1. Are married at baseline 2. Age between 18 and 35 at screening 3. Live in the city of Lilongwe (permanent residents) 4. Are currently non-pregnant and did not give birth in the 6 months prior to the initial screening 5. Have neither been sterilized nor have had a hysterectomy 6. Have given birth to at least one child (one live birth) in their lifetime 7. Live with their husbands at the time of the screening. Women who successfully meet these inclusion criteria and who consent to participate in the main part of our study will be recruited. In addition, no two eligible women will be enrolled from the same household. If multiple women from the same household are potentially eligible to be recruited into this part of our study based on the four criteria inclusion above, we shall choose the youngest eligible woman from the household to participate. In addition, we will interview husbands of women who are invited to participate in the counseling intervention.
Sample size (or number of clusters) by treatment arms
100 women in T0 (Control group), 200 in T1, 200 in T2, and 200 in T3. The descriptions of treatment groups T1-T3 can be seen from "Intervention" above.
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Assuming an attrition-adjusted sample of 700 women (400 women in “with husband invitations” arm and 300 women in “without husband invitations” arm) as described above, we will have 75.9 percent power to detect a 20 percent decrease in the modern contraceptive prevalence rate in the intervention arm from 50 percent to 60 percent (𝛼=0.05). Assuming an attrition-adjusted sample of 700 women (400 women in “with husband invitations” arm and 300 women in “without husband invitations” arm) as described above, we will have 85.61 percent power to detect a 10 percentage points increase in the intervention arm from 20 percent to 30 percent (𝛼=0.05, one sided tests).
Supporting Documents and Materials

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IRB

Institutional Review Boards (IRBs)

IRB Name
BU Charles River IRB
IRB Approval Date
2019-05-10
IRB Approval Number
5126E
IRB Name
National Health Sciences Research Committee
IRB Approval Date
2019-05-16
IRB Approval Number
N/A

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
Yes
Intervention Completion Date
February 15, 2020, 12:00 +00:00
Data Collection Complete
Yes
Data Collection Completion Date
February 15, 2020, 12:00 +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
744 women, randomized into 4 groups (T0 = 102, T1 = 213, T2 = 212, T3 = 217)
Was attrition correlated with treatment status?
No
Final Sample Size: Total Number of Observations
744 women, randomized into 4 groups (T0 = 102, T1 = 213, T2 = 212, T3 = 217)
Final Sample Size (or Number of Clusters) by Treatment Arms
744 women, randomized into 4 groups (T0 = 102, T1 = 213, T2 = 212, T3 = 217)
Data Publication

Data Publication

Is public data available?
No

Program Files

Program Files
No
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials