Improving Contraceptive Uptake: Improved Access, Cost of Children and Social Anxiety

Last registered on August 20, 2019

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Pre-Trial

Trial Information

General Information

Title

Improving Contraceptive Uptake: Improved Access, Cost of Children and Social Anxiety

RCT ID

AEARCTR-0004324

Initial registration date

August 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

August 20, 2019, 9:37 AM EDT

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

Locations

Country

Pakistan

Region

Punjab

Primary Investigator

Name

Agha Akram

Affiliation

Lahore University of Management Sciences

Contact Primary Investigator

Other Primary Investigator(s)

Additional Trial Information

Status

In development

Start date

2019-07-02

End date

2020-05-31

Keywords

Health

Additional Keywords

family planning, contraceptives, cost of children, social anxiety

JEL code(s)

Secondary IDs

Abstract

Current family planning strategies center on counseling and providing access to modern contraceptive techniques. But it is apparent that existing strategies have had limited impact on Pakistan’s population growth rate, in large part due to the quality of these strategies. Pakistan’s contraceptive prevalence rate is amongst the lowest in the South Asia region, at just 26% (Government of Pakistan 2017). Consequently, innovative new options to increase adoption of contraceptives need to be tested and scaled in Pakistan.

We hypothesize that behavioral biases are holding back demand for contraceptives. First, we hypothesize that because young people in Pakistan are not “trained” to buy condoms i.e. to have the seemingly innocuous interaction with shopkeepers to buy condoms, demand is suppressed. Therefore, on the supply-side, we will make accessing condoms an event that induces less social anxiety using anonymized phone-based door-step delivery of condoms (using low-cost bike-rider delivery services commonly available in Pakistan). Secondly, we hypothesize that parents-to-be or parents who may have more children may not fully rationalize the cost of children i.e. couples do not know what the full cost financial burden of children is. Therefore, on the demand-side, health workers will conduct short counseling sessions that fully account for the financial cost of children for a given household and what cost an additional child will impose on that household.

External Link(s)

Registration Citation

Citation

Akram, Agha. 2019. "Improving Contraceptive Uptake: Improved Access, Cost of Children and Social Anxiety." AEA RCT Registry. August 20. https://doi.org/10.1257/rct.4324-1.0

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Experimental Details

Interventions

Intervention(s)

The key research objective is to answer the following questions:

(1) Does increasing anonymity when procuring condoms increase uptake (by reducing social anxiety/embarrassment related to interacting with shopkeepers to buy condoms)?

(2) Does rationalizing the cost of children increase uptake of condoms?

We will attempt to answer these questions by leveraging a field experiment that we have designed and that local implementers will execute. The experiment has four-arms – a pure control and three treatment arms – that attempt to test the hypotheses above using supply-side and demand-side interventions. Rahnuma Family Planning Association of Pakistan (FPAP) along with a logistics partner, Cheetay, will implement the intervention.

The pure control will receive no intervention. This pure control will be "activated" if we are able to raise funds for an endline survey (our primary outcome measure is coupon uptake - since control households do not receive coupons, there is no way we can measure their contraceptive uptake without an endline survey).

Treatment-1 will receive one counseling session related to family planning and nearby locations where contraceptives can be obtained. Households in this arm will be given coupons to obtain condoms free of cost from a nearby Family Health Clinic operated by our project implementer, Rahnuma Family Planning Association of Pakistan (FPAP). Counselling will be constituted of standard counselling content as currently provided by FPAP.

Treatment-2 couples will receive counseling and coupons, as above, along with an option to use mobile phones to redeem coupons to order contraceptives via text/call on a toll-free number. The cost of each text/call will be borne by the project.

Treatment-3 couples will receive counseling and phone-redeemable coupons, as in Treatment-2. However, the counseling session will be an augmented interaction wherein the field workers will do a cost-of-children exercise with the parents. The cost of children exercise will highlight to parents the direct financial cost of children.

Intervention Start Date

2019-10-01

Intervention End Date

2019-11-30

Primary Outcomes

Primary Outcomes (end points)

Coupon redemption.

Primary Outcomes (explanation)

Couples in our sample will be given coupons to obtain contraceptives free of cost. The variable 'coupon redemption' will be our primary outcome variable and the data will be captured by our project implementers who will deliver contraceptives to household door-step or provide contraceptives at the Family Health Hospital/Clinic depending on the respective treatment.

Secondary Outcomes

Secondary Outcomes (end points)

Secondary Outcomes (explanation)

Experimental Design

We will administer a randomized controlled trial to answer our research questions.

First, we will administer a community survey (which will also serve as a baseline) to identify 1,500-eligible households prior to intervention deployment. Administrative data on coupon use from Cheetay will constitute our primary outcome data, however, if we are able to raise funds, we will also conduct an endline survey to gather detailed information on contraceptive use after project implementation. The experiment is located in one of the catchment areas of FPAP i.e. in Johar Town, Lahore.

Our experiment is constituted of four-arms: a pure control (n = 500) and three-treatments (n = 333 x 3). We will randomize households into one of four experimental arms: a pure control group, C (n = 500) and three treatment arms, i.e. T1, T2 and T3 with 333-households in each, for a total sample size of 1,500-households. This allows us to detect a difference of 5.9 percentage points between the pure control (500) and all treatments (1,000). The pure control will be "activated" if we are able to raise funds for an endline survey. The primary outcome measure - usage of coupons to claim condoms - is an administrative measure (recorded by the coupon claim system our logistics partner will maintain) that will be used to measure impact across the three treatment arms. The sample size of the three treatment arms will allow us to detect a 8.6 percentage point increase in contraceptive use over a base-case usage rate of 15 percent (Government of Pakistan, 2017) i.e. assuming T1 has a 15% uptake, we will be able to detect an 8.6 percentage point difference in uptake in T2 or T3.

The outcome of interest is coupon redemption by couples across the 3-arms of the experiment. We will use Ordinary Least Squares to statistically estimate the difference between contraceptive take-up across arms. We do not expect selection bias due to randomized treatment assignment (we will also stratify on number of children and age, and balance on strata).

A comparison between Treatment-1 & Treatment-2 will inform us about the marginal impact of improved and reliable access to contraceptives on uptake.

A comparison between Treatment-1 and Treatment-3 will inform us about the marginal impact of improved and reliable access to contraceptives and improving the information set of parents on uptake.

Furthermore, a comparison between Treatment-2 & Treatment-3 will inform us about the relative performance of just improving access vs just improving the information set of parents has.

Experimental Design Details

Randomization Method

Randomization done on computer software.

Randomization Unit

Household.

Was the treatment clustered?

Experiment Characteristics

Sample size: planned number of clusters

Sample size: planned number of observations

1,500 households. Of these, 1,000-households will be part of the core experiment and 500-households will be "activated" as a pure control if we are able to raise funds for an endline survey.

Sample size (or number of clusters) by treatment arms

Pure Control: 500-households
Treatment-1 (Impure Control): 333-households
Treatment-2: 333-households
Treatment-3: 333-households

Minimum detectable effect size for main outcomes (accounting for sample design and clustering)

The proposed research plan will randomize households into one of four experimental arms: a pure control group, C (n = 500) and three treatment arms, i.e. T1, T2 and T3 with 333-households in each, for a total sample size of 1,500-households. This allows us to detect a difference of 5.9 percentage points between the pure control (500) and all treatments (1,000). The pure control will be "activated" if we are able to raise funds for an endline survey. The primary outcome measure - usage of coupons to claim condoms - is an administrative measure (recorded by the coupon claim system our logistics partner will maintain) that will be used to measure impact across the three treatment arms. The sample size of the three treatment arms will allow us to detect a 8.6 percentage point increase in contraceptive use over a base-case usage rate of 15 percent (Government of Pakistan, 2017) i.e. assuming T1 has a 15% uptake, we will be able to detect an 8.6 percentage point difference in uptake in T2 or T3.

Supporting Documents and Materials

IRB