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Beyond Bias: Reducing Provider Bias Towards Adolescents to Increase Contraception Take-Up in Tanzania, Burkina Faso, and Pakistan
Initial registration date
February 10, 2020
February 11, 2020 1:46 PM EST
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Other Primary Investigator(s)
University of California, Los Angeles
Additional Trial Information
Beyond Bias will evaluate the impact of an intervention designed to reduce family planning provider bias towards young, unmarried, and nulliparous women in Tanzania, Burkina Faso, and Pakistan. The intervention has three components: 1) a summit that includes impactful stories told to and by family planning providers that highlight the consequences of provider bias, 2) a forum for continued communication between providers, and 3) a rewards program where clinics in which providers exhibit less biased client interactions or who have improved the most towards this end will be rewarded with social recognition and a ceremony. Half of the eligible clinics in each country (233 in total) are randomly assigned to receive the intervention, while the remaining half serves as control. The objective of the evaluation is to estimate the impact of the intervention on a range of outcomes related to quality of family planning care among young, unmarried, and nulliparous women. We hypothesize that the intervention will improve quality along 3 domains: 1) technical quality (e.g., appropriate counseling and questions asked), 2) patient centeredness (e.g. good treatment of clients), and 3) client outcomes (e.g. client receives appropriate method). We will collect four types of data to evaluate the intervention: 1) provider surveys, 2) mystery clients’ visits, 3) direct observations of client-provider interactions, and 4) qualitative interviews with clients, providers, and implementors.
Moucheraud, Corrina and Zachary Wagner. 2020. "Beyond Bias: Reducing Provider Bias Towards Adolescents to Increase Contraception Take-Up in Tanzania, Burkina Faso, and Pakistan." AEA RCT Registry. February 11.
The intervention has three components: 1) a summit that includes impactful stories told to and by family planning providers that highlight the consequences of provider bias, 2) a forum for continued communication between providers, and 3) a rewards program where clinics in which providers exhibit less biased client interactions or who have improved the most towards this end will be rewarded with social recognition and a ceremony.
Intervention Start Date
Intervention End Date
Primary Outcomes (end points)
We will have different primary outcomes for each domain of interest.
Technical quality outcome(s): Essential questions index and counseling on both short and long acting methods
Patient centered care outcome(s): Patient centered care index
Client outcome(s): Client received modern method and client received long acting method
Primary Outcomes (explanation)
Technical quality: Essential questions index and counseling on both short and long acting methods
For the essential questions index we will aggregate indicators for whether the provider asked about birth spacing preferences, contraceptive method preferences, and if the client had any questions for the provider. This information will be recorded in the exit surveys, provider observations, and mystery client visits. We will use the method outlined by Anderson (2008) to construct the index separately in each data source. counseling on short and long acting methods will be based on the set of short acting methods, which includes condoms and pills and the set of long acting methods, which includes IUDs, injectables, and implants. If the visit included counseling on at least one method from each set, the visit will be coded as a one (and zero otherwise). This information will be collected in exits surveys, mystery client visits, and provider observations. Patient centered care: Patient centered care index
The indexed will based on a scale created and validated by Sudhinaraset et al. (2018). We will use questions 37- 44 in the exit survey instrument and identical questions in the mystery client form to construct the index. Each of these questions has a response option of “No, never”, “Yes, a few times”, “Yes, most of the time”, and “Yes, all of the time”. In accordance with the index, we will set each of these 8 questions to 1 if the respondent/mystery client answered “Yes, all of the time” and to zero for all other response. We will then use the Anderson (2008) method to create the index.
Client outcomes: Client received modern method and client received long acting method These outcomes will be based on two indicators for whether the client received a long acting method or a modern method.
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Among the eligible facilities in each country, half of the facilities will be randomly assigned to receive implementation of the “Beyond Bias” intervention, while the other facilities will serve as a control group—standard adolescent and youth sexual and reproductive health or family planning program interventions—to establish a counterfactual. Provider-level assignment is infeasible due to the nature of the interventions: all providers within a given facility will have the same assignment as the facility.
Experimental Design Details
Randomization done in office using Stata
Was the treatment clustered?
Sample size: planned number of clusters
235 clinics (Tanzania: 75; Burkina Faso: 78; Pakistan: 80)
Sample size: planned number of observations
91,000 exit surveys (Tanzania: 39,000; Burkina Faso: 39,000; Pakistan: 13,000)
692 provider surveys (Tanzania: 300; Burkina Faso: 312; Pakistan: 80)
366 mystery client visits (Tanzania: 150; Burkina Faso: 156; Pakistan: 160)
612 direct observation (Tanzania: 300; Burkina Faso: 312)
210 interviews with clients (70 per country)
90 interviews with providers (30 per country)
65 interviews with clinic administrators (Tanzania: 25; Burkina Faso: 20; Pakistan: 20)
Sample size (or number of clusters) by treatment arms
117 treatment clinics, 116 control clinics (Tanzania: 38 intervention, 37 control; Burkina Faso: 39 intervention, 39 control; Pakistan: 40 intervention, 40 control)
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
INSTITUTIONAL REVIEW BOARDS (IRBs)
RAND Human Subject Protections Committee
IRB Approval Date
IRB Approval Number