Restrictive Social Attitudes Inhibiting the Adoption of Advanced Health Technologies: Evidence from a Field Study in the Bangladeshi Garment Sector

The intervention consists of two discussion sessions, lasting around 1h each, about the topic of menstruation. Around 10 to 15 female workers from the garment factory will come together at their workplace for these discussion sessions about menstruation. The aim of the sessions is to allow the women to exchange their personal experiences with their menstruation and have a safe space to open up and discuss this topic with other women. The sessions are moderated by two professional trainers. Given the restrictions due to the ongoing pandemic, these sessions will take place in a hybrid virtual and in-person format, with the trainers joining the session virtually via Zoom. Each woman visits 2 sessions about 7 to 10 days apart.

The intervention consists of two discussion sessions for each participant in the treatment group. These discussion sessions take place during working hours at the participants' workplace. To comply with regulations of health and safety during the pandemic, the group sizes of these discussions are limited to allow for sufficient distance between participants. Around 10-15 women will participate in each session. All participants are required to wear masks and windows are to be kept open. The moderators are professional trainers from Change Associates, a women-led non-profit organization committed to actively educating and empowering readymade garment workers. They are leading discussions with the women about their menstruation. The aim of the sessions is to empower the women to speak up about their menstruation, exchange their experiences with other women and reduce the taboos and the shameful feeling often associated with menstruation in their culture. Only women are present at these meetings to ensure they feel comfortable. It is explicitly not part of these sessions to increase the women's knowledge about menstruation or to provide them with new information or educate them, but instead the format seeks to explicitly target the taboos and "shyness" often experienced and expressed by the women in this context. Two discussion sessions are held in order to allow the women to familiarize themselves with the hybrid virtual format.

2021-04-11

2021-05-28

- Willingness to pay for the menstrual underwear (which has to be picked up from a male shopkeeper)
- Pick-up rate of the underwear when it is available for free (and has to be picked up from a male shopkeeper)

- Willingness to pay for the menstrual underwear (which has to be picked up from a male shopkeeper): elicited using a price list, where the women are offered a choice between an amount of money or the underwear, which they can pick up at the factory store, which is run by a man. The amounts of money offered are increasing. The WTP is taken to be the amount of money at which the women switch from preferring the underwear to preferring the money.
- Pick-up rate of the underwear when it is given for free (and has to be picked up from a male shopkeeper): The majority of women is offered the underwear for free and can pick it up at the factory store, which is run by a man. Pick-up is a binary variable measured for each woman equal to 1 if she picked up the underwear and 0 otherwise (after about 3 weeks after treatment). The individual binary variable is aggregated across the women in the treatment and control group to compute the share of women having picked up the underwear.

- Willingness to pay for a pack of pads
- Perceived social norms
- Perceived stigma
- Perceived taboo
- Outcome of a discrete choice experiment indicating the demand for different characteristics of sanitary pads

- Willingness to pay for a pack of pads (which has to be picked up from a male shopkeeper): elicited using a price list, where the women are offered a choice between an amount of money or a pack of pads, which they can pick up at the factory store, which is run by a man. The amounts of money offered are increasing. The WTP is taken to be the amount of money at which the women switch from preferring the pads to preferring the money.
- Perceived social norms: elicited by asking the women a few questions about their second-order beliefs which behavior other women find socially acceptable or not, on a 4-point Likert scale. The average across all questions (a number between 1 and 4) is the measure for perceived strictness of social norms. These questions are asked twice, in the baseline and after treatment in order to determine if the treatment had an effect on perceived social norms.
- Perceived stigma: elicited by asking the women how many of a list of 4 statements describing stigma around menstruation they agree to. The number of statements she agrees to (between 0 and 4) is taken as measure of perceived stigma. This question is asked twice, in the baseline and after treatment in order to determine if the treatment had an effect on perceived stigma.
- Perceived taboo: elicited by asking the women how many of a list of 4 statements describing taboos around menstruation they agree to. The number of statements she agrees to (between 0 and 4) is taken as measure of perceived taboos. This question is asked twice, in the baseline and after treatment in order to determine if the treatment had an effect on perceived taboo.
- Outcome of a discrete choice experiment indicating the demand for different characteristics of sanitary pads: three characteristics of sanitary pads with several dimensions each are included in the discrete choice experiment: location (purchasing it at the factory store/purchasing it at a normal shop), prices, and shopkeeper gender (purchasing it from a male shopkeeper /purchasing it from a female shopkeeper). The women are presented with consecutive choices between two bundles of these dimensions and asked which they would prefer. Their answers are then used to determine the relative valuation of the different characteristics using standard discrete choice experiment estimation procedures.

All participants are interviewed for the baseline survey via phone. The baseline survey measures the level of knowledge about menstruation, the perceived social norms, perceived stigma and taboos, and behavior in terms of menstrual management. After the survey, women are randomized into the treatment and control group, stratifying the randomization based on the menstrual material used at baseline. The treatment group then receives the intervention. Once the treatment group has completed the discussion sessions, the women are all called again for the outcome measurement survey, in which their willingness to pay for the menstrual underwear and for a pack of pads are elicited. In addition, the women are asked again some of the same questions on social norms, stigma and taboos as in the baseline to determine the effect of the treatment. After the outcome survey, the women can pick up a free underwear at the shop at the factory, where a male shop keeper will hand them out.

All participants are interviewed for the baseline survey via the phone. The survey takes around 20min. In this survey, the women's baseline knowledge about menstruation is measured, as well as their baseline behavior (such as which materials they use for menstrual management). The survey also measures their perception of the social norms, the stigma and the taboo surrounding menstruation. After the survey, women are randomized into the treatment and control group, stratifying the randomization based on the material used at baseline. The treatment group then receives the intervention, consisting of two discussion sessions for each participant in the space of 7-10 days. The control group does not receive anything during this time (placebo discussions were unfortunately not feasible due to logistical and COVID-related constraints). Once the treatment group has completed the discussion sessions, the women are all called for the outcome measurement survey, in which their willingness to pay for the menstrual underwear and for a pack of pads are elicited. This measure is incentivized by randomly selecting a few of the women in each group and realizing one of the choices, drawn at random (i.e. either giving them the money or the underwear/pack of pads). In addition, the women are asked questions to assess their perceptions on social norms, stigma and taboos to determine if the treatment affected those and if one was more affected than the other. After the outcome survey, the women are told that they can pick up a free underwear at the shop at the factory, where a male shop keeper will hand them out. For each woman a binary measure is recorded to determine if she picked up the underwear or not. These binary measures are aggregated into a measure of the share of women in the treatment and control group actually picking up the underwear. To do this, the shopkeeper records the worker ID of all the women picking up the underwear (also making sure only the eligible women receive them) and also notes down the day and time when it was picked up. This allows checking whether the women came to pick it up in groups or alone.

Randomization done in office by a computer (using STATA), stratified on baseline material use (use of pads)

individual

No

450 individuals

450 individuals

225 women in each treatment arm

Based on a pilot study run in March 2020, the minimum detectable effect size in WTP for the underwear with 225 women in each treatment arm is 15.61 BDT (or around 0.18$), from a baseline WTP of 137.31 BDT (or 1.62$) with a standard deviation of 58.98. So the minimum detectable effect size is a change in WTP of around 11% or 0.26 standard deviations. The minimum detectable effect size of the WTP for sanitary pads is expected to be very similar in size, though probably on a higher baseline level (since pads are already a well-known product, but the underwear is not). For the proportion of women picking up the underwear, the assumption was made that at baseline around 50-75% will pick up the underwear in the control group (since it is free). Based on this assumption, the minimum detectable effect size will be an increase in this share by 10 to 13 ppt, so going up to 63-85% of women picking it up in the treatment group.

Pre-Analysis Plan