Exploring User-Centered Counseling in Contraceptive Decision-Making
- 1. Exploring User-Centered Counseling in Contraceptive Decision-Making: Evidence from a Field Experiment in Urban Malawi Mahesh Karra 1 Kexin Zhang 2 1 Frederick S. Pardee School of Global Studies, Boston University 2Department of Economics, Boston University IFPRI Brown Bag Seminar Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 1 / 22
- 2. Motivation Family planning service provision is a bidirectional process: 1 Clients have a set of preferences (fertility/spacing/method...) 2 Providers guide clients to realize preferences and achieve outcomes (fertility-related, method-related, others) Contraceptive prevalence has been increasing globally From 46.1% in 2010 to 59.2% in 2016 in Malawi (MDHS 2010, 2015-16) In spite of increases in CPR, are women using the “best methods” that reflect their preferences? 37% of Malawian women discontinued within 12 months (49.1% due to unmet need) Frictions may exist in women’s realization of their ideal method Reasons Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 2 / 22
- 3. Motivation Emphasis on FP programs to provide “full, free, and informed choice” over FP methods Significant resources placed on providing complete information Approach emphasizes the role of counseling at the initial consultation Current FP counseling practice in Malawi: Group counseling then individual counseling Group Counseling Counselors introduce all FP methods following ‘Kulera’ flipchart as specified by MOH FP Flipchart Aim of this approach: to achieve “informed choice” - clients informed about all possible methods Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 3 / 22
- 4. Motivation But how well does such a counseling approach do in helping women make informed decisions? Informed decisions: women can update beliefs and preferences and can act on these updated preferences To what end are the current approaches “user-centered”? User-Centered Approaches: client is focal point of interaction and key decision-maker Preferences are elicited, and outcomes reflect updated and elicited preferences Recent examples: BCS, Human-Centered Design, “My Birth Control” Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 4 / 22
- 5. This Study We conduct a field experiment that: Tests elements of user-centered counseling aimed to help women identify and realize their preferences for FP methods Examines role of user-centered counseling on concordance between stated and revealed preferences Investigates two channels through which user-centered counseling may impact concordance: male involvement in counseling and short tailored counseling Experimental Setting Location: Lilongwe, Malawi Study Sample: 782 married women aged 18-35 Related Literature Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 5 / 22
- 6. Hypotheses Short tailored counseling would allow women to more effectively express and realize their contraceptive preferences. Male involvement may allow women to more effectively express their contraceptive preferences and, in turn, translate their preferences into behavior Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 6 / 22
- 7. Preview of Results, Short Counseling Women who received the short targeted counseling procedure were: slightly more likely to change their stated ideal method over time less likely to be using their stated ideal method at follow-up more unsatisfied with their currently used method at follow-up Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 7 / 22
- 8. Preview of Results, Male Involvement Women who were encouraged to invite their husbands/partners to counseling were: less likely to change their ideal method from counseling to follow-up more likely to switch from their currently used method to another method from counseling to follow-up (marginally significant) more likely to be using their stated ideal method at follow-up no more likely to be satisfied with their current method at follow-up Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 8 / 22
- 9. Experiment Design Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 9 / 22
- 10. Baseline and Randomization Baseline Survey: Screening, recruitment and baseline survey of 782 women at their homes Comprehensive survey to elicit information on: Contraceptive and fertility behavior Contraceptive and fertility preferences Method attribute preferences and ranking Method attributes: duration, effectiveness, side effect prevalence, and others Randomization: Following baseline survey, women randomized into 4 groups Balanced randomization on a range of baseline characteristics Eligibility Criteria Balance Tables Summary Statistics Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 10 / 22
- 11. Two Interventions No Husband Invitation Husband Invitation Standard (long) Counseling T0: 108 T1: 223 Short Tailored Counseling T2: 224 T3: 227 Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 11 / 22
- 12. Two Interventions Husband Invitation: Allows woman choose whether to invite husband to FP counseling session Differs from existing studies on male involvement Offers woman the choice to invite husband rather than requiring husband to attend counseling Short Tailored Counseling: Elicits preferred method attribute(s) and rank of attributes Ranking elicited most preferred attribute if more than one was chosen Survey Question - Eliciting Top Attribute Eliciting Top Attribute Counsel women on subset (up to 5) methods aligned with most preferred attribute Method Attribute Mapping Attribute-Specific Flipcharts Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 12 / 22
- 13. Post Counseling Services Following counseling, all women receive a bundle of free FP services for one month Three Components: 1 Free private transportation to the PSI Good Health Kauma Clinic in Lilongwe 2 Coverage of all FP-related costs incurred during the service period 3 Free mobile credit to make appointments with field manager / taxi driver ID Cards Private Taxi Good Health Kauma Clinic Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 13 / 22
- 14. Follow-Up One month follow-up: 1 At Kauma Clinic when women came for services 2 By phone if women did not come to the Kauma clinic 3 At woman’s home if she did not answer the phone Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 14 / 22
- 15. Empirical Framework Yi = α +βS ·Shorti +Xiγ +εi (1) Yi = α +βH ·Husbi +Xiγ +εi (2) where: Yi : Outcome variable of interest - ∆stated ideal method, ∆used method, uptake of ideal method, and concordance of current use and the ideal method Shorti : Short tailored counseling Husbi : Husband invitation to counseling Xi : Vector of baseline control variables including: women’s age, contraceptive use, chosen method attribute, total number of children, working status, ethnicity (Chewa or others) Analyses include area fixed effects and heteroskedastic-robust standard errors Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 15 / 22
- 16. Changes in Ideal, Current Methods Over Time Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 16 / 22
- 17. Results - Short Tailored Counseling Women who received short tailored counseling were: Slightly (but not significantly more likely) to change their stated ideal method from counseling to follow-up by 7.8 percent Short Ideal Method Change Less likely to be using their stated ideal method at follow-up by 16.8 percent Short Counseling Uptake Were more unsatisfied with their currently used method at follow-up by 12.1 percent Highlights relative inability to act on change in preferences in spite of increased access to services Short Counseling Switching Intention Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 17 / 22
- 18. Results - Husband Invitation Women in the husband invitation group were: Less likely to change their ideal method from counseling to follow-up by 15 percent Husband Ideal Method Change Marginally more likely to switch from their currently used method to another method from counseling to follow-up by 25.4 percent Husband Current Method Change More likely to be using their stated ideal method at follow-up by 17.0 percent, but were no more likely to be satisfied with their current method at follow-up Husband Uptake of Stated Ideal Method Husband Switching Intention Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 18 / 22
- 19. Discussion Both interventions speak to user-centered approach to counseling Both seek to prioritize women’s preferences and move closer towards goal of “informed choice” But neither approach likely gives a strictly preferred outcome In particular, short tailored counseling: Encouraged women to (slightly more) freely express and change preferences over time But preferences were not more likely to be realized Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 19 / 22
- 20. Discussion On the other hand, encouraging women to invite husbands: Translated to higher likelihood of realizing stated preferences Potentially “crowded out” woman’s expression of her own preferences A woman’s stated preferences, conditional on inviting her husband, would internalize husband’s preferences Potentially implies that woman changed her mind because of her husband’s presence Was this change of preference wanted? If not, leads to a deviation of stated ideal method from personal preferred method Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 20 / 22
- 21. Conclusions / Next Steps Need to further explore the trade-off women face between: 1 Making independent choices to reflect their individual preferences (but potentially less able to act on them), and 2 Incorporating partner’s preferences to make “jointly / socially better-off,” but not necessarily “individually better off” decisions Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 21 / 22
- 22. Exploring User-Centered Counseling in Contraceptive Decision-Making: Evidence from a Field Experiment in Urban Malawi Mahesh Karra 1 Kexin Zhang 2 1 Frederick S. Pardee School of Global Studies, Boston University 2Department of Economics, Boston University IFPRI Brown Bag Seminar
- 23. Reasons for Discontinuation - Malawi DHS 2015-16 Go Back Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 1 / 25
- 24. Related Literature Family Planning Counseling Ali, Cleland, and Shah (2012), Kim, Kole, and Mucheke (1998), Simmons, Baqee, Koenig, and Phillips (1988), Sultan, Cleland, Ali (2002), Douthwaite and Ward (2005), Barber (2007), Ceylan, Ertem, Saka, and Akdeniz (2009), Lee, Parisi, Akers, Borrerro, and Schwarz (2011), Weaver, Frankenberg, Fried, Thomas,Wheeler, and Paul (2013) ⇒ Conducts a randomized controlled trial to understand factors that affect concordance of women’s preferences and choices Cognitive overload, attribute salience, the Paradox of Choice Hensher (2006), Hogarth and Einhorn (1992), Deck and Jahedi (2015), Bordalo, Gennaioli, and Shleifer (2012), Thaler, Sunstein, and Balz (2010), Delavande (2008) ⇒ Provides evidence on the role of attribute salience in choice-making in the family planning realm
- 25. Related Literature Male Involvement in Family Planning Counseling El- Khoury et al. (2016), Wang et al. (1998), Terefe and Larson (1993), Shattuck et al. (2011), Ashraf et al. (2014), and McCarthy (2015) ⇒ Leaves it up to the woman whether to invite husband to the counseling session rather than coerce couples to receive the counseling Choice range and switching intention Curtis and Blanc (1997), Steele and Chloe (1997), Ali, Cleland, and Shah (2012) ⇒ Investigates two channels through which information provision affects concordance between stated and revealed preferences, i.e., male involvement and tailored counseling Go Back
- 26. Counseling Practice in Malawi Go Back
- 27. The Recommended FP Counseling Practice MOH, RHD Counselors introduce all 13 methods following the order in the flip chart Male/Female Sterilization IUD Implants Injectables Pills/ECP Male/Female Condoms Standard Days Method Two-Day Method Rhythm Method LAM Go Back
- 28. Survey: Eliciting Top Method Attribute In choosing a contraceptive method, what feature(s) would be most important to you? CHOOSE ALL THAT APPLY. Go Back Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 6 / 25
- 29. Eligibility Criteria for Recruitment We recruited 782 women who, at the time of the baseline: 1 were married 2 were between the ages of 18 and 35 3 lived in the city of Lilongwe (permanent residents) 4 were currently not pregnant and did not give birth in the 6 months prior to the initial screening 5 had neither been sterilized nor have had a hysterectomy 6 had given birth to at least one child in their lifetime 7 lived with their husbands at the time of the screening Go Back
- 30. Eliciting Top Attribute Eliciting women’s most valued attribute about contraceptive methods 20 Counters to be allocated across at most 3 attributes Go Back
- 31. Short Counseling - Attribute-Method Assignment Go Back
- 32. Summary Statistics Note: Currently working refers to women’s working status at baseline. Top attribute refers to whether the top method attribute is effectiveness or not. Weight to top attribute refers to the number of beans (out of 20 beans) the woman assigned to their top method attribute. Intention to switch is woman’s answer to the question, “if you had the choice to switch to another method, would you like to switch?” Husband approval refers to the question, “on a scale of 1 to 5, with 1 being strongly supportive and 5 being strongly opposed, how do you believe your husband feels towards using family planning methods?” Go Back Karra and Zhang Malawi Behavioral Biases Study IFPRI Brown Bag Seminar 10 / 25
- 33. Balance Table: Short Counseling
- 34. Balance Table: Husband Invitation Go Back
- 35. Short Counseling -Ten Flip charts All flipcharts corresponding to all “top attributes” Go Back
- 36. ID Cards Figure 1: Women’s ID cards for picking up services Go Back
- 38. The Good Health Kauma Clinic
- 39. The Good Health Kauma Clinic
- 40. The Good Health Kauma Clinic Go Back
- 41. Short Counseling - Ideal Method Change Go Back
- 42. Short Counseling - Uptake of Stated Ideal Method Go Back
- 43. Short Counseling - Switching Intention Go Back
- 44. Husband Invitation - Ideal Method Change Go Back
- 45. Husband Invitation - Current Method Change Go Back
- 46. Husband Invitation - Uptake of Stated Ideal Method Go Back
- 47. Husband Invitation - Switching Intention Go Back