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Behavioral economics approach to reduce injectable contraceptive discontinuation rate


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This was presented by Ali Karim as part of a preformed panel at the International Conference on Family Planning (ICFP) in Kigali, Rwanda in November 2018.
Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 35% in 2016, primarily attributed to the increase in injectable contraceptive method use from 3% in 2000 to 23% in 2016. Nonetheless, discontinuation rate among injectable contraceptive users was 38%.
Given that injectable methods are the preferred method among married women of reproductive age in Ethiopia, the Last Ten Kilometers Project (L10K) of JSI Research & Training Institute, Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral economics (BE) approaches to mitigate discontinuation of injectable contraceptives.
Methods: The project followed a BE methodology to conduct a behavioral diagnosis and design an intervention package, consisting of 1) health worker planner calendar, 2) client care checklist, and 3) client appointment cards.
Conclusion: Discontinuation can be influenced by health systems factors like supply issues. Nonetheless, the use of two BE tools—the appointment card and client care checklist—effectively decreased injectable discontinuation in the presence other health system bottlenecks. BE is an effective approach to enhance family planning programs in Ethiopia and elsewhere.

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Behavioral economics approach to reduce injectable contraceptive discontinuation rate

  2. 2. BACKGROUND 6% 35% 2000 2016 Contraceptive prevalence rate (CPR) increased from 2000 to 2016, mainly due to increase in injectable CPR. 3% 23% 2000 2016 Contraceptive Discontinuation Threatens Women’s Fertility Intentions Public sector is the major source for contraceptives (84%); thus contraceptives discontinuation has high cost to country’s health system. Contraceptive discontinuation rate within 12 months of uptake is 35% and is 38% among injectable users, which may threaten women’s fertility intentions. 38% 35% Injectable users All contraception users
  3. 3. BACKGROUND Behavioral Economics Approach Behavioral Economics (BE) can inform strategies to change health related behaviors and decision-making. JSI’s Last Ten Kilometers Project (L10K) 2020 and ideas42 worked with Ethiopia’s flagship Health Extension Program (HEP) to design and test behavioral approaches to mitigate the problem of discontinuation of injectable contraceptives. FUNDERS: IMPLEMENTERS:
  4. 4. AMHARA OROMIA TIGRAY SNNPR BACKGROUND Study Context 8 primary health care units (PHCUs) in 8 districts 2 2 2 2 2 HEWs at each satellite health post provide basic health including family planning services to 5,000 people supported by the Women’s Development Army network of volunteers Health Center Satellite health posts HEWs Women’s Development Army
  6. 6. METHODOLOGY STAGE I Problem Definition Use Problem Criteria to generate Problem Definition candidates Systematically evaluate the problem definition candidates Generate Final Problem Definition “Women of reproductive age who are using injectable contraceptives (actively or passively) discontinue use within 12 months of uptake” Problem Definition Process • behavioral issues among others • existence of intention- action gap • the problem could be moved by a BE Intervention • experimental design is feasible • desk reviews • L10K staff interviews • preliminary behavioral mapping • conversations with HEP frontline workers and FP clients • observation of service provision
  7. 7. METHODOLOGY The design team generated behavioral hypotheses (bottlenecks) for injectable discontinuation using the following: STAGE II Behavioral Diagnosis Desk review of previous behavioral research Conversations with women and service providers Behavioral economics insights
  8. 8. METHODOLOGY STAGE II Behavioral Diagnosis Behavioral bottlenecks contributing to: PASSIVE DISCONTINUATION 1. Prospective memory failure to follow-through on next injection | Design implication: salient, timely reminders for women 2. Tunneling leads to myopic planning or failures to plan for next injection | Design implication: prompt plan-making and contingency planning for return appointments 3. Hassle factors | Design implication: timely reminders of fertility intentions
  9. 9. METHODOLOGY STAGE II Behavioral Diagnosis Behavioral bottlenecks contributing to: ACTIVE DISCONTINUATION 4. Perception of limited choice set for continued use | Design implications: expand the choice set of methods women consider to be viable options; increase and maximize HEW & WDA touch-points with women PROVIDER BEHAVIOR 5. Bandwidth tax and time management | Design implication: simplify case management systems to reduce cognitive load of HEWs
  10. 10. METHODOLOGY STAGE III Intervention Design Interventions proposed based on behavioral diagnosis1 Feasibility, acceptability, and alignment with HEP policy assessed with L10K 2020 staff 2 Preliminary tools designed3 End user testing and modification of tools4 Final package of interventions5
  11. 11. METHODOLOGY STAGE III Intervention Design Intervention: Package of 3 Tools Appointment Cards Client Care Checklist HEW Planning Calendar Clients HEWs • Strengthening prospective memory • Provide better counseling during uptake and return visits Improved or increased: • Planning and time management • Case management • Retrospective follow-up for clients who missed appointments • Counseling DESIGN TARGETS DESIGN TARGETS
  12. 12. Appointment Card Client Care Checklist HEW Planning Tool METHODOLOGY STAGE III Intervention Design
  13. 13. METHODOLOGY STAGE IV Testing Stratified-pair cluster-randomization (one of the two PHCUs within a region was randomly allocated to intervention; 19 health posts received the intervention and 21 health posts were controls) STUDY DESIGN STUDY IMPLEMENTATION • Two-day training was developed & provided to 74 people (HEWs, L10K staff, health center & woreda health office supervisors) in the intervention area • Control area HEWs were oriented on FP client record keeping • Quarterly supportive supervision visits and six monthly performance review meetings
  14. 14. STUDY PARTICIPANTS Between February 2016 and November 2016, 1) women of reproductive age initiated using injectable contraceptives for the first time; 2) initiated using injectable contraceptives after six months of break; or 3) switched to injectables from another family planning method of contraception METHODOLOGY STAGE IV Testing SAMPLE SIZE Powered at 80% with 95% confidence interval to detect 14%-points reduction in injectable discontinuation rate, assuming design effect 2
  15. 15. METHODOLOGY STAGE IV Testing • IRB clearance was obtained from the 4 Regional Health Bureaus and JSI • Study area health posts were visited in October 2017 to assess intervention fidelity • List of women who visited the study area health posts to obtain injectable contraceptives during the enrolment period were visited in December 2017 and those eligible and consented were interviewed DATA COLLECTION ANALYSIS Intervention effects were adjusted study design, participants’ background, and health post characteristics
  16. 16. RESULTS Intervention Fidelity Appointment cards were available in 17 of the 19 intervention health post for use at least during the first year of the intervention 18 of the 19 health posts were using the client care checklist However, calendar was being used in only 4 of the 19 health posts
  17. 17. RESULTS Intervention Effects 1.43 1.67 1.16 1.67 1.67 1.16 Side-effects recalled* FP methods recalled Actions to take for side- effects reported Control (n=335) Intervention (n=408) *p<.01 Client Care Checklist increased side-effects recall MEAN NUBMER
  18. 18. RESULTS Intervention Effects 12% 74% 77% 81% 51% 50% 16% 61% 60% 78% 49% 40% Missed appointment Given appointment card Told about a local holiday as a reminder for next appointment* Told about other methods Told what to do if had side-effects Told about side-effects Control Intervention *p<.01 Appointment Card and Client Care Checklist increased awareness of holidays as reminder for next appointment
  19. 19. RESULTS Injectable Discontinuation Rate The BE intervention resulted in a lower discontinuation rate for injectable contraceptives 0 1 2 3 4 5 6 7 8 9 10 11 12 MONTH *The difference in discontinuation rate was statistically significant (p>.05) Control Intervention 53% 42%*DiscontinuationRate
  20. 20. CONCLUSIONS There could be bias due to loss to follow-up and unmeasured confounders. BIAS TOOL UPTAKE The planning calendar did not seem to fit within the HEWs’ work flow; while the other two BE tools did. Two of the three BE tools (appointment card and client care checklist) were being consistently used by the HEWs in the intervention area.
  21. 21. CONCLUSIONS Injectable contraceptive discontinuation rate was comparatively lower in the BE intervention area indicating effectiveness of the BE approach. Intervention effects were likely due to the introduction of the suite of tools. EFFECTS LOOKING FORWARD BE is a promising approach to ‘nudge’ supply and demand side behavioral factors to improve family planning programming.