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.

1. BEHAVIORAL ECONOMICS APPROACH
TO REDUCE INJECTABLE
CONTRACEPTIVE DISCONTINUATION
RATE IN ETHIOPIA:
A STRATIFIED-PAIR, CLUSTER-RANDOMIZED
FIELD STUDY
International Conference on
FAMILY PLANNING
Kigali, Rwanda
November 15, 2018

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. 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. 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

5. METHODOLOGY
Behavioral
Design
Methodology
FOUR STAGES OF BEHAVIORAL DESIGN METHODOLOGY
Datta and Mullainathan 2014
DEFINE DIAGNOSE DESIGN TEST
DEFINED
PROBLEM
ACTIONABLE
BOTTLENECKS
SCALABLE
INTERVENTION

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. 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. 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. 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. 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. 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. Appointment Card Client Care Checklist
HEW Planning Tool
METHODOLOGY
STAGE III
Intervention
Design

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. 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. 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. 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. 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. 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. 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. 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. 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.