Behavioral Economics and Reproductive Health Decision-making

By Manisha Shah, Public Policy Professor and GPA FCL of Global Health and Social Services, with Abigail Sellman & Temina Madon

Figure 1: Girls participate in ELA club activities, Tanzania

Behavioral economics (BE) is a complex field with few simple answers. But despite the complexity of its theory, the lessons of BE are applicable across many contexts. From business to marketing to public health, BE can be used as a tool to reveal new insights into human decision making, adding to the existing richness of economic theory. This approach may be particularly valuable when addressing problems in international development.

Academics and practitioners alike often attempt to solve development problems by expanding access to information or basic social services. However, gaining access to services may not improve a person’s economic or social welfare—particularly if complex planning or decision-making is required. For example, Kenyan farmers often know that fertilizer can increase crop yields, yet they procrastinate, postponing fertilizer purchases until later in the season (when they are less likely to have cash on hand) [1]. A simple, time-limited discount on fertilizer prompted many more farmers to purchase the product at harvest time, when cash is available. This should be a familiar story for all of us: our actions are often misaligned with our intentions. But for people living in poverty, decision-making is even more complex, occurring under conditions of uncertainty, scarcity, and social pressure. This can further bias the choices we make. Viewing poverty through the lens of BE can help practitioners diagnose problems and design better solutions [2].

BE is, in fact, gaining traction in international development. Commitment devices have helped farmers in Malawi save more money during the harvest season, decreasing the financial stress they face the rest of the year [3]. Reminders, in the form of stickers placed on public faucets, have helped communities in Colombia conserve water [4]. The World Bank even dedicated its annual World Development Report in 2015 to “Mind, Society, and Behavior” [5].

Despite its growing popularity, there has been little research on the application of BE to critical challenges in family planning and reproductive health (FP/RH). The Behavioral Economics in Reproductive Health Initiative (BERI), a research initiative housed at the Center for Effective Global Action, is applying BE to a number of “grand challenges” in FP/RH that contribute to poor outcomes for women in developing countries [6]. These include:

• Community norms and social influences that impact individuals’ RH decisions. For instance, parental pressure may cause a young girl drop out of school and marry early [7].
• Adolescents’ decisions, and their unique time, risk, and social preferences. For example, adolescents are more likely than adults to engage in risky behaviors, and researchers have found that peer influence can increase risk-taking behaviors [8].
• Male involvement in FP, which is manifest in the complexities of intra-household bargaining. In one study conducted in Zambia, women who were given access to contraceptives when their husbands were present proved 25% less likely to use concealable contraceptives, 19% less likely to seek FP services, and 27% more likely to give birth, compared to women who were offered these services privately [9].
• Contraceptive discontinuation, unmet need, and unintended pregnancies, which can be caused by a variety of behavioral constraints including procrastination and incorrect beliefs about the probability of pregnancy or about the side-effects of contraception. In the absence of evidence, the specific drivers of discontinuation still remain unclear [6].

In 2015, BERI released a framework describing a set of 4 decision-making factors that can disconnect our FP intentions from our behaviors and actions. These include prioritizing today versus tomorrow (e.g. present bias), focusing on others versus self (e.g. social pressures), embracing beliefs over reality (e.g. gambler’s fallacy), and thinking fast versus slow (e.g. automatic thinking). Tools that address these behavioral biases – like commitment devices that help us stick to our goals, or heuristics that simplify difficult decisions – can actually improve reproductive health outcomes [6]. The BERI framework[1] is intended to inspire researchers to think about questions in FP/RH that can be addressed through behavioral economics. It is also a tool to help practitioners to design health services that accommodate the predictable biases in human decision-making.

With a grant from BERI,[2] we are implementing a randomized controlled trial in BRAC’s Empowerment and Livelihood for Adolescent’s clubs (ELA) in Tanzania. These clubs aim to empower girls through mentorship and life skills trainings, and attempt to help them avoid adverse RH outcomes such as early marriage or HIV infection. Adolescents face unique behavioral barriers that influence their RH decision-making. They are more likely than adults to highly discount the future in favor of present returns, and they are known to engage in risky behaviors due to influences such as sensation-seeking [10]. Girls in ELA clubs who have experienced things like unintended pregnancy and STI infection often recognize, after the fact, that behavioral factors influenced their decisions. They say things like: “I knew this could happen, but I was blinded by love…” or “I thought this would never happen to me…” [11].

Figure 2: ELA club building, Tanzania

To help girls act on their intentions, we provide an opportunity for incentivized goal setting. In the club setting, we allow girls to pre-specify their RH goals, and if they meet these goals at the 6 and 12 month marks, they will be given a small cash grant.  However, it is important to acknowledge that girls are not alone in RH decision-making, and that boys are also important players. In discussions with ELA club members, it is clear that boys control much of the power in negotiations over contraceptive use. Therefore, our study also includes a focus on boys. We will select boys from the social networks of girls who participate in ELA clubs. These boys will be provided with sexual and reproductive health (SRH) education through soccer clubs. By adding male peers to the intervention, we will be able to test whether improving boys’ knowledge of SRH results in larger improvements in girls’ outcomes.

Our research is still at an early stage, but it is a step toward generating evidence about adolescent decision-making using approaches from behavioral economics. We hope that collectively we can demonstrate the utility of BE in this field, and find new solutions that empower health policy-makers and practitioners to help women achieve their desired reproductive outcomes.

References:

_{[1] Duflo, Kremer, and Robinson. (2011). Nudging Farmers to Use Fertlizer: Theory and Experimental Evidence from Kenya. American Economic Review. 101: 2350-2395.}

_{[2] Datta and Mullainathan. (2012). Behavioral Design: A New Approach to Development Policy. Center for Global Development. Policy Paper 016.}

_{[3] Brune, Giné, Goldberg and Yang. (2011). Commitments to save: a field experiment in rural Malawi. The World Bank. Policy Research Working Paper Series 5748.} 

_{[4] Guillot. (2014). Achieving Long Term City Wide Cooperation in Water Consumption Reduction: The Story of Bogota’s 1997 Water Supply Crisis. World Bank.}

_{[5] World Bank. (2015). World Development Report: Mind, Society, and Behavior. World Bank.}

_{[6] Ashton, Giridhar, Holcombe, Madon and Turner. (2015). A Review of Behavioral Economics in Reproductive Health. The Center for Effective Global Action:  Behavioral Economics in Reproductive Health Initiative.} 

_{[7] Pathfinder International. (2006). Report on the Causes and Consequences of Early Marriage in Amhara Region. Pathfinder International.}

_{[8] Gardner and Steinberg. (2005). Peer Influence on risk taking, risk preference, and risky decision making in adolescence and adulthood: an experimental study. Developmental Psychology. 41(4), 625.}

_{[9] Ashraf, Field, and Lee. (2014). Household Bargaining and Excess Fertility: An Experimental Study in Zambia. American Economic Review. 104(7):2210-37.}

_{[10] Gruber. (2001).  Risky Behavior Among Youths: An Economic Analysis. National Bureau of Economic Research.}

_{[11] These quotes are taken from un-published, in-depth qualitative interviews conducted by BRAC in Uganda. The interview questions aim to understand the causes of teenage pregnancy.}

_{[1] Please click here to reference BERI’s conceptual framework and an evidence based toolkit.}

_{[2] The Behavioral Economics in Reproductive Health Initiative (BERI) is generously supported through funding from the William and Flora Hewlett Foundation.}