Margaret McConnell

Getting to the Top of Mind: How Reminders Increase Saving

We develop and test a simple model of limited attention in intertemporal choice. The model posits that individuals fully attend to consumption in all periods but fail to attend to some future lumpy expenditure opportunities. This asymmetry generates some predictions that overlap with other models of present-bias. Our model also generates the unique predictions that reminders will increase saving, and that a reminder that makes a specific expenditure more salient will be especially effective. We find support for these predictions in three field experiments that randomly assign reminders to new savings account holders.

Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts

Importance Suicide is the second leading cause of death among adolescents between the ages of 15 and 24 years. Adolescents who are sexual minorities experience elevated rates of suicide attempts. Objective To evaluate the association between state same-sex marriage policies and adolescent suicide attempts. Design, Setting, and Participants This study used state-level Youth Risk Behavior Surveillance System (YRBSS) data from January 1, 1999, to December 31, 2015, which are weighted to be representative of each state that has participation in the survey greater than 60%. A difference-in-differences analysis compared changes in suicide attempts among all public high school students before and after implementation of state policies in 32 states permitting same-sex marriage with year-to-year changes in suicide attempts among high school students in 15 states without policies permitting same-sex marriage. Linear regression was used to control for state, age, sex, race/ethnicity, and year, with Taylor series linearized standard errors clustered by state and classroom. In a secondary analysis among students who are sexual minorities, we included an interaction between sexual minority identity and living in a state that had implemented same-sex marriage policies. Interventions Implementation of state policies permitting same-sex marriage during the full period of YRBSS data collection. Main Outcomes and Measures Self-report of 1 or more suicide attempts within the past 12 months. Results Among the 762 678 students (mean [SD] age, 16.0 [1.2] years; 366 063 males and 396 615 females) who participated in the YRBSS between 1999 and 2015, a weighted 8.6% of all high school students and 28.5% of students who identified as sexual minorities reported suicide attempts before implementation of same-sex marriage policies. Same-sex marriage policies were associated with a 0.6–percentage point (95% CI, –1.2 to –0.01 percentage points) reduction in suicide attempts, representing a 7% relative reduction in the proportion of high school students attempting suicide owing to same-sex marriage implementation. The association was concentrated among students who were sexual minorities. Conclusions and Relevance State same-sex marriage policies were associated with a reduction in the proportion of high school students reporting suicide attempts, providing empirical evidence for an association between same-sex marriage policies and mental health outcomes.

Rethinking HIV prevention to prepare for oral PrEP implementation for young African women

HIV incidence remains high among young women in sub‐Saharan Africa in spite of scale‐up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence‐based HIV prevention strategies, particularly emerging interventions such as pre‐exposure prophylaxis (PrEP).

Heeding the Call: The Effect of Targeted Two-Round Phone Banks on Voter Turnout

Field experiments in voter mobilization have indicated that personal contact is most effective, but that multiple contacts have no apparent additional impact on voter turnout. Yet, a number of theories from social psychology—cognitive dissonance theory, the theory of reasoned action, and the theory of the self-erasing nature of errors of prediction—would lead us to expect that a targeted follow-up contact, one that cues social norms, should have a greater impact on turnout. We test these theories using four phone-banking field experiments that utilized follow-up calls to committed voters. Contrary to previous studies, we find that this kind of targeted follow up greatly increases the effectiveness of phone-bank campaigns, in some cases almost tripling their effect on voter turnout.

Testing for heterogeneous treatment effects in experimental data: false discovery risks and correction procedures

We review the statistical models applied to test for heterogeneous treatment effects in the recent empirical literature, with a particular focus on data from randomised field experiments. We show that testing for heterogeneous treatment effects is highly common, and likely to result in a large number of false discoveries when conventional decision rules are applied. We demonstrate that applying correction procedures developed in the statistics literature can fully address this issue, and discuss the implications of multiple testing adjustments for power calculations and experimental design.

To Charge or Not to Charge: Evidence from a Health Products Experiment in Uganda

In a field experiment in Uganda, we find that demand after a free distribution of three health products is lower than after a sale distribution. This contrasts with work on insecticide-treated bed nets, highlighting the importance of product characteristics in determining pricing policy. We put forward a model to illustrate the potential tension between two important factors, learning and anchoring, and then test this model with three products selected specifically for their variation in the scope for learning. We find the rank order of shifts in demand matches with the theoretical prediction, although the differences are not statistically significant.

Direct provision versus facility collection of HIV self-tests among female sex workers in Uganda: A cluster-randomized controlled health systems trial

Background HIV self-testing allows HIV testing at any place and time and without health workers. HIV self-testing may thus be particularly useful for female sex workers (FSWs), who should test frequently but face stigma and financial and time barriers when accessing healthcare facilities. Methods and findings We conducted a cluster-randomized controlled health systems trial among FSWs in Kampala, Uganda, to measure the effect of 2 HIV self-testing delivery models on HIV testing and linkage to care outcomes. FSW peer educator groups (1 peer educator and 8 participants) were randomized to either (1) direct provision of HIV self-tests, (2) provision of coupons for free collection of HIV self-tests in a healthcare facility, or (3) standard of care HIV testing. We randomized 960 participants in 120 peer educator groups from October 18, 2016, to November 16, 2016. Participants’ median age was 28 years (IQR 24–32). Our prespecified primary outcomes were self-report of any HIV testing at 1 month and at 4 months; our prespecified secondary outcomes were self-report of HIV self-test use, seeking HIV-related medical care and ART initiation. In addition, we analyzed 2 secondary outcomes that were not prespecified: self-report of repeat HIV testing—to understand the intervention effects on frequent testing—and self-reported facility-based testing—to quantify substitution effects. Participants in the direct provision arm were significantly more likely to have tested for HIV than those in the standard of care arm, both at 1 month (risk ratio [RR] 1.33, 95% CI 1.17–1.51, p < 0.001) and at 4 months (RR 1.14, 95% CI 1.07–1.22, p < 0.001). Participants in the direct provision arm were also significantly more likely to have tested for HIV than those in the facility collection arm, both at 1 month (RR 1.18, 95% CI 1.07–1.31, p = 0.001) and at 4 months (RR 1.03, 95% CI 1.01–1.05, p = 0.02). At 1 month, fewer participants in the intervention arms had sought medical care for HIV than in the standard of care arm, but these differences were not significant and were reduced in magnitude at 4 months. There were no statistically significant differences in ART initiation across study arms. At 4 months, participants in the direct provision arm were significantly more likely to have tested twice for HIV than those in the standard of care arm (RR 1.51, 95% CI 1.29–1.77, p < 0.001) and those in the facility collection arm (RR 1.22, 95% CI 1.08–1.37, p = 0.001). Participants in the HIV self-testing arms almost completely replaced facility-based testing with self-testing. Two adverse events related to HIV self-testing were reported: interpersonal violence and mental distress. Study limitations included self-reported outcomes and limited generalizability beyond FSWs in similar settings. Conclusions In this study, HIV self-testing appeared to be safe and increased recent and repeat HIV testing among FSWs. We found that direct provision of HIV self-tests was significantly more effective in increasing HIV testing among FSWs than passively offering HIV self-tests for collection in healthcare facilities. HIV self-testing could play an important role in supporting HIV interventions that require frequent HIV testing, such as HIV treatment as prevention, behavior change for transmission reduction, and pre-exposure prophylaxis. Trial registration ClinicalTrials.gov NCT02846402

Do active patients seek higher quality prenatal care?: A panel data analysis from Nairobi, Kenya.

Despite poverty and limited access to health care, evidence is growing that patients in low-income countries are taking a more active role in their selection of health care providers. Urban areas such as Nairobi, Kenya offer a rich context for studying these “active” patients because of the large number of heterogeneous providers available. We use a unique panel dataset from 2015 in which 402 pregnant women from peri-urban (the “slums” of) Nairobi, Kenya were interviewed three times over the course of their pregnancy and delivery, allowing us to follow womens care decisions and their perceptions of the quality of care they received. We define active antenatal care (ANC) patients as those women who switch ANC providers and explore the prevalence, characteristics and care-seeking behavior of these patients. We analyze whether active ANC patients appear to be seeking out higher quality facilities and whether they are more satisfied with their care. Women in our sample visit over 150 different public and private ANC facilities. Active patients are more educated and more likely to have high risk pregnancies, but have otherwise similar characteristics to non-active patients. We find that active patients are increasingly likely to pay for private care (despite public care being free) and to receive a higher quality of care over the course of their pregnancy. We find that active patients appear more satisfied with their care over the course of pregnancy, as they are increasingly likely to choose to deliver at the facility providing their ANC.

Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya.

BackgroundSince the 2009 WHO and UNICEF recommendation that women receive home-based postnatal care within the first three days after birth, a growing number of low-income countries have explored integrating postnatal home visit interventions into their maternal and newborn health strategies. This randomized trial evaluates a pilot program in which community health workers (CHWs) visit or call new mothers three days after delivery in peri-urban Kiambu County, Kenya.MethodsParticipants were individually randomized to one of three groups: 1) early postnatal care three days after delivery provided in-person with a CHW using a simple checklist, 2) care provided by phone with a CHW using the same checklist, or 3) a standard of care group. Surveys were conducted ten days and nine weeks postnatal to measure outcomes related to compliance with referrals, self-reported health problems for mother and baby, care-seeking behaviors, and postnatal knowledge and practices around the recognition of danger signs, feeding, nutrition, infant care and family planning.ResultsThe home visit administration of the checklist increased the likelihood that women recognized postnatal problems for themselves and their babies and increased the likelihood that they sought care to address those problems identified for the child. In both the home visit and mobile phone implementation of the checklist, actions taken for postnatal problems happened earlier, particularly for infants. Knowledge was found to be high across all groups, with limited evidence that the checklist impacted knowledge and postnatal practices around the recognition of danger signs, feeding, nutrition, infant care and family planning.ConclusionWe find evidence that CHW-administered postnatal checklists can lead to better recognition of postnatal problems and more timely care-seeking. Furthermore, our results suggest that CHWs can affordably deliver many of the benefits of postnatal checklists.Trial registrationClinicalTrials.gov NCT02104635; registered April 2, 2014.

The impact of household and community cash transfers on children's food consumption in Indonesia

The current state of child nutrition is critical. About 5.9 million children under the age of five still died worldwide with nearly half are attributable to undernutrition. One explanation is inequality in childrens food consumption. One strategy to address inequality among the poor is conditional cash transfers (CCTs). Taking advantage of the two large clustered-randomized trials in Indonesia from 2007 to 2009, this paper provides evidence on the impact of household cash transfer (PKH) and community cash transfer (Generasi) on childs food consumption. The sample sizes are 14,000 households for PKH and 12,000 households for Generasi. After two years of implementation, difference-in-differences (DID) analyses show that both cash transfers lead to significant increases in food consumption particularly for protein-rich items. The programs significantly increase the consumption of milk and fish by up to 19% and 14% for PKH and Generasi, respectively. Both programs significantly reduce some measures of severe malnutrition. PKH significantly reduces the probability of wasting and severe wasting by 33% and 41% and Generasi significantly reduces the probability of being severely underweight by 47%. This underscores the potential of household and community cash transfers to fight undernutrition among the poor.