Rebecca Thornton

Early female marriage in the developing world

Many women in the developing world are subject to marriage at an early age. Most such women have little choice in the age at which they marry, or whom they marry. In this article, we examine patterns and trends of early marriage in the developing world. The incidence varies widely, from a high of 70 per cent in south Asia to a low of 30 per cent in South East Asia. Women who marry young tend to have less education and begin childrearing earlier, and have less decision-making power in the household. They are also more likely to experience domestic violence.

Incentives to Learn

We study a randomized evaluation of a merit scholarship program in which Kenyan girls who scored well on academic exams had school fees paid and received a grant. Girls showed substantial exam score gains, and teacher attendance improved in program schools. There were positive externalities for girls with low pretest scores, who were unlikely to win a scholarship. We see no evidence for weakened intrinsic motivation. There were heterogeneous program effects. In one of the two districts, there were large exam gains and positive spillovers to boys. In the other, attrition complicates estimation, but we cannot reject the hypothesis of no program effect.

Increasing the acceptability of HIV counseling and testing with three C's: Convenience, confidentiality and credibility

Agencies engaged in humanitarian efforts to prevent the further spread of HIV have emphasized the importance of voluntary counseling and testing (VCT), and most high-prevalence countries now have facilities that offer testing free of charge. The utilization of these services is disappointingly low, however, despite high numbers reporting that they would like to be tested. Explanations of this discrepancy typically rely on responses to hypothetical questions posed in terms of psychological or social barriers; often, the explanation is that people fear learning that they are infected with a disease that they understand to be fatal and stigmatizing. Yet when we offered door-to-door rapid blood testing for HIV as part of a longitudinal study in rural Malawi, the overwhelming majority agreed to be tested and to receive their results immediately. Thus, in this paper, we ask: why are more people not getting tested? Using an explanatory research design, we find that rural Malawians are responsive to door-to-door HIV testing for the following reasons: it is convenient, confidential, and the rapid blood test is credible. Our study suggests that attention to these factors in VCT strategies may mitigate the fear of HIV testing, and ultimately increase uptake in rural African settings.

Social Security Health Insurance for the Informal Sector in Nicaragua: A Randomized Evaluation

This article presents the results from an experimental evaluation of a voluntary health insurance program for informal sector workers in Nicaragua. Costs of the premiums as well as enrollment location were randomly allocated. Overall, take-up of the program was low, with only 20% enrollment. Program costs and streamlined bureaucratic procedures were important determinants of enrollment. Participation of local microfinance institutions had a slight negative effect on enrollment. One year later, those who received insurance substituted toward services at covered facilities and total out-of-pocket expenditures fell. However, total expenditures fell by less than the insurance premiums. We find no evidence of an increase in health-care utilization among the newly insured. We also find very low retention rates after the expiration of the subsidy, with less than 10% of enrollees still enrolled after one year. To shed light on the findings from the experimental results, we present qualitative evidence of institutional and contextual factors that limited the success of this program.

Acceptance of repeat population-based voluntary counselling and testing for HIV in rural Malawi.

Objective: To examine the acceptance of repeat population-based voluntary counselling and testing (VCT) for HIV in rural Malawi. Methods: Behavioural and biomarker data were collected in 2004 and 2006 from approximately 3000 adult respondents. In 2004, oral swab specimens were collected and analysed using ELISA and confirmatory Western blot tests, while finger-prick rapid testing was done in 2006. We used cross-tabulations with χ2 tests and significance tests of proportions to determine the statistical significance of differences in acceptance of VCT by year, individual characteristics and HIV risk. Results: First, over 90% of respondents in each round accepted the HIV test, despite variations in testing protocols. Second, the percentage of individuals who obtained their test results significantly increased from 67% in 2004, when the results were provided in randomly selected locations several weeks after the specimens were collected, to 98% in 2006 when they were made available immediately within the home. Third, whereas there were significant variations in the sociodemographic and behavioural profiles of those who were successfully contacted for a second HIV test, this was not the case for those who accepted repeat VCT. This suggests that variations in the success of repeat testing might come from contacting the individuals rather than from accepting the test or knowing the results. Conclusions: Repeat HIV testing at home by trained healthcare workers from outside the local area, and with either saliva or blood, is almost universally acceptable in rural Malawi and, thus, likely to be acceptable in similar contexts.

Cohort Profile: The Malawi Longitudinal Study of Families and Health (MLSFH)

The Malawi Longitudinal Study of Families and Health (MLSFH) is one of very few long-standing, publicly available longitudinal cohort studies in a sub-Saharan African (SSA) context. It provides a rare record of more than a decade of demographic, socioeconomic and health conditions in one of the worlds poorest countries. The MLSFH was initially established in 1998 to study social network influences on fertility behaviours and HIV risk perceptions, and over time the focus of the study expanded to include health, sexual behaviours, intergenerational relations and family/household dynamics. The currently available data include MLSFH rounds collected in 1998, 2001, 2004, 2006, 2008, 2010 and 2012 for up to 4000 individuals, providing information about socioeconomic and demographic characteristics, sexual behaviours, marriage, household/family structure, risk perceptions, social networks and social capital, intergenerational relations, HIV/AIDS and other dimensions of health. The MLSFH public use data can be requested on the project website: http://www.malawi.pop.upenn.edu/.

Are Rural Road Investments Alone Sufficient to Generate Transport Flows? Lessons from a Randomized Experiment in Rural Malawi and Policy Implications

This paper draws lessons from an original randomized experiment in Malawi. In order to understand why roads in relatively good condition in rural areas may not be used by buses, a minibus service was subsidized over a six-month period over a distance of 20 kilometers to serve five villages. Using randomly allocated prices for use of the bus, this experiment demonstrates that at very low prices, bus usage is high. Bus usage decreases rapidly with increased prices. However, based on the results on take-up and minibus provider surveys, the experiment demonstrates that at any price, low (with high usage) or high (with low usage), a bus service provider never breaks even on this road. This can contribute to explain why walking or cycling is so widespread on most rural roads in Sub-Saharan Africa. In terms of policy implications, this experiment explains that motorized services need to be subsidized; otherwise a road in good condition will most probably not lead to provision of service at an affordable price for the local population.

HIV testing, subjective beliefs and economic behavior

This paper examines the effects of learning HIV status on economic behavior among rural Malawians. According to economic life-cycle models, if learning HIV results is informative about additional years of life, being diagnosed HIV-positive or negative should predict changes in consumption, investment and savings behavior with important micro and macro-economic implications. Using an experiment that randomly assigned incentives to learn HIV results, I find that while learning HIV results had short term effects on subjective belief of HIV infection, these differences did not persist after two years. Consistent with this, there were relatively few differences two years later in savings, income, expenditures, and employment between those who learned and did not learn their status.

Responding to Risk: Circumcision, Information, and HIV Prevention

Understanding behavioral responses to changes in actual or perceived risk is important because risk-reduction goals can be undermined by risk-compensating behavior. This paper examines the response to new information about the risk of HIV infection. Approximately 1,200 circumcised and uncircumcised men in rural Malawi are randomly informed that male circumcision reduces the HIV transmission rate, predicting asymmetric behavioral responses. We find no evidence that the information induces circumcised men to engage in riskier sex while uncircumcised men practice safer sex in response to the information. There were no significant effects of the information on child circumcisions after one year.

Perceptions of Male Circumcision among Married Couples in Rural Malawi

Voluntary medical male circumcision (VMMC) is being suggested as an essential HIV prevention strategy in high-prevalence areas. These analyses reflect data collected from 360 married couples, 50% of which included a circumcised husband and the other 50% uncircumcised, in rural Malawi. Regardless of their circumcision status, men were more likely to perceive that being circumcised was less painful than having a tooth pulled, giving birth, and having malaria. Men reported having the same sexual pleasure regardless of the circumcision status, while women were 2.0 times more likely to report greater sexual pleasure with a circumcised partner. Participants identified the medical benefits of VMMC and highlighted the potential personal benefits of VMMC. As VMMC has become a promising method of HIV prevention, this study revealed opportunities for intervention development to increase rates of VMMC among men.