Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral economics informed approaches to mitigate discontinuation of injectable contraceptives. Methods: Behavioral diagnosis was conducted to identify the primary drivers of discontinuation of injectable contraceptives. Using these insights, a user-centered behavioral design approach was implemented to create an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods adjusted for study design, participants’ backgrounds, and contextual factors, were used to estimate the intervention’s effect on discontinuation rates. Results: Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. This was not surprising as using appointment cards and the job aid was within the routine workflow of health extension workers, but using the planner was not. The injectable discontinuation rate was 10.8 % points lower in the intervention area compared to the control area during the post intervention follow-up survey. Conclusion: The use of two behavioral economics informed tools—the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics approaches have the potential to enhance family planning programs in Ethiopia and elsewhere. Trial registration: ISRCTN ISRCTN17390653 (10/04/2019)