Public health and behavioral economics

{***Pause/Music***}

{***Noah***}

Coming up on Harvard Chan: This Week in Health…

Blending public health and behavioral economics.

{***Jessica Cohen Soundbite***}

(The starting point for this was that women express a strong preference for delivering in high quality facilities, but don’t seem to be getting there. So, the idea is to empower them to achieve that outcome. And that is what a lot of behavioral economics is about.)

In this week’s episode, researchers see whether lessons from behavioral economics can improve maternity care for women in Kenya.

{***Pause/Music***}

{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health. It’s Thursday, December 14, 2017. I’m Noah Leavitt.

{***Amie***}

And I’m Amie Montemurro.

{***Noah***}

Amie, each year in sub-Saharan African more than a million women and newborns die during childbirth—or shortly thereafter.

One key to reducing these deaths is ensuring that women give birth in facilities that have the ability to manage common delivery complications—such as employing well-trained health care workers or having essential medicines and supplies.

{***Amie***}

But many African health care facilities are not able to deliver quality maternal care.

In Kenya, for example, only five percent of facilities can perform c-sections.

And in many facilities, women report experiencing disrespect or abuse during childbirth.

{***Noah***}

The lack of high quality facilities is one issue.

But getting women to actually deliver at one of the higher quality facilities is also a challenge.

{***Amie***}

And that’s the issue we’re focusing on in today’s podcast.

{***Jessica Cohen Soundbite***}

(Hi, I’m Jessica Cohen, and I’m an associate professor here at the Harvard T.H. Chan School of Public Health.)

{***Noah***}

That’s Jessica Cohen, who is in the Department of Global Health and Population here at the Harvard Chan School.

And her research focuses on the intersection of public health and behavioral economics.

{***Amie***}

You’ve probably heard that term before.

Behavioral economics weaves together human psychology and economics to explain the decisions we make

Just recently economist Richard Thaler was awarded the Nobel Prize in Economics for his contributions to the field of behavioral economics.

According to the Nobel committee, Thaler’s findings have, quote, “built a bridge between the economic and psychological analyses of individual decision-making.”

{***Noah***}

Behavioral economists, like Jessica Cohen, draw on knowledge about human psychology to better understand how people make decisions.

And today we’ll be talking to Cohen about how women in Nairobi, Kenya decide where to give birth.

{***Amie***}

As you’ll hear from Cohen in a few moments, women in that city have an almost overwhelming number of choices of maternity facilities.

And she a team of researchers wanted to see if some so-called behavioral “nudges” could influence women to give birth at the higher quality facilities—and in turn receive better care.

{***Noah***}

Those nudges took the form of cash transfers, which are a form of financial assistance widely used in low- and middle-income countries.

Some are unconditional—which means the money is given without strings attached. We’ll be talking more about a separate study on that kind of transfer later on in the podcast.

In this study, researchers tested two kinds of transfers: one was a variation on an unconditional cash transfer, while another had some some strings attached.

{***Amie***}

One group was given cash and told the money was to help them deliver where they wanted—a “labeled” transfer.

A second group was given cash that combined labeling, along with a commitment to deliver at a pre-specified facility as a condition of receiving the final payment.

{***Noah***}

I had an in-depth conversation with Cohen about this specific study, but also the broader field of behavioral economics and public health.

I started our conversation by asking her what drew her to this research.

{***Jessica Cohen Interview***}

JESSICA COHEN: I’ve always been very interested in how patients make decisions about their health care or the health care of their families. I used to do a lot of work in malaria and thinking about how caregivers and patients make decisions about preventing malaria and treating it.

And my research had evolved into maternal care. Along with Margaret McConnell, who is in my department, we did quite a bit of qualitative work with pregnant women and new mothers in Nairobi. And we found that the decisions around childbirth and planning which facility to deliver in were really rich and interesting and important questions. And that’s how we got involved in this research.

NOAH LEAVITT: So it’s like looking at, I guess, what are some of the levers you can pull to influence where a mother chooses to give birth and what the quality of care is like. Is that what you’re looking at?

JESSICA COHEN: It’s interesting. So actually the fact that started us on this journey was we started interviewing women during pregnancy, throughout pregnancy, and then shortly after delivery. The original project related to financial savings for delivery actually. And as part of that project, we were trying things, and they just weren’t really working. And so we went back and interviewed women about their choices and thought process during pregnancy.

And what we found is that women very late in pregnancy, eighth month, ninth month, were still considering three or four different options for where they were going to deliver. And then when we talked to them a month after delivery, 2/3 of them ended up delivering in places they weren’t even considering, and they’re toward the end of their pregnancy. And so rather than starting out with something we were trying to fix, we actually started from this question of, what could the implications of that be? A very disjointed, last minute decision making process.

Clearly, this decision was not in women’s hands much of the time. And what you saw was a lot of last minute decisions about where to deliver. And often, women going to the closest place that was open and affordable at the time they were in labor, which surely had implications for the quality of care they were receiving, how much planning that they had done around childbirth, and that kind of thing. So that actually– we began this with that motivating question.

NOAH LEAVITT: I mean that kind of making a last minute decision– I mean, is that something that was unique to Nairobi and that’s why you chose to study it? Or is that something that you see in a lot of low and middle income countries?

JESSICA COHEN: We had never found that before in the context of maternal health. There has been some discussion of women delivering in places they didn’t go for prenatal care and the potential harms of that. But this fact that there were so many last minute decisions– this was the first time that I had encountered that. Where you see this type of line of research and what interested in is in questions around decision making and choice environments and behavioral economics.

So what you often see are studies that look at contexts where there’s an enormous amount of choice, like Medicare plans. And we find that people often make suboptimal decisions and often put decisions off because of the complexity of making them.

NOAH LEAVITT: In this context with mothers preparing to deliver, I guess, what were some of the complexities they are facing?

JESSICA COHEN: There are about 800 places you can deliver your baby in Nairobi, and they vary widely. So they vary from a tiny place in someone’s home, someone who’s not very well trained, to a really well put together, well-equipped hospital. And there’s private facilities, public facilities, religious facilities, NGOs, and very little transparency about the quality and even the cost of these various options. Extremely crowded marketplace. And I think that’s what leads to the complexity of the choice.

NOAH LEAVITT: The women in the study received these two different kinds of cash transfers. So can you explain what the difference is in the transfers they received were and how that may play into their decision making?

JESSICA COHEN: Sure. So normally, we think of cash transfers to help overcome financial barriers. So common financial barriers to delivery and facilities, maternity facilities, as opposed to delivering a home, for example, are things like the cost of transportation or supplies, that type of thing. Typically, some of those cash transfers are also conditional cash transfers, meaning that they’re only paid conditional on the behavior occurring, which is targeting not just financial barriers to access to care but also maybe behavioral barriers. So you’re trying to directly incentivize that behavior.

So the first level of what the cash transfers are trying to address is just on a pure financial level. So these women lived in the informal settlements of Nairobi or the slums. And they tended to live further from the higher quality facilities, and it was a non-trivial transportation cost to get to the center of city.

But then what we did was we added on top of that two insights from behavioral economics to help ensure that the cash transfers got used in a more targeted, more effective way. So we tried to see whether we could use behavioral economics to enhance the impact of the cash transfers on top of just removing that financial barrier.

The first was what’s called labeling. One group was given what we call the labeled cash transfer, which was an unconditional cash transfer given in the eighth month of pregnancy but with a label that said, this cash is intended to help you deliver where you want. And the idea in behavioral economics and psychology is that labeling increases the salience and the importance of an activity. It also relates to what’s often called mental accounting. So even though money is fungible across actions, if you say this is a health savings account, or this is a cash transfer for delivery, reduces the chances that it gets spent on other things or other people’s preferences or priorities take over. So one group got just that, a labeled unconditional cash transfer in the eighth month of pregnancy.

The other group got that. And they also in their eighth month were asked to pre-commit to a delivery facility and, if they ended up delivering there, were paid an additional cash transfer after delivery. And the idea behind pre-commitment is that in complex decision environments, so when you have a really complex choice, pre-commitment or often, broadly speaking, active choice– it can encourage active choice. So you impose a deadline on decision making. And it can reduce procrastination and indecision. And also, what we hoped was get women to plan earlier and think through with their families more thoroughly where they wanted to deliver and what their options were.

NOAH LEAVITT: So it’s– so it’s interesting that it’s– I mean, as you describe it, it’s not just about the financial part. But it also seems like it’s about having these multiple touch points with the mothers along the way. Is that what the– I mean, to get them to think more critically about their care. But also, I mean, I don’t know if it’s reminders about you’re coming up on delivery day.

JESSICA COHEN: Yeah, that’s a really good point. So one thing that we didn’t do explicitly but was implicitly part of this design was related to something else in behavioral economics that’s often proposed in complex choices and difficult behaviors is implementation prompting and implementation applying. So even little things like not just telling someone, you should get a flu shot, but saying, when do you plan to go? And how will you get there? And here’s a map for getting there. Or not just, how much will you put in your 401K, but thinking through what you need for– so prompting people to think through the steps that they would need to go through.

And our surveys did ask a lot of questions like, how will you get to the facility? Who’s going to take care of your other children when you give birth? Things that prompted them to think through the process more carefully.

NOAH LEAVITT: And so looking at these two different types of cash transfers, what impact did they have, I guess, on one where the women gave birth and then the quality of care they received once they actually did give birth?

JESSICA COHEN: The three things, I’d say, that we hypothesized in advance this might affect– the first thing is not covered in this paper but was covered in a paper in the American Economic Review that came out a few months ago was on delays. So one thing– there’s two things that are thought to really jeopardize women in health outcomes for mothers and newborns in childbirth. One is arriving too late in labor for essential interventions to be undertaken. And another is just going to a really bad place.

And so the first paper really looked at that first question. So we thought that especially the pre-commitment could get women planning earlier about how to get to facilities on time. And we did see important reductions in late arrival, very late in labor. What we also looked at was whether these cash transfers could get women to higher quality facilities in the sense of being facilities that were more equipped to handle basic emergencies and even to do routine things, like infection control and that sort of thing. And then we also looked at, like you said, women’s experiences of delivery. So in particular, their experiences and reports of interpersonal quality of care principally around disrespect and abuse, which is becoming more and more important in the maternal health care policy agenda, is trying to improve that aspect of quality of care.

So what we found was that both cash transfers seem to lead to women experiencing better quality of care in the interpersonal aspects. So in both arms, they reported less disrespect and abuse. And there were some improvements in the quality of facility used in the arm that got just the unconditional cash transfer. But across the board, the women who got the cash transfer with pre-commitment had the best outcome. So they went to higher quality facilities in terms of the facilities ability to handle routine newborn care and any newborn emergencies. And they also experienced higher quality of care. They reported higher quality care and delivery.

And the pre-commitment arm had other interesting effects. It got women to travel a little bit farther away from their homes for deliveries, so outside of the slums. We substantially reduced the probability of walking to a delivery facility actually if you could believe people actually walked to a delivery. And in general, we saw really large impacts on reducing the intention-action gap. So if you asked women in their eighth month of pregnancy, where do you want to deliver? What do you think is the highest quality place? Where do you intend to go? The probability that they actually ended up going where they wanted and where they thought was good and all of those things was substantially increased in the pre-commitment.

NOAH LEAVITT: Seems like you’re showing promising results in Nairobi, but you mentioned that there were 800 birth facilities in Nairobi So is part of the challenge now seeing would this work in maybe a more rural area where there are fewer birth facilities available? Like I guess– and so what are some of the next steps for this area?

JESSICA COHEN: That’s a good point. I think this work generalizes to other urban settings in low income countries or at least settings where there is some amount of choice because this is really about empowering patients to use higher quality care. And so for that to happen, they need to have some choice. I think the next steps are, in that context, to think about other ways to empower demand for high quality care. So there’s a lot of interesting work going on on improving the supply of health care, so treating providers and improving infrastructure.

The work around patients, or the research around patients has really focused on making care closer to you, building buildings, or improving transportation, and making it cheaper. But it hasn’t really focused on other ways to empower demand for high quality care. So we have been really thinking about both behavioral barriers to reaching high quality care and information gap. So what do women know about what’s high quality? What aspects of quality do they care about, and how does that relate to the ability of a facility to save their life? We see a disconnect a bit in maternity facilities’ readiness to handle complications and how respectfully they treat women. So there is a lot of trade-offs there. And so that’s the direction we hope to take this research.

NOAH LEAVITT: And so this idea that the conditional cash transfers work but in the context of all the other improvements that are going on.

JESSICA COHEN: Well, I think they seemed to work but could work a lot better if women were empowered with information, for example, and other things we’ve thought about. For example, improving the quality of prenatal care so that this starts earlier in the process and that kind of thing.

NOAH LEAVITT: So I think it’s interesting that you use that word empower. And that– I guess, can you explain maybe why that is an important distinction? So it’s not you must go to this high quality health facility. But I guess, if the patient feels like I have the choice to go to high quality facility, is that the distinction?

JESSICA COHEN: That’s a good point. So there’s often this word in behavioral economics called nudge that I think there’s a technical definition, although no one really uses it. But it relates to choice architecture. And the idea is that all environments involve choice architecture. And if you can just change the choice architecture a little bit, often, you can get people to do behavior that is actually more in line with their own preferences and their own well-being. So really, the starting point for a lot of behavioral economics is that people don’t end up acting consistently with their stated goals and intentions and even their preferences and thinking about how to modestly change the environment or change prompts or information to help them achieve what they wanted to achieve anyway.

So that’s, I think that’s exactly right that we– the starting point for this was that women express a strong preference for delivering in high quality facilities but don’t seem to be getting there. And so the idea is to try to empower them to achieve that outcome. And that is a lot of what behavioral economics is about. So people want to go to the gym but then stop going. Or they want to get a flu shot and then they– or they want to contribute to a 401K plan. But it’s too complicated to think about it, and they don’t have time. And so it’s empowering people to achieve their behaviors in line with their goals and preferences.

NOAH LEAVITT: And why do you think behavioral economics and public health are such a good fit? A lot of the examples that I know you’ve worked on, whether it’s this or malaria– it’s a lot of people in maybe low resource settings who don’t have a lot of money to begin with. So, I guess, why are behavioral economics and public health a good match, do you think?

JESSICA COHEN: I think the reason that I came to it and the place where I see it adding the most value is that so many public health programs– I mentioned this earlier– have focused on accessibility and affordability. So make health care available and affordable. Build it, and they will come. And they just so often fail. And that seems to have so much to do with the way people make choices– and not just patients but providers as well– how people act on their goals, and how people make choices, and the complexity of the health care environment.

A big– one of the common biases that’s been identified in behavioral economics relates to myopia, I guess you would call it, which is that things that would benefit us in the future we put off. And that relates to adherence behavior and preventive care and all of those things. And that is something that behavioral economics has key insights about. So key things about public health, like medication adherence and health care seeking, take-up of health insurance, all of those things. I think behavioral economics has a lot of insight to add.

NOAH LEAVITT: And can you– are there any good examples of where using insights from behavioral economics have helped people working in public health design a more successful intervention or improve utilization of health care services? I guess, what were some of the success stories be?

JESSICA COHEN: The evidence based in developing countries is much, much smaller than in higher income countries. There are actual government units now devoted to this called Nudge Units in the UK and in the US– there’s one coming out of the White House– that really think about how can you design tax policy, environmental policy, all of these things to incorporate insights from behavioral economics.

My sense is that some of the things that have worked are around, for example, decision support for providers. So how providers make decisions in managing– I guess you could think a bit of checklists as a behavioral economic insight to help deal with cognitive load and that kind of thing. Also, workplace wellness programs, so getting people to stick to choices about going to the gym or smoking cessation, that type of thing. There’s been a bit of growing evidence in the education literature and financial savings. But the literature in global health is nascent.

NOAH LEAVITT: And so just a last question– I mean, you mentioned that the body of evidence is still relatively small in developing countries and global health. So what would be the things that you would be most interested in looking at going forward? Are there any big questions that you still want answered?

JESSICA COHEN: One of the things that I have become very interested in is how people– is risk perception. And this is actually an area where there’s been some work done in high income countries and also some work in lower income settings around HIV for example. But we don’t have great understanding of how people perceive the risk of certain diseases. And I got interested in this around malaria, but it applies to a lot of other– I mean, you could apply it to maternal health care too and how women assess the probability of complications in childbirth. 5% of the newborns in this study died actually. So the probability of something bad happening is not even close to zero.

And so how people perceive the risk of diseases or bad health care and how that translates into health behavior, all kinds of health behaviors, how promptly they see a doctor, whether they adhere to medication, what type of provider they see, and that kind of thing has really started to interest me. And I’ve been doing some work on malaria in that area. People shy away from this because they think it’s too hard to measure. But actually, we have better and better measures of how people perceive risk. And you can measure people’s subjective probability assessments in low income settings. It just takes some piloting and some thought.

{***Noah***}

That was my interview with Jessica Cohen on behavioral economics and public health.

If you want to read the study we discussed in this interview, we’ll have a link on our website, hsph.me/thisweekinhealth.

{***Amie***}

We’ll also have much more information about Cohen’s work—including her research on malaria.

{***Noah***}

And we mentioned at the beginning of the podcast that we’d also be chatting briefly about unconditional cash transfers.

{***Ramon Pabayo Soundbite***}

(My name is Ramon Pabayo, I’m an assistant professor at the University of Alberta School of Public Health and also a visiting scientist here at Harvard T.H. Chan School of Public Health.)

{***Amie***}

Ramon Pabayo and his colleagues just completed a large review of unconditional cash transfers.

{***Noah***}

They looked at the evidence from 21 studies to assess the effects of unconditional cash transfers on the use of health services, health outcomes—such as someone reporting being sick, social determinants of health—such as a child going to school, or meeting food guidelines, and health care expenditures among children and adults.

{***Amie***}

And as we mentioned at the beginning of the episode, unconditional cash transfers are given with no strings attached.

So, a family would receive the cash to spend however they see fit.

{***Noah***}

The review by Pabayo and colleagues compared outcomes between those who received transfers and those who did not.

They found the transfers had no effect on the utiliziation of health care services.

But there were positive associations in other areas.

{***Ramon Pabayo Soundbite***}

(For example, an unconditional cash transfer probably reduces the odds of having any illness in the last two to 20 weeks by 27 percent. And this was significant; that’s a profound decrease in odds. Unconditional cash transfers may also improve food security and dietary diversity. Meaning that they were able to purchase food, and also have a varied diet, so they meet the food recommendations, for example, the food pyramid. We also found they probably improved one social determinant, namely increased school attendance. So when there was an unconditional cash transfer, those that receive the transfer were more likely to attend school.)

{***Noah***}

We were struck by the association with schooling.

And Pabayo says it’s not clear why exactly the cash transfers made it more likely that children would attend school.

{***Amie***}

But he says there are some theories—one is that the cash transfers empower people—and give people the financial flexibility to send their children to school.

{***Noah***}

One thing that is clear, says Pabayo, is that more research is needed on unconditional cash transfers, to see how they can be used more effectively.

{***Amie***}

According to Pabayo, one emerging and interesting area of research focuses on how these transfers are a form of basic income.

That’s a type of social security where residents of a country receive regular, unconditional payments from a government.

{***Noah***}

Finland is currently in the midst of a basic income experiment, and Pabayo says researchers will be watching closely to see if that has any effect on health in that country.

{***Amie***}

And that’s all for this week’s episode.

Just a note that this is our last episode of 2017, as we’ll be taking a couple of weeks off at the end of December.

{***Noah***}

We’ll return in early January with all new episodes. And as always, you can find those on iTunes, Soundcloud, and Stitcher.