A Randomized-Controlled Trial to Increase the Uptake of LARCs in Cameroon

Study Overview
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Brief Summary
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Cameroon exhibits a high and non-decreasing level of maternal mortality (roughly 600 per 100,000 live births), partially related to its relatively high total fertility rate (roughly 4.6). Survey evidence furthermore suggests that a significant fraction of these pregnancies is unwanted or considered mistimed by the mother, especially among females aged 15-19. Despite this, the rate of utilization of family planning (FP) is low: e.g. only 48% of sexually active unmarried women use any form of (modern) contraception, or MC, and even then, it is primarily condoms. The use of LARCs (long-acting reversible contraceptives, i.e. the IUD and implant) is less than 1% according to the most recent Demographic Health Survey. The study investigators propose to use an integrated behavioral science approach to increase the take-up of both SARCs (short-acting reversible contraceptives, i.e. the pill and injectable) and especially LARCs among reproductive-age females in Cameroon, including adolescents who may be unmarried and/or nulliparous. In addition to decreasing maternal mortality and undesired pregnancies, indirect effects for the community will include: increased welfare from reduced side effects that arise due to current one-size-fits-all FP counseling; healthier children due to improved birth spacing; and increased human capital formation both for children and for young (often school-aged) potential mothers. The study investigators propose to conduct the study at HGOPY for a duration of 12 months. The study investigators will provide tablets to each of five nurses that conduct FP counseling to participants at the hospital. The tablets contain a counseling app (or decision-support tool or a job-aid) that was jointly developed by professionals from HGOPY, the World Bank, and the Ministry of Health. The study investigators propose an individually-randomized experiment, where the participants will be offered randomly varying discounts for the modern contraceptive methods they wish to adopt. The study investigators also propose to experiment with certain aspects of the app to improve its effectiveness - both for the participant and for the nurse. More details on the experimental design are provided below.

Official Title
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A Sequential and Adaptive Experiment to Increase the Uptake of Long-acting Reversible Contraceptives in Cameroon

Conditions
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Contraceptive Usage, Contraception, Contraception Behavior, Contraceptive Method Switching

Intervention / Treatment
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* Behavioral: Price discounts for SARCs
* Behavioral: Price discounts for LARCs
* Behavioral: Sequential vs. simultaneous recommendations


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female Ages 10-49 Presenting at HGOPY seeking FP counseling/services HGOPY clients referred to the family planning unit for consultation Exclusion Criteria: * No exclusion criteria

Ages Eligible for Study
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Minimum Age: 10 Years
Maximum Age: 49 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Sequential Assignment
Interventional Model Description: The study independently experiments with two aspects of the health provider-client relationship: First, a tablet-based counseling app that is used by the provider gives random discounts to clients - separately for LARCs and SARCs. Second, the tablet-based app presents recommendations to the client sequentially (i.e. the top-ranked method, followed by the next one if that recommendation is declined by the client, etc.) vs. simultaneously (i.e. presenting the top recommendations to the client all at once and asking her to choose which one to discuss further).
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Free SARC, Free LARC, Recommendation<br>Free SARC, Free LARC, Sequential recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Free SARC, LARC=500, Recommendation<br>Free SARC, LARC=500 CFA, Sequential recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Free SARC, LARC=1000, Recommendation<br>Free SARC, LARC=1000 CFA, Sequential recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Free SARC, LARC=2140, Recommendation<br>Free SARC, LARC=2140 CFA, Sequential recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Free SARC, LARC=5000, Recommendation<br>Free SARC, LARC=5000 CFA, Sequential recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>|
| Experimental: Regular SARC, Free LARC, Recommendation<br>Regular price SARC, Free LARC, Sequential recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Regular SARC, LARC=500, Recommendation<br>Regular price SARC, LARC=500 CFA, Sequential recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Regular SARC, LARC=1000, Recommendation<br>Regular price SARC, LARC=1000 CFA, Sequential recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| Experimental: Regular SARC, LARC=2140, Recommendation<br>Regular price SARC, LARC=2140 CFA, Sequential recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>|
| No Intervention: Regular SARC, LARC=5000, Recommendation<br>Regular price SARC, LARC=5000 CFA, Sequential recommendation | |
| Experimental: Free SARC, Free LARC, No Recommendation<br>Free SARC, Free LARC, Simultaneous recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Free SARC, LARC=500, No Recommendation<br>Free SARC, LARC=500 CFA, Simultaneous recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Free SARC, LARC=1000, No Recommendation<br>Free SARC, LARC=1000 CFA, Simultaneous recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Free SARC, LARC=2140, No Recommendation<br>Free SARC, LARC=2140 CFA, Simultaneous recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Free SARC, LARC=5000, No Recommendation<br>Free SARC, LARC=5000 CFA, Simultaneous recommendation | Behavioral: Price discounts for SARCs<br>* SARCs are offered free to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Regular SARC, Free LARC, No Recommendation<br>Regular Price SARC, Free LARC, Simultaneous recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Regular SARC, LARC=500, No Recommendation<br>Regular Price SARC, LARC=500 CFA, Simultaneous recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Regular SARC, LARC=1000, No Recommendation<br>Regular Price SARC, LARC=1000 CFA, Simultaneous recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Regular SARC, LARC=2140, No Recommendation<br>Regular Price SARC, LARC=2140 CFA, Simultaneous recommendation | Behavioral: Price discounts for LARCs<br>* LARCs are offered at lower prices to the client<br>Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|
| Experimental: Regular SARC, LARC=5000, No Recommendation<br>Regular Price SARC, LARC=5000 CFA, Simultaneous recommendation | Behavioral: Sequential vs. simultaneous recommendations<br>* Top ranked methods are presented to the client sequentially or simultaneously<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The client adopted a LARC | using data from the counseling sessions | 1-day | 
| The client adopted a modern contraceptive method (LARC or SARC) | using data from the counseling sessions | 1-day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Was the client treated with respect by the provider during the counseling session? | Self-reported indicator variable using follow-up surveys two weeks after counseling session | 2-weeks | 
| Did the client trust the provider during the counseling session? | Self-reported indicator variable using follow-up surveys two weeks after counseling session | 2-weeks | 
| Did the health provider give information about contraceptive methods that was easy to understand during the counseling session? | Self-reported indicator variable using follow-up surveys two weeks after counseling session | 2-weeks | 
| Client satisfaction with adopted contraceptive method | using 2-week and 16-week follow-up surveys | 2-week and 16-week measurements | 
| Discontinuation of adopted contraceptive method | using 2-week, 16-week, and 52-week follow-up surveys | 2-week, 16-week, and 52-week measurements | 
| Percentage of participants with unintended pregnancy within the time frame | using 16-week and 52-week follow-up surveys | 16-week and 52-week measurements | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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adolescent sexual and reproductive health, maternal mortality, teen pregnancy, LARCs, family planning counseling