Improving Reproductive Health through Participatory Intervention
- Post by: Maria Sophia Aguirre
- December 24, 2017
Evidence from a Randomized Staged Field Experiment in Alta Verapaz, Guatemala
Asociación Puente (AP) is a Guatemalan non-profit organization, which seeks to reduce extreme poverty and prevent malnutrition through the development of skills in women who live in extremely poor rural communities with unmet basic needs. Between 2011 and 2014 the organization implemented the community development program Aprendamos Juntas (AJ) in six different communities of Santa María Cahabón in Alta Verapaz, Guatemala. In these municipalities of Santa María Cahabón, 78.8% of the inhabitants live in extreme poverty. Stunted growth among schoolchildren is 51.1%, indicative of the malnutrition prevalence among children in these communities.1
AJ brings about community and societal change, through working with women to improve their lives and the lives of their families in accordance with a person’s dignity. It has five axes: food security and nutrition, health, education, entrepreneurship, and community agency. We carried out an impact evaluation of AJ, which was completed in 2014.2 The final sample for the evaluation included 1,112 subjects composed of women, their husbands, and two of their children, from ten different communities of Santa María Cahabón. Data collected comprised baseline and after-treatment data, from both control and treatment groups.
The overall outcomes of the evaluation indicated a significant improvement in the lives of AJ’s participants and their families in all five areas. Findings also indicated areas where more efficiency could be achieved. Among the problems encountered in the reproductive health component of the program was a great dissatisfaction, on the part of the women, with the use of contraceptive injections (Depo-Provera or medroxyprogesterone). Specifically, women reported that the use of Depo-Provera caused menstrual disturbances, lower abdominal pain, sporadic spotting, and in some cases depression. In addition, we also discovered that the bargaining power of the woman was undermined through the use of these injections. Reproductive health, in the communities served by AP, is still a “taboo” topic, so women resorted to Depo-Provera without their husbands’ knowledge instead of sharing with them their health problems and desire for spacing children. In fact, women used contraceptives administered by injections because they were concealable to their husbands.
There are many factors that influence a couple’s desires to have children, their decision on how many children they wish to have, as well as the number of children they actually have. The development, supply, and dissemination of contraceptives have been, for some time now, a major public health issue and one that has been extensively researched. These studies, more often than not, address other methods than natural family planning (NFP). Studies report that, in many developing countries, women social networks influence their members’ decision to use contraceptives,3 and that when encouraged by other friends to use contraceptives, women are more likely to do so. Social networks theory research has highlighted the relevance of relations for understanding health outcomes of individuals. In doing so, they have shifted the focus of study from the individual to his or her relationship with others. Husbands, however, are rarely included as part of the relational network in these studies. Akerlof and Yellen, Bishop and Davis, and Durflo and Saez, among others, show how participation itself as well as a richer community life can assist in achieving more efficient economic outcomes. In their participatory approach, these studies do not include husband and wife relationships. This paper seeks to complement the literature in participation and networks by exploring the impact of introducing a proactive participatory approach to couples’ decision process regarding their regulation of fertility.
Specifically, the randomized framed staged field experiment discussed in this paper was intended to test solutions to the dissatisfaction encountered in the reproductive health component of AP, and do so in a manner that recognized the social dimension of each person both in the methodology used and in the outcomes obtained. Following an integral approach to experimental design, the intervention introduced in the experiment was a proactive participatory intervention (PPI), which took the form of a participatory or collaborative decision process in the spouses’ regulation of fertility. The experiment was carried out in July 2015 and it included 110 indigenous women and their husbands—a total of 220 subjects.
Results indicate that participatory or collaborative solutions rather than marginalization, which undermines a person’s decision ability, generate more efficient outcomes. The participatory intervention utilized in the experiment prompted spouses to prefer the use of NFP over other artificial methods. They perceived NFP as affordable, less intrusive for the couple, and, above all, healthier for the women. While their desire for use of contraceptives declined in favor of NFP, their desire to regulate their fertility for economic reasons remained. We found the latter to prevail among those who were relatively better off vis a vis other households within their communities. A full-fledged randomized field experiment on the introduction of NFP by encouraging couples to share in their regulation of fertility decision is currently being carried out.
The structure of the paper is as follows. Section I provides details of the program for which the experiment was designed. In Section II the methodology is presented, including the description of the data utilized. Section III presents the outcomes. The paper ends with the conclusions.
Section I: The Program
As previously mentioned, Aprendamos Juntas seeks to reduce extreme poverty and prevent malnutrition through the development of skills in women with unmet basic needs. The intervention lasts three years in each community. The program promotes human dignity, with the underlying assumption that a person does not have power of decision when he or she does not have or know about other options. Between 2011 and 2013, AJ trained women in six different communities of Santa María Cahabón in Alta Verapaz, Guatemala.
AJ’s intervention was structured around a two-phase skills training. These were imparted through workshops. In each community, AJ carried out one workshop per month. The first phase, called “how to live better,” covered 17 areas. In general, the first phase focused on self-esteem, health, reproductive health, nutrition and hygiene in the family, as well as on civic engagement. The reproductive health section of the training included family planning. The hope was that through these trainings, women would grow in awareness of their own dignity and how to live in a manner that was consistent with it. Hence, it encouraged them to decide for themselves, exercise their rights, promote values, assume their responsibilities in the community, and strengthen their own capabilities as well as those of their families.
The second phase of AJ’s program was called “how to generate revenue” and encompassed seven workshops. Among these were the setting up of local saving associations and credit, access to seed capital or micro credit, workshops on 5Ps, production techniques, formulation of a business development plan, and the accompaniment of income-generation projects by the trainers. In short, the second phase of the skill training focused on financial management and entrepreneurship. Women who completed the second phase of the training could join an informal community saving group. The entrepreneurial trainer assisted them with the saving groups and also advised each woman in the start-up of a business.
The evaluation outcome revealed the existence of women with significant levels of dissatisfaction with the use of contraceptive injections (Depo-Provera or medroxyprogesterone). As previously mentioned, they reported problems with their reproductive as well as mental health. In addition, we also discovered that their bargaining power was undermined as they used injections, in spite of their high levels of dissatisfaction, because the injections were concealable to their husbands.
In Guatemala, Mayans have resisted the adoption of family planning because they believe that having a lot of children, especially sons, will be beneficial and will ensure their livelihoods. They often face high infant and child mortality rates, which generate uncertainty as to whether their children will survive. Furthermore, because of their Mayan traditions and beliefs, they think that to use contraception is to go against the Supreme Being, who wills the birth of children destined to be born. Even for those Mayan women who would actually like to regulate their fertility, the obstacles are great because there is high social disapproval of contraceptive use. These women typically do not like to be seen at family planning clinics. De Broe et al. found that, after controlling for marital status, educational level, and level of traditionalism, the odds for indigenous mothers to be currently using family planning is 64% lower than for ladino women. Moreover, they found that family planning methods have side effects that are unacceptable to the indigenous population, such as the menstrual disturbances caused by Depo-Provera.
In addition, indigenous men play a major role in family planning decision-making, and they highly disapprove of their wives using contraceptives because they believe that such use allows them to have extramarital affairs. The more accepted method of family planning among indigenous women is birth spacing or NFP. Hence, the use of contraceptives is an important issue to address in Guatemalan indigenous communities such as the ones that are part of this study. Given the conditions of these indigenous women as well as the mentioned lack of bargaining power with their husbands regarding regulation of fertility issues, it is not surprising that if they used contraceptives, they typically opted for Depo-Provera. Even if they were suffering negative side effects, they could hide its use from their spouses. These injections were provided at no cost in the local clinic, to which all women had access.
Section II: Methodology
We used an integral approach to economic development to carry out AJ’s impact evaluation and to design the randomized framed staged field experiment. At the core of the methodology is the acknowledgement of persons’ social dimension and that, as such, they maximize not as self-utility maximizers but rather as social persons. Consequently, this methodology takes into account the interpersonal-relational dimension of economic actions, as the way persons interact can help or jeopardize sustainable development. It follows that because of this, the economic agent can be an agent of change when carrying out economic decisions. Therefore, the integral approach to impact evaluation seeks to identify effective channels of relationships that make economic development sustainable. It focuses on the direct beneficiaries of an intervention as well as on the interpersonal relationships around the beneficiaries, and it gives primacy to “action” when measuring. In addition, this approach, when evaluating an intervention, seeks to measure beyond the direct or immediate impact, i.e., the participants’ knowledge and use of reproductive health. Rather, it defines the success of AP’s intervention also by the impact that it has on the quality of life of its beneficiaries, on their family, and on their community. Such an approach requires measuring and evaluating the change in the way of life and actions of those benefitting from the program. It is a way of life that should reflect the dignity that all human beings possess as well as the way they live out their social and civic responsibility. To achieve this objective, the integral approach to evaluation uses three tools: behavioral and experimental economics, survey design and market research techniques modified to allow for a rigorous quantitative analysis, and econometrics. In designing randomized experiments, the integral approach introduces proactive participatory intervention (PPI) to encourage changes in behavior that improve outcomes.
As previously mentioned, the approach breaks away from the standard economic assumption of self-utility maximizers’ economic agents. Instead, the integral approach offers a more complex understanding of maximization in the decision-making process, as it understands the economic agent as a person who is social by nature and maximizes as such. A direct consequence of this expansion in the maximization process for the design of this randomized framed staged field experiment is that we do not rely on solely monetized incentives to stimulate a change in behavior. Instead, drawing from the seminal work of Schein and other organizational sociologists/psychologists, the intervention provided in this case is the opportunity for spouses to engage in their regulation of fertility’s decision process in a participatory manner.
Within this framework, as it is the case in standard experimental design, the subjects in the experiments are motivated by their desire to better their lives, yet they do not receive cash or any monetary compensation for their participation and/or as an incentive. Instead incentives are generated by providing participatory alternatives that seek to create opportunities for the spouses to make joint decisions and act according to those decisions regarding regulation of fertility. As it follows the canons for a standard randomized experiment it requires baseline and post for control and treatment groups.
The design of the randomized field experiment takes the form of a framed stage experiment, but our experiment is conducted in the real environment in which the subjects live. This modification provides for a more real environment than the typical framed experiment. Stages were added, each composed of a series of steps. By resorting to the introduction of stages, the experiment seeks to move couples from where they are (a passive non-participatory position) to a more participatory role in which they change their mindset and actions not only to maximize their personal utility but to improve their lives as spouses and as a family. To achieve this, the stages involve different role playing (in this case that of a wife and husband) that place participants in real situations they face in their lives regarding their desired regulation of fertility, and the role playing makes them experience these situations following a 360 methodology. As the stages progress, a more participatory behavioral option is presented. The steps included in each stage move from passive to proactive behavior, allowing participants to develop an understanding of personal responsibilities and their consequence for action. Figure 1 presents a diagram of the framed stage experimental design.
Figure 1: Diagram of Framed Stage Experimental Design
Framed experiments can raise some concerns regarding outcomes. Part of the treatment may react to the intervention provided during the experiment in a way that leads to bias in the results. On one hand, the bias could be due to participant awareness of the artificial set-up. On the other hand the bias can also be due to a self-selection problem. Framed randomized field experiments and the use of role-playing techniques address these concerns. The former tackles the two problems mentioned because the experiment occurs in the environment where the subjects are naturally undertaking their tasks. As such, it provides randomization and realism. Introducing role playing addresses the risk of bias in behavioral outcomes because it requires subjects to put themselves in a hypothetical situation so that they judge as if they were experiencing the situation in real life. This method is able to capture subjects’ psychological processes while also effectively generating acceptable levels of subjects’ involvement. Role playing, however, identifies not actual but intended behavior. We incorporate role playing by designing stages within the framed field experiment. Nevertheless, it is of value since it reveals whether the intervention provided, in this case participatory behavior in husband and wife regulation of fertility, can or cannot contribute towards improving the reproductive health of women. It does so because it reveals the value participants give to this intervention in choosing whether to modify or not modify their intended behavior.
Our experiment is a field experiment in that all participants, treatment and control, live in similar communities of Santa María Cahabón and in that the experiment was carried out in the communities where they live. Specifically, the experiments were run in the community’s meeting place where they typically gather on Sundays or for other types of meetings. Since the stage framed experiment occured in the subjects’ natural living environment, it provides different parameter estimates than those obtained from laboratory and artificially run experiments. In addition, both control and treatment groups were randomized, thus eliminating any self-selection bias. Thus, the potential biases of framed field experiments are overcome.
Two additional benefits can be identified in the use of this methodology. On one hand, it provides a tool for rigorously testing recommendations in the context of impact evaluation before scaling up their implementation. On the other hand, it significantly decreases the costs while increasing efficiency, by avoiding running ineffective large-scale randomized field experiments. There have been numerous randomized experiments conducted that have required the allocation of large sums of funds only for the outcomes to indicate that the solutions tested were not effective. This approach allows for a less financially straining way to discover potential solutions to problems encountered in impact evaluations, without compromising effectiveness and methodological rigor. Because of the proposed approach to overcoming design experiment shortcomings and because of cost effectiveness, the proposed experiment can be a significant contribution to the literature of public health for both experimental design and impact evaluation.
Specifics of the Experiment Design
The purpose of the experiment is to shift, in a short period of time (30-40 minutes), the intended behavior of the women and their husbands so as to improve reproductive health outcomes. As previously mentioned, while many women (40%) express the desire to space their children, they also reported high degrees of dissatisfaction with the use of Depo-Provera injections, the most utilized form of contraception in the communities evaluated, as means of contraceptives (60%). The main reason for the use of injections as reported by the women was the ability to hide the use of contraceptives from their husbands (66%). Therefore, the experiment design sought to foster a more participatory approach between the spouses in their decisions regarding regulation of fertility so as to help women overcome the health problems reported when using contraceptive injections, while enhancing their engagement capacity in these decisions.
The particular frame provided in this experiment addressed real situations in couples’ lives, which include the dissatisfaction encountered among the women utilizing contraceptives because of their side effects, and their desire and/or need to space their children. Other situations include the hostility on the part of several husbands to their wives using contraceptives, their high frequency of alcohol abuse, and the lack of knowledge of NFP on the part of most of the women and their husbands. Therefore, the introduction of NFP to resolve the current problem could be an opportunity to encourage a participatory approach to decisions regarding the regulation of fertility in each couple, while eliminating the negative side effects suffered by the women using Depo-Provera as well as fostering a more responsible behavior on the part of their husbands regarding alcohol consumption.
Through the use of consecutive steps in every stage, individuals (women and their husbands) are gradually moved from the most passive course of action, which in this case would mean women continuing utilizing Depo-Provera injections in spite of their discomfort and side effects; to the most proactive behavior, which in this case would be to involve their husbands in their decision to regulate fertility by means of NFP. As the subjects move through the scenarios presented to them in each stage, they are called to role play, sometimes as wives and sometimes as husbands, so that they experience and think as the other experiences and thinks. Each stage leads couples to work together more and make decisions in a more participatory manner so as to be able to regulate their fertility by means of NFP if they wish to do so. In this manner, the change desired in behavior could be achieved. The design included five stages with ten steps each.
The starting point of the experiment requires the participant to place him/herself in the position of a wife who is encouraged by AJ to decrease the number of pregnancies in order to improve her quality of life and that of her family. She attends a clinic and more often than not she is encouraged to reduce the number of children by means of contraceptive injections. The remainder of the experiment seeks to foster participation through demonstrating the responsibilities and capabilities that each spouse has. The overall idea is to design a course of action for the subjects to follow in order to resolve the problem they face regarding their regulation of fertility and in order to take advantage of the opportunity they have available, in a proactive and participatory manner. In this particular case, the missed opportunity is the possibility of increasing the use of NFP to regulate their fertility.
Following the intervention, it was predicted that spouses should desire to act in a more participatory manner and, as a consequence, be more open to resorting to NFP in lieu of Depo-Provera injections.
As the experiment sought to improve outcomes in the reproductive health component of AJ’s intervention between 2011-2013, the randomized sample for the experiment was obtained from subjects within the treatment groups. Randomization was carried at the level of aldeas (small group of houses) within each community.The aldeas are far from each other and of difficult access. Thus the risk of contamination is low. For the purpose of the experiment, these women were randomly assigned to two groups: one control and another treatment. The latter group of women and their husbands took part in the experiment, while the former and their husbands did not. Right before the running of the experiments, pre-surveys were conducted on treatment and control groups. Given that the experiment was designed as a framed field experiment and its duration was 45 to 60 minutes, there was no need for post data collection from the control group as no change would be expected in such a short period of time on their behavior. Thus we collected baseline and post experiment data from the treatment group, and baseline from the control group. The baseline control group was collected immediately before the experiment was run. The experiment was run in the summer of 2015. Participants in the experiment included 110 women and their husbands.
We compare the demographic characteristics of the treatment and control groups as well as the pre-experiment survey control and treatment groups’ responses to questions regarding their regulation of fertility behavior. We did so to ensure no factors other than the intervention provided in the experiment affected the post response in regards to their regulation of fertility intended behavior.
Table 1 presents the control and treatment comparative statistics for the women and their husbands before the experiment was run. The treatment and control groups have similar distributions with regards to education, levels of income, race, marital status, religion, age, and number of children. This is the case for both women and men groups. Women tend to have a lower level of education than men. Most of the latter have completed partially their primary education (51%) while among the women, only 1% had done so. Men report a monthly income five times higher (2,500Q) than the women (500Q). One hundred percent of the subjects in the study are indigenous, 61% of them are married, and, on average, have 4 children.
In our pool, 49% of the women and 50% of the men report using some type of contraceptives before the experiment was run. Of these, 51% of the women reported use of injections as contraceptives, while 41% of the men reported their wives used injections to regulate their fertility. The discrepancy on the reporting is consistent with the evaluation findings, which indicate women often used injections to hide from their husbands their actual use of contraceptives. Finally, only 25% of the women reported using NFP, while 17% of the men reported this as the preferred method used. The control group reported similar behavior.
Section III: Estimations and Results
We utilize a Difference in Difference methodology for the analysis of the experiments’ outcomes. The first difference comes from the change between the post-experiment survey responses and the pre-experiment survey responses of the variables of interest (dependent variable). In order to capture the influence of the proactive participatory intervention on the reported change in the intended behavior, we include as an independent variable the change between the last stage and the first stage of the experiment. We call this measure the participatory index.
The participatory index consists in a weighted index, which measures the change in intended participatory behavior as a result of the experiment. To construct it, the following steps were followed. First, each step in a given stage was assigned the value of 1 or -1 to capture respectively a proactive (participatory) or passive (not participatory) response.
Second, each of these values was transformed exponentially. The justification for this mathematical transformation is that the participatory intervention, since it is repeated in each stage, generates a cumulative effect in the subjects. Thus, after several repetitions, it is expected to generate a change of intended behavior that will last (a habit). Therefore, once the subject changes his or her intended behavior (makes decisions regarding the couple’s regulation of fertility in a participatory manner), the remaining stages should report the same or minor changes in the participatory index value. In the third step, the transformed exponential values were then multiplied by a cumulative weight, which ranges from 0 to 2 for each stage. The number 2 was assigned to the best proactive and participatory decision in each stage. All other steps received a weight between 0 and 1. The calculated multiple was then multiplied by the actual response of the subject in each of the steps of a given stage. Finally we summed the results. The larger the estimated sum index, the more proactive and participatory is the intended behavior of the subject. Finally, we subtracted the estimated sum of the last stage index from the first stage estimated sum index to measure the change in intended participatory behavior throughout the experiment. For the experiment to be effective, the change in the participatory index should be significant in determining the reported intended behavioral change. Its distribution should follow an exponential form, as this would capture the cumulative nature of the learning process. If the intervention is effective, once the subjects change from passive to proactive intended behavior, this proactive intended behavior should be sustained for the remainder of the experiment. Table 2 presents the participatory index means, percentage change, and test for significance. The index changes at a decreasing rate as it moves from stages 1 to 5. After stage 4, the change is not significant, indicating stability in the change of intended behavior.
Table 1: Control and Treatment Comparative Statistics
Table 2: Change in Participatory Index
Figure 2 displays the cumulative distribution of the participatory index change. The values of the change in the index range from -10 to 25. The negative range reflects the 20% of the subjects for which the experiment did not generate the expected behavior change. The positive change in behavior was registered in 80% of the subjects.
Figure 2: Participatory Index’s Change Cumulative Distribution
Thus, the impact of the PPI on the change of intended behavior can be evaluated by means equation 1. Fixed effects for house ownership (δ) and access to electricity (λ) were included in the estimation, while controlling for other demographic characteristics:
where Post-Pre is the difference of the survey’s responses of the post-experiment survey minus the pre-experiment surveys for the variable of interest, ΔIndex is the change in the last versus the first stage estimated participatory index, and Demographics is a vector, which includes: age, gender (woman=0, men=1), level of education, marital status (1= marriage or permanent unions, 0 otherwise), house materials (1 being brick and 8 being wood and hay, so as the numbers increase the quality of the materials used for the house construction deteriorate), and Religion (1=Catholic, 2=Evangelical, and 3= animist and others). As 100% of the population is indigenous in the communities under study, race is not included among the demographic characteristics.
Table 2 lists the variables of interest utilized to measure the behavioral change generated by the experiment. Table 3 presents the results of equation (1) estimation, for each of the variables of interest listed in Table 2. In all cases results indicate a significant response to the PPIs on the part of both spouses, as captured by the change in the participatory index coefficient. The intended change in behavior generated is consistent with the expected outcomes. A more participatory behavior between spouses generates significant and positive intended behavioral changes with regard to their regulation of fertility decisions. Specifically, an increase of participation between spouses in the decision process regarding their regulation of fertility decreases the probability of contraceptive use by 13%, increases the probability of NFP use by 24%, and more specifically decreases the probability of resorting to contraceptive use to regulate their fertility for economic reasons by 53%. Younger couples have a slightly lower (1%) probability of desire for contraceptives. A lower level of education also lowers the spouses’ desire for contraceptives and NFP used (by 4%), while making them less responsive to participatory intervention. The latter suggests that the lower the level of education, the more relevant it is to educate couples, rather than only women, in matters of fertility regulation. This is relevant, as this is not typically the manner in which reproductive health training is imparted.
Table 3: Dependent Variable Questions
We also find that married couples are more willing to use NFP and that they are more responsive to participatory intervention (the preference to use NFP increases by 24%). Finally, outcomes from the experiment also indicate that couples desire to control their fertility for economic reasons. This desire increases per child, the higher the number of children (21%) and if they are married. It also increases the wealthier they are (captured by the materials the home is made of), and the less participatory they are. When there is no participatory process in a couple’s fertility regulation decision process, women are not willing to change their behavior regarding their use of contraceptives if they use them for economic reasons. These last outcomes seem to suggest that it is the number of children rather than income that drives this change in intended behavior. Nevertheless, even if the desire for regulating fertility due to economic reasons still prevails, results suggest that couples who take a participatory approach in decisions of fertility regulation will opt out of contraceptive use (Depo-Provera), especially injections, were NFP available and taught.
To further understand why couples who engaged in a participatory decision process regarding their fertility opted for NFP in lieu of contraceptive injections, we asked the subjects why they preferred the former. These reasons included affordability (12.42%), and above all, healthier for the women (84%), and less intrusive for the couple (98%).
Table 4: Outcomes Estimation Equation (1)
Apredamos Juntas is an intervention that seeks to reduce extreme poverty and prevent malnutrition through the development of skills in women in extremely poor rural communities with unmet basic needs. Its full implementation in a community takes place in the span of three years. The program promotes human dignity by encouraging women, the primary beneficiaries of the intervention, to become positive leaders in the development process of their communities.
Between 2011 and 2013, AJ trained women in six different communities in the Department of Alta Verapaz. As part of its efforts to improve the lives of these indigenous women and their families, reproductive health was offered. The evaluation carried out of the entire program between 2013 and 2014 revealed a high level of discontent with the use of Depo-Provera (contraceptive injections) as a means for the regulation of fertility. Women reported severe side effects such as menstrual disturbances, lower abdominal pain, and sporadic spotting. In addition, the bargaining power of the woman was undermined through the use of contraceptive injections, as the main reason for its use was the need to hide the desire to regulate fertility. With the purpose of solving these two problems, a randomized framed staged field experiment was implemented with participation of women that have been part of AJ and their husbands. The intervention for the experiment consisted in the introduction of participatory opportunities in the decision of the couple’s regulation of fertility. Outcomes suggest that the intervention provided was effective in changing the intended behavior in the couples in favor of healthier options for their regulation of fertility.
Figure 3: Distribution of Contraceptive, NFP, and Economic Reason for Contraceptive Use (Before and After Experiment)
Specifically, when couples make decisions regarding their fertility in a participatory manner, their desired use of contraceptives decreases in favor of NFP. This helps eliminate the undesired health effects, while also empowering women by increasing their bargaining power. The fact that the intended behavioral change is found for both wife and husband supports the benefit of engaging the husbands in the women’s decision process.
In this particular case, this cost effective and rigorous intervention suggests that introducing NFP as part of reproductive health education and training could be of great benefit and something the members of these communities would choose if they were presented with this option. Specifically, an increase of participation between spouses in the decision process regarding their regulation of fertility decreases the probability of contraceptive use by 13%, increases the probability of NFP use by 24%, and decreases the probability of resorting to contraceptives to regulate their fertility for economic reasons by 53%. This approach, even though it is being presented here as a small-scale intervention, provides evidence of success and thus supports a trial implementation in a larger-scale study. The latter is being implemented at this time.
Maria Sophia Aguirre & Martha Cruz-Zuniga
Dr. Maria Sophia Aguirre is an ordinary professor of economics in integral economic development at The Catholic University of America.
Dr. Martha Cruz-Zuniga is an associate professor of economics and also the director of economics programs at The Catholic University of America.
 Estimations based on baseline data collected. Ritcher et al reported a malnutrition rate of 69.3% among indigenous children living in rural areas for the country. Cf. Susan M. Richter et al., Strengthening and Evaluating the Preventing Malnutrition in Children under 2 Approach in Guatemala: Report of the Enrollment Survey, Food and Nutrition Medical Assistance (FANTA), Guatemala (2013).
 Maria Sophia Aguirre and Martha Cruz-Zuniga, Patricia Pintado, and Tien-Hao Lee, “An Impact Evaluation of Aprendamos Juntas in Guatemala: An Integral Approach,” IED Report #3, School of Business and Economics, The Catholic University of America, 2015.
 J.B. Casterline (ed.), Diffusion Processes and Fertility Transition: Selected Perspectives, National Research Council (U.S.) Committee on Population, (Washington, D.C.: National Academies Press [U.S.], 2001).
 Kaberi Gayen and Robert Raeside, “Social Networks and Contraception Practice of Women in Rural Bangladesh,” Social Science Medicine 71.9 (2010): 1,584-92.
 Thomas W. Valente, Social Networks and Health: Models, Methods, and Application (New York: Oxford University Press, 2010); Thomas Valente, “Social networks and Health Behavior,” in Karen Glanz, Barbara K. Rimer, K. Viswanath (eds.), Health Behavior: Theory, Research, and Practice (California: Jossey-Bass, 2015): 205-22.
 Stephen P. Borgatti, Everett Martin, and Jeffrey Johnson, Analyzing Social Networks (London: Sage, 2013); John Scott, Social Network Analysis: A Handbook, 2nd ed. (Thousand Oaks: Sage, 2000); see also, Thomas Valente, Social Networks and Health, and “Social Networks and Health Behavior.”
 George Akerlof and Janet Yellen, “Gang Behavior, Law Enforcement, and Community Values,” Brookings Institution Press, 1994.
 Patrick Bishop and Glyn Davis, “Mapping Public Participation in Policy Choices,” Australian Journal of Public Administration 61 (2001): 14-29
 Esther Duflo and Emmanuel Saez, “The Role of Information and Social Interactions in Retirement Plan Decisions: Evidence from a Randomized Experiment,” Quarterly Journal of Economics 118.3 (2002): 815-42.
 R. Santiso-Gálvez and J.T. Bertrand, “The Delayed Contraceptive Revolution in Guatemala,” Human Organization 63.1 (2004): 57-67.
 Sofie De Broe, Andrew Hinde, Zoe Matthews, and Sabu Padmadas, “Diversity in Family Planning Use Among Ethnic Groups in Guatemala,” Journal of Biological Science 37.3 (301-17).
 Brent Metz, “Politics, Population, and Family Planning in Guatemala: Ch’orti’ Maya Experiences,” Human Organization 60.3 (Fall 2001): 259-71.
 Ward Kischer, “In defense of human development,” Linacre Quarterly 59 (1992): 68-75; Anne Terborgh et al., “Family Planning Among Indigenous Populations in Latin America,” International Family Planning Perspectives 21.4 (1995): 143-49, 166.
 Terborgh, “Family Planning Among Indigenous Populations in Latin America.”
 Maria Sophia Aguirre, “An Integral Approach to an Economic Perspective: The Case of Measuring Impact,” Journal of Markets and Morality 16.1 (2013): 53-67; Maria Sophia Aguirre, “Achieving Sustainable Development: An Integral Approach to an Economics Perspective,” in The Ethics of Sustainable Development, Luis G. Franceschi (ed.) (Nairobi, Kenya: Strathmore University Press, 2011).
 Edgar Schein, Process Consultation Revised (Englewood Cliffs, NJ: Prentice Hall, 1999); Edgar Schein, Organizational Culture and Leadership (San Francisco: Jossey-Bass, 2009 & 2010).
 On the shortcomings and distortions generated by monetary incentives see Samuel Bowles and Sandra Polania-Reyes, “Economic Incentives and Social Preferences: Substitutes or Complements?” Journal of Economic Literature 50.2 (2012): 368-425.
 Uri Gneezy and John A. List, “Putting Behavioral Economics to Work: Testing for Gift Exchange in Labor Markets Using Field Experiments,” Econometrica 74.5 (2006): 1,365–84; Craig Landry, Andreas Lange, John A. List, Michael K. Price, and Nicholas Rupp, “Toward an Understanding of the Economics of Charity: Evidence from a Field Experiment,” Quarterly Journal of Economics 121.2 (2006): 747-82.
 Omar Al-Ubaydli and John A. List, “On the Generalizability of Experimental Results in Economics,” in G. Frechette and A. Schotter, Handbook of Experimental Economic Methodology (New York: Oxford University Press, 2015).
 John List, “Why Economists Should Conduct Field Experiments and 14 Tips for Pulling One Off,” Journal of Economic Perspectives 25.3 (2011): 3-16.
 Sina Fichtel, “What is Beautiful is Good: Impact of Employee Attractiveness on Market Success,” München FGM-Verl. (2009); John Derek Greenwood, “Role-Playing as an Experimental Strategy in Social Psychology,” European Journal of Social Psychology 13.3 (1983): 235-54.
 Jerald Greenberg and Don E. Eskew, “The Role of Role Playing in Organizational Research,” Journal of Management 19.2 (1993): 221-41.
 See for example this study on education, HIV, and Early Fertility: Esther Duflo, Pascaline Dupas, and Michael Kremer, “Education, HIV, and Early Fertility: Experimental Evidence from Kenya,” American Economic Review 105.9 (2015): 2,757–97.