Learning by doing something else: Experience with alternatives and adoption of a high-barrier menstrual hygiene technology

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1 Learning by doing something else: Experience with alternatives and adoption of a high-barrier menstrual hygiene technology February 10, 2014 Vivian Hoffmann IFPRI Sarah Adelman Mount Holyoke College Ashwini Sebastian University of Maryland The market for menstrual hygiene products in developing countries is expanding rapidly, driven both by private demand and by public efforts to improve girls educational outcomes as well as women s health and dignity. However, many girls and women cannot consistently afford the monthly cost of disposable menstrual products and revert to less hygienic solutions when facing cash constraints. Reusable technologies such as menstrual cups are much less expensive over the lifetime of their use, but are characterized by barriers to adoption, including a higher initial cost of purchase, learning costs, and psychological barriers to insertion. Previous non-experimental work shows that consumer choices over substitute goods are highly persistent over time, suggesting that early experiences may determine lasting preferences for a particular product or technology. On the other hand, if barriers to the adoption of a particular technology exist, experience with other technologies that achieve similar outcomes could demonstrate the value of overcoming these barriers. Two menstrual hygiene technologies, one with low barriers to adoption (disposable sanitary pads) and one with higher adoption barriers (reusable menstrual cups) were distributed free of charge to 960 women across 60 rural villages in the state of Bihar, India. Receiving pads for free strongly increased subsequent demand for pads, as well as demand for a menstrual cup. The findings suggest that in this context, demonstration of the returns to adoption through experimentation with a substitute technology outweighs any preference or demand formation effect specific to the first technology used.

2 1. Introduction Uncertainty about the benefits of a technology, particularly in the context of high up-front costs, may constitute a barrier to adoption. Low adoption may persist over time if learning from others about the technology s benefit is imperfect, and could be compounded by the impact of habit formation if substitute technologies with lower up-front costs are taken up more readily. If a particular technology has long-run cost advantages over substitutes, or generates positive externalities, understanding how uncertainty barriers can be overcome may be relevant to policy. In this paper, we examine consumer demand for two alternative menstrual hygiene technologies: one with higher barriers to adoption (the reusable menstrual cup), and one with lower barriers to adoption but higher private and social costs (the disposable sanitary pad). Our findings indicate that in the case of a new product category, experience with a low-barrier substitute can increase demand for the higher-barrier good, and that this effect outweighs any impact of habit formation from use of the low-barrier substitute. Concerns about women s health, dignity, and girls education are fueling efforts by the public and non-profit sectors to promote availability of modern menstrual hygiene products (MHP) in developing countries (Dolan et al., 2013). Evidence from several contexts shows an association between traditional means of managing menstruation, such as repurposed cloths or rags, and infections of the urinary and reproductive tract (Morison et al., 2005; Mudey et al., 2010; Balamurugan and Bendigeri, 2012). Additionally, lack of access to effective MHP and appropriate facilities for washing and disposal have been linked to school absenteeism and reduced work force participation (Mahon and Fernandes, 2010; Dolan et al., 2013; HER Project, no date), though scientific evidence on these points is thin. Indeed, only one adequately powered randomized study to date has tested the impact of access to MHP on school attendance. In the four suburban Nepalese schools studied, menstruation had close to no impact on girls attendance at baseline, and no improvement due to provision of MHP was observed (Oster and Thornton, 2010). 1 While the case for the public provision of menstrual hygiene products is still unclear, there is little doubt that their use increases rapidly with income growth, suggesting significant private benefits 1 Girls at these schools had access to private bathrooms with running water, leading some to question the study s external validity (Dolan et al., 2013). 1

3 to women. A recent study showed the exponential increase from 1992 to 2010 of disposable menstrual products imported by developing countries (Sebastian et al., 2013). Use of purchased reusable menstrual products, including menstrual cups, is not well documented, but the small number and size of companies offering such products in developing countries suggests these account for a very small share of the MHP market. Both pads and cups offer potential health benefits to adopters, but as a disposable product, sanitary pads have two important disadvantages. First, they must be purchased each month, which can constitute a significant financial burden in low income settings, especially for women, who often have limited control over the household s cash resources. When women are unable to afford improved products, they may revert to less effective solutions, such as tissue paper, newspaper, or used cloths (PATH, 2013). Second, due to the stigma associated with menstruation, menstrual waste is often disposed of in ways that achieve discretion, but may impose negative externalities. For example, a global survey of sanitation engineers revealed that inappropriate disposal of menstrual waste through sanitation systems contributes significantly to service disruptions and increasing maintenance costs in both piped and non-piped systems (Sommer et al., in press). As a reusable product, the menstrual cup does not present these problems, but has higher barriers to initial adoption because of its high upfront cost and, as an insertable product, steeper learning curve for use. The rapid growth of demand in MHP, and current public interest in expanding access to these products among vulnerable populations, provide an opportunity to test hypotheses related to the determinants of adoption of alternative technologies. Understanding how exposure to disposable products affects demand for a reusable technologies has implications for the role of the public sector in promoting particular menstrual technologies and may have implications for choice among substitutes more generally. Consumer choices over substitute goods are generally highly persistent. Consumers exhibit strong brand loyalty despite wide fluctuations in relative prices over time (Dekimpe et al. 1997, Bronnenberg et al. 2012), and frequently inability to discern between competing brands in blind tests (Thumin 1962; Allison and Uhl 1964). One recent longitudinal study found that 40% of brand loyalty is driven by product experience (Bronnenberg et al, 2012). The importance of experience in preference formation has been demonstrated through studies linking current patterns of food 2

4 consumption among migrants to relative prices in the country or state of origin (Logan and Rhode, 2010; Atkin, 2010). On the other hand, if a consumer has no experience with any goods in a particular product category, experience with one good in this category may provide information about the utility benefits of the category generally, increasing demand both for the experienced good and for substitutes. This hypothesis would suggest that providing access to a low-barrier substitute may be a way of overcoming uncertainty about the benefits of adopting a higher barrier technology such as a menstrual cup. While this hypothesis has not, to our knowledge, been tested in the context of product choice or technology adoption, the idea is related to literature demonstrating the impact of information about outcomes on choice. Nguyen (2008) finds that providing students in Madagascar with information on the income returns to education increased test scores. Similarly, Wiswall and Zafar (2011) show planned choice of major among American college students is affected by information on mean earnings by major. We conducted a randomized-controlled trial to assess the acceptability of and demand for two substitute menstrual hygiene products: a high-barrier menstrual cup and low-barrier sanitary pads. We randomly varied distribution and marketing of sanitary pads and menstrual cups to 960 women across 60 villages in rural Bihar, India, where nearly all women used cloth at baseline. Women were assigned randomly a supply of pads, a menstrual cup or a non-menstrual gift (control group) at baseline. At 2-, 6-, and 8-month follow-ups visits, women were asked about acceptability of the assigned product. In the second and third follow-up visits, they were also offered an opportunity to choose between pads and a commonly used food staple, and then between pads and a menstrual cup. This method allows us to examine how exposure to a particular product affect long-term demand for that product and for other goods in the same product class. We find that women who are given menstrual pads subsequently exhibit higher demand for pads, as well as higher demand (in terms of the number of pads given up) for a menstrual cup. These findings suggest that women learn about the potential benefits of the high-barrier technology by experimenting with the lowbarrier technology, and that this effect outweighs any habit or preference formation effect of experience with the latter. 3

5 We also explore how social network exposure and village-level marketing of each product affects acceptability of each product. We randomly varied the proportion of each woman s social contacts who received a given product and conducted village-level promotional meetings of the product or products distributed in each villages. We find that having friends or neighbors who also received menstrual cups increases the chance that a woman who received a cup reports using it. Distribution of pads to contacts positively affects demand for pads, but the receipt of menstrual cups by contacts has a limited effect on demand for these, perhaps because of the higher psychological barriers to adoption of an insertive technology. 3. Theoretical framework The effect of learning about a particular technology through experimentation with a substitute can be illustrated through the following simple model. Let θθ represent the highest possible benefit it is possible to derive from the use of a particular class of technologies, any of which can be used to achieve a given end, and let dd ii represent the deviation from the maximum that can be achieved with the particular technology i. The actual benefit derived from the use of a particular technology i within the class, is thus bb ii = θθ dd ii. It is not possible to observe θθ directly, but since θθ bb ii = θθ dd ii, the maximum benefit previously experienced from the use of a technology within the class, as an individual experiences technologies within the class that deliver greater benefits, her expected value of θθ converges upward toward its true value. It s quite possible to ride a heavy old bicycle that s too big for the rider and has sticky breaks 20 miles to reach a destination. This is a particular technology within the class of bicycles for which dd ii is large. But it s a lot more enjoyable to ride a brand new, light-as-a-feather, custom-fitted bicycle with ultra-responsive brakes the same distance. In fact, by test riding such a bike one discovers just how far she has been her whole life from θθ, and may be thus induced to invest in a new machine, maybe not quite as expensive as this lightest, fastest model, but at least a bit lighter, and at least better fitting than the old one. 4

6 In the present paper, most women have only ever used cloth to manage their menses. Cloth achieves the desired outcome of absorbing menstrual fluid, but not at the same level of comfort or efficacy as disposable sanitary pads, which are held in place with adhesive strips, can absorb a large volume of liquid, contain leaks through an impermeable plastic layer, and consist of multiple layers of different materials so that moisture is held away from the skin. The menstrual cup offers an arguably even greater level of efficacy compared to disposable pads. It holds more fluid than most women discharge over a 12 hour period and only needs to be removed as often as it fills up. It also has the advantage of no recurring cost, but the potential disadvantage of requiring vaginal insertion, something that elicits squeamishness among many women and causes physical discomfort to some. An individual s perceived support of θθ is bounded below by the maximum benefit she has previously experienced due to the use of a technology in the same class, bb pp, and bounded above by a function of the most positive information from other sources, for example through marketing or from other consumers, about the benefits of technologies in the same class. We denote this function as ff(mmmmxx bb oooo ): EE[θθ]εε [MMMMMM bb pp, ff(mmmmmm bb oooo )]. (1) The individual s willingness to experiment with, or pay for, a particular technology in this class with which she has no previous personal experience is an increasing function of EE ii [θθ], the highest possible benefit she can expect to derive from this new technology. If EE ii [θθ] is low expending effort or other scarce resources to try the new technology is likely not worth the ultimate payoff. But the higher EE[θθ], the higher the potential benefit from using this new technology. The new technology s expected benefit, can be described by the function: EE ii [bb nn ] = EE[θθ ss nn ] = EE[θθ] gg(bb oooo, aa nn ), (2) 5

7 where the technology-specific deviation from θθ is a function g of both information received from others about the particular technology, bb oooo, and the observable attributes of the technology, aa nn. In the experiment described here, most women have only ever used cloth to manage their menses. By distributing one of two menstrual hygiene products to study participants, we provide an exogenous shock to bb nn. By providing these products to others in their social networks, and promoting them in the villages where these women live, we also shock MMaaaa bb oooo and bb oooo. According to the model, these information shocks are expected to result in the following changes to demand for menstrual hygiene technologies: 1) To the extent that any technology with which a woman experiments delivers a benefit in excess of the benefits she has previously experienced from using a technology within this class, she will revise EE[θθ] upward and her demand for other technologies in the same class will be positive affected. 2) Secondary information (received from other users) about the benefits of using a particular technology, may either increase or decrease demand for that technology, depending on the nature of the information. 3) Secondary information about a particular technology may have a positive or null impact on the demand for substitutes, but not a negative effect. These predictions stand in sharp contrast to the implications of habit formation models, which suggest that early experience with a particular technology will have lasting impact on consumers choices within the technology class. 2. Experimental design 2.1 Sampling protocol 6

8 Data from the 2011 census was used to define a sampling frame of villages in Jehanabad, Kako, and Ratni Faredpur blocks within Jehanabad District, in the state of Bihar. Inclusion in the sampling frame was restricted to villages that met the following criteria: within two hours driving distance from Patna, located at least 5 kilometers from a market, population greater than 300 persons. Sixty villages were randomly selected from among the villages meeting these criteria. Women were recruited during March and April of Upon entering a village, enumerators created a village map with assistance from local residents. Using the map, field managers divided the village in to four quadrants. Each quadrant consisted of a minimum of 20 households. In many cases, individual quadrants also represented distinct tolas, clusters of homes located some distance apart from one another within a single village. One node household was randomly selected within each quadrant through the roll of a pair of dice. Within a selected household, prospective participants were screened for eligibility based on the following inclusion criteria: female, married, absence of reported symptoms of vaginal infection, and access to clean water for washing. If more than one woman meeting eligibility criteria was present in a selected household, the participant was selected randomly through a die roll. Exclusion based on these criteria was negligible, but if a node respondent was ineligible to participate, a new node participant was selected through the same procedure. Node respondents were asked to provide the names of their three closest friends or neighbors (referred respondents), who were in turn screened for eligibility. If the node respondent was unable to refer three friends or neighbors, or if any of those referred ineligible, women in adjacent households were screened until three referred respondents were identified. Following screening, informed consent was obtained. In this way, sixteen women were selected in each of the 60 villages, for a total sample of 960 women. 2.2 Treatment Assignment Each of the 60 study villages was randomly assigned to one of four treatment groups: CUPS VILLAGE, PADS VILLAGE, MIXED VILLAGE, or CONTROL VILLAGE. Within each village, each 7

9 cluster was randomly assigned to a mix of products. The product assignment of each woman in the cluster was also random. Thus, treatment assignment at baseline was as follows: CUPS VILLAGE: 6 women given cups, 10 given a bar of soap (15 villages) CUPS Cluster A: 2 cups / 2 soap CUPS Cluster B: 1 cup / 3 soap CUPS Cluster C: 3 cups / 1 soap CUPS Cluster D: 4 soap PADS VILLAGE: 6 women given pads, 10 given soap (15 villages) PADS Cluster A: 2 pads / 2 soap PADS Cluster B: 1 pads / 3 soap PADS Cluster C: 3 pads / 1 soap PADS Cluster D: 4 soap MIXED VILLAGE: 6 women given pads, 6 cups, 4 soap (15 villages) 2 MIXED Cluster A: 2 pads / 1 cup / 1 soap MIXED Cluster B: 1 pads / 2 cups / 1 soap MIXED Cluster C: 2 pads/ 2 cups / 0 soap MIXED Cluster D: 1 pads/ 1 cup/ 2 soap CONTROL VILLAGES: 16 bars of soap (15 villages) CONTROL Cluster A: 4 bars of soap CONTROL Cluster B: 4 bars of soap CONTROL Cluster C: 4 bars of soap CONTROL Cluster D: 4 bars of soap A subset of six respondents in each of the PADS villages who had been assigned to receive the soap at baseline were randomly assigned to receive pads two months later, after the first follow-up interview. 3 This was intended to provide variation in the duration over which women had experienced using pads. Due to attrition at the first follow-up visit, 20% of the women assigned to receive pads at this time did not receive them, weakening the impact of this treatment. Throughout the analysis we use final product assignment (those given pads 2 In the first three mixed product villages, the randomization of products differed slightly. In these villages, 4 cups, 4 pads, and 8 bars of soap were given out instead of 6 pads, 6 cups, and 4 bars of soap. 3 Two of the soap recipients in each of the three mixed villages where fewer menstrual products had been assigned at baseline were also given pads at this time. 8

10 at the first follow-up are included in the pads group), and include a control for the time at which the product was given. 2.3 Data collection and product promotion Baseline survey A baseline survey was administered immediately following recruitment. During this interview, subjects were asked questions regarding their menstrual and sanitation behavior, income generating behavior, and basic demographic information. Responses in all rounds of data collection were recorded on handheld PDAs and data were inspected at the end of each day for quality control. If available, women s husbands were also informed about the study and interviewed about their attitudes toward menstruation and menstrual hygiene products. Ten percent of participants were selected for random repeat interviews during which a subset of questions were repeated and checked against the original responses. At the end of the baseline interview, the enumerators opened a sealed envelope containing individual product assignments, and offered the participants soap, a menstrual cup, or a twomonth supply of pads. 4 Women who were given pads or a menstrual cup were shown diagrams describing how to use the product they had received and video testimonials of women encouraging them to do so. Two-month follow-up A follow-up survey was administered to 848 of the 960 participants between two and three months after the baseline. Participants were asked about their usage of and experience with the product they had received at baseline. At the end of the interview, both who had previously received pads, and those who were newly assigned to receive these, were provided with 3 months supply of pads. 4 One packet of 8 pads was considered a one-month supply. This is consistent with the average monthly reported expenditure among those who reported purchasing menstrual products at baseline. 9

11 After being interviewed, all study participants in PADS, CUPS and MIXED villages were invited to an hour-long MHP promotional meeting the same day, where information was provided about the product or products distributed in that village. Respondents were asked to bring others to the meeting, and provided a small cash incentive (up to 20 rupees or about 0.3 USD) which depended on the number of other women they brought. At the meeting, women who had in the village who had received menstrual products through the study were encouraged to share their experiences using these. After the meeting, pads were offered for sale at PADS and MIXED villages at a price of one rupee each, and cups were available for sale at a price of 20 rupees in CUPS and MIXED villages. The majority of MHPs sold at these meetings were purchased by women other than those in the study. A total of twenty-six study participants across all villages purchased any pads (a median of 16 mean of 24 pads each) and 12 purchased at least one menstrual cup (one respondent purchased three cups; the rest purchased one). A total of 169 non- study participants purchased pads, with the mean and median number of pads purchased 18 and 16 respectively; 32 non-participants purchased a menstrual cup, and one of these purchased two. Six-month follow-up A second round of follow-up interviews was conducted six months after baseline. Participants were again asked about their usage of and experience with the product they had received at baseline. At the end of the interview, all participants were asked to make a series of choices between pads, cups, and sugar. 5 The first set of choices participants were asked to make were between eight successively greater quantities of sugar (with the quantity of sugar increasing by approximately 200 gram increments from 200 to 1525 grams) and a constant quantity of pads (two packets of eight). In the second part, respondents were asked 5 Offering participants the choice between money and menstrual products was deemed likely to generate conflict within villages. Sugar was chosen as the most consistently used commodity which could be easily transported by enumerators during household visits. 10

12 to choose between one menstrual cup and five different quantities of pads (from one to five packages of eight). Before the beginning of the choice module, participants were told that one of the choices they made would be randomly selected and implemented. After the end of the choice module, the PDA displayed one randomly assigned question and the participant s response, and the respondent was given the corresponding gift. Eight-month follow-up The third and final round of data collection was conducted eight months after baseline. Participants were again asked about their usage of and experience with the product they had received at baseline or at the end of the previous interview. At the end of the interview, participants were given the same choices between gifts as during the five-month follow-up interview. 3. Results 3.1 Baseline characteristics and balance check Before proceeding with the analysis, we present summary statistics on the sample, as well as tests for equality of means across each of the experimental treatment groups in Table 1. At baseline, the vast majority of women in the sample used cloth to absorb menstrual fluid. Twenty-two percent had ever used disposable, and only six percent of women reported using disposable MHPs regularly. Only three women reported ever having used tampons. Among those regularly purchasing disposable products, the mean monthly expenditure on these was 31 Rs /month. This constitutes 29% of the mid-2012 mean daily female agricultural wage in Bihar, according to the Labor Bureau of India (2012). The average age of participants was 30 years. Fifty-seven percent of women had some formal education, but only 43 percent said they were able to read a paragraph in a newspaper. Sixty percent of respondents did no income-generating work, and just under a third earned an income 11

13 through employment outside the home. The remainder contributed to their households income-generating activities, which mostly consisted of farming. The average age at which participants had married was 16 years, and the typical participant had three children. A wealth index, constructed from variables indicating household ownership of or access to 21 items, 6 had an average of zero by construction. Eight percent of the sample was Muslim, with the remainder of Hindu faith. Tests of means across each of the three individual treatment arms are shown in columns (4) through (6). Of the 33 comparisons conducted, six of the means are significantly different at the 10% level and two are significant at the 5% level. These results are more or less in line with what would be expected given a random draw, implying that the randomization of treatments was implemented successfully. In case the differences we observe at baseline contribute to any of the differences in outcomes across treatment groups, we present results with and without controls for these baseline variables throughout the paper. Attrition in follow-up rounds is balanced across treatment arms, and ranges from 11.9% at the 2-month follow-up to 15.8% at the 6-month visit (Table A.1) 3.2 Self-reported product use and satisfaction Table 2 presents statistics on participants self-reported use of and preferences for the menstrual hygiene products received through the study. At the time of the first two followup interviews, all of those who had been given a menstrual hygiene product through the study had been randomly assigned to receive it. 7 By the final follow-up at 8 months, some participants had a received pads or cups as a result of their choices during the previous interview. We present data from those who had received each product by treatment and by choice separately. 6 Items included in the asset index were: home ownership, electricity connection, mattress, bed or cot, mosquito net, cow or buffalo, goat, agricultural land, non-agricultural land, mobile phone, computer, internet data card, water pump, water filter, bicycle, solar lantern, motorcycle or scooter, radio, television, car, and generator. 7 By the second follow-up participants could also have purchased products at the promotional meeting, but in practice only XX who had not already received a given product purchased it at the meeting. Data from these individuals is not reported in Table 2. 12

14 Two months after receiving a menstrual cup at baseline, 42% of women had attempted to use it, and 37% had succeeded. Of those who succeeded in using the cup, most (77%) preferred it to the menstrual hygiene method they had been using at baseline, but given the low rate of usage, this accounted for just 28% of those in the cups treatment group overall. Over the next few months, possibly catalyzed by the first follow-up visit or the subsequent promotional meeting, the proportion of those trying and succeeding in using the cup increased, to 51% and 50%. Respectively. Of those who tried it, almost all 48% of cup recipients reported using it during their most recent cycle, and 41% said they preferred the cup to the method they had used prior to the cup. By the final follow-up, however, usage had fallen to just 23% of those who had received a cup. This may be partially due to the receipt of pads through the choice exercise during the previous survey round: 30% of those who had not received pads at that time were still using the cup. However, the higher rate of continued usage in this group cannot be causally attributed to the lack of recent pad receipt, since receiving pads in the second follow-up was a result of participants choices and thus reflects preferences over pads versus cups. The chief reason given for disadoption, cited by 49% of those who had previously used the cup, but had not used it during their most recent cycle, was preference for another product. 8 The next most common reason for disadoption, cited by 27%, was discomfort while wearing the cup, followed by difficulty boiling the cup between cycles (20%). Recipients were instructed to boil the cup between uses based manufacturer instructions, but this is no longer recommended by all cup manufacturers since it is not necessary from a hygiene perspective and may reduce the life of the product. The next column in Table 2 shows the same figures for those who received a cup through the choice exercise conducted at the end of the six-month follow-up interview. One would expect that women who expressed a preference for cups over pads would be more likely to use the cup than a randomly selected group of women. It is therefore somewhat surprising that the proportion of these participants who reported trying or using the cup is virtually the same as among those who had been assigned to receive the cup (though this rate of usage was 8 Of the 20 respondents who said they preferred using a different method, 17 preferred pads and 3 preferred cloth. 13

15 achieved more quickly among those who chose the cup just two months, rather than six months after receiving it). Among those women who chose and then used the cup, most (82%) continued to use it up to their most recent menstrual cycle. This could be due to the relatively short time elapsed between receiving the cup and the final interview rather than any difference in long-run adoption between these women and those in the cups treatment group. Columns (3) and (4) show use of pads among those who received them through treatment assignment, and who chose them, respectively. Pad use is much higher than cup use, beginning at 86% at the first follow-up, and increasing to 97% at the second follow-up. By the eight months after baseline, 17% of women who had previously used pads were no longer doing so. The primary reason for disadoption, cited by 72% of this group, was running out of pads. Among those who had not received pads in the most recent survey round, usage had fallen to 60% by the final round of data collection. Only 9 of the 333 women who had pads in their possession at the time of the final follow-up had purchased these from outside the study. Given the large number of pads distributed relative to the duration of follow-up data collection, it is not possible to observe the long-run effect of experience with these products on usage, or to know how many women would eventually revert back to cloth due to the cost of disposables. 3.3 Effects of own experience, peer experience, and marketing information We next turn to the impact of the MHP distribution and marketing treatments on adoption and demand. Table 3 presents the results of series of linear probability model regressions in which the dependent variable is equal to one if the respondent reports ever having used the menstrual cup she received through the study at two months (Panel A) and six months (Panel B) after baseline, and zero otherwise. 9 At two months, 30% of the cup recipients in villages where only cups had been distributed reported having used it. Reported usage was higher, though not statistically significantly so, in villages where pads had also been distributed (column 1). 9 The proportion of who reported ever using the cup was essentially unchanged between six and eight months. 14

16 Since the village-wide promotional meeting had not yet occurred by the time of the twomonth follow-up interview, any effect of living in a MIXED treatment village as opposed to a village where only cups were distributed would have been through the products received by one s social contacts. Columns (2) and (5) show that the greater then number of friends or neighbors who received either a cup or pads, the greater the probability that a woman reported using the cup. Interestingly, the point estimate of this social learning effect is higher for the number of contacts who received pads than the number who were given cups. This result is in line with the predictions of the model of learning presented in the previous section, since women were more likely to prefer pads to their previously used method than they were to prefer cups. Participants social contacts who had received pads would thus have been be more likely to pass on information that suggested a higher maximum potential benefit of MHP use (θθ), than those who had been given a cup. By the six-month follow-up, the village-wide promotional meeting had occurred, resulting in greater dispersion of knowledge about the benefits of both pad and cup use. The number of contacts who were given pads no longer has any impact on cup usage. Within the framework of the model, this suggests that hearing about other women s experiences using either the cup or pads during the meeting had approximately the same impact on EE[θθ]: women in both CUPS and MIXED villages learned that it was possible to achieve a higher level of menstrual hygiene comfort than they had previously appreciated; any difference in the level of comfort attainable by using pads versus cups did not matter. Knowing others who had received cups, however, still has a positive impact on cup usage at six months, suggesting that in this context, the type of technology-specific information available from social contacts is important beyond the information available through more general marketing messages or testimonials from others. Tables 4a and 4b present the impacts of the same treatments on demand for both pads and menstrual cups, as expressed through participants choices between sugar or pads, and between pads and a menstrual cup, respectively, at the six-month follow-up. We present the results from regressions in which the dependent variable is equal to one if a participant is willing to trade any of one good for the other (Panel A, both tables) and also the maximum amount of the alternative good she is willing to forgo (Panel B). 15

17 Own experience with pads increases the probability that a participant is willing to trade some amount of sugar for two more packets of pads by between 8 and 10% (columns 1, 3, and 4, Panel A, Table 4a). There is some evidence that receipt of pads by one s social contacts also increases this measure of demand, though this effect is not robust to the inclusion of baseline controls. Neither own experience with either menstrual product, nor the experience of peers, has any detectable effect on the maximum amount of sugar women are willing to give up to for additional pads (Panel B). Since the menstrual cup is a reusable technology, receiving one may have two countervailing effects on demand for substitutes: demand may increase due to the upward revision of θθ, and it may decrease because the need for the technology has been satisfied. Empirically, the net impact of these two effects is zero, and receiving a cup does not affect demand for pads. Similar to the positive impact of pad receipt on cup use, those who received pads are willing to trade a larger number of pads for cups relative to those who did not receive a menstrual product (Table 4b, Panel B). This result is apparent across specifications at either the 10 or 5% level, but stronger when controlling for the village-level marketing treatment or number of contacts given pads and cups. Exposure to both pads and cups through the MIXED village treatment appears to tip demand away from cups and toward pads (columns 8 and 11), possibly because women in these villages were able to obtain information on the relative benefits of cups and the more popular pads. Since one cup is sufficient for personal use, the negative impact of prior cup receipt on subsequent demand for a cup is as expected. In contrast to the sugar versus pad results, the maximum amount of pads a participant is willing to give up in exchange for a menstrual cup is a more sensitive measure of the impact of prior experience with pads (Table 4b, Panel A). This could reflect the difficulty of overcoming the reluctance some women have to using a vaginally inserted menstrual hygiene technology. Table 5 shows the choice results at the following round of data collection, eight months after baseline. At this time, respondents were given the same choices as at six months. By this time, some of the participants not originally assigned to receive a particular product had received them during the previous visit through the choice exercise. While this is not expected to substantially diminish demand for pads, more of which can always be used later, 16

18 it is expected to saturate demand for cups (and thus the sensitivity of this outcome as a response to treatments at baseline), since a single cup can be reused for up to ten years. We therefore report only on participants choices between sugar and pads. The effect of having received pads through the study on demand for additional pads is stronger in this second choice exercise than in the previous round: assignment to receive pads through the study increases participants willingness to trade off some amount of sugar for pads by 17%. This could be due to a reduction in measurement error resulting from participants experience with the choice mechanism. 10 Evidence for the impact of social contacts experiences is also stronger in this round. If cups are used by those who received them, receiving a cup should reduce demand for pads, since cups and pads are substitutes. While treatment assignment to receive a cup negatively affects demand for pads across specifications, this effect is never statistically distinguishable from zero. In addition to those who were assigned to receive cups, 49 of those interviewed in the eight-month survey had received cups through the choice exercise in the previous round. Because receiving a cup in this way is determined by participants preferences, OLS cannot be used to obtain an unbiased estimate the effect of cup receipt on demand for pads. The sign of the bias is ambiguous since those who chose cups over pads may value pads more than sugar (as seen in the five month demand results), or they may be more likely to use cups and thus not have any need for pads. We therefore use an instrumental variables approach to estimate the effect of pad and cup receipt on demand for pads. The excluded instruments used to predict receipt are treatment assignment and indicator variables for which choice was randomly selected to be implemented at 5 months. Participants preferences had no influence on any of these variables, but they strongly predict the receipt of cups and pads, with F statistics of 21.5 and 15.8 respectively. As shown in columns (4) and (8), cup receipt reduces the probability that a participant was willing to trade any amount of sugar for pads by between 7.8 and The increase could also potentially be due to a longer duration of experience with pads among this group. However, those given pads at two months did not exhibit higher demand during the first choice exercise than who had received pads since baseline, suggesting that the duration of time using the product does not affect demand. 17

19 percentage points, or between 14% and 18% on a base of 54.3% who ever chose pads over sugar. This effect is significant at the 10% level. The average amount of sugar participants were willing to forgo for pads (columns 12 and 16) is not however significantly affected by owning a cup. These results suggest that for about 10 percent of women, cups are a substitute for pads, and owning one reduces their demand for pads to zero. A larger group of women who own and report using cups, however, prefer using pads, and are willing to forgo something of value (sugar) to obtain them. The fact that we see the impact of cup receipt only at the extensive margin of ever choosing pads over sugar, and no impact on the intensive margin of how much sugar participants are willing to forgo, suggests that product-specific preferences are quite strong. 3.4 Attitudes toward menstrual hygiene practices To understand the mechanism behind the result that those supplied with pads subsequently had higher demand for the cup, we turn to participants responses to a series of attitudinal questions administered during the eight-month survey round. During the eight-month interview, women were asked about the comfort and convenience of using cloth to absorb blood, as well as their openness to trying new menstrual hygiene products. By this point, many of those who had not been assigned to a receive a particular product had obtained that product through sales at the village meeting, or the choice exercise at five months, so the estimated treatment effects represent lower bounds of these, and the village level treatments may also capture individual experience with the products promoted in those villages. With this caveat in mind, we see strong effects of the pad treatments on attitudes toward using cloth as well as openness to trying new products. Women in villages where pads were promoted were more likely to perceive using cloth as uncomfortable and inconvenient, and expressed greater interest in trying menstrual products they had not used before. 18

20 The findings that experimentation with pads both reduces women s stated satisfaction with the most commonly used technology at baseline, and increases their stated openness to trying an unfamiliar product, provide further support for a model in which experience with substitutes affects one s expectations about the performance of other technologies in the same class. 4. Conclusion The results of this study provide insights about the acceptability of and demand for two menstrual products in rural India, as well as more general lessons about technology adoption and the importance of the order in which alternative technologies are introduced. Sanitary pads were almost universally accepted and used, whereas approximately half of the women who were given a menstrual cup reported using it. Usage of menstrual cups fell off sharply when women these were later given pads, suggesting that many women prefer pads, but will use the cup if pads are not available or affordable. Of women who received a cup but did not later receive pads, 30% reported using the cup during their most recent cycle eight months after receiving it. For a significant minority of women, constituting between 8 to 10 percent of those who received cups, owning a menstrual cup eliminated the demand for pads entirely. The chief reason for disadoption of pads was running out. This suggests that while pads are popular, many poor women lack the financial resources to purchase these on a regular basis. Promoting the use of high quality reusable menstrual hygiene products may thus be a more financially sustainable way to improve women s menstrual management options at least for those women who are willing to use them than the promotion of disposable products. We conclude from these results that the menstrual cup is an acceptable menstrual management option for approximately a third of women in rural Bihar. Including this option among the menu of products available to women in this region has could significantly reduce waste, and has the potential to improve to urogenital health by reducing the use of cloth, which has been linked to higher rates of infection in several settings. We find that while social 19

21 learning induces low-cost experimentation (trading pads for sugar, trying a cup once one owns it), inducing market demand for products characterized by higher entry barriers may require other approaches. Finally, promotion of disposable sanitary pads strongly increased subsequent demand for pads, and also increased demand for the menstrual cup. These results imply a model in which individuals learn about the potential benefits of a class of technologies through experimentation with any of the particular technologies within that class. In the context of menstrual hygiene products, this learning effect is more important than any habit formation effect resulting from the historical use of a particular technology. This implies that the window of opportunity for promoting menstrual hygiene products with a lower waste burden will not close with the introduction of disposable products. In fact, women may be more open to experimenting with unfamiliar technologies after experiencing the benefits of easier to adopt disposable products. This finding has broader implications for the promotion of innovative technologies in undeveloped markets: when there are barriers to adopting a particular technology, such as high fixed monetary or learning costs, experience with a lower-barrier substitute technology may increase adoption of the highbarrier technology. 20

22 References Allison, Ralph I., and Kenneth P. Uhl Influence of Beer Brand Identification on Taste Perception. Journal of Marketing Research 1 (3): Atkin, D. (2010). Trade, tastes and nutrition in India (No. 986). Center Discussion Paper, Economic Growth Center. Balamurugan SS, Bendigeri N. Community-based study of reproductive tract infections among women of the reproductive age group in the urban health training centre area in hubli, karnataka. Indian journal of community medicine : official publication of Indian Association of Preventive & Social Medicine. Jan 2012;37(1): Bronnenberg, B. J., Dubé, J. P. H., & Gentzkow, M. (2012). The evolution of brand preferences: Evidence from consumer migration American Economic Review, 102(6): Dekimpe, Marnik G., Jan-Benedict E.M. Steenkamp, Martin Mellens, and Piet Vanden Abeele. (1997) Decline and Variability in Brand Loyalty. International Journal of Research in Marketing 14 (5): Dubé, J. P., Hitsch, G. J., & Rossi, P. E. (2010). State dependence and alternative explanations for consumer inertia. The RAND Journal of Economics, 41(3), Dolan, C. S., Ryus, C. R., Dopson, S., Montgomery, P., & Scott, L. (2013). A blind spot in girls education: menarch and its webs of exclusion in Ghana. Journal of International Development. HER Project, (no date) Changing health behavior : Keane, M. P. (1997). Modeling heterogeneity and state dependence in consumer choice behavior. Journal of Business & Economic Statistics, 15(3), Logan, Trevon D., and Paul W. Rhode Moveable Feasts: A New Approach to Endogenizing Tastes. Unpublished. Mahon T, Fernandes M Menstrual hygiene in South Asia: a neglected issue for WASH (water, sanitation and hygiene) programmes. Gender and Development, 18(1): Morison L, Ekpo G, West B, et al. Bacterial vaginosis in relation to menstrual cycle, menstrual protection method, and sexual intercourse in rural Gambian women. Sexually transmitted infections. Jun 2005;81(3): Mudey A, Kesharwani N, Mudey G, Goyal R. A Cross-sectional Study on Awareness Regarding safe and Hygenic Practices amongst School Going Adolescent Girls in Rural Area of Wardha District, India. Global Journal of Health Science. 2010;2(2):

23 Nguyen, T. (2008). Information, role models and perceived returns to education: Experimental evidence from Madagascar. Unpublished manuscript. Oster, E., & Thornton, R. (2011). Menstruation, sanitary products, and school attendance: evidence from a randomized evaluation. American Economic Journal: Applied Economics, 3(1), PATH (2013). Final Project Report, Menstrual Management and Sanitation Systems: Findings from two case studies in South Africa and India. 76 pp. Sebastian, A., V. Hoffmann, and S. Adelman. (2013) Menstrual management in low-income countries: needs and trends. Waterlines. 32(2): Sommer, Marni, Marianne Kjellen, and Chibesa Pensulo. (in press) Girls and Women s Unmet Needs for Menstrual Hygiene Management (MHM): The Interactions between MHM and Sanitation Systems in Low-Income Countries, Journal of Water, Sanitation and Hygiene for Development. Thumin, Frederick J Identification of Cola Beverages. Journal of Applied Psychology 46 (5): Wiswall, Matthew; Zafar, Basit (2011) : Determinants of college major choice: Identification using an information experiment, Staff Report, Federal Reserve Bank of New York, No

24 Table 1. Summary Statistics and Balance Check Experimental Arm CONTROL CUP PADS CONTROL = CUP Tests for equality of means CUP = PADS CONTROL = PADS (1) (2) (3) (4) (5) (6) Mean Std. Dev. Mean Std. Dev. Mean Std. Dev. p-value p-value p-value Ever used disposable pads (0.40) (0.43) (0.25) Normally uses pads (0.21) (0.21) (0.27) Age (in years) (6.82) (6.06) (7.25) Any formal education (0.50) (0.50) (0.49) Can read paragraph of newspaper (0.49) (0.50) (0.50) Does not work (0.49) (0.50) (0.48) Earns income (0.46) (0.49) (0.46) Age at marriage (in years) (3.01) (3.16) (3.09) Number of children (1.85) (1.60) (1.71) Wealth index (1.91) (1.90) (2.06) Muslim (0.25) (0.32) (0.25) Observations Notes : Means tests control for timing of pad distribution.

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