Research

Love in the Time of HIV: How Beliefs about Externalities Impact Health Behavior  (Journal of Development Economics, Preprint)

with Adamson Muula and Joep van Oosterhout 

Despite the widespread availability of lifesaving antiretroviral drugs, demand for HIV testing is low. Antiretrovirals have a positive externality: they prevent HIV transmission. We use an experiment in Malawi to show that informing communities about this externality can shift beliefs and increase HIV testing in the short term, with a larger effect for sexually-active demographics. We also see a change in attitudes toward sexual partners taking antiretrovirals. Learning about a positive externality can increase demand for healthcare.

Restricted Access: How the Internet Can Be Used to Promote Reading and Learning (Journal of Development Economics, previously circulated as "Searching for Answers: The Impact of Student Access to Wikipedia", Preprint)

with Catherine M Leclerc and Pedro CL Souza

Can schools use the internet to promote reading and learning? We provided Wikipedia access to randomly-selected students in Malawian boarding secondary schools. Students used the online resource broadly and intensively, and found it trustworthy, including for information about news and safe sex. We find a 0.10 SD impact on English exam scores, and a higher impact among low achievers (0.20 SD). Students used Wikipedia to study Biology, and exam scores increased for low achievers (0.14 SD). Our results show that by restricting internet access to a source of engaging and accessible reading material, it is possible to encourage independent reading and affect educational outcomes.

Health Knowledge and Non-Pharmaceutical Interventions During the COVID-19 Pandemic in Africa (Journal of Economic Behavior and Organization, NBER)

with Anne Fitzpatrick, Sabrin Beg, Anne Karing, Jason Kerwin, Adrienne Lucas, Natalia Ordaz Reynoso and Munir Squires

Providing health information is a non-pharmaceutical intervention designed to reduce disease transmission and infection risk by encouraging behavior change. But does knowledge change behavior? We test whether coronavirus health knowledge promotes protective risk mitigation behaviors early in the COVID-19 pandemic across four African countries (Ghana, Malawi, Sierra Leone, and Tanzania). Despite reputations for weak health sectors and low average levels of education, health knowledge of the symptoms and transmission mechanisms was high in all countries in the two months after the virus entered the country. Higher knowledge is associated with increased protective measures that would likely lower disease risk with one exception–knowledge is inversely correlated with social distancing. Respondents largely adhered to mask mandates and lockdowns, but continued coming into contact with others at small, informal gatherings, gatherings not affected by mandates. Knowledge alone appears unlikely to reduce all risky activities, especially gatherings within other people's homes. Even early in the pandemic income loss or stress were commonly reported. Our results suggest that early and consistent government provision of health information, likely reduced the severity of the pandemic in Africa but was not a panacea.

Healthcare Appointments as Commitment Devices (Conditionally accepted at The Economic Journal)

with Jason Kerwin, Natalia Ordaz Reynoso, and Olivier Sterck

Health behaviors are plagued by self-control problems, and commitment devices are frequently proposed as a solution. We show that a simple alternative works even better: appointments. We randomly offer HIV testing appointments and financial commitment devices to high-risk men in Malawi. Appointments are much more effective than financial commitment devices, more than doubling testing rates. In contrast, most men who take up financial commitment devices lose their investments. Appointments address procrastination without the potential drawback of commitment failure, and also address limited memory problems. Appointments have the potential to increase demand for healthcare in the developing world.

Who Knows? The Effect of Information Access on Social Network Centrality (Revision requested at AEJ: Applied)

with Pedro CL Souza

Economic processes depend on the structure of the social network, and on individual network positions. Network centrality in particular plays a key role in learning, technology adoption, and information diffusion. Yet, the causal determinants of network centrality are not well understood. In this paper, we show that information access plays an important causal role in determining network position. We conducted a randomized experiment in Malawian boarding secondary schools. We provided exclusive access to Wikipedia, an online information source, throughout the school year, to a sparse subset of students. We measured complete social networks at baseline and endline, including many types of links. The intervention has a large and lasting effect on social network position. Treated nodes become significantly more central according to several measures of network centrality, and are more likely to be among the most central nodes in the network. We calibrate and simulate a model of strategic network formation to demonstrate important implications for network-based targeting, information diffusion, inequality and welfare.

Privacy at What Cost? Saving the Lives of HIV Patients With Electronic Medical Records (Revision requested at REStat)

with Anita M. McGahan and Leandro Pongeluppe

We show that the use of electronic medical records (EMRs) can prevent AIDS deaths by enabling patient tracing.  Paradoxically, patients who initially state a preference for privacy in fact benefit most from improved tracing practices. HIV patients receive antiretroviral therapy (ART), a highly effective treatment that also prevents transmission, for free in many parts of the world. Yet patients frequently lapse from care, resulting in increased community transmission and unnecessary deaths. EMRs allow health providers to manage patient data, trace lapsed patients, and encourage lapsed patients to reinitiate treatment. We implement an event study analysis using data from 106 Malawian clinics between 2007 and 2019. We find that the introduction of EMRs leads to an increase in the number of patients actively in care and to a decline in patient deaths. After five years of implementation, facilities with EMRs have approximately 34 percent more patients in care and 28 percent fewer annual deaths than facilities without EMRs. These effects are concentrated among patients under 50 years of age, and are larger among young children. Effects are also concentrated among patients who do not wish to be traced despite the fact that these patients are more likely to lapse from care and require tracing. Robust to additional specifications and supported by interview findings, the results demonstrate that an initial preference for privacy gives way to patient reinstatement in care when the health consequences are critical.