Research Design and Data

The interventions used in this study address safe childbirth. For a detailed description of the interventions, see the evaluation articles of the main RCTs (Diba et al., 2018;

Kuhnt and Vollmer, 2018). Two-thirds of mother and newborn deaths globally occur due to causes, which could largely be prevented if well-established essential practices were followed (WHO, 2018). However, the gap between the knowledge about what should be done to ensure safe deliveries and what is actually done is large. Following the ideas of the rational choice theory that describes independent agents striving to

medical fields suggests that checklists could be a promising tool to motivate health personnel to follow essential practices and tackle the know-do gap. Checklists compress and bundle the necessary information into easy-to-use actionable items and herewith reduce a possible “information overload” (e.g., Workman et al., 2007; Borchard et al., 2012; Haugen et al., 2015). Insights from behavioral economics suggest that human behavior is bounded by limitations of the working memory. In situations characterized by high levels of cognitive load – the amount of mental activity imposed – the successful execution of certain tasks might be interrupted or impaired (e.g., Croskerry, 2002;

Burgess, 2010; Hoffman et al., 2011; Deck and Jahedi, 2015; Lichand and Mani, 2016).

Checklists can be especially helpful to reduce additional cognitive load and allow a reduction of complexity of the task at hand by reminding the user of the essential steps to follow.

Using cluster randomized controlled trials, we evaluated the SCC in 32 health fa-cilities in Indonesia, as well as in 17 health fafa-cilities and among 149 individual health providers in Pakistan. In both countries, the intervention we conducted was very simi-lar. The treatment (SCC) was randomly introduced to approximately half of the health providers to causally identify the effect of the intervention on studied outcomes. The randomization took place at the facility level. Hence, all staff working in the same facility were jointly allocated to either treatment or control group.

4.2.1 The TPB in the Setting of the SCC Intervention

In this section, we apply the logic of the Theory of Planned Behavior to the SCC intervention. This identifies the TPB determinants as illustrated in Figure 4.1. In the logic of Ajzen (1991) the attitude towards the checklist, the subjective norm of health personnel and the perceived behavioral control about checklist use will jointly determine whether health staff intends to use the checklist, which finally leads to whether the checklist is actually used during deliveries. We will go into more detail in the following.

The puzzle of this study is as follows: If health personnel know that the checklist entails necessary essential practices supporting the safety of deliveries, why would they decide not to use the checklist. This is where we apply the TPB to carve out how the perception about the checklist’s usefulness and relevance (“Attitude towards the Behavior”), support, and peer-pressure among staff members (“Subjective Norm”), as

Figure 4.1 Applying the TPB to the SCC Intervention

Source: Authors’ depiction.

Note: Own illustration based upon Ajzen (1991).

the benefits, however, presumes that health personnel also believed in the information attained. Trusting in the checklist would therefore be a first important precondition for checklist uptake (attitude towards the behavior). On the perspective of the do-side from the know-do gap, people might still not use the checklist as they feel unable to use it (perceived behavioral control) or not obliged to do so (subjective norm). Using the real-world setting of the SCC interventions in Indonesia and Pakistan, we are able to empirically test the influence of the TPB determinants on intended and actual use of the SCC.⁴ Of all TPB determinants, theattitude towards the behavior building on how trust-worthy the intervention is perceived seems to be particularly well in control of the intervention implementer. We therefore elaborate additionally on this determinant within our field experiment.

Data: Measuring TPB Determinants and Outcomes

We measured our data through surveys with health personnel and clinical observations of the delivery process. Our TPB determinants were collected through survey questions

attreatment facilities. This leaves us with 79 respondents in Pakistan and 163 health workers in Indonesia.⁵ Including only the treatment facilities, gives us a non-random sample limiting causal inference, which is discussed below.

The numerous applications of the TPB to a wide array of contexts ease the measure-ment of TPB determinants (e.g., French and Hankins, 2003; McEachan et al., 2011).⁶ We were thus able to follow the respective literature when formulating survey questions.

The first determinant attitude towards the behavior, here towards the use of the SCC, we prompt by asking the respondents to judge the usefulness of the SCC in their pro-fessional context (based upon Kam et al. (2012)). Subjective norm would translate into the degree of support by health practitioners’ superiors. Perceived behavioral control takes into account how easy the health practitioners judge the checklist to be applicable in their daily work routine. The judgment on the three TPB determinants was gen-erally very positive. For all three determinants and in both contexts the respondents provide a rating of five on a scale ranging from one to six, where six corresponds to

“fully agree.”⁷ However, Appendix Tables D.4 and D.5 indicate some distinct variation, which we exploit in our analysis. Beyond the main TPB variables, surveys included demographic background information, which serves as control variables.

Following the TPB, the three components then influence whether health staff intends to use the checklist and, ultimately, if they actually use it during deliveries conducted (see Figure 4.1). Intentions to use the checklist and actual checklist use represent our outcome measures. We investigated respondents’ intended behavior towards the SCC use, by asking whether they intend to continue using the SCC after termination of

5The Pakistani health staff worked at 70 different providers (including individual providers but also larger health facilities). While we surveyed every individual provider, we increased the number of interviews at health facilities proportionally with their number of delivery staff to get a more nuanced picture within larger teams. The Indonesian trial involved interviews at 16 health facilities.

6It has to be noted that the TPB can be applied in various ways, which is likely to influence its effects (Lugoe and Rise, 1999). In order to increase the TPB’s explanatory power and flexibility to address also varying intentions and behavior, several studies extended the original framework by further constructs and components (e.g., Conner and Armitage, 1998; Perugini and Bagozzi, 2001;

Armitage and Conner, 2001; Bilic, 2005; Cheon et al., 2012). We will stick to the original theory when applying it to development economics, while we acknowledge the propositions made to deepen

Figure 4.2 Intentions to use the Safe Childbirth Checklist