Entertainment-Education for Better Health: Insights from a Field Experiment in India

Abstract

Entertainment-education has been touted as a potent delivery channel for health education campaigns. Yet, there is little evidence of its causal effects. This paper aims to fill the gap in the literature by using a field experiment in India to study two questions on the efficacy of health entertainment-education. First, can health entertainment-education, particularly through films that show role models and draw on emotions, lead to lasting, positive change in health knowledge and behavior? Second, can financial incentives for ex-post health literacy boost the effectiveness of health entertainment-education? The results show that health entertainment-education successfully increased health knowledge (e.g. knowledge about cleanliness and hygiene) by 16 percent. These gains persist almost one year later, although there were no observed impacts on health behaviors. Further, financial incentives do not appear to have any effects. These insights contribute to our knowledge of what works for health education in low-income settings, so that future education campaigns can be crafted with more meaningful impact.

Keywords:

• entertainment-education
• financial incentives
• health
• randomized controlled trial
• India

Acknowledgements

I am grateful to Saath for their partnership in this project; to Shawn Cole, Jeremy Shapiro, and Bilal Zia for their collaboration in the field experiment; and to Stuti Tripathi, Bhakti Shah, and the Center for Microfinance for excellent research and field work assistance. I thank Simon Galle, Tom Muir, Hege Johanne Magnussen, and participants at the Experimental Evidence in Education Economics workshop at KU Leuven and the 45th Annual Meeting of the Norwegian Association of Economists for useful comments. I also thank the editor and two referees for helpful suggestions that substantially improved the paper. An earlier version of this paper was circulated with the title ‘Delivering Effective Health Education in Developing Countries: Insights from a Field Experiment in India.’ The field experiment in this paper is registered in the AEA RCT Registry (ID # AEARCTR-000017) and received approval from Harvard University’s IRB (CUHS # F17663-109). Funding from the World Bank for the field experiment is gratefully acknowledged. All participants gave their informed consent prior to their inclusion in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The replication package for this paper is available at https://doi.org/10.7910/DVN/EJ03JR.

Notes

1 All field staff were trained extensively to ensure adherence to project protocols. The respondent’s study arm assignment was revealed during the first program session.

2 While the results indicate that this allocation was sufficiently powered, an alternative allocation (i.e., 42 percent to control, 29 percent each to HEE and HEEC) would have improved power (Muralidharan, Romero, & Wüthrich, 2023; Özler, 2022).

3 The baseline did not collect data on whether the respondent is the main decision-maker, earning member, or earning member’s spouse. The closest available variable is a dummy for whether the respondent has any income in the last 12 months. This variable is balanced across the study arms.

4 Supplementary Material A details the placebo film content. Financial planning and services was chosen as the placebo topic because this study was integrated into a broader project to minimize field work costs (see Carpena, Cole, Shapiro, and Zia (2019) who study the effects of financial education on financial outcomes). As part of this broader project, the financial film group was randomized into additional financial-related treatments: (1) financial counseling; (2) goal setting; and (3) a cash reward for financial literacy. Subjects assigned to the latter intervention have been excluded from the present study to obtain a cleaner comparison between HEE, HEEC, and the control arm. In other words, this study’s control arm is a composite of the financial films, financial counseling, and goal setting interventions. Supplementary Material F shows that the results are robust to restricting the control arm to “pure” control subjects—i.e., those assigned to financial films, but not financial counseling, goal setting, or cash rewards for financial literacy.

5 After randomization, classes were formed by grouping subjects based on their education program assignment and the day/time availability they specified at recruitment (see Section 2.1). The latter was meant to give participants a feasible class time, increasing the likelihood of attendance.

6 An alternative approach to control for income effects would have been to provide non-HEEC respondents with the average winnings of HEEC respondents.

7 It is necessary to inform study participants of their cash incentives assignment because the intervention’s objective is to test whether the promise of monetary rewards can increase motivation to learn from the health program.

8 As will be shown in the results, differences between HEE and HEEC are generally not statistically significant. Moreover, if reminders did impact intrinsic motivation, it could be a level effect given that all participants received information and reminders about their cash incentives assignment.

9 Among Wave 1 participants (N = 191), midline data are missing for 102 people (53 percent) of which 100 (52 percent) belong to the control study arm.

10 Results are similar when excluding strata fixed effects in the regressions (see Supplementary Material F).

11 Results are similar when clustering standard errors at the wave-class level (see Supplementary Material F). Here, a wave refers to a separate iteration from recruitment to endline, and a class refers to a group of participants with identical education program assignment (i.e., health or placebo), who met at the same day and time every week for the film screenings (see Section 2). In each wave, there were roughly 15 classes: 5 for health films and 10 for financial films. In practice, the number of participants per class was similar, at around 20 persons. However, because this study was integrated into a broader field project, some participants in the financial films group were assigned to additional cash incentives for financial literacy. These subjects—corresponding to 1/3 of the full project sample—have been excluded from the present study to obtain a cleaner comparison between the HEE, HEEC, and control arms.

12 Supplementary Material E presents estimates of Equation (1)(1) $$\begin{array}{cc}{Y}_{\mathit{\text{is}}}={\beta }_0\hfill & +{\beta }_1{\mathit{\text{HEE}}}_{\mathit{\text{is}}}+{\beta }_2{\mathit{\text{HEEC}}}_{\mathit{\text{is}}}+{\varphi }_s+{ϵ}_{\mathit{\text{is}}},\hfill \end{array}$$(1) with attendance as the outcome variable.

13 The sample size here is only 755 because of missing data from Wave 1 control group (see Section 2.4). Supplementary Material D shows that the results are similar when excluding all Wave 1 respondents from the regression sample.

14 To manage the survey length, the midline did not cover night blindness, and it was instead covered in the endline.

15 Financial incentives may have demotivated participants to learn “Cleanliness and Hygiene” because they were already well-versed in this concept. At baseline, 92–93 percent in each study arm were aware they should wash hands after defecation (Table 1, Panel C). Similarly, at endline, the control group exhibited the highest average score in “Cleanliness and Hygiene” across all modules. Research on the psychology of motivation contends that cash rewards perceived as controlling or affecting autonomy can diminish intrinsic motivation (Deci & Ryan, 1985; Frey & Oberholzer-Gee, 1997). Given participants’ existing proficiency in “Cleanliness and Hygiene,” it may be that they viewed the rewards as controlling or a threat to their autonomy; the rewards would then result in detrimental effects, in line with findings in prior psychological research.

16 The nightblindness outcome is constructed from the open-ended question “Can you list the precautions you take to ensure that you or your family member doesn’t contract nightblindness?” (see Supplementary Material C). Almost 60 percent of interviewees did not have a response to this question, and any text responses were hand-coded to create the indicator variable. Apart from eating more nutritious foods, some examples of other responses to this question are keeping eyes clean, reducing alcohol intake, and not watching TV—all of which were not relevant based on the content of the health education films.