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Improving the utilization of vouchers for low-income families with young children:

Evidence from France

26/04/2016Dr. Marieke Huysentruyt

SnO Research Centre, HEC Paris (FR)Stockholm School of Economics (SE)

Ideas42 (US)RSA (UK)CSB (BE)

Background

• Programme Malin started up in 2011 by Danone, Blédina and Croix Rouge.

• The goal of Programme Malin is to improve the nutritional status of children (0 -3 years) from low-income households by enhancing access to suitable, quality foods and providing families with information about child nutrition.

• The programme has two major pillars:

• Financial support via discount vouchers to be used on a selection of Blédina products, suitable from the age of 6 months through 2 years.

• Educational support via website, flyers, training sesions about child nutrition, aimed at supporting food diversification and preparing the exit from the programme.

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Selection process

• Programme Malin grants prescribers (social workers) considerable latitude in defining key concepts such as low-income, fragile households and household structure.

• Since June 2014, people can also self-select or register themselves online and provide a justifying document. This can be a salary slip, a document provided by CAF (Caisse d’Allocations Familiales).

Compared to Healthy Start (UK) and WIC (US)

Program Malin (FR) Healthy Start (UK) WIC (US)

Mission Improve the nutritional status of children (O-3 years) from low-income households by enhancing access to suitable, quality foods and accompanying families on issues about child nutrition.

Promote healthy lifestyles by changing diets. Safeguard health of low-income WIC at nutritional risk. Ensure basic levels of nutrition.

Organization Private initiative, with Danone and Croix Rouge in the lead

Government scheme Government scheme

Eligibility criteria Pregnant, postpartum, and breastfeeding women, infants, and children up to age 3 who meet income eligibility – as judged by local social workers, or if you register yourself, as evidenced by one of the following documents: salary slip, child benefit, etc.

Be at least 10 weeks pregnant, or have at least 1 child under 4 years.Income eligibility – you must be receiving any of the following: Income Supportincome-based Jobseeker’s AllowanceChild Tax Credit (but only if your family’s annual income is £16,190 or less), income-related Employment and Support Allowance,Working Tax Credit (but only if your family is receiving the 4 week ‘run-on’ payment)

Pregnant, postpartum, and breastfeeding women, infants, and children up to age 5 who meet income eligibility and State residency, and individually determined to be at “nutrition risk” by a health professional or a trained health official.

Registration process Social workers play a gatekeeper role, but since mid-2014, families can register themselves with official document of proof.

Health professionals play a gatekeeper role: Familye needs to fill in form + signature of midwife, health visitor or registered doctor or nurse (online or offline).

State agencies are gatekeepers

Offering Vouchers for selection of Blédina products sent once every 3 months, nutrition education. Website: Recipes, Food and Health tips

Vouchers sent every week - one per week if you’re pregnant and have a child aged between 1 and 4 – Two vouchers per week if you have a child under 1. You also get free vitamin supplements. Website: Recipes, Food and Health Tips.

Provide nutritious foods to supplement diets, nutrition education (including breastfeeding promotion and support), and referrals to health and other social services. Vouchers are sent every month.

Products eligible for voucher A selection of Blédina products only Milk, plain fresh and frozen fruit and vegetables and infant formula milk. Plus vitamins.

Infant cereal, baby foods, iron-fortified adult cereal, fruits and vegetables, vitaminC-rich fruit or vegetable juice, eggs, milk, cheese, yogurt,soy-based beverages, tofu, peanut butter, dried and canned beans/peas, canned fish, whole wheat bread and other whole-grain options. For infants of women who do not fully breastfeed, WIC provides iron-fortified infant formula. Special infant formulas and medical foods may also be provided if medically indicated

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Reach so far

• As of April 2015: 1340 families registered

• Estimated take-up rate in Nancy and Grenoble range between 30% and 40% of eligible families.

• Healthy Start in the UK, comparable figure: 72% - 86%

• WIC serves 51% of all infants born in the US. There the problem is more one of oversubscription.

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Room for improvement

• Costs of take-up:• Administrative hassles: people find it too costly to register, to interact with the

relevant social workers who can enroll families onto the program.• Bad information flows: people don’t understand the Programme Malin-offer.• Stigma: people find it stigmatizing to interact with social service professionals

(prescribers) or use the voucher at the cashier.

• Behavioral reasons: • Present-bias: people undervalue the benefits of healthy eating. • Complexity and status quo bias: people don’t see through the veil.• Limited attention: people forget to upload documents to proof eligibility.

These barriers might sometimes deter the neediest. There is a risk of mis-targeting whereby those who stand to benefit most fail to opt in.

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Problem 1: Imperfect take-up

Problem 2: Low voucher utilization rate

• Low voucher utilization rate• Over half of all the registered families have never used a voucher.

• Of those who used a voucher at least once, big variation in the intensity of use.

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Positive deviants

Benchmark: According to official figures, 90% of Healthy Start vouchers are used (Department of Health, 2009)

Diagnosis: Why such low utilization rates?

• We analysed Programme Malin’s own data on the registered families There were 2 datasets.

1. First dataset included names of parent (typically mother), name of child, date of birth, date when they enrolled, total number of vouchers received, share of vouchers used, address, who prescribed them to the program.

2. Second dataset included information on the products for which the voucher was used, and dates when the supermarket cashed in the vouchers.

• Using software program, we inferred gender of child, to check whether there were any gender effects (the answer is no)

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• Repetition matters: The number of coupons sent consistently predicted utilization. The more coupons people received, the more likely it is that they will have used a coupon at least once. And so families with multiple kids are indeed more likely to use a coupon at least once.

• Clarifying the Program Malin-offer matters as well: We see big differences in ‘real usage rates’ based on who prescribes. Who prescribes matters.

• No effect: Age of the child at the time of enrollment, gender of the child, date when vouchers were sent, whether they enrolled via internet (though here still low sample)

• Those who enroll via internet need to provide a proof of eligibility – so you would expect these people to be especially interested. Even so, preliminary data analysis suggests an intention-action gap is at play.

• One striking thing is that the majority of families registered have non-French sounding names (Northern Africa, Sub-Sahara Africa, Central and Eastern Europe) – This suggests that possibly costly language barrier are at play.

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Results: What predicts using a voucher at least once?

Qualitatitive next step: In a positive deviance mindset• Speak with the 3-5 families who have used the vouchers very

intensively so far.

• Meet with people at the few local structures whose families enrolled use the vouchers very intensively.

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Experimental next step: Test the effect of seemingly minor cues or changes in Programme Malin’s communication with enrolled families on actual voucher utilization.

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Three types of interventions

# 1: Clarifying/visualizing how the vouchers really work• Relevant given possible literacy barrier or language barrier (French as a second language)

• Step by step- plan – removing complexity of how these vouchers really work – and countering fear that the vouchers will be rejected.

# 2: Making salient the money wins involved.• Relevant given possible poor numeracy skills.

#3: Reminding people of Program Malin• Relevant given problems of limited attention, limited bandwidth.

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Sample

• Criteria to be included in the sample: enrolled in 2015, valid postal address, validemail adress, baby of at least 6 months old

• Inscription en 2015 / +6 mois / adresse postale : 967 families (as of June 1st 2015)

• Inscription en 2015 / + 6 mois / adresse mail : 731 families (as of June 1st 2015)

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Experimental design

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Group 1

Info Programme Malin + Step-by-

step plan

Mailing

Group 2 (control group for

group 1)

Info Programme Malin

Mailing

Hyp 1: Complexity

Groupe 3

Welcome +Info average

savings per year

Email

Groupe 4

Welcome +Info average

savings per month

Email

Groupe 5

Welcome +Support

information

Email

Groupe 7(control group for

group 3-6)

Welcome

Email

Hyp 2: Discount saliency Hyp 4: Reminder effect

Groupe 6

Welcome+ Bi-weekly

repetition email

Email

Hyp 3: Support information

Group 1

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Pensez aussi à utiliser vos planches de réduction ! Au total, vous pouvez

économiser 262€ si vous utilisez tous les bons du Programme Malin.

Rien qu’entre les 6 et les 12 mois de votre enfant, en

utilisant tous les bons, vous pouvez économiser

jusqu’à 172 €

Bel été !

Groupe 3

Intro +Info économies

par an

Mail

Bonjour,

N’hésitez pas à consulter régulièrement le site du Programme :

www.programme-malin.com. Vous y trouverez plein de conseils,

d’astuces et de recettes pour l’alimentation de votre bébé.

- 172€

6 mois 12 mois

Group 3

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En utilisant tous les bons, vous pouvez économiser entre 45 et 60€ tous

les 3 mois.

Sur 1 mois, en achetant les produits suivants avec

les bons de réduction Malin, vous pouvez par

exemple économiser 19,40€

o

u

+ +

- 19,40€

+

Bel été !Groupe 4

Intro +Info économies

par mois

Mail

Bonjour,

N’hésitez pas à consulter régulièrement le site du Programme :

www.programme-malin.com. Vous y trouverez plein de conseils,

d’astuces et de recettes pour l’alimentation de votre bébé.

Group 4

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L’été avec le Programme Malin

15 Juillet

Profitez des fruits d’été pour faire de délicieuses compotes pour bébé !Avec des pommes et des pêches par exemple.

Les bons de réduction vous sont envoyés tous les 3 mois, à partir des 6 mois de votre bébé

D’autres recettes sur le site, ici

Si vous ne les recevez pas, n’hésitez pas à nous écrire en cliquant ici, il y a peut-être tout simplement un problème avec votre adresse

Quand la température monte, pensez à proposer régulièrement de l’eau à votre bébé

L’eau est la seule boisson recommandée pour votre bébé. Votre enfant peut avoir besoin de boire en dehors des repas. Ses besoins en eau augmentent lorsqu’il a de la fièvre ou qu’il fait chaud. Les boissons sucrées, les jus de fruits et les sodas sont à éviter au maximum.

Groupe 6

4 newsletters Malin sur 2 mois

MailGroup 6

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RECETTES D'ETE POUR BEBE

L'été, c'est le moment de profiter des courgettes !Le Programme Malin vous propose une recette de purée, facile et rapide.

UN COUP DE POUCE POUR VOS COURSES

PARLEZ-EN-AUTOUR DE VOUS!

Faites profiter du Programme Malin à vos amis et connaissances!

Donnez leur l’adresse du site internet : www.programme-malin.com et dites leur qu’ils peuvent s’inscrire en quelques clics via la page « je m’inscris »

D’autres recettes sur le site, ici

Les bons de réduction du Programme Malin sont utilisables partout

Ils sont acceptés dans tous les supermarchés, près de chez vous, petits et grands. Si vous avez eu un soucis en caisse, n'hésitez pas à nous écrire, en cliquant ici

L’été avec le Programme Malin

29 Juillet

Groupe 6

4 newsletters Malin sur 2 mois

MailGroup 6 (cont.)

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RECETTES D’ETE POUR BEBE

Faites la même recette, pour vous et pour bébé !

Avec des courgettes, des tomates et des aubergines par exemple, faites une bonne ratatouille

D’autres recettes sur le site, ici

L’été avec le Programme Malin

12 Août

Groupe 6

4 newsletters Malin sur 2 mois

Mail

Les bons de réduction sont valables sur du lait, de la Blédine, des petits-pots, des Blédichef et de la compote.

Pour le lait et la Blédine, 1 bon = 1 produit

Pour les petits pots, les assiettes et la compote, 1 bon = 2 produits

Les légumes sont meilleurs de saison et ils coutent alors moins chers !

Vous trouverez un calendrier des légumes de saison sur le site du Programme Malin. Tous les détails, ici !

Group 6 (cont.)

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RECETTES D’ETE POUR BEBE

Profitez des légumes d ’été pour faire de bons petits platsAvec des aubergines par exemple, vous pouvez réaliser une bonne terrine pour vous et pour bébé

D’autres recettes sur le site, ici

L’été avec le Programme Malin

26 Août

Groupe 6

4 newsletters Malin sur 2 mois

Mail

DES REPÈRES POUR LES REPAS DE BÉBÉ

Selon l’âge de votre enfant, consultez les menus type sur le site

UN COUP DE POUCE POUR VOS COURSESLes bons de réduction vous sont envoyés tous les 3/4 mois, à partir des 6 mois de votre bébé.

Ils vous sont envoyés automatiquement,

vous n’avez rien à faire.

Vous les recevrez donc au 6, 9, 12, 16 et

20 mois de votre enfant. Si vous avez

reçu les premiers, soyez patients vous

recevrez les autres aussi !

Des repères simples pour vous inspirer avec ce menu type préparé pour vous par l’équipe du Programme et ses pédiatres.Pour les 6-12 mois par exemple, c’est ici

Group 6 (cont.)

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Des bons de réduction pour acheter des aliments adaptés à bébé dans n’importe quel supermarché

Ci-joint un petit mémo pour savoir comment les utiliser.

Bonjour

Vous êtes inscrit au Programme MALIN !

Mais MALIN c’est quoi déjà ?

C’est aussi tout savoir sur les repas de bébé grâce à notre site Internet:

www.programme‐malin.com !

Vous y trouverez plein de recettes, astuces en vidéo et des conseils facileset pas cher pour l’alimentation de votre bébé.

Le + : Vous y trouverez également des contacts de professionnels près de

chez vous pour recevoir des conseils et des guides pratiques, échanger entre

parents et poser vos questions

Des questions sur le Programme ?

N’hésitez pas à nous écrire à programme.malin@gmail.com

L’équipe du Programme Malin vous souhaite un bel été

Groupe 7(témoin du 3,4,5

et 6)

Intro

Mail

Des conseils,

recettes et

contacts

Des bons

de réduction

Group 7

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Execution

• Groups 1 and 2: Mailings were sent by mail on 28th of July 2015

• Group 3: Email with emphasis on annual savings was sent on 27/07

• Group 4: Email with emphasis on montly savings was sent on 27/07

• Group 5: Email with support offer was sent on 27/07

• Group 6: Newsletters were sent by email on 15/07; 29/07; 12/08; 26/08

• Group 7: Control email was sent on 21/07

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Design choices

• Stratify group along a number of criteria:• Age of the child, location, prescriber/internet, ...

(we don’t have information about the ethnic background of the mother –apparently it is prohibited to ask this in France)

• Outcome variables• Utilization of vouchers during 6 month period following the interventions.

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Verify random assignment

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Table 1: Sumary statistics

Mailing Email Plan Control Annual Monthly Support Reminder Control Variables Demographic Infant age 12.47

(3.47) 12.26 (3.64)

11.16 (3.69)

11.05 (3.67)

11.21 (3.62)

11.27 (3.65)

11.31 (3.77)

% Nantes 0.45 (0.49)

0.45 (0.49)

0.6 (0.49)

0.6 (0.49)

0.59 (0.49)

0.6 (0.49)

0.6 (0.49)

% Grenoble 0.14 (0.35)

0.13 (0.33)

0.19 (0.39)

0.18 (0.39)

0;18 (0.39)

0.19 (0.39)

0.19 (0.39)

% registerd via PMI

73.10 74.31 18.80 18.05 18.18 17.42 16.67

% registered online

0 0 64.66 64.66 63.64 64.39 64.30

Engagement Days enrolled

179.4 (115.50)

176.16 (120.73)

88.07 (95.81)

90.95 (106.51)

99.19 (119.54)

97.2 (109;22)

95.03 (105.1)

% used at least once (May)

0.35 (0.48)

0.36 (0.48)

0.2 (0.4)

0.38 (0.49)

0.29 (0.46)

0.31 (0.47)

0.38 (0.49)

Number of vouchers sent as of end of June

69.69 (21.11)

70.53 (22.45)

54.73 (19.47)

54.54 (21.00)

55.48 (20.58)

55.98 (19.93)

56.12 (21.24)

N 145 144 133 133 133 132 132

Notes: N= 751 Households

Results

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Table 2: Change in Reach

Mailing Email Plan Control Annual Monthly Support Reminder Control Dependent Variables

Demographic % used at least once (May)

0.35 (0.48)

0.36 (0.48)

0.2 (0.4)

0.38 (0.49)

0.29 (0.46)

0.31 (0.47)

0.38 (0.49)

% used at least once (November)

0.61* (0.49)

0.54 (0.49)

0.67 (0.46)

0.68* (0.47)

0.66 (0.47)

0.72** (0.45)

0.58 0.49

N 145 144 133 133 133 132 132

Notes: p-value in parentheses. *p<0.10, **p<0.05, ***p<0.01.

Conclusion

• Classic economic perspective: People do not utilize a particular because they do not utilize a service because the benefits don’t weigh up against the costs. He/she doesn’t want to.

• Our intuitions—and those in economic models—overlook many of the important things that make people tick.

• Behavioral perspective: Contextual/situational/behavioral factors, can explain why someone fails to follow through on his/her intentions.

• Consequential: how we understand/diagnose a problem, how we design programs/solutions to problems…

Next steps

• Looking to collaborate with CAF (Loire Atlantique) to extend and further enrich these preliminary findings.

• Robustness

• Underlying mechanisms?

• Contrast with other triggers: social forces?

• Possibilities in Belgium

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