Barriers to family planning use amongst the urban poor in Pakistan

This paper examines the determinants of family planning service use and the barriers in accessing family planning services among urban poor women in Pakistan. Data were collected from a household survey of 5338 married women of reproductive age (15-45) from slum areas of six cities.The use of family planning services by women in urban slums is strongly linked to individual and household socioeconomic factors. In particular, women were ten times more likely to have used a family planning service if her husband approved. This research has highlighted two key issues regarding the provision of family planning services to the urban poor. First, the urban poor cannot be treated as a homogenous group; there exist important socio-demographic variations within the urban poor population in relation to their use of family planning services and the barriers faced in service utilization. Second, although the urban poor are both economically and physicallydisadvantaged in access to services, women identified socio-cultural factors as the greatest barrier to family planning service use. This finding is consistent with studies focusing on the general population of Pakistan

Giving voice to the ‘silent majority’

"There appears to be a widespread assumption that there is a ‘silent majority’ of people who support proposals but do not make submissions, and that those who do make submissions tend to be opposed and therefore do not reflect the true state of public opinion. The New Zealand Wind Energy Association (a membership-based wind industry association) suggested that it would be useful to examine whether this was actually the case, in respect to wind farms in particular. As researchers we were also interested in the broader question of why non-submitters might not be participating in formal planning processes, so we developed our research to address two questions: (a) how do non-submitters’ perspectives of proposed wind farms differ from those of submitters; and (b) why do nonsubmitters not make submissions? While these questions are relevant to all development proposals, wind farms are an excellent context for inquiry because they are highly visible, and thus potentially have an impact on a geographically widespread population, and because they are known to create strong feelings of support or opposition." • Janet Stephenson is a social scientist with a particular interest in societal responses to environmental challenges. She is the Director of the Centre for Sustainability at the University of Otago. Rob Lawson is in the marketing department at the University of Otago. His special area of expertise is in the study of consumer behaviour, with strong interests in the development of marketing theory. Policy Quarterly – Volume 9, Issue 1 – February 201

Impact of estimation techniques on regression analysis: an application to survey data on child nutritional status in five African countries

This paper illustrates the impact of ignoring survey design and hierarchical structure of survey data when fitting regression models. Data on child nutritional status from Ghana, Malawi, Tanzania, Zambia, and Zimbabwe are analysed using four techniques: ordinary least squares; weighted regression using standard statistical software; regression using specialist software that accounts for the survey design; and multilevel modelling. The impact of ignoring survey design on logistic and linear regression models is examined. The results show bias in estimates averaging between five and 17 per cent in linear models and between five and 22 per cent in logistic regression models. The standard errors are also under-estimated by up to 49 per cent in some countries. Socio-economic variables and service utilisation variables are poorly estimated when the survey design is ignored

Exploring the Impact of Targeted Distribution of Free Bed Nets on Households Bed Net Ownership, Socio-Economic Disparities and Childhood Malaria Infection Rates: Analysis of National Malaria Survey Data from three Sub-Saharan Africa countries.

The last decade has witnessed increased funding for malaria control. Malaria experts have used the opportunity to advocate for rollout of such interventions as free bed nets. A free bed net distribution strategy is seen as the quickest way to improve coverage of effective malaria control tools especially among poorest communities. Evidence to support this claim is however, sparse. This study explored the effectiveness of targeted free bed net distribution strategy in achieving equity in terms of ownership and use of bed nets and also reduction of malaria prevalence among children under-five years of age. National malaria indicator survey (MIS) data from Angola, Tanzania and Uganda was used in the analysis. Hierarchical multilevel logistic regression models were used to analyse the relationship between variables of interest. Outcome variables were defined as: childhood test-confirmed malaria infections, household ownership of any mosquito net and children's use of any mosquito nets. Marginal effects of having free bed net distribution on households with different wealth status were calculated. Angolan children from wealthier households were 6.4 percentage points less likely to be parasitaemic than those in poorest households, whereas those from Tanzania and Uganda were less likely to test malaria positive by 7 and 11.6 percentage points respectively (p < 0.001). The study estimates and present results on the marginal effects based on the impact of free bed net distribution on children's malaria status given their socio-economic background. Poorest households were less likely to own a net by 21.4% in Tanzania, and 2.8% in Uganda, whereas both poorer and wealthier Angolan households almost achieved parity in bed net ownership (p < 0.001). Wealthier households had a higher margin of using nets than poorest people in both Tanzania and Uganda by 11.4% and 3.9% respectively. However, the poorest household in Angola had a 6.1% net use advantage over children in wealthier households (p < 0.001). This is the first study to use nationally representative data to explore inequalities in bed net ownership and related consequences on childhood malaria infection rates across different countries. While targeted distribution of free bed nets improved overall bed net ownership, it did not overcome ownership inequalities as measured by household socioeconomic status. Use of bed nets was disproportionately lower among poorest children, except for Angola where bed net use was higher among poorest households when compared to children in wealthier households. The study highlights the need for malaria control world governing bodies and policy makers to continue working on finding appropriate strategies to improve access to effective malaria control tools especially by the poorest who often times bears the brunt of malaria burden than their wealthier counterparts

Energy cultures: A framework for understanding energy behaviours

Achieving a ‘step-change’ in energy efficiency behaviours will require enhanced knowledge of behavioural drivers, and translation of this knowledge into successful intervention programmes. The ‘Energy Cultures’ conceptual framework aims to assist in understanding the factors that influence energy consumption behaviour, and to help identify opportunities for behaviour change. Building on a history of attempts to offer multi-disciplinary integrating models of energy behaviour, we take a culture-based approach to behaviour, while drawing also from lifestyles and systems thinking. The framework provides a structure for addressing the problem of multiple interpretations of ‘behaviour’ by suggesting that it is influenced by the interactions between cognitive norms, energy practices and material culture. The Energy Cultures framework is discussed in the context of a New Zealand case study, which demonstrates its development and application. It has already provided a basis for cross-disciplinary collaboration, and for multi-disciplinary research design, and has provided insights into behavioural change in a case study community. As the conceptual basis of a 3-year research project, the framework has further potential to identify clusters of ‘energy cultures’ – similar patterns of norms, practices and/or material culture – to enable the crafting of targeted actions to achieve behaviour change

Dyadic Characteristics and Intimate Partner Violence among Men Who Have Sex with Men.

OBJECTIVE: Although the research community has begun to recognize intimate partner violence (IPV) as an important issue in same-sex relationships, there has been a lack of attention to characteristics of these relationships that may be associated with IPV. In particular, there has been a lack of attention paid to the associations between dyadic characteristics and IPV in same-sex relationships. This paper examined associations between dyadic characteristics, including relationship satisfaction, communal coping and efficacy, and perpetrating and experiencing IPV among a sample of United States men who have sex with men (MSM). METHODS: We collected data via an online survey with 528 MSM, who were greater than 18 years of age and reported at least one male sex partner in the last 12 months. The analysis examined dyadic factors associated with reporting of experiencing and perpetrating emotional violence, physical violence, and sexual violence. RESULTS: The prevalence of violence in the sample ranged from nine percent reporting perpetrating sexual violence to 33% of men reporting experiencing emotional violence. MSM who reported greater satisfaction with their relationship or who reported a higher degree of concordance with their partner on lifestyle choices were less likely to report experiencing or perpetrating emotional violence. MSM who perceived a stigma to being in a male same-sex couple were less likely to report experiencing or perpetrating sexual violence. CONCLUSION: The results presented here demonstrate high levels of IPV among MSM and that dyadic characteristics are associated with the occurrence of IPV. Understanding relationship characteristics associated with increased IPV among same-sex male couples can contribute to the development of more accurate IPV screening tools, and more sensitively and appropriately designed intervention messages

Behaviour change techniques in brief interventions to prevent HIV, STI and unintended pregnancies : a systematic review

Background : Behaviour-change interventions have been consistently considered an essential part of comprehensive HIV, STI and unintended pregnancy prevention. In 2015, the World Health Organization reviewed and assessed existing evidence on brief behavioural interventions, leading to the publication of Brief sexuality-related communication: recommendations for a public health approach. This guideline recommends the use of brief behaviour intervention and communication programmes to promote sexual health and to prevent HIV, STIs, and unintended pregnancies in primary health services, particularly sexual and reproductive health services. Objective : With the purpose of informing the development of a brief behaviour intervention in sexual and reproductive health, we conducted a systematic review of brief intervention to prevent HIV, STI and unintended pregnancies, to identify behaviour change techniques (BCTs) used in health care settings. Methods : Participants from all ages and genders were included. Brief interventions delivered in <= 60 minutes were included. Data was extracted, and interventions were coded following the Behaviour Change Techniques Taxonomy (BCTTv1) guidelines. Results : Of the 6.687 articles identified, 355 were reviewed and 37 studies were included. In effective interventions, we identified 48 behaviour change techniques (BCTs). A core set of 8 frequently used behaviour change techniques was identified: "Problem solving", "Feedback on behaviour", "Social support (unspecified)", "Instructions on how to perform the behaviour", "Information about health consequences", "Information about social and environmental consequences", "Demonstration of the behaviour" and "Credible source". Conclusions : The technical content of brief behaviour interventions was identified in a reliable and standardized way providing preliminary indications on potentially effective techniques to achieve behaviour change

A positive deviance approach to understanding HIV risk and testing

Session presented on Sunday, September 18, 2016: Applied to HIV testing, positive deviants would be men who test routinely for HIV in an environment of low testing and where cultural norms are against testing. In this study we analyze Demographic Health Survey (DHS) data from six African countries; Cameroon, Ghana, Malawi, Lesotho, Swaziland and Zambia were selected to represent environments with differing levels of HIV prevalence

How communities shape unmet need for modern contraception: An analysis of 44 low-and middle-income countries

Session presented on Thursday, July 21, 2016 and Friday, July 22, 2016: Background: Access to modern contraception and its resulting decline in fertility is associated with reduced poverty, improved health outcomes for women, and gains in female empowerment. However, fewer than 40% of women in the least-developed countries are currently using any method of modern contraception. As a result, fertility rates are higher in Low and Middle Income Countries (LMICs) than in developed countries and declining rates of fertility in the second half of the 20th century have slowed or stalled in many LMICs- especially those in sub-Saharan Africa. Despite worldwide efforts to increase access to modern pharmacological methods of family planning, less than half of the total demand for family planning was met by modern methods in 2015 in 54 of the world\u27s poorest countries. Unmet Need, a measure of the disparity between a partnered, fecund woman\u27s desire for modern family planning and her use of contraception, is a useful indicator in tracking progress towards universal access to family planning. Unmet need consists of two components- unmet need for spacing and unmet need for limiting. Having an unmet need for limiting occurs when a woman wants to increase the interval between her births but is not using modern contraception, while the latter is present when a woman wants to stop having children altogether, but is not using modern contraception. While the individual-level drivers of unmet need are well documented, there is little data on how community-level characteristics influence this important indicator. To explore this, we created a comprehensive dataset of parous women from the 44 Demographic and Health Surveys (DHS) published since 2010 (n=528,101). We analyzed the influence of 13 community-level variables on unmet need as a whole and for its two components, unmet need for spacing and unmet need for limiting, as outcome variables. We then repeated the analysis, stratifying countries by low, medium, and high total fertility rate (TFR) to determine if the effect of community-level variables change with TFR. This is the first multi-country analysis that examines how community-level factors shape unmet need in resource-constrained settings. Methods: Data: This analysis utilized data from the women\u27s questionnaire of all 44 Demographic and Health Surveys collected in or after 2010. The initial sample for this study contained all women ages 15-49 from the 44 countries studied (n=721, 539). Nulliparous women do not answer DHS questions related to fertility and childbirth, 193,438 childless respondents were removed from the sample, resulting in a final sample of 528,101 pregnant, postpartum-amenorrheic, and/or parous women across five WHO regions. Three outcome variables were considered: total unmet need, unmet need for spacing, and unmet need for limiting. All are binary variables coded one for total unmet need, unmet need for limiting, or unmet need for spacing. Community-level variables were categorized into four domains: 1) community demographics and fertility norms consisting of five variables: the mean age at marriage for women in the community, mean age at first intercourse for women in the community, mean age at first birth for women in the community, mean ideal of number of children each woman would have in the community, and gender composition of the children in the community; 2) community economic prosperity, measured by the mean household wealth index score for each PSU; 3) community gender norms and inequities, measured by the mean community violence justification index score, mean community decision-making autonomy score, proportion of women in the community with at least a primary education, proportion of men in the community with at least a primary education, and ratio of men to women employed in the community; and 4) health literacy and media exposure, measured by the mean community HIV knowledge index score and mean exposure to family planning media messages in the community. Analysis: A multilevel modeling approach was used to account for the hierarchical nature of DHS data and allow for the observation of community-level influences on unmet need for family planning. The PSU was included as the only random effect term. This allowed the intercept to vary across communities and provided a measure of the extent to which the odds of reporting unmet need, unmet need for spacing, and unmet need for limiting varied between PSUs. After controlling for individual and household-level factors known from the literature to influence contraceptive use, the 13 community-level covariates were added. Identical models for unmet need, unmet need for spacing, and unmet need for limiting were fitted using STATA 14. To assess whether the role of community-level effects on unmet need varies with fertility, the countries were then stratified by total fertility rate (TFR) and divided into Low, Medium, and High countries using UN data of TFR. Separate random effects logistic regression models were fitted for total unmet need, unmet need for limiting and unmet need for spacing in in each group of country (low, medium and high fertility). In total, 12 random-effects multiple logistic regression models were produced to examine the effect of community-level variables on unmet need for family planning in the study sample. Results: Results indicate that unmet need is significantly influenced by community-level variables in all three models (Unmet Need: SE=0.008, ?_\u27=0.148, PSU random intercept= 0.13, (95% CI: 0.08-0.21); p\u3c0.000; Spacing: SE= 0.008, ?_\u27=0.140, PSU random intercept= 0.10, (95% CI: 0.05-0.19); p=\u3c.000; Limiting: SE= 0.010, ?_\u27=151, PSU random intercept= 0.01, (95% CI: 0.00-0.02); p\u3c0.000). These models measure the variation in unmet need, unmet need for spacing, and unmet need for limiting between communities which is not explained by any of the included fixed effects. While the models themselves are significant, they indicate substantial unobserved heterogeneity in the determination of unmet need in the study sample. The effect size and directionality of community variables in all four domains changed significantly by TFR. For example, while residing in a community with a higher average age of cohabitation was associated with reduced odds of having total unmet need and unmet need for limiting in the 44-nation sample, it was associated with increased odds of total unmet need and unmet need for spacing in high fertility countries (unmet need: OR: 1.12, (95% CI: 1.02-1.23), p\u3c0.05; spacing: OR: 1.13, (95% CI: 1.01-1.27), p\u3c0.05). Conversely, communities with higher boy-girl ratios were associated with reporting increased odds of unmet need and unmet need for limiting in the larger sample, but was not significant in any of the stratified models. For economic prosperity, women in the 44-nation sample who resided in wealthier-than-average communities reported more unmet need for limiting, increased community wealth was associated with reduced odds of unmet need, unmet need for spacing and unmet need for limiting in low fertility countries (unmet need: OR: 0.86, (95% CI: 0.81-0.92), p\u3c0.000); spacing: OR: 0.85, (95% CI: 0.78-0.93), p\u3c0.000; limiting: OR: 0.88, (95% CI: 0.82-0.94), p\u3c0.000) and with reduced total unmet need in high fertility countries (OR: 0.88, (95% CI: 0.78-0.98), p\u3c0.005). concerning the domain Gender Norms and Inequalities, women in communities of higher primary education attainment reported less unmet need of all kinds in the 44-nation sample (unmet need: OR: 0.29, (95% CI: 0.24-0.36), p\u3c0.000; spacing: OR: 0.73, (95% CI: 0.56-0.99), p\u3c0.05; limiting: OR: 0.19, (95% CI: 0.15-0.25), p\u3c0.000), but this was associated with reporting more unmet need for spacing in medium fertility countries (OR: 1.83, 95% CI: 0.15-2.92), p\u3c0.05). HIV knowledge score, nested in Community Health Knowledge and Media Exposure, showed that living in communities with greater average knowledge of HIV was associated with reporting more total unmet need and unmet need for limiting (unmet need: OR: 1.10 (95% CI: 1.05-1.16), p\u3c0.000; limiting: OR: 1.12, (95% CI: 1.05-1.19), p\u3c0.000). However, higher average scores on the HIV knowledge index were associated with reporting less total unmet need in low fertility countries (OR: 0.91, (95% CI: 0.84-0.99), p\u3c0.05). Discussion: This is the first large, multi-country study of the community\u27s effect on unmet need in LMICs. Our analysis of 13 community-level variables shows that the community has a significant impact on a woman\u27s access to modern contraception. Further, it highlights that combining these indicators into four broad domains is a valid way to view their collective effects on unmet need. The change in directionality of these indicators across different contexts (defined by levels of TFR) suggests that research studies, interventions, and policies should be tailored to the community domains which have the largest effect for the target population. Nonetheless, additional studies are required to explicate the mechanisms underlying the relationship between these community-level effects and unmet need, unmet need for spacing, and unmet need for limiting. This information is critical to accelerating progress towards universal access to family planning and reproductive health services in Low and Middle Income Countries