Investigating Pakistan's Contraception Rate Plateau: a Multilevel Analysis
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University of South Florida Scholar Commons Graduate Theses and Dissertations Graduate School 3-29-2016 Investigating Pakistan’s Contraception Rate Plateau: A Multilevel Analysis to Understand the Association between Community Contextual Factors and Modern Contraception Use Mahmooda Khaliq Pasha University of South Florida, [email protected] Follow this and additional works at: http://scholarcommons.usf.edu/etd Part of the Epidemiology Commons, and the Other Social and Behavioral Sciences Commons Scholar Commons Citation Pasha, Mahmooda Khaliq, "Investigating Pakistan’s Contraception Rate Plateau: A Multilevel Analysis to Understand the Association between Community Contextual Factors and Modern Contraception Use" (2016). Graduate Theses and Dissertations. http://scholarcommons.usf.edu/etd/6348 This Thesis is brought to you for free and open access by the Graduate School at Scholar Commons. It has been accepted for inclusion in Graduate Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. Investigating Pakistan’s Contraception Rate Plateau: A Multilevel Analysis to Understand the Association between Community Contextual Factors and Modern Contraception Use. by Mahmooda Khaliq Pasha A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Community and Family Health College of Public Health University of South Florida Major Professor: Carol Bryant, Ph.D. Roger Boothroyd, Ph.D. William Sappenfield, MD, MPH Linda Whiteford, Ph.D., MPH Date of Approval: April 7, 2016 Keywords: Reproductive Health, Multilevel Modeling, Social Epidemiology, Pakistan Copyright © 2016, Mahmooda Khaliq Pasha TABLE OF CONTENTS LIST OF TABLES vi LIST OF FIGURES vii ABSTRACT viii CHAPTER 1 INTRODUCTION 1 Problem and Significance 2 Contraception use 2 Role of physical and social environment 3 Need for research on community context 3 Purpose of Study 5 Community context and South Asia 5 Pakistan 6 Research Questions 8 The CSDH Framework 9 Determinants of Fertility Framework (DFF) 9 Definition of Terms 11 CHAPTER 2 LITERATURE REVIEW 13 Individual and Household Level 13 Individual level 13 Age 14 Education 14 Employment 16 Parity 16 Beliefs about contraception 17 Interpersonal level 18 Husband-wife relationship 18 Proximity of spouse 19 In-laws’ perception 20 Desired family size 20 Perception of community norms 21 Community level 21 Region of residence 22 Wealth 22 Access/quality of services 22 Religion 23 Contextual level 24 Culture 25 Son preference 26 Grandmother taboo 27 i Gender norms and role of women 27 Sexual empowerment 28 Domestic violence 28 Media 29 Research on Community Context and Modern Contraception Use 30 Community approval 30 Community education 30 Community parity 31 Theoretical Framework 31 Frameworks used to study community context 32 Demographic Transition Theory 33 New Home Economies and Easternlin Framework 33 Ideation/Diffusion-of-Innovation Theory 34 Need for a conceptual framework that is contextual, multilevel and Comparative 35 Study purpose and conceptual framework 36 Commission on Social Determinants of Health conceptual framework (CSDH) 36 Socio-Economic and Political Context 39 Structural Determinants 39 Social position and social class 39 Intermediary Determinants of Health 40 Bongaarts Determinants of Fertility Framework 40 Conceptual framework for community context and modern contraception use 42 Advantages and disadvantages of framing research question using CSDH and DFF 43 CHAPTER 3 METHODOLOGY 45 Purpose of Study 45 Research Design 45 Multilevel Modeling 47 Limitations 49 Instrument – Pakistan Demographic Health Survey 49 Demographic Health Survey 51 DHS question domains 51 DHS questionnaires 52 Implementation 53 DHS Sampling 53 DHS analysis/dissemination 54 Study Sample 54 Sampling frame 55 Variables 57 Dependent variables 57 Independent variables 57 Research question 1 & 2 60 Socio-Economic and Political Context 61 ii Research question 1 61 Research question 2 61 Research question 3 & 4 61 Social position 61 Income 62 Education 62 Occupation 62 Social Class 62 Gender 62 Race/ethnicity 63 Research question 5 63 Health system 63 Community level variables 63 Inclusion/exclusion criteria 65 Limitations 65 Conceptual framework 65 Community level variables 66 Secondary data 66 Data Analysis 68 Modeling Structure 69 Explained variance 70 Estimation 71 Model evaluation and assumption 71 Analysis software 71 Ethical considerations 71 CHAPTER 4 RESULT 72 Background Characteristics of Individual and Community 72 Individual background characteristics 72 Community background characteristics 74 Research question 1 – Economic and public policy 74 Research question 2 – Cultural/societal norms and values 75 Research question 3 – Social position 76 Research question 4 – Social class 76 Research question 5 – Health system 77 Modern Contraception Use by Women’s Background Characteristics 79 Multilevel Analysis Results 80 Individual Level Characteristics (Model 1) 81 Model one explained variance 82 Community Level Characteristics (Model 2-6) 82 Socioeconomic/Political Context 82 Research question 1 – Economic and public policy (Model 2) 82 Research question 2 – Cultural/societal norms and values (Model 2) 83 Model 2 explained variance 83 Research question 3 – Social position (Model 3) 84 Model 3 explained variance 84 iii Research question 4 – Social class (Model4) 84 Model 4 explained variance 86 Research question 5 – Health system (Model 5) 86 Model 5 explained variance 87 Community contextual factors association with modern contraception use (Model 6) 87 Model 6 explained variance 88 CHAPTER 5 DISCUSSION 92 Policy and Women’s Autonomy Related Variables Key 92 Public policy 93 Public policy as defined by access to health system 94 Economic policy as influenced by region of residence 94 Women’s autonomy as defined by social position and social class 96 Empowerment and ability to make decision 96 Community allow woman to choose spouse and ownership 97 Future research on policy and autonomy needed 98 Placing Findings within Existing Literature 100 Individual level (Level 1) 100 Age 100 Education 101 Wealth 101 Parity 101 Community level (Level 2) 102 Community exposure to family planning messaging 102 Community preference for gender 102 Community wealth 103 Community women’s education 103 Community empowerment 103 Community women have a say in choosing husband 104 Community visit to health facility or service outlets Providing family planning services 104 Community contextual factors not investigated in this study 105 Strengths/Limitations 105 Theoretical strength 105 Methodological strengths 106 Strength in using secondary data 107 Limitations 107 Theoretical framework 107 Methodological 108 Secondary data 108 Weak community effects 108 Implications 109 Contribution to public health 109 Contribution to Pakistan 110 Research findings shape program and policy 112 iv Dissemination 113 Creation of community level variables for surveys 114 Conclusion 117 REFERENCES 118 APPENDIX A INSTITUTIONAL REVIEW BOARD APPROVAL 132 v LIST OF TABLES Table 1 Terms and Acronyms 12 Table 2 Type of Studies 46 Table 3 Demographic Health Survey Implementation Schedule 53 Table 4 Study Conceptual Framework and Independent Variables Selected from the Dataset 59 Table 5 Operational Definition of Individual and Community Level Variables 64 Table 6 Modeling Structure for Data Analysis 70 Table 7 Background characteristics of married women of reproductive age (15-49) in Pakistan 73 Table 8 Description of community variables in Pakistan 77 Table 9 Distribution of modern contraception use in Pakistan according to background Characteristics 80 Table 10 Summary of multilevel models studied 89 vi LIST OF FIGURES Figure 1 Conceptual framework guiding study 10 Figure 2 Commission on Social Determinants of Health Conceptual Framework 38 Figure 3 Determinants of Fertility Framework 42 Figure 4 Map of Pakistan with survey administration information 56 Figure 5 Conceptual framework for study with selected variables from dataset 58 vii ABSTRACT South Asia has the highest absolute number of women with an unmet need for contraception in the world. The total number of women with unmet need is 142 million. Of this, Asia accounts for 84 million followed by Sub-Saharan Africa at 32 million. Within South Asia, some countries have seen unmet need decrease and the contraception rate increase; however, Pakistan remains the exception to the rule. Pakistan has a low rate of contraception use, high rate of contraception discontinuation, high unmet need and high rate of unwanted fertility. A number of theories have hypothesized that community-level factors influence a couple’s fertility decisions. Yet until recently, studies of contraceptive use dynamics have focused on individual and household-level determinants. Within Pakistan, this focus on individual and household level has not been able to explain the changes in use, which goes beyond socio-economic and cultural boundaries. As a result, there is impetus on researchers to shift focus and look at the interaction between and within the individual and the community. This study aims to address this gap in the literature by examining the association between community contextual factors and modern contraception use in a developing country using multilevel modeling. The Commission on Social Determinants of Health and the Determinants of Fertility framework were used to test five research questions,