Application of the Integrated Behavior Model to Explain and Promote Uptake of Modern Family Planning Methods Among Married Women of Reproductive Age in Rural Areas of Punjab, Pakistan: The IRADA Project
Open AccessDespite a reported desire to regulate fertility, there is low adoption of modern family planning methods by women in rural Pakistan. The country has high rates of unintended pregnancies with the widespread use of induced abortions as a family planning method. The current landscape highlights a persistent inability of family planning programs to convert latent demand for family planning into modern contraceptive use. Despite documented challenges to women’s agency for family planning, programs have not considered adoption of empowerment education approaches for increasing family planning uptake. Unfortunately, the role of behavior change theory in informing effective behavior change programs has not been fully recognized by family planning researchers and programmers in Pakistan. Cross-cultural application of western-oriented theories in eastern contexts has been cited as an impediment. Also documented are methodological challenges of cross-cultural psychometric research, particularly across languages. Another impediment is the notion that scientifically rigorous, theory-driven empirical research to inform behavior change intervention design and evaluation is prohibitively resource-intensive for family planning programs. The dissertation applies the Integrated Behavior Model (IBM) to explain the adoption of modern family planning births to space birth by rural Pakistan women. The theorized model for Pakistan (referred to as the IRADA model in this dissertation) was applied, tested, and validated to identify culturally congruent psycho-social drivers for a behavior change intervention with the same name (referred to as the IRADA intervention herein). The intervention tested the effectiveness of participatory health education tools in creating favorable shifts in empirically supported psycho-social drivers of modern family planning among the target audience. The present dissertation describes the results of this effort as three discrete studies embedded within a donor-funded, private-sector social franchise program for family planning services in rural areas, implemented by a local NGO in Pakistan. Study 1 describes the application of the Integrated Behavior Model (IBM) to develop and validate psychometric scales for measuring psycho-social constructs hypothesized by IBM to predict intention to use and adoption of modern family planning methods. An initial pool of 55 items for measuring IBM constructs was developed through formative research and subjected to factor analytic techniques to identify and validate a seven-factor model with 23 items measuring intention (3 items), perceived value (3 items), perceived health risk (3 items), injunctive norms (4 items), personal agency (3 items), perceived control (3 items), and self-efficacy (3 items). Challenges related to cross-cultural application of theory, conceptualizing constructs across cultures, and developing scales for measurement are discussed. Study 2 applies structural equation modeling to the measurement scales from study 1 to test and validate the IRADA behavior change model for predicting intention and adoption of modern family planning methods for spacing births, by women in Pakistan. The results validate an IBM-aligned, five-factor model with intention as the primary predictor of modern method use. Intention was predicted by perceived value and personal agency. Perceived health risk was an inverse predictor of perceived value, and injunctive norms predicted perceived value and personal agency. The IRADA model demonstrated theoretical sufficiency and explained 71.5% of the total variance in the adoption of any modern method, 91% of the total variance in the adoption of a LARC method, and 34.9% of the total variance in the adoption of a short-term method. Study 3 presents the application of the IBM-informed, IRADA model to design a behavior change intervention that built on and strengthened an established social franchise program with a voucher program for LARC services and referral cards for subsidized short term contraceptive methods. The voucher enabled free access to insertion of a LARC method, follow-up, and removal of LARC if relevant at a private clinic which was Social Franchised by an NGO. The IRADA intervention used a structured, theory-informed approach and trained field workers to use participatory reflection and analysis tools in interpersonal settings to create a favorable shift in women’s psycho-social predictors of modern family planning use. The IRADA intervention was implemented for a period of three months. Effectiveness in promoting modern method adoption using the IRADA approach was compared to the conventional approach to health education comprising non-participatory marketing of family planning services to women. Results of this quasi-experimental study with two intervention groups indicated that IRADA was more successful in reaching a greater number of women and delivering greater levels of exposure to the intervention. Although both approaches were equally effective in promoting uptake; approximately 20% in each arm adopted a modern method in both study arms, multinomial logistic regression controlling for clustering effects, psychosocial factors, and background characteristics at baseline, indicated that women who were exposed to the IRADA approach were 2.4 times relatively more likely to adopt a LARC method compared to women exposed to the traditional marketing approach, with no method adoption as the base outcome. This dissertation establishes conceptual and methodological precedence for undertaking rigorous developmental work in behavior change for family planning in Pakistan. Results support the applicability of IBM in Pakistan’s context, and the dissertation provides a methodological roadmap for undertaking rigorous research into family planning behaviors. The results also demonstrate that behavior change programs for family planning in Pakistan can potentially garner greater returns on investment by training field health educators to use simple participatory health education tools linked to theory informed, and evidence-based psychosocial drivers of modern family planning use.
- All rights reserved
Notice to Authors
If you are the author of this work and you have any questions about the information on this page, please use the Contact form to get in touch with us.