Publications by authors named "Sohail Agha"

41 Publications

How Donors Can Collaborate to Improve Reach, Quality, and Impact in Social and Behavior Change for Health.

Glob Health Sci Pract 2021 06 30;9(2):246-253. Epub 2021 Jun 30.

Bill & Melinda Gates Foundation, Seattle, WA, USA.

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http://dx.doi.org/10.9745/GHSP-D-21-00007DOI Listing
June 2021

Understanding how social norms affect modern contraceptive use.

BMC Public Health 2021 06 4;21(1):1061. Epub 2021 Jun 4.

The University of Washington, Seattle, USA.

Background: An aim of this study is to introduce a practitioner-friendly behavior model. Few theories of health behavior explicitly take the effect of social norms on behavior into account. Generally, theories that do take social norms into account assume that the effect of social norms on behavior operates through motivation. We use the Fogg Behavior Model (FBM), a behavior model that is new to public health, to explore whether social norms are associated with modern contraceptive use among Nigerian women, and whether they affect behavior through motivation or through ability. In other words, do social norms that discourage contraception lower women's motivation to use contraception or do they lower women's ability to use contraception.

Methods: This study uses data from a cross-sectional household survey of Nigerian women, ages 14-24. The survey collected data on socio-economic and demographic characteristics of women, whether they were sexually experienced, and whether they used contraception. Modern contraceptive use was the outcome of interest for the study. The survey also collected data on social norms around premarital sex and contraceptive use. Multivariate logistic regression was used for the analysis.

Results: After adjusting for a range of socio-economic and demographic variables, we found that social norms that discourage contraception had a statistically significant negative association with contraceptive use (aOR = 0.90, p < 0.001). The analysis found that the negative association between social norms and contraceptive use remained statistically significant after controlling for motivation but did not remain statistically significant after controlling for ability.

Conclusion: These findings suggest that social norms may affect contraceptive use in Nigeria through ability rather than motivation. In terms of programmatic implications, these finding suggest that public health interventions may be able to counter the negative effects of social norms that discourage contraceptive use by increasing women's ability to practice contraception.
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http://dx.doi.org/10.1186/s12889-021-11110-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178889PMC
June 2021

Using 'Theories of Change' and responsive feedback to design a digital service business for patent and proprietary medicine vendors in Nigeria.

Gates Open Res 2019 13;3:1493. Epub 2019 Jun 13.

Integrated Delivery, Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA.

In a paper titled "Responsive feedback: Towards a new paradigm to enhance intervention effectiveness", Viswanath . argue that dominant models of intervention design do not account for the complexity and unpredictability of implementation challenges.  Particularly in the behavioural sciences, intervention designs need to consider many factors that will be uncertain, or unknown, at the beginning of a new project.   This letter describes how we were able to respond to feedback during the design phase of a proof-of-concept project to create a digital service business for Nigerian patent and proprietary medicine vendors (PPMVs).  Our approach was to create an initial 'Theory of Change' (ToC) based on a similar project with Kenyan shopkeepers.  This ToC was revised following user feedback and a landscape analysis with key stakeholders.  The new ToC required us to access additional funding to create a 'digital ordering' facility for the PPMVs.  Digital ordering provides a mechanism whereby we can reduce the prevalence of counterfeit medicines, offer the PPMVs credit and group-buying facilities, and reduce supply chain costs through co-distribution with fast-moving consumer goods.  An important learning point was that while our focus was on designing a platform to meet users' needs, changes in regulation meant that we spent considerably more time than anticipated meeting the needs of multiple stakeholders. However, the importance of ensuring stakeholders' continued buy-in cannot be underestimated and has likely increased the sustainability of the project in the longer term.  As Viswanath . suggest, for responsive approaches to be widely adopted needs more flexibility than exists in current funding models and project plans.  Both funding bodies and grantees will need to be more responsive to feedback coming from the field.
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http://dx.doi.org/10.12688/gatesopenres.13028.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993493PMC
June 2019

An illustration of how responsive feedback in a social marketing tobacco control intervention in Ghana enabled managers to make decisions that increased intervention effectiveness.

Gates Open Res 2019 9;3:1534. Epub 2019 Sep 9.

Global Policy and Advocacy, The Bill & Melinda Gates Foundation, Seattle, Washington, 98040, USA.

This report illustrates how a feedback loop, set up to provide data and insights to a donor and designers/implementers of a social marketing tobacco prevention intervention in Ghana, helped adapt the original design of the intervention to one that was more suited to the social and media contexts of Ghana. The designers/implementers had previously, successfully implemented a tobacco control intervention with adolescents in Botswana. This experience had informed the initial intervention design in Ghana. As the feedback generated by evaluators started demonstrating just how different the Ghanaian social and media contexts were from the Botswanan one, implementers started making changes to their selection of channels, resulting in a design which was quite different from the original one. The close involvement of the donor in this process enabled implementers to make rapid changes to the design of the intervention. This illustration adds to a small but growing literature establishing the importance of feedback loops to improve the design and implementation of development interventions.
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http://dx.doi.org/10.12688/gatesopenres.13062.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904888PMC
September 2019

Quality of labor and birth care in Sindh Province, Pakistan: Findings from direct observations at health facilities.

PLoS One 2019 17;14(10):e0223701. Epub 2019 Oct 17.

Jhpiego, Baltimore, Maryland, United States of America.

This study presents data from the first observation of labor, childbirth and immediate newborn care in a clinical setting in Sindh, the second most populous province of Pakistan. Trained midwives observed 310 births at 126 district level referral facilities and primary health care facilities in 10 districts of Sindh where the USAID-funded Maternal Child Health Integrated Program (MCHIP) was implemented. The facility participation rate was 78%. The findings show that monitoring vital signs during the initial examination was conducted for less than one-in-ten women. Infection prevention practices were only observed for one-in-four women. Modesty was preserved for less than half of women. In spite of an absence of monitoring during the first and second stages of labor, providers augmented labor with oxytocin in two-thirds of births. To prevent post-partum hemorrhage, oxytocin was administered within a minute of birth in 51% of cases. Immediate drying of the baby was nearly universal and eight out of ten babies were wrapped in a dry towel. Newborn vital signs and the baby's weight were taken in one-in-ten cases. Breastfeeding was initiated during the first hour of birth in 18% of cases. A support-person was present during labor and birth for 90% of women. While quality of care is poor across all facilities, the provision of care at district-level referral facilities was even lower quality than at primary health care facilities. This is because dais or assistants without formal training provided labor, birth, and newborn care for 40% of deliveries during night shifts at referral facilities. This study found many examples of suboptimal practice by skilled birth attendants across all levels of health facilities. There remains an urgent need to improve quality of service provision among skilled birth attendants in Pakistan.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223701PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797184PMC
March 2020

Responsive feedback: Towards a new paradigm to enhance intervention effectiveness.

Gates Open Res 2019 28;3:781. Epub 2019 May 28.

Global Development, Bill & Melinda Gates Foundation, Seattle, WA, 98109, USA.

The current dominant models of intervention design in the development sector do not account for the complexity and unpredictability of implementation challenges. Decision makers and implementers need timely feedback during implementation to respond to field realities and to course-correct. This letter calls for a new approach of "responsive feedback" or "feedback loops" that promotes interactions between project designers, implementers, researchers and decision-makers to enable course corrections needed to achieve intended outcomes. A responsive feedback approach, in theory, should be agile, flexible, adaptive, iterative, and actionable. There can be multiple challenges associated with incorporating this approach into practice including donor requirements, organizational structure and culture, concerns about the additional time required to adopt such an approach, resource and operational constraints, the absence of skill sets needed for such an approach within smaller organizations and inadequate inter-departmental communication. However, these barriers to adaptation can be overcome. For responsive feedback to become a part of the culture of development organizations, commitment is needed from donors, decision-makers, project designers and implementers. We believe that, to generate opportunities for learning and adaptation, donors should provide the stimulus to break down silos between implementers and researchers.
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http://dx.doi.org/10.12688/gatesopenres.12937.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6480401PMC
May 2019

Use of the Fogg Behavior Model to Assess the Impact of a Social Marketing Campaign on Condom Use in Pakistan.

J Health Commun 2019 4;24(3):284-292. Epub 2019 Apr 4.

b University of Washington, Strategic Analysis, Research, and Training (START) Center , Seattle , WA , USA.

The Fogg Behavior Model (FBM) is a new framework which posits that behavior happens when three factors - motivation, ability, and a prompt - occur in the same moment. The FBM categorizes people into four groups based on motivation and ability and posits that those with high motivation and high ability will adopt a behavior when prompted. Two rounds of panel survey data from 617 married men in urban Pakistan were used to test this hypothesis. Multilevel mixed-effects logistic regression was used for the analysis. The results show the relationships between ability, motivation, the prompt and condom use to be as hypothesized by the FBM. After adjustment for a range of variables including fertility desires, education, and household wealth, the odds of condom use among men with high motivation and high ability were 34 times higher than the odds of condom use among men with low motivation and low ability. Moreover, the association between the prompt and condom use operated through increased motivation and ability. The FBM has potential for use in the design and evaluation of behavior change interventions in developing countries.
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http://dx.doi.org/10.1080/10810730.2019.1597952DOI Listing
March 2020

The timing of antenatal care initiation and the content of care in Sindh, Pakistan.

BMC Pregnancy Childbirth 2016 07 27;16(1):190. Epub 2016 Jul 27.

Jhpiego - an affiliate of Johns Hopkins University, Baltimore, Maryland, USA.

Background: Policymakers and program planners consider antenatal care (ANC) coverage to be a primary measure of improvements in maternal health. Yet, evidence from multiple countries indicates that ANC coverage has no necessary relationship with the content of services provided. This study examines the relationship between the timing of the first ANC check-up, a potential predictor of the content of services, and the provision of WHO recommended services to women during their pregnancy.

Methods: The study uses data from a representative household survey of Sindh with a sample comprising of 4,000 women aged 15-49 who had had a live birth in the two years before the survey. The survey obtained information about the elements of care provided during pregnancy, the timing of the first ANC check-up, the number of ANC visits made during the last pregnancy and women's socio-economic and demographic characteristics. Bivariate analysis was conducted to examine the relationship between the proportion of women who receive six WHO recommended services and the timing of their first ANC check-up. Multivariate analysis was conducted to identify predictors of the number of elements of care provided.

Results: While most women in Sindh (87 %) receive an ANC check-up, its timing varies by parity, education and household wealth. The median time to the first ANC check-up was 3 months for women in the richest and 7 months for women in the poorest wealth quintiles. In multivariate analysis, wealth, education, parity and age at marriage were significant predictors of the number of elements of care provided. Women who received an early ANC check-up were much more likely to receive WHO recommended services than other women, independent of a range of socio-economic and demographic variables and independent of the number of ANC visits made during pregnancy.

Conclusions: In Sindh, the timing of the first ANC check-up has an independent effect on the content of care provided to pregnant women. While it is extremely important that providers are adequately trained and motivated to provide the WHO recommended standards of care, these findings suggest that motivating women to make an early first ANC check-up may be another mechanism through which the quality of care provided may be improved. Such a focus is most likely to benefit the poorest, least educated and highest parity women. Based on these findings, we recommend that routine data collected at health facilities in Pakistan should include the month of pregnancy at the time of the first ANC check-up.
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http://dx.doi.org/10.1186/s12884-016-0979-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4962355PMC
July 2016

Quality of antenatal care and household wealth as determinants of institutional delivery in Pakistan: Results of a cross-sectional household survey.

Reprod Health 2016 Jul 19;13(1):84. Epub 2016 Jul 19.

Jhpiego, 1615 Thames St., Baltimore, MD, 21231, USA.

Background: Pakistan has a high burden of maternal and newborn mortality, which would be largely preventable through appropriate antenatal and delivery care. While the influence of socio-economic status on institutional delivery is well established in the literature, relatively little is known about the relationship between the quality of antenatal care and institutional delivery.

Methods: A household survey of 4,000 currently married women who had given birth in the two years before the survey was conducted in Sindh province in 2013. The survey collected data on socio-economic and demographic variables, the quality of antenatal care provided during a woman's last pregnancy and whether she delivered at a health facility. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals around independent variables for institutional delivery.

Results: In the multivariate analysis, a variable measuring quality of antenatal care showed the strongest association with institutional delivery. Moreover, there was a dose-response relationship between the number of elements of quality provided and the odds of institutional delivery: receiving one element of quality increased the odds of institutional delivery 1.7 times, receiving three elements increased the odds 3.8 times and receiving seven elements increased the odds 10.6 times. Household wealth had a statistically significant relationship with institutional delivery but the effect was weaker than that of quality of care. Urban-rural differentials in institutional delivery did not remain significant after adjusting for household wealth and education.

Conclusions: The quality of antenatal care provided to a woman during her pregnancy is more strongly associated with institutional delivery than household wealth. Improving the quality of care at health facilities in Sindh should be the foremost priority. Improving the quality of antenatal care services is likely to contribute to rapid increases in skilled birth attendance and better health outcomes for women and children.
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http://dx.doi.org/10.1186/s12978-016-0201-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4950643PMC
July 2016

Testing the Validity of Campaign Ad Exposure Measures: A Family Planning Media Campaign in Pakistan.

J Health Commun 2016 07 23;21(7):773-81. Epub 2016 Jun 23.

c Bill & Melinda Gates Foundation , Seattle , Washington , USA.

Although prior research has tested the nomological validity of media campaign exposure, including the related comparative validity of some measures, it has not well studied predictive validity or made extensions to other types of media campaign exposure. To help build on research in this area, the current study tested the nomological and predictive validity of 5 ad recall and recognition measures specific to the Touch condom media campaign in Pakistan. Between-effects regression of panel survey data confirmed the nomological validity of each of the 5 measures of Touch ad exposure. In addition, 2 sets of panel regression models (i.e., fixed-effects models and fixed-effects with lag models) confirmed the predictive validity of each of the 5 ad exposure measures. Results on comparative validity were quite similar for nomological and predictive validity, indicating that confirmed ad recall and recognition measures tend to have greater validity than unconfirmed measures.
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http://dx.doi.org/10.1080/10810730.2016.1157655DOI Listing
July 2016

Case Study: Effects of a Media Campaign on Breastfeeding Behaviors in Sindh Province, Pakistan.

World Health Popul 2015;16(2):39-45

Senior Program Officer, Bill & Melinda Gates Foundation, Seattle, WA, USA.

A 2013-2014 media campaign in Sindh Province, Pakistan, promoted healthy breastfeeding practices. According to data from annual household surveys, 26.7% of mothers saw one television spot and 19.4% saw another. The proportion of mothers who received breastfeeding information via television increased from 8.3% to 29.4% after the campaign (p≤0.05) and the percentage receiving information from doctors, mothers-in-law and relatives/friends nearly doubled (p≤0.05). However, no improvements in breastfeeding practices were reported. The experience in Sindh suggests that, in order to change breastfeeding practices, mass media interventions should be linked with other interventions, such as provider counseling, that involve influential family members in addition to mothers.
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http://dx.doi.org/10.12927/whp.2016.24494DOI Listing
January 2015

Estimating Causal Effects With Propensity Score Models: An Evaluation of the Touch Condom Media Campaign in Pakistan.

J Health Commun 2016 8;21(4):415-23. Epub 2016 Feb 8.

b Integrated Delivery , The Bill and Melinda Gates Foundation , Seattle , Washington , USA.

Rapid population growth in Pakistan poses major risks, including those pertinent to public health. In the context of family planning in Pakistan, the current study evaluates the Touch condom media campaign and its effects on condom-related awareness, attitudes, behavioral intention, and behavior. This evaluation relies on 3 waves of panel survey data from men married to women ages 15-49 living in urban and rural areas in Pakistan (N = 1,012): Wave 1 was March 15 to April 7, 2009; Wave 2 was August 10 to August 24, 2009; and Wave 3 was May 1 to June 13, 2010. Analysis of variance provided evidence of improvements in 10 of 11 condom-related outcomes from Wave 1 to Wave 2 and Wave 3. In addition, there was no evidence of outcome decay 1 year after the conclusion of campaign advertising dissemination. To help compensate for violating the assumption of random assignment, propensity score modeling offered evidence of the beneficial effects of confirmed Touch ad recall on each of the 11 outcomes in at least 1 of 3 time-lagged scenarios. By using these different time-lagged scenarios (i.e., from Wave 1 to Wave 2, from Wave 1 to Wave 3, and from Wave 2 to Wave 3), propensity score modeling permitted insights into how the campaign had time-variant effects on the different types of condom-related outcomes, including carryover effects of the media campaign.
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http://dx.doi.org/10.1080/10810730.2015.1095818DOI Listing
August 2016

The Role of Quality Health Services and Discussion about Birth Spacing in Postpartum Contraceptive Use in Sindh, Pakistan: A Multilevel Analysis.

PLoS One 2015 20;10(10):e0139628. Epub 2015 Oct 20.

Jhpiego/Pakistan, Karachi, Pakistan.

Introduction: Rapid population growth, stagnant contraceptive prevalence, and high unmet need for family planning present significant challenges for meeting Pakistan's national and international development goals. Although health behaviors are shaped by multiple social and environmental factors, research on contraceptive uptake in Pakistan has focused on individual and household determinants, and little attention has been given to community characteristics that may affect access to services and reproductive behavior.

Methods: Individual and community determinants of contraceptive use were identified using multivariable multilevel logistic regression to analyze data from a 2014 cross-sectional survey of 6,200 mothers in 503 communities in Sindh, Pakistan.

Results: Only 27% of women who had given birth in the two years before the study reported using contraceptives. After adjusting for individual and community characteristics, there was no difference in the odds of contraceptive use between urban and rural women. Women who had delivered at a health facility had 1.4 times higher odds of contraceptive use than women who delivered at home. Those who received information about birth spacing from a doctor or relatives/friends had 1.81 and 1.38 times higher odds of contraceptive use, respectively, than those who did not. Living in a community where a higher proportion of women received quality antenatal care and where discussion of birth spacing was more common was significantly associated with contraceptive use. Community-wide poverty lowered contraceptive use.

Conclusions: Quality of care at the community level has strong effects on contraceptive use, independent of the characteristics of individual households or women. These findings suggest that powerful gains in contraceptive use may be realized by improving the quality of antenatal care in Pakistan. Community health workers should focus on generating discussion of birth spacing in the community. Outreach efforts should target communities where the demand for contraception appears to be depressed due to high levels of poverty.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0139628PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618283PMC
June 2016

Does the antenatal care visit represent a missed opportunity for increasing contraceptive use in Pakistan? An analysis of household survey data from Sindh province.

Health Policy Plan 2016 Apr 23;31(3):325-31. Epub 2015 Jul 23.

Department of Monitoring, Evaluation and Research, Jhpiego.

During the last two decades, the use of maternal health services has increased dramatically in Pakistan, with nearly 80% of Pakistani women making an antenatal care (ANC) visit during their pregnancy. Yet, this increase in use of modern health services has not translated into significant increases in the adoption of contraception. Even though Pakistan has had a national family planning programme and policies since the 1950s, contraceptive use has increased slowly to reach only 35% in 2012-13. No evidence is currently available to demonstrate whether the utilization of maternal health services is associated with contraceptive adoption in Pakistan. This study uses data from a large-scale survey conducted in Sindh province in 2013 to examine whether ANC utilization is a significant predictor of subsequent contraceptive use among women. In an analysis which controls for a range of variables known to be important for family planning adoption, the findings show that ANC is the strongest predictor of subsequent family planning use among women in Sindh. The antenatal visit represents an enormous opportunity to promote the adoption of family planning in Pakistan. The family planning programme should ensure that high-quality family planning counselling is provided to women during their ANC visits. This approach has the potential for contributing to substantial increases in contraceptive use in Pakistan.
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http://dx.doi.org/10.1093/heapol/czv065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779145PMC
April 2016

A profile of women at the highest risk of maternal death in Pakistan.

Authors:
Sohail Agha

Health Policy Plan 2015 Sep 16;30(7):830-6. Epub 2014 Jul 16.

Jhpiego, F-79, Block 5, Clifton, Karachi, Pakistan

Traditionally, health interventions implemented in Pakistan have been designed to increase the supply of maternal health services, but have not focused on reaching the poorest women or on providing high-quality services. Demand-side barriers to the utilization of health services are substantial in Pakistan, as are supply-side constraints to the provision of quality health care. This study uses data from the Pakistan Demographic and Health Survey 2006-07 to develop a profile of the poorest women in Pakistan in order to understand demand-side barriers to accessing maternal health care. The study shows stark differences in human capital, material and demographic resources between the poorest women and other women. It illustrates how these differences translate into low levels of service utilization among the poorest women. The purpose of the study is to stimulate a discussion of both the difficulty and the importance of reaching the poorest women with high-quality maternal health interventions. The findings from several pilot projects in Pakistan suggest that the poorest women can be reached at disproportionately higher rates than non-poor women through targeted, community-based, interventions. There is little demonstrable evidence, however, that high-quality care has been provided through these interventions. Evidence-based approaches, which have the potential to overcome financial and sociocultural barriers to service utilization, should be scaled up as soon as possible. However, measures should be taken to ensure that the quality of care provided through these interventions is adequate and able to lead to significant reductions in mortality.
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http://dx.doi.org/10.1093/heapol/czu066DOI Listing
September 2015

Factors associated with HIV testing and condom use in Mozambique: implications for programs.

Authors:
Sohail Agha

Reprod Health 2012 Sep 5;9:20. Epub 2012 Sep 5.

Population Services International, 1120 19th Street, NW, Suite 600, Washington DC 20036, USA.

Background: To identify predictors of HIV testing and condom use in Mozambique.

Methods: Nationally representative survey data collected in Mozambique in 2009 was analyzed. Logistic regression analysis was used for two outcomes: HIV testing and condom use.

Results: Women at a higher risk of HIV were less likely to be tested for HIV than women at a lower risk: compared to married women, HIV testing was lower among never married women (OR = 0.37, CI: 0.25-0.54); compared to women with one lifetime partner, HIV testing was lower among women with four or more lifetime partners (OR = 0.62, CI: 0.47-0.83). Large wealth differentials were observed: compared to the poorest women, HIV testing was higher among the wealthiest women (OR = 3.03, CI: 1.96-4.68). Perceived quality of health services was an important predictor of HIV testing: HIV testing was higher among women who rated health services as being of very good quality (OR = 2.12, CI: 1.49-3.00). Type of sexual partner was the strongest predictor of condom use: condom use was higher among men who reported last sex with a girlfriend (OR = 9.75, CI: 6.81-13.97) or a casual partner (OR = 11.05, CI: 7.21-16.94). Being tested for HIV during the last two years was the only programmatic variable that predicted condom use. Interestingly, being tested for HIV more than two years ago was not associated with condom use. Frequent mass media exposure was neither associated with HIV testing nor with condom use.

Conclusions: The focus of HIV testing should shift from married women (routinely tested during antenatal care visits) to unmarried women and women with multiple sexual partners. Financial barriers to HIV testing appear to be substantial. Since HIV testing is done without a fee being charged, these barriers are presumably related to the cost of transportation to static health facilities. Mechanisms should be developed to cover the cost of transportation to health facilities. Substantially increasing community-based counseling is one way of reducing the cost of transportation. Men should be encouraged to test for HIV periodically.
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http://dx.doi.org/10.1186/1742-4755-9-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500716PMC
September 2012

Assessing a thematic condom advertising campaign on condom use in urban Pakistan.

J Health Commun 2012 24;17(5):601-23. Epub 2012 Jan 24.

Population Services International/Tulane University, Karachi, Pakistan.

This study aims to assess communication processes involving a thematic condom advertising campaign in Pakistan in 2009. To evaluate the social marketing campaign for Touch condoms, the authors conducted a nationally representative survey of 1,606 men married to women aged 15-49 years. About 15% of urban married men were aware of Touch advertising. After controlling for a range of other variables including daily television viewership, confirmed awareness of Touch advertising was associated with a higher level of belief in the effectiveness of condoms, reduced embarrassment in negotiating condom use, reduced embarrassment in purchasing condoms, increased discussion of family planning, and increased use of condoms and other contraceptive methods. The findings have implications for the further development and dissemination of contraceptive advertising in Pakistan, as well as the broader construction of scientific knowledge on how advertising can influence contraceptive and other critical health behaviors in other contexts.
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http://dx.doi.org/10.1080/10810730.2011.635768DOI Listing
August 2012

Clinical training alone is not sufficient for reducing barriers to IUD provision among private providers in Pakistan.

Reprod Health 2011 Dec 30;8:40. Epub 2011 Dec 30.

Population Services International, 1120 19th Street, NW, Suite 600, Washington, DC 20036, USA.

Background: IUD uptake remains low in Pakistan, in spite of three major efforts to introduce the IUD since the 1960s, the most recent of these being through the private sector. This study examines barriers to IUD recommendation and provision among private providers in Pakistan.

Methods: A facility-based survey was conducted among randomly selected private providers who were members of the Greenstar network and among similar providers located within 2 Kilometers. In total, 566 providers were interviewed in 54 districts of Pakistan.Logistic regression analysis was conducted to determine whether correct knowledge regarding the IUD, self-confidence in being able to insert the IUD, attitudes towards suitability of candidates for the IUD and medical safety concerns were influenced by provider type (physician vs. Lady Health Visitor), whether the provider had received clinical training in IUD insertion in the last three years, membership of the Greenstar network and experience in IUD insertion. OLS regression was used to identify predictors of provider productivity (measured by IUD insertions conducted in the month before the survey).

Results: Private providers consider women with children and in their peak reproductive years to be ideal candidates for the IUD. Women below age 19, above age 40 and nulliparous women are not considered suitable IUD candidates. Provider concerns about medical safety, side-effects and client satisfaction associated with the IUD are substantial. Providers' experience in terms of the number of IUDs inserted in their careers, appears to improve knowledge, self-confidence in the ability provide the IUD and to lower age-related attitudinal barriers towards IUD recommendation. Physicians have greater medical safety concerns about the IUD than Lady Health Visitors. Clinical training does not have a consistent positive effect on lowering barriers to IUD recommendation. Membership of the Greenstar network also has little effect on lowering these barriers. Providers' barriers to IUD recommendation significantly lower their monthly IUD insertions.

Conclusions: Technical training interventions do not reduce providers' attitudinal barriers towards IUD provision. Formative research is needed to better understand reasons for the high levels of provider barriers to IUD provision. "Non-training" interventions should be designed to lower these barriers.
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http://dx.doi.org/10.1186/1742-4755-8-40DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275525PMC
December 2011

Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention.

Authors:
Sohail Agha

Int J Equity Health 2011 Nov 30;10:57. Epub 2011 Nov 30.

Population Services International, 1120 19th Street, NW, Suite 600 Washington DC 20036, USA.

Background: Demand-side financing projects are now being implemented in many developing countries, yet evidence showing that they reach the poor is scanty.

Methods: A maternal health voucher scheme provided voucher-paid services in Jhang, a predominantly rural district of Pakistan, during 2010. A pre-test/post-test quasi-experimental design was used to assess the changes in the proportion of facility-based deliveries and related maternal health services among the poor. Household interviews were conducted with randomly selected women in the intervention and control union councils, before and after the intervention.A strong outreach model was used. Voucher promoters were given basic training in identification of poor women using the Poverty Scorecard for Pakistan, in the types of problems women could face during delivery, and in the promotion of antenatal care (ANC), institutional delivery and postnatal care (PNC). Voucher booklets valued at Rs. 4,000 ($48), including three ANC visits, a PNC visit, an institutional delivery, and a postnatal family planning visit, were sold for Rs. 100 ($1.2) to low-income women targeted by project outreach workers. Women suffering from complications were referred to emergency obstetric care services.Analysis was conducted at the bivariate and the multivariate levels. At the multivariate level, logistic regression analysis was conducted to determine whether the increase in institutional delivery was greater among poor women (defined for this study as women in the fourth or fifth quintiles) relative to non-poor women (defined for this study as women in the first quintile) in the intervention union councils compared to the control union councils.

Results: Bivariate analysis showed significant increases in the institutional delivery rate among women in the fourth or fifth wealth quintiles in the intervention union councils but no significant changes in this indicator among women in the same wealth quintiles in the control union councils. Multivariate analysis showed that the increase in institutional delivery among poor women relative to non-poor women was significantly greater in the intervention compared to the control union councils.

Conclusions: Demand-side financing projects using vouchers can be an effective way of reducing inequities in institutional delivery.
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http://dx.doi.org/10.1186/1475-9276-10-57DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3248861PMC
November 2011

Measuring client satisfaction and the quality of family planning services: a comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana.

BMC Health Serv Res 2011 Aug 24;11:203. Epub 2011 Aug 24.

Department of Global Health Systems and Development, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2200-TB46, New Orleans, Louisiana, USA.

Background: Public and private family planning providers face different incentive structures, which may affect overall quality and ultimately the acceptability of family planning for their intended clients. This analysis seeks to quantify differences in the quality of family planning (FP) services at public and private providers in three representative sub-Saharan African countries (Tanzania, Kenya and Ghana), to assess how these quality differentials impact upon FP clients' satisfaction, and to suggest how quality improvements can improve contraceptive continuation rates.

Methods: Indices of technical, structural and process measures of quality are constructed from Service Provision Assessments (SPAs) conducted in Tanzania (2006), Kenya (2004) and Ghana (2002) using direct observation of facility attributes and client-provider interactions. Marginal effects from multivariate regressions controlling for client characteristics and the multi-stage cluster sample design assess the relative importance of different measures of structural and process quality at public and private facilities on client satisfaction.

Results: Private health facilities appear to be of higher (interpersonal) process quality than public facilities but not necessarily higher technical quality in the three countries, though these differentials are considerably larger at lower level facilities (clinics, health centers, dispensaries) than at hospitals. Family planning client satisfaction, however, appears considerably higher at private facilities - both hospitals and clinics - most likely attributable to both process and structural factors such as shorter waiting times and fewer stockouts of methods and supplies.

Conclusions: Because the public sector represents the major source of family planning services in developing countries, governments and Ministries of Health should continue to implement and to encourage incentives, perhaps performance-based, to improve quality at public sector health facilities, as well as to strengthen regulatory and monitoring structures to ensure quality at both public and private facilities. In the meantime, private providers appear to be fulfilling an important gap in the provision of FP services in these countries.
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http://dx.doi.org/10.1186/1472-6963-11-203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224259PMC
August 2011

Determinants of institutional delivery in rural Jhang, Pakistan.

Int J Equity Health 2011 Jul 30;10:31. Epub 2011 Jul 30.

Population Services International, 1120 19th Street, NW, Suite 600, Washington DC 20036, USA.

Background: There is expert consensus that delivery at a health facility substantially reduces the risk of maternal death. By increasing the use of antenatal (ANC), postnatal care (PNC) and family planning, the risk of maternal death can be further reduced. There has been little investigation of factors associated with the use of these services in Pakistan.

Methods: A representative household survey was conducted in rural areas of Jhang district, Pakistan, to determine the effect of demographic, economic and program factors on the utilization of maternal health services. Married women who had children ages 12 months or younger were interviewed. Data was collected from 2,018 women on socio-demographic characteristics and the utilization of health services. Logistic regression analysis was conducted to identify the correlates of health services use. Marginal effects quantify the impact of various factors on service utilization.

Results: Parity and education had the largest impact on institutional delivery: women were substantially less likely to deliver at a health facility after their first birth; women with primary or higher education were much more likely to have an institutional delivery. Age, autonomy, household wealth, proximity to a health facility and exposure to mass media were also important drivers of institutional delivery. The use of family planning within a year of delivery was low, with parity, education and husband's approval being the strongest determinants of use.

Conclusions: The findings suggest that rural women are likely to respond to well-designed interventions that remove financial and physical barriers to accessing maternal health services and motivate women by emphasizing the benefits of these services. Interventions should specifically target women who have two or more living children, little formal education and are from the poorest households.
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http://dx.doi.org/10.1186/1475-9276-10-31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159141PMC
July 2011

Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan.

Authors:
Sohail Agha

Reprod Health 2011 May 3;8:10. Epub 2011 May 3.

Population Services International, 1120 19th Street, NW, Suite 600, Washington, DC 20036, USA.

Background: Only 39% of deliveries in Pakistan are attended by skilled birth attendants, while Pakistan's target for skilled birth attendance by 2015 is > 90%.

Methods: A 12-month maternal health voucher intervention was implemented in Dera Ghazi Khan City, located in Southern Punjab, Pakistan in 2009. A pre-test/post-test non-experimental study was conducted to assess the impact of the intervention. Household interviews were conducted with randomly selected women who delivered in 2008 (the year prior to the voucher intervention), and with randomly selected women who delivered in 2009. A strong outreach model was used and voucher booklets valued at $50, containing redeemable coupons for three antenatal care (ANC) visits, a postnatal care (PNC) visit and institutional delivery, were sold for $1.25 to low-income women targeted by project workers. Regression analysis was conducted to determine the impact of the voucher scheme on ANC, PNC, and institutional delivery. Marginal effects estimated from logistic regression analyses were used to assess the magnitude of the impact of the intervention.

Results: The women targeted by voucher outreach workers were poorer, less educated, and at higher parity. After adjusting for these differences, women who delivered in 2009 and were sold voucher booklets were significantly more likely than women who delivered in 2008 to make at least three ANC visits, deliver in a health facility, and make a postnatal visit. Purchase of a voucher booklet was associated with a 22 percentage point increase in ANC use, a 22 percentage point increase in institutional delivery, and a 35 percentage point increase in PNC use.

Conclusions: A voucher intervention implemented for 12 months was associated with a substantial increase in institutional delivery. A substantial scale-up of maternal health vouchers that focus on institutional delivery is likely to bring Pakistan closer to achieving its 2015 target for institutional delivery.
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http://dx.doi.org/10.1186/1742-4755-8-10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108911PMC
May 2011

The impact of a quality-improvement package on reproductive health services delivered by private providers in Uganda.

Authors:
Sohail Agha

Stud Fam Plann 2010 Sep;41(3):205-15

Tulane University School of Public Health and Tropical Medicine, USA.

This study assesses the effectiveness of a quality-improvement (QI) package designed to enable small-scale commercial reproductive health (RH) service providers to improve the services they offer. The study was conducted among midwives who are members of the Uganda Private Midwives Association. A pretest-post-test quasi-experimental panel study design was used wherein midwife clinics were allocated to two experimental groups and one control group. Baseline and follow-up measurements of structural and process attributes of quality were taken at the clinics by means of a facility inventory, interviews with midwives, and observations of client-provider interactions. Nearly 70 percent of the midwives who were trained to use the package reported that it was easy to use. Among clinics in which midwives received training in the use of the self-assessment tool and in developing action plans, structural and process attributes of quality improved only among those clinics in which the midwives' supervisors received training in finding solutions to the problems identified through self-assessments. The QI package may be implemented with small-scale private providers of RH services who are part of a professional association, network, or franchise that supervises their performance.
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http://dx.doi.org/10.1111/j.1728-4465.2010.00244.xDOI Listing
September 2010

Impact of an advertising campaign on condom use in urban Pakistan.

Stud Fam Plann 2010 Dec;41(4):277-90

Population Services International, 1120 19th Street, NW, Suite 660, Washington, DC 20360, USA.

This study describes an assessment of the impact on condom use in urban Pakistan of the second phase of an intensive condom advertising campaign conducted as part of a social marketing program. Between April and June 2009, advertisements for Touch condoms appeared on private television channels and on radio stations. To assess the impact of the campaign, a nationally representative panel survey of men married to women aged 15-49 was conducted, collecting information on behaviors related to condom use and recall of contraceptive advertisements. We employed conditional change regression analysis to determine whether awareness of the Touch ad at follow-up was associated with improved attitudes toward condoms and condom use. Respondents with confirmed awareness of the Touch campaign experienced significant improvements in indicators related to condom use, even after controlling for region, socioeconomic and demographic characteristics, the values of the indicators at baseline, and exposure to the first phase of the campaign. They experienced increases in the following: perceived availability of condoms; discussion of family planning; approval of family planning; procurement of condoms; and ever use, current use, and consistent use of condoms with wife. The study indicates that condom advertising can be effective in increasing condom use in urban Pakistan.
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http://dx.doi.org/10.1111/j.1728-4465.2010.00253.xDOI Listing
December 2010

Changes in contraceptive use and method mix in Pakistan: 1990-91 to 2006-07.

Health Policy Plan 2012 Mar 26;27(2):166-74. Epub 2011 Mar 26.

Department of International Health, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.

Objectives: To determine (a) whether the influence of the determinants of family planning use in Pakistan changed between 1990-91 and 2006-07, and (b) if these changes were associated with changes in the method mix.

Methods: Data from the Pakistan Demographic and Health Surveys (PDHS) of 1990-91 and 2006-07 were used in the analyses. Data on 5184 married, non-pregnant, fecund women in 1990-91 and 8041 married, non-pregnant, fecund women in 2006-07 were used. Logistic regression analysis was used to identify factors associated with the use of any contraceptive method and whether the influence of these factors changed between the survey years. Changes in the method mix were examined.

Results: The effects of urban/rural residence, wealth and education on contraceptive use changed between 1990-91 and 2006-07. Differentials in contraceptive use by residence, wealth and education declined and were accompanied by changes in the method mix. In rural areas and among less-educated women, the contribution of traditional methods to the method mix increased. Among the poorest women, the method mix shifted towards traditional methods and condoms.

Conclusions: Less-educated, rural, Pakistani women increased the use of family planning at a faster rate than more-educated, urban, women by adopting the use of traditional family planning methods. Poor women also increased family planning use more quickly than non-poor women, by adopting condoms and traditional methods. The more rapid increase in the demand for family planning among poorer, less-educated, rural women is a positive trend. In order to convert this demand into the use of longer-term modern methods, however, access to high quality services must be improved in rural and low-income urban areas.
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http://dx.doi.org/10.1093/heapol/czr022DOI Listing
March 2012

Intentions to use contraceptives in Pakistan: implications for behavior change campaigns.

Authors:
Sohail Agha

BMC Public Health 2010 Aug 2;10:450. Epub 2010 Aug 2.

Population Services International, 1120 19th Street, NW, Suite 600, Washington, DC 20036, USA.

Background: Since 1990-91, traditional method use has increased at a faster rate in Pakistan than modern method use. The importance of hormonal methods or the IUD has diminished and that of traditional methods has increased in the method mix. There is a need to identify factors motivating and deterring the adoption of specific family planning methods among married men and women in Pakistan.

Methods: In addition to social and demographic characteristics of respondents, a representative household survey collected information on psychological correlates of family planning behavior from 1,788 non-pregnant wives and 1,805 husbands with not-pregnant wives. Males and females were from separate households. Principal components analysis was conducted to identify the underlying constructs that were important for each gender. Multinomial logistic regression analysis was conducted to determine the correlates of male and female intentions to use contraceptive methods.

Results: Amongst women, the perception that her in-laws support family planning use was the strongest determinant of her intentions to use contraceptive methods. A woman's belief in the importance of spacing children and her perception that a choice of methods and facilities with competent staff were available were also powerful drivers of her intentions to use contraceptive methods. The strongest obstacle to a woman's forming an intention to use contraceptive methods was her belief that family planning decisions were made by the husband and fertility was determined by God's will. Fears that family planning would harm a woman's womb lowered a woman's intentions to use methods requiring procedures, such as the IUD and female sterilization.The perception that a responsible, caring, husband uses family planning to improve the standard of living of his family and to protect his wife's health was the most important determinant of a man's intention to use condoms. A husband's lack of self-efficacy in being able to discuss family planning with his wife was the strongest driver of the intention to use withdrawal. A man's fear that contraceptives would make a woman sterile and harm her womb lowered his intention to use modern contraceptive methods.

Conclusions: These findings highlight the importance of having secondary target audiences such as mothers-in-law and husbands in family planning behavior change campaigns implemented in Pakistan. Campaigns that stress the importance of child spacing are likely to have an impact. Client perceptions of the quality of care are important determinants of intentions to use contraceptive methods in Pakistan. Client concerns that the IUD and sterilization procedures might harm a woman's womb and cause sterility should be addressed. The findings suggest that there is a need to assess the actual quality of service delivery in Pakistan.
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http://dx.doi.org/10.1186/1471-2458-10-450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920282PMC
August 2010

The quality of family planning services and client satisfaction in the public and private sectors in Kenya.

Authors:
Sohail Agha Mai Do

Int J Qual Health Care 2009 Apr 3;21(2):87-96. Epub 2009 Feb 3.

Population Services International, Karachi, Pakistan.

Objective: To compare the quality of family planning services delivered at public and private facilities in Kenya.

Methods: Data from the 2004 Kenya Service Provision Assessment were analysed. The Kenya Service Provision Assessment is a representative sample of health facilities in the public and private sectors, and comprises data obtained from a facility inventory, service provider interviews, observations of client-provider interactions and exit interviews. Quality-of-care indicators are compared between the public and private sectors along three dimensions: structure, process and outcome.

Results: Private facilities were superior to public sector facilities in terms of physical infrastructure and the availability of services. Public sector facilities were more likely to have management systems in place. There was no difference between public and private providers in the technical quality of care provided. Private providers were better at managing interpersonal aspects of care. The higher level of client satisfaction at private facilities could not be explained by differences between public and private facilities in structural and process aspects of care.

Conclusions: Formal private sector facilities providing family planning services exhibit greater readiness to provide services and greater attention to client needs than public sector facilities in Kenya. Consistent with this, client satisfaction is much higher at private facilities. Technical quality of care provided is similar in public and private facilities.
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http://dx.doi.org/10.1093/intqhc/mzp002DOI Listing
April 2009

Does an expansion in private sector contraceptive supply increase inequality in modern contraceptive use?

Authors:
Sohail Agha Mai Do

Health Policy Plan 2008 Nov 16;23(6):465-75. Epub 2008 Sep 16.

Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2200, New Orleans, LA 70112, USA.

Objective: To determine whether an expansion in private sector contraceptive supply is associated with increased socio-economic inequality in the modern contraceptive prevalence rate (MCPR inequality).

Methods: Multiple rounds of Demographic and Health Surveys data were analysed for five countries that experienced an increase in the private sector supply of contraceptives: Morocco, Indonesia, Kenya, Ghana and Bangladesh. Information on household assets and amenities was used to construct wealth quintiles. A concentration index, which calculates the degree of inequality in contraceptive use by wealth, was calculated for each survey round.

Results: Socio-economic inequality in the MCPR (MCPR inequality) declined in Morocco and Indonesia, where substantial expansion in private sector contraceptive supply occurred. In both countries, poor women continued to rely heavily on contraceptives supplied by the public sector even as they increased use of contraceptives obtained from the private sector. A marginally significant decline in MCPR inequality occurred in Bangladesh, where the increase in private sector supply was modest. There was no significant overall change in MCPR inequality in Kenya or Ghana. In Kenya, this lack of significant overall change disguised trends moving in opposite directions in urban and rural areas. In urban Kenya, MCPR inequality declined as low-income urban women increased use of contraceptives obtained primarily from the public sector. In rural Kenya, MCPR inequality increased. This increase was associated with a decline in the supply of contraceptives by the public sector and non-governmental organizations to the poorest, rural, women.

Conclusions: The study found no support for the hypothesis that an increase in private sector contraceptive supply leads to higher MCPR inequality. The findings suggest that continued public sector supply of contraceptives to the poorest women protects against increased MCPR inequality. The study highlights the role of the public sector in building contraceptive markets for the private sector to exploit.
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http://dx.doi.org/10.1093/heapol/czn035DOI Listing
November 2008

Changes in the timing of sexual initiation among young Muslim and Christian women in Nigeria.

Authors:
Sohail Agha

Arch Sex Behav 2009 Dec 19;38(6):899-908. Epub 2008 Aug 19.

Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA.

Sexual initiation during adolescence has important demographic and health consequences for a population, yet no systematic analysis of changes in the timing of sexual initiation has been conducted in Nigeria. Two rounds of national surveys conducted in 1990 and 2003 were used to examine changes in the timing of sexual initiation among female adolescents in Nigeria. Multivariate survival analysis using Cox proportional hazards models was used to assess changes in the risk of sexual initiation and to identify the correlates of first sex. Contrary to what has been reported in several Nigerian studies, there was no decline in age at first sex among Christian adolescents. Age at first sex did not change significantly for Christian adolescents, although premarital sex appears to have increased-primarily due to an increase in the age at marriage. Age at first sex did increase among Muslim women. Premarital sex remained low among Muslim women. A number of socioeconomic variables were associated with the timing of sexual initiation. Weekly exposure to the mass media was associated with earlier sexual initiation. The degree to which an environment was liberal or restrictive was a key determinant of the timing of sexual initiation in Nigeria. The findings also illustrate the important role of socioeconomic factors in determining the timing of sexual initiation in Nigeria. As secondary education increases in Northern Nigeria, additional increases in the age at sexual debut are likely among Muslim women. The study raises concerns about the influence of the mass media on the timing of first sex in Nigeria. The evidence of an absence of changes in the timing of sexual initiation among Christian women in more than a decade implies that programs which aim to delay the timing of sexual initiation in Southern Nigeria may have limited success. With age at marriage already high among Christian women, programs that focus on abstinence until marriage may also be pursuing an approach with limited chances of success.
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http://dx.doi.org/10.1007/s10508-008-9395-0DOI Listing
December 2009

The impact of a reproductive health franchise on client satisfaction in rural Nepal.

Health Policy Plan 2007 Sep 20;22(5):320-8. Epub 2007 Jul 20.

Department of International Health and Development, School of Public Health & Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.

This study evaluates the impact of a nurse and paramedic reproductive health franchise in rural Nepal on client satisfaction and utilization of services. A quasi-experimental study design, with baseline and follow-up measurements on nonequivalent control groups, was used to assess the effects of the intervention. The study collected data from exit interviews with male and female clients at clinics and from household interviews with married women. Our assessment covers the project's performance for about a year of actual implementation. Client satisfaction with the quality of services increased across a range of indicators at intervention clinics but not at control clinics. Overall satisfaction with services also increased only at intervention clinics but not at control clinics. Consistent with these changes, loyalty increased among clients of franchised clinics. The analysis showed a positive relationship between client satisfaction and loyalty. Although the project's implementation was examined over a relatively short period of time, there appears to have been a net positive effect of the intervention on obtaining family planning products from medical stores/pharmacies. The study shows that franchising reproductive health services increases a provider's interest in delivering better quality services in rural areas of a developing country.
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http://dx.doi.org/10.1093/heapol/czm025DOI Listing
September 2007
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