The community-level effects of women's education on reproductive behaviour in rural Ghana

Prevalence and dynamics of contraceptive use by type during the COVID-19 pandemic: Evidence from Western Iran

Contraception represents a deliberate choice made by individuals, both men and women, to regulate their desired number of children. The primary objective of this study was to examine the prevalence and predictors of contraceptive use, while also exploring the shifts in contraception methods following the COVID-19 pandemic. This study employed a quantitative approach with a survey technique. The survey was conducted in Kermanshah, one of Iran's metropolises located in the western part of the country. The sampling methodology employed in this study involved a combination of multi-stage classification and systematic random methods. The survey took place between July and August 2022. The target population for the survey included women between the ages of 15 and 49. A total of 600 women from this population were selected and included in the survey sample. The sample was described using frequency tables, as well as central and dispersion indices (mean and standard deviation). Additionally, multivariate analysis was conducted through the application of logistic regression. Findings pointed out that approximately 65% of the women in the sample utilized contraception methods. Among these methods, the condom and oral pill were found to be the most prevalent choices. Moreover, the findings indicated that an increase in the number of both living and ideal children was associated with a decreased likelihood of contraceptive use. Following the occurrence of the COVID-19 pandemic, there was an observed increase in the utilization of traditional and natural methods of contraception. This shift highlights the importance of considering a broader range of contraceptive options and not solely focusing on restricting contraception services. In the midst of the coronavirus outbreak, women turned to traditional contraceptives, which may increase the risk of unintended pregnancies and subsequent miscarriages. Therefore, providing in-person services to women at their place of residence is necessary during epidemics.

Individual and community level factors associated with modern contraceptive utilization among married women in the emerging region of Ethiopia: a multilevel mixed effects analysis of the 2019 Ethiopia Mini-Demographic and health survey

BACKGROUND

A demonstrated technique to enhance reproductive health and economic progress is through ensuring that family planning services are accessible universally. Those studies that used Ethiopia Demographic and Health Survey (EDHS) data did not assess individual and community-level factors in contraceptive utilization. Thus, the study employs a multilevel mixed effects analysis approach, which allows for the examination of individual and community-level factors that influence contraceptive utilization.

METHODS

This study analyzed the 2019 Ethiopia Min Demographic and Health Survey datasets. A total of 1916 married women in the 2019 surveys were included in the analysis. The data were analyzed using Stata version 17.0. The data were analyzed using Multi-level mixed-effect logistic regression to identify the individual and community-level factors associated with modern contraceptive utilization. An adjusted odds ratio with a 95% confidence interval was used to. Show the strength and direction of the association and statistical significance was declared at a P value less than 0.05.

RESULTS

Factors significantly associated with modern contraceptive utilization were; Muslim and protestant followers [AOR = 0.31, 95% CI: (0.134, 0.714)] and [AOR = 0.35, 95% CI: (0.173, 0.691)] respectively, women with no education (OR = 0.46; 95% CI: 0.293, 0.710), those women who belong to the poor and middle wealth of household [AOR = 0.35, 95% CI: (0.237, 0.527)] and [AOR = 0.56, 95% CI: (0.347, 0.919)] respectively, women who had one to five and greater than or equal to six living children [AOR = 11.36, 95% CI:(2.119, 60.918)] and [AOR = 7.44, 95% CI:(1.437, 38.547)]respectively, Women in clusters poor wealth status [AOR = 0.40, 95% CI: (0.183, 0.875)] and women who belong to the Somali region [AOR = 0.20, 95% CI: (0.0.070, 0.506)].

CONCLUSION

The study revealed that both individual and community-level factors determined modern contraceptive utilization. At the individual level, the religion of women, educational status, the wealth of the household, and the total number of living children were significantly associated with modern contraceptive utilization. At community-level factors, community wealth status and belonging to the Somali region were significantly associated with modern contraceptive utilization. The findings suggest that interventions aimed at increasing modern contraceptive utilization should target women with lower levels of education, those living in households with lower wealth, and those with larger families. Additionally, efforts should be made to improve access to modern contraceptives in communities with lower wealth status and in regions where traditional beliefs may hinder their use.

Sociodemographic correlates of discrimination against PLHIV in High HIV prevalence states of India, NFHS 2016-21

This study investigates the socio-demographic correlates of HIV discrimination among individuals aged 15-49 years. This study also aims to assess the change in discriminatory attitudes towards PLHIV in high HIV prevalence states from 2016 to 2021 using data from the national Demographic Health Survey (4th and 5th). To identify factors associated with discriminatory attitudes, a multivariable logistic regression analysis was performed. Further, predicted probabilities and average marginal effects were computed, and the difference in discriminatory attitudes across both rounds was examined using a non-linear Fairlie decomposition. Mass media exposure, improved wealth index, and comprehensive knowledge significantly reduced the discriminatory attitudes towards PLHIV. Fairlie decomposition indicated that comprehensive knowledge, knowledge of mother-to-child transmission, and mass media exposure was significant contributor to the differences observed in the discriminatory attitude towards PLHIV across survey rounds. This study emphasizes the importance of spreading accurate information about HIV transmission modes and reinforces existing programmes and policies aimed at reducing stigma and discrimination against PLHIV. These programmes' efficiency and effectiveness can be ensured by linking them with community-level programmes and activities organized by Self Help Groups (SHGs), which have resulted in a paradigm shift in empowering women in India.

Community characteristics and the risk of non-communicable diseases in Ghana

Non-communicable Diseases (NCDs) are rising quickly in low- and middle- income countries. In Ghana, chronic diseases are major causes of morbidity and mortality, yet data and the evidence- base for awareness, detection, and management of NCDs are lacking. Using data from the 2014 Ghana Demographic and Health Survey (GDHS), the first national study with information on hypertension and other risk factors, we examine the correlates and community characteristics associated with the risk of hypertension, obesity, and anemia among women. We find that hypertension prevalence in Ghana was 16 percent and 17 percent were overweight/obese, while 41 percent had anemia of any form. On community characteristics, the level of poverty in a community was significantly associated with lower risks of all three NCDs, while the aggregate level of employment had higher risks. On individual characteristics, the wealth of a household, women's educational level and urban residence were significant predictors of NCDs. We interpret the findings within the literature on neighborhood characteristics, the social gradient of health and in the context of speeding up the attainment of the Sustainable Development Goals (SGDS) to reduce premature deaths by one-third by 2030.

Intra-cluster correlations in socio-demographic variables and their implications: An analysis based on large-scale surveys in India

Individuals who share similar socio-economic and cultural characteristics also share similar health outcomes. Consequently, they have a propensity to cluster together, which results in positive intra-class correlation coefficients (ICCs) in their socio-demographic and behavioural characteristics. In this study, using data from four rounds of the National Family Health Survey (NFHS), we estimated the ICC for selected socio-demographic and behavioural characteristics in rural and urban areas of six states namely Assam, Gujarat, Kerala, Punjab, Uttar Pradesh, and West Bengal. The socio-demographic and behavioural characteristics included religion & caste of the household head, use of contraception & prevalence of anaemia among currently married women and coverage of full immunization services among children aged 12-23 months. ICC was computed at the level ofPrimary Sampling Units (PSUs), that is, villages in rural areas and census enumeration blocks in urban areas. Our research highlights high clustering in terms of religion and caste within PSUs in India. In NFHS-4, the ICCs for religion ranged from the lowest of 0.19 in rural areas of Kerala to the highest of 0.67 in urban areas of West Bengal. For the caste of the household head, the ICCs ranged from the lowest of 0.12 in the urban areas of Punjab to the highest of 0.46 in the rural areas of Assam. In most of the states selected for the study, the values of ICC were higher for the use of family planning methods than for full immunization. The value of ICC for use of contraception was highest for rural areas of Assam (0.15) followed by rural areas of Gujarat (0.13). A higher value of ICC has considerable implications for determining an effective sample size for large-scale surveys. Our findings agree with the fact that for a given cluster size, the higher the value of ICC, the higher is the loss in precision of the estimate. Knowing and taking into account ICCs can be extremely helpful in determining an effective sample size when designing a large-scale demographic and health survey to arrive at estimates of parameters with the desired precision.

Individual, household, and community-level predictors of modern contraceptive use among married women in Cameroon: a multilevel analysis

Background

Unintended pregnancy remains a major public health and socio-economic problem in sub-Saharan African countries, including Cameroon. Modern contraceptive use can avert unintended pregnancy and its related problems. In Cameroon, the prevalence of modern contraceptive use is low. Therefore, this study investigated the individual/household and community-level predictors for modern contraceptive use among married women in Cameroon.

Methods

Data for this study were derived from the nationally representative 2018–2019 Cameroon Demographic and Health Survey. Analysis was done on 6080 married women in the reproductive age group (15–49 y) using Stata version 14 software. Pearson χ² test and multilevel logistic regression analysis were conducted to examine the individual/household and community-level predictors of modern contraceptive use. Descriptive results were presented using frequencies and bar charts. Inferential results were presented using adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

Results

The results show only 18.3% (95% CI 16.8 to 19.8) of married women in Cameroon use modern contraceptives. Women's age (45–49 y; aOR 0.22 [95% CI 0.12 to 0.39]), education level (secondary education; aOR 2.93 [95% CI 1.90 to 4.50]), occupation (skilled manual; aOR 1.46 [95% CI 1.01 to 2.11]), religion (Muslim; aOR 0.63 [95% CI 0.47 to 0.84]), wealth quintile (richest; aOR 2.22 [95% CI 1.35 to 3.64]) and parity (≥5; aOR 3.59 [95% CI 2.61 to 4.94]) were significant individual/household-level predictors. Region (East; aOR 3.63 [95% CI 1.97 to 6.68]) was identified as a community-level predictor.

Conclusions

Modern contraceptive use among married women in Cameroon is low. Women's education and employment opportunities should be prioritized, as well as interventions for married women, ensuring equity in the utilization of modern contraceptives across regions.

HIV stigma beliefs in context: Country and regional variation in the effects of instrumental stigma beliefs on protective sexual behaviors in Latin America, the Caribbean, and Southern Africa

Does the relationship between the expression of HIV stigma beliefs and the practice of protective sexual behaviors vary by social context? To answer this question, we apply multilevel techniques to Demographic and Health Survey data from seven low HIV prevalence Latin American and Caribbean countries and seven high HIV prevalence Southern African countries to examine contextual variation in this relationship. We examine whether the relationship between stigma beliefs and sexual behaviors differs across these two sets of countries and across regions within each set of countries. We first find that in high prevalence Southern African countries, one unit increases in HIV stigma beliefs are associated with 8% declines in the odds of practicing protective sexual behaviors. Conversely, in low prevalence Latin American and Caribbean countries, unit increases in HIV stigma beliefs are associated with 8% increases in the odds of those same sexual behaviors. Second, the relationship between stigma beliefs and protective sexual behaviors varies across regions within each set of countries, with a wider variance in regional stigma effects located in Southern Africa than in Latin America and the Caribbean. Third, in Southern Africa, the negative effect of stigma beliefs is even more negative in regions where conservative stigma beliefs are pronounced. Overall, our findings demonstrate the importance of taking country and regional context into account when examining the degree to which HIV beliefs affect personal sexual behaviors, which in turn, can contribute to the spread of HIV. Importantly, the implications of our results offer potential guidance to experts who wish to design policies and programs aimed at reducing the expression of negative HIV beliefs towards those infected with HIV.

Early Marriage, Cohabitation, and Childbearing in West Africa

The prevalence of child marriage in West Africa is one of the highest in the global south. Yet, much of what we know about the harmful effects of early marriage and why it persists comes from research on South Asia. Adopting life course family development perspectives on adolescent sexuality, we examine the linkages between the timing of union formation and childbearing across multiple countries with high rates of child marriage. Using the latest round of data from the Demographic and Health Surveys (DHS), we find that by age 18, 28 percent of adolescents in Nigeria, 25 percent in Burkina Faso, and as high as 60 percent in Niger are in a union, whilst 13 percent of Nigerian adolescents, 12 percent in Burkina Faso, and 27 percent in Niger have had a first birth. The results demonstrate that, net of individual characteristics, community variables are strong predictors of union formation and childbearing. Individual characteristics such as women's education, economic status of households, and residing in female-headed households and rural areas are other salient determinants of adolescent family transitions. We discuss the findings in the context of revamping stalled fertility transitions and the post-2015 framework for development in sub-Saharan Africa.

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS, sexually transmitted infections, and risky sexual behavior in sub-Saharan Africa: a systematic review

PURPOSE

To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

METHODS

Ten databases were searched through May 29, 2016. Two reviewers completed screening and full-text review. Studies examining the influence of contextual factors on HIV/AIDS, STIs, and RSB and using MLMs for analysis were included. The Quality Assessment Tool for Quantitative Studies was used to evaluate study quality.

RESULTS

A total of 118 studies met inclusion criteria. Seventy-four studies focused on HIV/AIDS-related topics; 46 focused on RSB. No studies related to STIs other than HIV/AIDS met the eligibility criteria. Of five studies examining HIV serostatus and community socioeconomic factors, three found an association between poverty and measures of inequality and increased HIV prevalence. Among studies examining RSB, associations were found with numerous contextual factors, including poverty, education, and gender norms.

CONCLUSIONS

Studies using MLMs indicate that several contextual factors, including community measures of socioeconomic status and educational attainment, are associated with a number of outcomes related to HIV/AIDS and RSB. Future studies using MLMs should focus on contextual-level interventions to strengthen the evidence base for causality.

THE ROLE OF COMMUNITY STRUCTURE IN SHAPING AFRICAN FERTILITY PATTERN: EVIDENCE FROM DEMOGRAPHIC AND HEALTH SURVEYS

Anthropological explanations of demographic outcomes have emphasized the need to understand how community structures contribute to those outcomes. However, studies on fertility dynamics in Africa have largely focused on micro-level factors, thus ignoring the influence of community contexts. Using the most recent Demographic and Health Survey data from Egypt (Northern Africa), Cameroon (Middle Africa), Kenya (Eastern Africa), Nigeria (Western Africa) and Zimbabwe (Southern Africa), the study employed multilevel Poisson regression models to examine the influence of community factors on African fertility levels and patterns. The number of sampled women (aged 15-44) ranged from 7774 in Kenya (2008-09) to 30,480 in Nigeria (2008). The findings demonstrate some significant community effects on African fertility patterns, even after controlling for a number of individual-level factors. For instance, residence in socioeconomically disadvantaged regions, rural settings, poor neighbourhood and communities with high family size norm were found to be associated with higher fertility levels in the selected countries. The emerging African fertility patterns require the need to go beyond addressing individual-level characteristics in the efforts to reduce fertility levels in Africa.

Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghana

Background

Understanding what factors influence the receipt of postabortion contraception can help improve comprehensive abortion care services. The abortion visit is an ideal time to reach women at the highest risk of unintended pregnancy with the most effective contraceptive methods. The objectives of this study were to estimate the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two separate outcomes: (1) the likelihood of adopting postabortion contraception; (2) postabortion contraceptors’ likelihood of receiving a long-acting and permanent versus a short-acting contraceptive method.

Methods

We used retrospective cohort data collected from 64 health facilities in three regions of Ghana. The dataset includes information on all abortion procedures conducted between 1 January 2008 and 31 December 2010 at each health facility. We used fixed effect Poisson regression to model the associations of interest.

Results

More than half (65 %) of the 29,056 abortion clients received some form of contraception. When midwives performed the abortion, women were more likely to receive postabortion contraception compared to house officers (RR: 1.18; 95 % CI: 1.13, 1.24) or physicians (RR: 1.21; 95 % CI: 1.18, 1.25), after controlling for facility-level variation and client-level factors. Compared to women seen by house officers, abortion clients seen by midwives and physicians were more likely to receive a long-acting and permanent rather than a short-acting contraceptive method (RR: 1.46; 95 % CI: 1.23, 1.73; RR: 1.58; 95 % CI: 1.37, 1.83, respectively). Younger women were less likely to receive contraception than older women irrespective of provider type and indication for the abortion (induced or PAC).

Conclusions

When comparing consultant physicians, house officers, and midwives, the type of abortion provider is associated with whether women receive postabortion contraception and with whether abortion clients receive a long-acting and permanent or a short-acting method. New strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception and to ensure that women seen by house officers have access to long-acting and permanent contraceptive methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1875-2) contains supplementary material, which is available to authorized users.

Community-level education accelerates the cultural evolution of fertility decline

Explaining why fertility declines as populations modernize is a profound theoretical challenge. It remains unclear whether the fundamental drivers are economic or cultural in nature. Cultural evolutionary theory suggests that community-level characteristics, for example average education, can alter how low-fertility preferences are transmitted and adopted. These assumptions have not been empirically tested. Here, we show that community-level education accelerates fertility decline in a way that is neither predicted by individual characteristics, nor by the level of economic modernization in a population. In 22 high-fertility communities in Poland, fertility converged on a smaller family size as average education in the community increased-indeed community-level education had a larger impact on fertility decline than did individual education. This convergence was not driven by educational levels being more homogeneous, but by less educated women having fewer children than expected, and more highly educated social networks, when living among more highly educated neighbours. The average level of education in a community may influence the social partners women interact with, both within and beyond their immediate social environments, altering the reproductive norms they are exposed to. Given a critical mass of highly educated women, less educated neighbours may adopt their reproductive behaviour, accelerating the pace of demographic transition. Individual characteristics alone cannot capture these dynamics and studies relying solely on them may systematically underestimate the importance of cultural transmission in driving fertility declines. Our results are inconsistent with a purely individualistic, rational-actor model of fertility decline and suggest that optimization of reproduction is partly driven by cultural dynamics beyond the individual.

Targeting women at risk of unintended pregnancy in Ghana: Should geography matter?

Unintended childbearing in Ghana is estimated to be about 0.7 births per woman, thus contributing to the high total fertility rate of more than 4 births. About one-third of women of reproductive age have an unmet need for family planning and there are strong geographic differences between and within ecological zones. Spatial analysis of risk of unintended pregnancies planning can reveal differences in the provision and usage of contraceptive commodities, thereby providing information of areas where programmes should be strengthened. This study uses data from the 1998 and 2003 Ghana Demographic and Health Surveys to examine geographical variation in the risk of unintended pregnancies among women in the three ecological zones of Ghana (Savannah, Forest, and Coastal). The data was analysed using multilevel logistic regression. Approximately 55% of Ghanaian women (married or in union) are at risk of unintended pregnancies and there are differences between urban and rural women, with rural women more likely to have their demand for contraception unmet. After adjusting for the socio-economic and demographic factors, the results show little differences between ecological zones in the levels of women exposed to the risk of unintended pregnancy, but they demonstrate significant within community effects, which influence the risk of unintended pregnancies for women within the community. Communities, therefore, can be used as units for targeting services aimed at increasing coverage of contraceptive commodities.

Individual- and community-level determinants of social acceptance of people living with HIV in Kenya: results from a national population-based survey

Using the 2003 Kenya Demographic and Health Survey, we investigated the influence of individual- and community-level factors on accepting attitudes toward people living with HIV (PLHIV) using three outcomes: (1) willingness to care for an infected household member, (2) willingness to buy vegetables from an infected vendor, and (3) willingness to allow an infected female teacher to continue teaching. In multilevel logistic regression models, we found that individuals who expressed greater acceptance of PLHIV were more likely to be male, older, more educated, high AIDS knowledge, and exposed to mass media. At the community level, differences in accepting attitudes were associated with community AIDS knowledge, community education, and community AIDS experience, but not for region, or place of residence. The findings suggest the important role of community factors in determining social acceptance of PLHIV. Programmatic strategies aimed at increasing these accepting attitudes should consider both individual- and community-level factors.