Implementation practice models for development in low- and middle-income countries: systematic review of peer-reviewed literature.

INTRODUCTION: This study operationally defines a relatively small, but growing field of study on implementation practice models for health behavior change in the context of international development. We define 'implementation practice models' as theoretical models that take a practical and practitioner-focused approach to behavior change, and we illustrate how these models have been developed and applied. The paper examines the continuum of behavioral theories and their application in the context of development programs and research in low- and middle-income countries (LMICs). We describe implementation practice models, examine how they have been used to design and evaluate theory-based interventions in LMIC, and describe the state of evidence in this field of study. METHODS: The authors conducted a systematic search of the published, peer-reviewed literature following the widely accepted PRISMA methods for systematic reviews. We aimed to identify all relevant manuscripts published in the English language in health, social science, and business literature that apply implementation practice models, located in an LMIC, with a behavior change objective. We located 1,078 articles through database searching and 106 through other means. Ultimately, we identified 25 relevant articles for inclusion. RESULTS: We found that the peer-reviewed literature on implementation practice models for development has been growing in recent years, with 80% of reviewed papers published since 2015. There was a wide range of different models revealed by this review but none demonstrated clear-cut evidence of being most effective. However, the models found in this review share common characteristics of focusing on the three central tenets of Opportunity, Ability, and Motivation (OAM). CONCLUSIONS: This review found that implementation practice models for development are a promising and growing approach to behavior change in LMICs. Intervention practice models research should be expanded and applied in new domains, such as vaccination.

Understanding how social norms affect modern contraceptive use.

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.

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

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.

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

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.

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

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.

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

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.

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

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.

Behavioral Insights from Vaccine Adoption in Nigeria: Cross-Sectional Survey Findings.

BACKGROUND: To generate behavioral insights for the development of effective vaccination interventions, we need approaches that combine rapid and inexpensive survey data collection with instruments based on easy-to-use behavior models. This study demonstrates how an inexpensive digital survey helped identify the drivers of COVID-19 vaccination in Nigeria. OBJECTIVE: This study aims to illustrate how behavioral insights can be generated through inexpensive digital surveys. METHODS: We designed and conducted a cross-sectional survey with multistage sampling. Data were collected from Nigerians (aged ≥18 years) from 120 strata based on age, sex, state, and urban or rural location. Respondents were recruited via advertisements on Meta platforms (Facebook and Instagram) using the Virtual Lab open-source tool. We used a Meta Messenger chatbot for data collection; participants were compensated with 400 naira (US $0.87 cents). Data collection took 2 weeks. In total, 957 respondents completed the survey, at an advertising cost of US $1.55 per respondent. An 18-item instrument measuring core motivators, ability barriers, sociodemographic characteristics, and respondents' vaccination status was pretested before data collection. We ran separate logistic regression models to examine the relationships between vaccine uptake and core motivators, ability barriers, and sociodemographic variables. A final model that predicted vaccine uptake included all 3 sets of variables. RESULTS: About 56% (n=540) of respondents reported that they had received at least 1 COVID-19 vaccination. Three core motivators were positively associated with vaccine uptake: the belief that the COVID-19 vaccine promised a better life (adjusted odds ratio [aOR] 3.51, 95% CI 2.23-5.52), the belief that the vaccine would allow respondents to do more things they enjoyed (aOR 1.97, 95% CI 1.33-2.93), and respondents' perception that their friends and family members accepted their decision to get vaccinated (aOR 1.62, 95% CI 1.06-2.48). Two ability barriers were negatively associated with vaccine uptake: cost- or income-related concerns lowered the odds of being vaccinated (aOR 0.35, 95% CI 0.24-0.50) and the lack of availability of vaccines at places respondents routinely visited also lowered their odds of being vaccinated (aOR 0.29, 95% CI 0.21-0.40). After adjusting for other variables, the perceived fear of getting COVID-19 and the hardship associated with the disease were no longer associated with vaccine uptake. CONCLUSIONS: These findings suggest that hope is more important for Nigerians than fear when it comes to vaccine adoption, enjoying life is more important than worrying about getting the disease, and approval from friends and family is more powerful than their disapproval. These findings suggest that emphasizing the benefits of leading a fuller life after being vaccinated is more likely to succeed than increasing Nigerians' fear of COVID-19. This study identifies a very different set of factors associated with COVID-19 vaccine adoption than previous Nigerian studies.

Determinants of Human Papillomavirus Vaccine Acceptance among Caregivers in Nigeria: A Fogg Behavior Model-Based Approach.

Human papillomavirus (HPV) vaccine uptake among adolescent girls is critical to reducing the burden of HPV-related cancers in Nigeria. This study assesses the factors influencing caregivers' acceptance of HPV vaccination for their charges, using the Fogg Behavior Model (FBM) as a theoretical framework. We analyzed cross-sectional data from 1429 caregivers of girls aged 9-17 in six Nigerian states, using a survey instrument based on the FBM. Participants were recruited via Facebook and Instagram advertisements and interviewed through Facebook Messenger in August and September 2023. The study received ethical clearance from Nigeria's National Health Research Ethics Committee. We applied bivariate and multivariate analyses to assess the relationships between the caregiver's perception of how likely their adolescent girl was to get vaccinated in the next 12 months and motivation, ability, social factors (such as discussions with family and friends), injunctive norms, previous COVID-19 vaccination, and respondents' sociodemographic characteristics. Adjusted odds ratios derived from logistic regression analyses revealed that caregivers' motivation and ability, as well as social factors, were significantly associated with their perception that the adolescent girl in their care would get vaccinated within the next 12 months. Our findings suggest that behavioral interventions tailored to enhance motivation, ability, and social support among caregivers could significantly increase HPV vaccine uptake among adolescent girls in Nigeria.

Randomised experimental evaluation of a social media campaign to promote COVID-19 vaccination in Nigeria.

Background: The coronavirus disease 2019 (COVID-19) pandemic has challenged public health and behaviour change programmes, and has led to the development of innovative interventions and research. In low -and middle-income countries (LMICs) such as Nigeria, new strategies to promote vaccination, increase pro-vaccination social norms, and reduce vaccine hesitancy have been deployed through social media campaigns and evaluated using digital media platforms. Methods: We conducted two randomised experimental evaluations of social media content designed to promote COVID-19 vaccination and to complement research on a nationwide vaccination promotion campaign in Nigeria run in 2022. We conducted two studies in March and August 2022 among Nigerians drawn from 31 states that had not been targeted in the aforementioned nationwide campaign. We randomised the participants to either receive the pro-vaccination social media campaign or not and collected data at pre- and post-test time points to evaluate psychosocial predictors of vaccination and vaccination outcomes following the Theory of Change based on Diffusion of Innovations; the Social Norms Theory, and the Motivation, Opportunity, Ability (MOA) framework. Data were collected through a novel intervention delivery and data collection platform through social media. Results: We found that pro-vaccination social norms and vaccination rates increased, while vaccine hesitancy decreased among participants randomised to the social media intervention study arm. Conclusions: Social media campaigns are a promising approach to increasing vaccination at scale in LMICs, while social norms are an important factor in promoting vaccination, which is consistent with the Social Norms Theory. This study demonstrates the capability and potential of new social media-based data collection techniques. We describe implications for future vaccination campaigns and identify future research priorities in this area. Registration: Pan African Clinical Trial Registry: PACTR202310811597445.

Outcomes of a social media campaign to promote COVID-19 vaccination in Nigeria.

The COVID-19 pandemic has been an historic challenge to public health and behavior change programs. In low -and middle-income countries (LMICs) such as Nigeria, there have been challenges in promoting vaccination. Vaccine hesitancy and social norms related to vaccination may be important factors in promoting or inhibiting not only COVID vaccination, but other routine vaccinations as well. The aim of this study was to conduct a national-level quasi-experimental evaluation of a social media based COVID-19 vaccination promotion campaign in Nigeria run in 2022. We followed a longitudinal cohort of Nigerians (at baseline) drawn from all 37 states in Nigeria over a 10-month period. This was done at 3 time points to evaluate psychosocial predictors of vaccination and vaccination outcomes following a theory of change based on Diffusion of Innovations, Social Norms Theory, and the Motivation, Opportunity, Ability (MOA) Framework. In a quasi-experimental design, participants in 6 Nigerian states where the social media campaign was run (treatment) were compared to participants from non-treatment states. This study highlights new social media-based data collection techniques. The study found that vaccination rates increased in treatment states compared to non-treatment states, and that these effects were strongest between baseline and first follow up (December 2021 to March 2022). We also found that more pro-vaccination social norms at one time point are associated with higher vaccination rates at a later time point. Social media campaigns are a promising approach to increasing vaccination at scale in LMICs, and social norms are an important factor in promoting vaccination, which is consistent with the Social Norms Theory. We describe implications for future vaccination campaigns and identify future research priorities in this area.

Development and Assessment of a Six-Item Index to Gauge Motivation to Receive COVID-19 Vaccination.

This study examined the factors influencing vaccine uptake using the Fogg Behavioral Model (FBM) and validated a multi-dimensional index for measuring a key construct in the FBM, motivation, using Confirmatory Factor Analysis (CFA) and Cronbach's alpha. The research was conducted in Yopougon Est, Côte d'Ivoire, and Kinshasa, Democratic Republic of Congo. We aimed to develop a motivation index for COVID-19 vaccination uptake informed by the FBM. The motivation index was developed and refined using interviews and cognitive testing, and then used in baseline and endline surveys to measure the motivation to uptake COVID-19 vaccination among 2173 respondents. The index was simplified to six items validated using Confirmatory Factor Analysis (CFA) and demonstrated strong internal reliability with Cronbach's alphas of 0.89 for the baseline and 0.77 for the endline. The study's findings indicate that this motivation index is a valid tool for measuring motivation to receive COVID-19 vaccination, with potential applications in other vaccination campaigns. However, further testing in diverse settings is needed to enhance generalizability, including in rural areas. This research provides valuable insights for designing effective behavior change interventions to increase COVID-19 vaccination rates.

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

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

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.

Use of a Practitioner-Friendly Behavior Model to Identify Factors Associated with COVID-19 Vaccination and Other Behaviors.

The lack of capacity for the design and implementation of behavioral interventions in low-and-middle income countries (LMICs) has been recognized by the World Health Organization (WHO) and other global health institutions. There is a need to task-shift, to translate social and behavioral science concepts into "practitioner-friendly" models-models which can be used by intervention designers, implementers, and evaluators with limited technical and financial resources. We illustrate the use of the Fogg Behavior Model (FBM), a model identified as being easy for practitioners to adopt in low-resource settings. The study uses data across four different behaviors in Nigeria, Pakistan, and India. The behaviors examined are COVID-19 vaccine uptake, condom use, iron folate use, and modern contraceptive use. The data are from surveys of healthcare workers (HCWs), married men, women of reproductive age, and adolescents, respectively. The FBM states that behavior happens when both motivation and ability are present, and a prompt occurs. In other words, persons with high motivation and high ability are the first to adopt a behavior. We created a categorical variable for motivation and ability and tested whether high motivation and high ability are associated with a greater likelihood of adopting a behavior. In Nigeria, HCWs with high motivation and high ability had 27 times higher odds of being vaccinated. In Pakistan, married men with high motivation and high ability had 35 times higher odds of condom use with their wives. In India, women with high motivation and high ability had 9 times higher odds of iron folate use. In Nigeria, adolescents and young women with high motivation and high ability had 8 times higher odds of contraceptive use. The study findings suggest that the FBM has the potential to be applied in low resource settings for the design, implementation, and evaluation of behavioral interventions. Rigorous testing of the FBM using data from experimental or quasi-experimental studies is recommended.

Digital Media for Behavior Change: Review of an Emerging Field of Study.

Digital media are omnipresent in modern life, but the science on the impact of digital media on behavior is still in its infancy. There is an emerging evidence base of how to use digital media for behavior change. Strategies to change behavior implemented using digital technology have included a variety of platforms and program strategies, all of which are potentially more effective with increased frequency, intensity, interactivity, and feedback. It is critical to accelerate the pace of research on digital platforms, including social media, to understand and address its effects on human behavior. The purpose of the current paper is to provide an overview and describe methods in this emerging field, present use cases, describe a future agenda, and raise central questions to be addressed in future digital health research for behavior change. Digital media for behavior change employs three main methods: (1) digital media interventions, (2) formative research using digital media, and (3) digital media used to conduct evaluations. We examine use cases across several content areas including healthy weight management, tobacco control, and vaccination uptake, to describe and illustrate the methods and potential impact of this emerging field of study. In the discussion, we note that digital media interventions need to explore the full range of functionality of digital devices and their near-constant role in personal self-management and day-to-day living to maximize opportunities for behavior change. Future experimental research should rigorously examine the effects of variable levels of engagement with, and frequency and intensity of exposure to, multiple forms of digital media for behavior change.

Factors associated with the adoption of a digital health service by patent proprietary medicine vendors (PPMVs) in Lagos, Nigeria.

Background: Patent proprietary medicine vendors (PPMVs) are the first point of care for low-income Nigerian households. They are likely to have an important role in a digital care pathway established for low-income Nigerian women and children. Yet, little is known about what drives the adoption of digital platforms by PPMVs. Methods: This study explores factors associated with the adoption of a digital service, NaijaCare, created to enable PPMVs to increase the range and quality of products and services they offer. A structured, quantitative, face-to-face survey was conducted among 248 PPMVs in Lagos in February and March 2020. Multivariate analysis was conducted to identify factors associated with the adoption of NaijaCare. Results: Women comprise the majority (67%) of medicine vendors in Lagos. Most medicine vendors (64%) had gotten health training on the job. About a quarter (27%) of medicine vendors reported seeking business advice on the internet. Medicine vendors who had obtained on-the-job training had a 12.31 times higher odds ratio (p < 0.01) of adopting the digital service. Medicine vendors who sought business advice on the internet had a 6.48 times higher odds ratio (p < 0.001) of adopting NaijaCare. Conclusion: The study findings suggest that PPMVs' use of the digital service was driven by their desire to increase business profits. Digital care pathways targeting low-income households should be aligned with the business interests of informal providers.

Identifying Drivers of COVID-19 Vaccine Uptake among Residents of Yopougon Est, Abidjan, Côte d'Ivoire.

This study applied the Fogg Behavioral Model (FBM) to identify and prioritize factors influencing COVID-19 vaccination among residents of Yopougon Est, Abidjan, Côte d'Ivoire. A total of 568 respondents were recruited from among individuals entering eleven participant recruitment and data collection sites located near high pedestrian trafficked areas. Among all respondents, 52% reported being vaccinated versus 48% who reported not being vaccinated. Of those who reported being vaccinated, 42% reported received a single dose, 54% a double dose, and 4% three or more doses. A categorical regression analysis suggested that potential predictors of COVID-19 vaccination included acceptance and rejection factors, which are both aligned with motivation in the FBM and socio-demographic characteristics, proximity to services, and religion. Our findings suggest that demand creation activities should target individuals with less formal education, those who are not formally employed, non-Catholic Christians, and individuals who do not identify as Akan. Results also suggest the need to design programmatic messages and activities that focus on generating family and community support for COVID-19 vaccination.

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.

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.

Determinants of institutional delivery in rural Jhang, Pakistan.

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.