The power of women's and men's Social Networks to catalyse normative and behavioural change: evaluation of an intervention addressing Unmet need for Family Planning in Benin.

BACKGROUND: In Benin, despite good knowledge and availability, modern contraceptive prevalence remains relatively low, and the unmet need for family planning is relatively high. This is partly due to insufficient attention to socio-normative barriers that influence need and method use. Applying social network theory, Tékponon Jikuagou (TJ) aims to reduce socio-normative barriers preventing modern contraceptive use in rural Benin. After community identification, TJ trains influential network actors who encourage critical dialogue about unmet need, family planning, gender, and other social norms within their networks, complemented by radio and services linkages. This paper evaluates TJ's effectiveness and how intervention components affect intermediate and primary FP outcomes. METHODS: We report findings from pre/post-intervention cross-sectional research with a comparison group conducted at baseline with 1,043 women and 1,030 men, and 14 months later at endline with 1,046 women and 1,045 men. Using sex-stratified models, we assessed balance across intervention and comparison groups on background characteristics using Pearson's chi-square tests of independence; performed bivariate tests of independence to assess differences between baseline to endline on intermediate outcomes and primary FP outcomes; used logistic regression to examine the effect of intervention components on intermediate and primary FP outcomes. RESULTS: Statistically significant improvements in primary outcomes: women's intentions to use modern contraception, achieve met need, and reduce perceived met need. The fourth primary outcome, actual use, showed substantial gains, although not statistically significant. Men's achievement of met FP need and reduced perceived met need were also statistically significant. Assessing intermediate outcomes at individual, couple, normative-network levels, TJ led to statistically significant increases in couple and network communication on fertility desires and family planning use and self-efficacy and confidence to access services. Both women and men showed significant shifts in the acceptability of discussing FP in public. Results for other indicators of norms change were inconsistent. CONCLUSIONS: An easy-to-implement, short-duration, gender-equitable social network intervention with a limited set of network actors, TJ effectively decreases social and normative barriers preventing women and men from seeking and using FP services. Results support the broader use of innovative social and behaviour change strategies that diffuse family planning ideas through social networks, diminish normative and communication barriers, and catalyse modern family planning use.

In many places with relatively low family planning use, insufficient program attention is paid to socio-normative barriers that influence need and method use. TJ catalyses women and men's social networks to spread new ideas and break communication and other social barriers that prevent women and men with unmet needs ­ people who wish to space their next birth but are not using effective family planning methods - from acting on their desires. A rigorous evaluation of the approach in rural Benin showed after only 14 months, TJ led to statistically significant improvements in intention to use contraception and met need. While showing substantial gains, women's use of contraception was not statistically significant.TJ increased women's and men's partner and network communication on fertility desires and family planning use and individual self-efficacy and confidence to act on intentions to address unmet need. The network influence on family planning use was equally significant. TJ led to new ideas within communities/social networks, including the perception that one's social networks approve of FP. Women and men who report that their network approves of FP were significantly more likely to discuss method use with their partners and seek services. TJ led to new perceptions that one's networks support FP.TJ represents an underused strategy for social and behaviour change. The social network approach encourages addressing the often-neglected social factors that stop women and men from acting on their desires to space births and use modern family planning methods.

Black-White Disparities in Preterm Birth: Geographic, Social, and Health Determinants.

INTRODUCTION: Reducing racial/ethnic disparities in preterm birth is a priority for U.S. public health programs. The study objective was to quantify the relative contribution of geographic, sociodemographic, and health determinants to the black, non-Hispanic and white, non-Hispanic preterm birth disparity. METHODS: Cross-sectional 2016 U.S. birth certificate data (analyzed in 2018-2019) were used. Black-white differences in covariate distributions and preterm birth and very preterm birth rates were examined. Decomposition methods for nonlinear outcomes based on logistic regression were used to quantify the extent to which black-white differences in covariates contributed to preterm birth and very preterm birth disparities. RESULTS: Covariate differences between black and white women were found within each category of geographic, sociodemographic, and health characteristics. However, not all covariates contributed substantially to the disparity. Close to 38% of the preterm birth and 31% of the very preterm birth disparity could be explained by black-white covariate differences. The largest contributors to the disparity included maternal education (preterm birth, 11.3%; very preterm birth, 9.0%), marital status/paternity acknowledgment (preterm birth, 13.8%; very preterm birth, 14.7%), source of payment for delivery (preterm birth, 6.2%; very preterm birth, 3.2%), and hypertension in pregnancy (preterm birth, 9.9%; very preterm birth, 8.3%). Interpregnancy interval contributed a more sizable contribution to the disparity (preterm birth, 6.2%, very preterm birth, 6.0%) in sensitivity analyses restricted to all nonfirstborn births. CONCLUSIONS: These findings demonstrate that the known portion of the disparity in preterm birth is driven by sociodemographic and preconception/prenatal health factors. Public health programs to enhance social support and preconception care, specifically focused on hypertension, may provide an efficient approach for reducing the racial gap in preterm birth.

The Role of Health Literacy in Family Planning Use among Senegalese Women.

Health communication has contributed to an increase in family planning use through education and mass media as a means to increase health literacy. In this research, we investigate health literacy as an auxiliary component of health communication. We test the validity of the Health Literacy Skills Framework by examining the correlation of health literacy indicators to family planning use among Senegalese women in the 2014 Demographic Health Survey. We found that increased family planning use was most strongly associated with hearing family planning messages through television and radio. Other health literacy indicators, including access to printed family planning messaging, textual literacy, and knowledge of ovulatory cycles did not strengthen family planning use, even when performing a subgroup analysis of women who could read. The implications are that the Health Literacy Skills framework can measure health literacy's ability (assessed through proxy indicators of health literacy) to predict modern family planning use among Senegalese women and that audio and visual health literacy measures are most strongly associated with increased family planning use.

Racial/Ethnic Differences in Unintended Pregnancy: Evidence From a National Sample of U.S. Women.

INTRODUCTION: Racial and ethnic minorities experience greater burden of unintended pregnancy in the U.S. This study examined the factors associated with racial and ethnic disparities in unintended pregnancy among women in the U.S. using the social ecological model. METHODS: This study utilized the National Survey of Family Growth data from 2006 to 2010. Data were analyzed in Autumn 2014 and Winter 2015. Decomposition analyses examined which intrapersonal, interpersonal, institutional, community, and public policy factors explained racial and ethnic disparities in unintended pregnancy. RESULTS: Unadjusted analyses found that black and Hispanic women had a greater likelihood of unintended pregnancy compared with white women. Decomposition models explained 51% of the disparity in unintended pregnancy between black and white women and 73% of that between Hispanic and white women. Factors contributing to the disparity between black and white women included age, relationship status, respondent's mother's age at first birth, Federal Poverty Level, and insurance status. Between Hispanic and white women, these factors included age, U.S.-born status, education, and relationship status. CONCLUSIONS: Given that the results showed factors at different levels of the social ecological model contribute to racial and ethnic disparities in unintended pregnancy, interventions that aim to reduce these disparities should target at-risk groups of women such as younger, unmarried, lower-income, less-educated, non-U.S. born women and uninsured or publicly insured women.

Linking uninsured patients treated in the emergency department to primary care shows some promise in Maryland.

Use of the emergency department (ED) has increased significantly over the past twenty years, especially among people who lack access to regular care, such as from a primary care provider. Not only are many ED visits avoidable, but receiving care through the ED also may disrupt continuity of care and result in increased overall health care costs. This article analyzes one of the twenty-nine local projects funded by the Centers for Medicare and Medicaid Services: the Emergency Department-Primary Care Connect initiative of the Primary Care Coalition of Montgomery County, Maryland. The initiative linked low-income or uninsured patients with local safety-net primary care providers. In the period 2009-11, five participating hospital EDs referred 10,761 low-income uninsured ED patients to four local primary care clinics. The intervention did not significantly reduce overall subsequent ED visits, but there was a significant reduction in subsequent ED visits among the subpopulation with chronic physical or behavioral conditions if they had more than two visits to the same primary care clinic. Our findings suggest that expansion of safety-net clinics, combined with strategies to link high-need patients in the ED with these primary care providers, can reduce subsequent ED use.