Applying the Transtheoretical (Stages of Change) Model to Understand Women's Experience of Adopting Modern FP Methods in Pakistan

Summary:

This abstract pertains to the application of the Transtheoretical (Stages of Change) Model to understand Married Women of Reproductive Age (MWRAs) experience of adopting modern FP methods in Pakistan. This research also explored the use of TTM as an appropriate theory to base modern FP interventions focusing on women in Pakistan. The study employed a qualitative approach in which MWRAs were bifurcated by age to groups of youth (18-24) and older women (25-34). A semi-structured in-depth questionnaire was also developed through which 117 MWRAs were interviewed to understand their different stages and processes of change in their awareness, decision to use, use and experience, maintenance, and discontinuation of modern FP methods. Of the 10 processes of change, 5 were observed to facilitate movement between stages. However, the posits of TTM processes did not manifest as facilitators of behavior change; they were operating negatively in the current Pakistani context. The findings support the development of a contextualized replication of TTM in non-western countries settings to understand women's overall experience (positive/negative) about FP. A quantitative study could be done to establish relationships and assess statistical significance for applicability of behavioral predictors and to understand extraneous variables that may affect behaviors. This also has implications for the field level where programs and interventions can then utilize specific assessments of women's position on the adoption stage, assess which influencing processes and constructs of change would be most beneficial, and tailor interventions appropriately, as according to the context.

Background/Objectives:

In Pakistan, 1 in 4 women currently uses a modern method, a number that has remained stagnant since the last PDHS. Similarly, long-acting reproductive contraception (LARC) uptake has remained unchanged over the last decade. This highlights a need to understand why adoption rates have remained low. This study sought to unpack the determinants of modern FP adoption by examining the application of Transtheoretical Model (TTM) to understand MWRA's experience of adopting modern FP methods along the adoption change. This research also explored use of TTM as an appropriate theory to base modern FP interventions focusing on women in Pakistan.

Description of Intervention and/or Methods/Design:

The study employed a qualitative approach in which MWRAs were bifurcated by age to groups of youth (18-24) and older women (25-34). A semi-structured in-depth questionnaire was developed to understand MWRAs' different experiences in their awareness, decision to use, use and experience, maintenance, and discontinuation of modern FP methods. Data collection was initiated in March 2019 and concluded in September 2019. A total of 117 interviews were conducted across 3 provinces in Pakistan (Sindh, Punjab and Khyber Pakhtunkhwa) in urban and rural areas. After data collection, thematic analysis was conducted with emerging themes being applied to the Transtheoretical Model to situate results in accordance with the 5 stages which have 10 additional processes (conscious raising, dramatic relief, self-re-evaluation, environmental re-evaluation, social and self-liberation, helping relationships, counter-conditioning, reinforcement management, and stimulus control) that are covert and overt activities/experiences employed by individuals to modify behavior.

Results/Lessons Learned:

Of the 10 processes of change, 5 were observed to facilitate movement between stages. At pre-contemplation stage, women experienced consciousness-raising after the birth of a child which facilitated women to move onto contemplation and preparation. At the action stage, lack of social liberation and environmental re-evaluation processes emerged which impeded adoption. For maintenance, environmental re-evaluation and decisional balance emerged which focused on the disadvantages of FP (side-affects) leading to discontinuation. Close relationships that encouraged/discouraged FP use and emotional response of others and the woman about FP were present throughout the stages which acted as deterrents or incentives. However, the posits of TTM processes did not manifest as facilitators of behavior change; they were operating negatively. For example, TTM posits that social liberation identifies opportunities that show society's approval but for this setting, society's disapproval through negative views, distant facilities and behavior of healthcare providers was more apparent.

Discussion/Implications for the Field:

In Pakistan's setting, 5 processes (consciousness raising, dramatic relief, environmental re-evaluation, social liberation, and close relationships) were observed to contribute as negative manifestations. This supports the development of a contextualized replication of TTM to understand women's overall experience (positive/negative) about FP. A quantitative study could be done to establish relationships and assess statistical significance for applicability of behavioral predictors. Steps must be taken to design and implement interventions for women which can utilize specific assessments to their position on the adoption stage, assess which influencing processes and constructs of change would be most beneficial and tailor interventions appropriately.

Abstract submitted by: 

Ayesha Leghari

Saif Ur Rehman Jamali

Mahnoor Fatima

Mahesh Paudel