acase@tulane.edu

acase@tulane.edu

Background: Despite the contraceptive prevalence of 67.4% in Morocco, one woman out of 10 has unmet need for birth spacing or limiting and, only one woman out of two is using modern contraception. Although, Moroccan national family program [FP] was launched in the sixties and aimed to increase use of FP among married Moroccan women; the program is still facing some limits to improve couple’s contraceptive care. This paper examines to what extent women’s status, husband’s FP approval and mass media positive exposure to FP messages translate into increased modern contraceptive uptake. This study uses the socio ecological framework to assess factors that influence FP use among married women in Morocco. In this model factors from individual, interpersonal and programmatic levels were identified based on a review of the literature as having an effect on contraception use. Objectives: The main objectives of this study are to: (1) explore the effect of women’s status including their education, their occupation and, their FP decision making on women’s desire for more children, (2) examine if husbands’ FP approval impacts women’s fertility desire, (3) assess how positive mass media FP messages ‘exposure influences women’s desire for children, (4) explore the effect of women’s fertility desire on women’s FP approval and,(5) assess if women’s FP approval increases modern contraception adoption. Methods: This analysis is based on secondary data from the 2004 Demographic Health Survey and, 2011 Morocco National Survey on Population and Family Health which were conducted among married women aged between 15 and 49 years old. Data were collected using a two-stage sampling scheme and the study population was 8,106 women in 2004 and 9,317 women in 2011. Path analysis, using series of multiple regression modeling analyses, was conducted to investigate the relationship between women’s desire for more children and predictors related to women’s status, husbands’ FP approval and, women’s exposure to FP messages via mass media. Full models were fitted to test the relationships between women’s desire for more children and women’s FP approval; women’s approval of FP and modern contraception use. Results: Descriptive analysis between 2004 data and 2011 data analysis showed similar results for women’s and husbands’ predictors. Women in 2011 who used modern contraception were mostly aged more than 35 years old (51%), lived in urban areas (56%), mostly rich (40.3%), educated (46%), with no occupation (89%), did not decide FP use alone (73.3%), whose husbands discussed FP with them (62%) and, approved contraceptive use (98%). Positive exposures to FP messages on mass media were measured only in 2004 data and showed that among women who adopted modern contraception, only 2.9% read FP messages in newspapers, 12.6% heard them in the radio and 25.5% heard them on television. Path analyses showed some differences between 2004 data and 2011data. In 2011 data educated women were 1.42 (O.R. = 1.42, C.I. 1.26–1.6) more likely to desire more children than those with no education. Women with occupation were 1.25 (O.R. = 1.25, C.I. 1.01–1.47) times more likely to desire children than those with no occupation. However, women’s education and women’s occupation factors were not related to women’s fertility desire in 2004 data. Husbands’ FP approval was not significantly associated to women’s fertility desire in both 2004 and 2011 data analyses. Mass media exposure to FP messages was examined only in 2004 and showed no significant association with women’s fertility desire. Similar results were observed between 2004 data and 2011 data and showed that women who decided for FP were 0.75 (O.R. = 0.75, C.I. 1.01–1.47) times less likely to desire more children than those who were not FP decision makers. Moreover, in 2004 women who decided for FP were 2, 32 times more likely to use modern contraception than women who were not FP decision makers [O.R. 2, 31 (CI 1.79-3.01)]. In 2011 data analysis, women who approved FP were 5.72 (O.R. = 5.72, C.I. 3.06–10.7) more likely to use modern contraception than those who did not approve FP. Furthermore, women whose husbands approved FP were 2.55 times more likely to adopt modern contraception (O.R. = 2.55, CI 1.845-3.513). Conclusions: This study results indicated women’s and, husband’s factors affecting women’s fertility desire and women’s contraceptive use. The factors effects varied between 2004 data and 2011 data. In 2011 data women’s education, women’s occupation, women’s FP decision making and, husbands’ FP discussion variables, had a significant effect on women’s fertility desire. However, in 2004 data only husband’s FP discussion had a positive effect on women’s fertility desire which had a positive effect on women’s FP approval. Women’s exposure to mass media FP messages did not have a significant effect on both women’s fertility desire and women’s contraceptive outcomes. Husbands’ FP approval and husbands’ FP discussion with their wives were highly predictive for women’s contraceptive use and remained essential factors for which Moroccan health policy makers should take into consideration in order to reduce unmet needs and improve couple’s contraceptive care in Morocco. / acase@tulane.edu

Village Malaria Workers (VMWs) play an important role in the prevention and treatment of malaria as frontline volunteers in Cambodia, a nation implementing decentralisation initiatives and that is reliant on task shifting to address health worker shortages. Studying the performance of VMWs and understanding the social capital that they are able to mobilise, including enabling and reinforcing factors while fighting malaria in Cambodia’s Pailin province, will benefit performance enhancement and program scale up. This dissertation examines the factors associated with the perceived performance of VMWs, which has the potential to provide practical guidance for Cambodian health system managers and local health practitioners to capitalize on locally-available human resources to implement their health initiatives as per the country’s decentralisation plans. The study was done in 2 districts of Pailin province in Cambodia. The findings were based on 35 semi-structured surveys, 13 key informant interviews, 6 focus group discussions, 3 group interviews and 2 in-depth interviews covering VMWS and stakeholders from the commune council, village health support groups, health center management committee, provincial health offices, a referral hospital, a pharmacy, village chiefs, and administrative officials. The interviews and discussions were conducted using set guides, which allowed for flexibility and asking for follow-up questions as well as probing for more information and clarification. Pre-determined themes were used in designing the instruments, and data from the survey, focus groups, and interviews were thematically coded for manual data analysis. This study showed that VMWs’ performance is affected by a variety of factors that emerge from the complex context in which they work. These include socio-demographic variables; their health system knowledge; access to enabling and reinforcing factors, including family and social support; personal motivation; resource availability, including budget, supplies, and equipment; ways of being selected; access to learning, training and capacity-building opportunities; and institutional communication and implementation of decentralised health program. Factors such as perceived corruption also were seen to affect VMW’s performance. The participants suggested various ways to address these challenges. In order to improve the performance of VMWs, people’s participation in all local governance arms, including the CC, VHSG, HCMC and the HC, needs to be strengthened. The roles and expectations regarding citizen participation need to be clarified using simple messages. Training and capacity-building support needs to be made available for learning key new skills as relevant. The equipment and supplies necessary for work as well as adequate reimbursement of transportation allowances need to be provided along with instilling a proper system of VMW supervision and mentoring that adequately recognises those that are high performing. Targeted capacity assessments for VMWs and the VHSG, HC and HCMC need to be undertaken followed by needed training and mentoring in order to address areas that need further support to enhance productivity. A volunteer selection process needs to follow the rules described in the CPP policy ensuring deliberate attempts to open up entry points for public service to those that have been excluded on the basis of formal qualifications, lack of kinship, or political affiliation. / acase@tulane.edu

acase@tulane.edu