Graduation Year


Document Type




Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Community and Family Health

Major Professor

Carol Bryant, Ph.D.

Committee Member

Roger Boothroyd, Ph.D.

Committee Member

William Sappenfield, M.D., MPH

Committee Member

Linda Whiteford, Ph.D., MPH


Reproductive Health, Multilevel Modeling, Social Epidemiology, Pakistan


South Asia has the highest absolute number of women with an unmet need for contraception in the world. The total number of women with unmet need is 142 million. Of this, Asia accounts for 84 million followed by Sub-Saharan Africa at 32 million. Within South Asia, some countries have seen unmet need decrease and the contraception rate increase; however, Pakistan remains the exception to the rule. Pakistan has a low rate of contraception use, high rate of contraception discontinuation, high unmet need and high rate of unwanted fertility.

A number of theories have hypothesized that community-level factors influence a couple’s fertility decisions. Yet until recently, studies of contraceptive use dynamics have focused on individual and household-level determinants. Within Pakistan, this focus on individual and household level has not been able to explain the changes in use, which goes beyond socio-economic and cultural boundaries. As a result, there is impetus on researchers to shift focus and look at the interaction between and within the individual and the community. This study aims to address this gap in the literature by examining the association between community contextual factors and modern contraception use in a developing country using multilevel modeling.

The Commission on Social Determinants of Health and the Determinants of Fertility framework were used to test five research questions, on the association between modern contraception use and socioeconomic and political context, social position, social class, health system and overall community contextual factors. Community contextual factors tested were found to be associated with modern contraception use and explained 32% of the variance in the outcome. Specifically, the variables that played a significant role and showed a strong association with modern contraception use were related to public policy; community knowledge of the presence of a lady health worker, community access to a family planning service outlet, and community region of residence, and women’s autonomy; community women’s education, community women’s ability to choose a spouse and own land or home.

This study moves the discussion from a focus on individual level factors that impact contraceptive us to community-level factors. Numerous studies and anecdotal evidence have pointed to the importance of community context in contraceptive use; however, there has been a paucity of research investigating this realm. This study bridges this gap by providing evidence for existing programs and policies, strengthening the call for more community-based initiatives and helping to understand individual behavior as it relates to the community in which the person resides.