{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T18:23:14Z","timestamp":1787595794133,"version":"build-2736575974"},"reference-count":23,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T00:00:00Z","timestamp":1787529600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["INV-051108"],"award-info":[{"award-number":["INV-051108"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Unintended pregnancies remain a major public health challenge in Pakistan, driven in part by low and inconsistent contraceptive use. While prior research has largely focused on demographic and access-related determinants, less attention has been given to the role of health beliefs within a broader reproductive context. This study applied a revised Health Belief Model (HBM) to examine how perceived threat and perceived benefits are associated with contraceptive use among married women in Pakistan, alongside fertility preferences and health system interaction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This study used data from the Pakistan Demographic and Health Survey (PDHS 2017\u201318), including 14,494 currently married women aged 15\u201349 years with complete data. Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to estimate associations between HBM constructs and current contraceptive use. Psychological constructs were operationalized using proxy indicators, while health system interaction was captured through contact with family planning providers and facilities. Three models were estimated: a baseline HBM model, a model adjusted for demographic and socioeconomic characteristics, and an extended model incorporating fertility preferences and partner-related factors. Model performance was assessed using R\u00b2, Cohen\u2019s f\u00b2 effect sizes, and bootstrapped confidence intervals based on 5,000 resamples.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Perceived threat (\u03b2\u2009=\u20090.045; 95% CI: 0.029, 0.061) and perceived benefits (\u03b2\u2009=\u20090.018; 95% CI: 0.002, 0.038) were positively associated with contraceptive use, but with small effect sizes. Health system interaction remained consistently associated across models (\u03b2\u2009=\u20090.079; 95% CI: 0.063, 0.096). In the extended model, fertility-related variables showed the largest magnitude associations, particularly preferred birth spacing (\u03b2\u2009=\u20090.501; 95% CI: 0.451, 0.550) and pregnancy intention (\u03b2\u2009= \u22120.298; 95% CI: \u22120.349, \u22120.245), followed by births in the last five years (\u03b2\u2009=\u20090.096; 95% CI: 0.079, 0.113) and husband\u2019s fertility preference (\u03b2\u2009= \u22120.090; 95% CI: \u22120.103, \u22120.075). Model explanatory power increased across specifications, with R\u00b2 rising from 0.032 in the baseline model to 0.138 in the extended model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Contraceptive use in Pakistan is more strongly associated with fertility preferences and health system interaction than with health beliefs alone. The limited contribution of perceived threat and perceived benefits highlights the need to move beyond awareness-based approaches toward interventions that strengthen service delivery and align with women\u2019s reproductive intentions. Programs that improve access to providers, support birth spacing goals, and address partner dynamics may be more effective in increasing contraceptive uptake. Given the cross-sectional design, findings should be interpreted as associations rather than causal relationships.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0356281","type":"journal-article","created":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T17:25:55Z","timestamp":1787592355000},"page":"e0356281","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Revisiting the health belief model: The role of fertility preferences and health system interaction in contraceptive use in Pakistan"],"prefix":"10.1371","volume":"21","author":[{"given":"Maheen","family":"Sughra","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aisha","family":"Irum","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad","family":"Ibrahim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3816-3943","authenticated-orcid":true,"given":"Adnan Ahmad","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,8,24]]},"reference":[{"issue":"5","key":"pone.0356281.ref001","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1080\/14767058.2018.1500538","article-title":"Consequences of unintended pregnancy on mother and fetus and newborn in North-East of Iran","volume":"33","author":"M Gharaee","year":"2020","journal-title":"J Matern Fetal Neonatal Med"},{"issue":"2","key":"pone.0356281.ref002","doi-asserted-by":"crossref","first-page":"020429","DOI":"10.7189\/jogh.09.020429","article-title":"The impact of underuse of modern methods of contraception among adolescents with unintended pregnancies in 12 low- and middle-income countries","volume":"9","author":"S Bellizzi","year":"2019","journal-title":"J Glob Health"},{"key":"pone.0356281.ref003","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-017-1339-z","article-title":"Prevalence and determinants of unintended pregnancies amongst women attending antenatal clinics in Pakistan","volume":"17","author":"MA Habib","year":"2017","journal-title":"BMC Pregnancy and Childbirth"},{"issue":"1","key":"pone.0356281.ref004","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2024-017239","article-title":"Abortion and unintended pregnancy in Pakistan: new evidence for 2023 and trends over the past decade","volume":"10","author":"Z Sathar","year":"2025","journal-title":"BMJ Glob Health"},{"issue":"3","key":"pone.0356281.ref005","first-page":"950","article-title":"The relationship between contraceptive use and unintended pregnancies among married women in Thatta district, Pakistan","volume":"5","author":"S Ali","year":"2017","journal-title":"Journal of Midwifery and Reproductive Health"},{"issue":"4","key":"pone.0356281.ref006","first-page":"588","article-title":"Barriers to family planning In Pakistan","volume":"32","author":"M Imran","year":"2020","journal-title":"J Ayub Med Coll Abbottabad"},{"key":"pone.0356281.ref007","article-title":"Safeguarding women\u2019s health: trends, inequities, and opportunities in Pakistan\u2019s abortion and post-abortion care services","author":"AM Mir","year":"2024","journal-title":"Population Council"},{"issue":"4","key":"pone.0356281.ref008","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1177\/109019817400200405","article-title":"The health belief model and preventive health behavior","volume":"2","author":"IM Rosenstock","year":"1974","journal-title":"Health Education Monographs"},{"issue":"4","key":"pone.0356281.ref009","doi-asserted-by":"crossref","first-page":"1849","DOI":"10.4314\/ahs.v21i4.43","article-title":"Psychosocial factors influencing contraceptive use among adolescent mothers in the Volta Region of Ghana: application of the Health Belief Model","volume":"21","author":"PY Akonor","year":"2021","journal-title":"Afr Health Sci"},{"issue":"3","key":"pone.0356281.ref010","doi-asserted-by":"crossref","first-page":"153","DOI":"10.4314\/jcmphc.v34i3.12","article-title":"Predictors of willingness to use modern contraceptives among female undergraduate students in a tertiary institution in Nigeria: The Health Belief Approach","volume":"34","author":"F Fehintola","year":"2022","journal-title":"J Com Med and PHC"},{"issue":"1","key":"pone.0356281.ref011","doi-asserted-by":"crossref","first-page":"55","DOI":"10.26911\/thejhpb.2019.04.01.06","article-title":"Application of health belief model on factors influencing long-term contraceptive use","volume":"4","author":"AD Pitaloka","year":"2019","journal-title":"J Health Promot Behav"},{"issue":"22","key":"pone.0356281.ref012","doi-asserted-by":"crossref","first-page":"11892","DOI":"10.3390\/ijerph182211892","article-title":"Exploring readiness for Birth control in improving women health status: Factors influencing the adoption of modern contraceptives methods for family planning practices","volume":"18","author":"AM Shah","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"pone.0356281.ref013","doi-asserted-by":"crossref","first-page":"1810","DOI":"10.1016\/S0140-6736(06)69480-4","article-title":"Family planning: the unfinished agenda","author":"J Cleland","year":"2006","journal-title":"Lancet"},{"issue":"4","key":"pone.0356281.ref014","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1353\/dem.2007.0043","article-title":"The estimation of unwanted fertility","volume":"44","author":"JB Casterline","year":"2007","journal-title":"Demography"},{"issue":"2","key":"pone.0356281.ref015","doi-asserted-by":"crossref","first-page":"76","DOI":"10.2307\/3181061","article-title":"The link between quality of care and contraceptive use","volume":"29","author":"S RamaRao","year":"2003","journal-title":"Int Fam Plan Perspect"},{"issue":"1","key":"pone.0356281.ref016","doi-asserted-by":"crossref","first-page":"1","DOI":"10.2307\/1966656","article-title":"Fertility reduction and the quality of family planning services","volume":"20","author":"AK Jain","year":"1989","journal-title":"Stud Fam Plann"},{"key":"pone.0356281.ref017","unstructured":"Studies P. Pakistan demographic and health survey 2017-2018. 2019."},{"key":"pone.0356281.ref018","unstructured":"Westoff CF. Desired number of children: 2000-2008. 2010."},{"key":"pone.0356281.ref019","doi-asserted-by":"crossref","unstructured":"Bongaarts J. Do reproductive intentions matter? International Family Planning Perspectives. 1992:102\u20138.","DOI":"10.2307\/2133409"},{"issue":"7","key":"pone.0356281.ref020","doi-asserted-by":"crossref","first-page":"1233","DOI":"10.2105\/AJPH.2005.071522","article-title":"Contextual influences on modern contraceptive use in sub-Saharan Africa","volume":"97","author":"R Stephenson","year":"2007","journal-title":"Am J Public Health"},{"issue":"1","key":"pone.0356281.ref021","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1007\/s11205-021-02633-7","article-title":"Women decision making autonomy as a facilitating factor for contraceptive use for family planning in Pakistan","volume":"156","author":"M Nadeem","year":"2021","journal-title":"Soc Indic Res"},{"issue":"2","key":"pone.0356281.ref022","doi-asserted-by":"crossref","first-page":"229","DOI":"10.2307\/3004054","article-title":"Men matter: additive and interactive gendered preferences and reproductive behavior in Kenya","volume":"35","author":"FN Dodoo","year":"1998","journal-title":"Demography"},{"key":"pone.0356281.ref023","volume-title":"Health behavior: Theory, research, and practice","author":"K Glanz","year":"2015"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0356281","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T17:26:01Z","timestamp":1787592361000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0356281"}},"subtitle":[],"editor":[{"given":"Saeed","family":"Ahmad","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,24]]},"references-count":23,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,24]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0356281","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,24]]}}}