Alison Norris

Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.

Alcohol and transactional sex: How risky is the mix?

This study examines alcohol use, transactional sex (TS), and sexually transmitted infection (STI) risk among sugar plantation residents near Moshi, Tanzania, from 2002 to 2004. We compare popular discourse gathered through ethnographic methods with cross-sectional questionnaire and STI prevalence data to illuminate the close correspondence of alcohol use and TS with STI transmission. People attributed to alcohol varied consequences: some socially desirable (relaxing, reducing worries) and others (drunkenness, removing shame) thought to put alcohol abusers at risk for STIs. TS-exchanging money, food, gifts, alcohol or work for sex-was not stigmatized, but people believed that seeking sexual partners for money (or providing money to sexual partners) led to riskier sexual relationships. We explore popular discourse about how alcohol use and TS independently and in combination led to increased STI exposure. Popular discourse blamed structural circumstances-limited economic opportunities, few social activities, separated families-for risky sex and STIs. To understand individual behavior and risk, we surveyed 556 people. We measured associations between their self-reported behaviors and infection with herpes simplex virus type-2 (HSV-2), syphilis, and HIV in 462 participants who were tested. Alcohol abuse was associated with prevalent STI and HIV infection. Exchanging sex for alcohol and work were both associated with prevalent STI. Participants who both abused alcohol and participated in TS had greatest risk for STI. Findings from the two analytic methods-interrogation of popular discourse, and association between self-reported behavior and STIs-were largely in agreement. We posit explanations for discrepancies we found through the concepts of sensationalization, self-exceptionalization, and the influence of an authoritative moral discourse.

Barriers and Facilitators to Adolescents' Use of Long-Acting Reversible Contraceptives.

Most pregnancies among teenagers are unintended and many can be attributed to contraception misuse or nonuse. The etonogestrel implant and intrauterine devices, referred to as long-acting reversible contraceptives, or LARCs, are the most effective reversible contraceptive methods. These methods are safe for use by adolescents, yet the number of LARC users remains low among adolescents in the United States. In this review we examine recent literature about barriers and facilitators to LARC use among adolescent women. Factors that influence decision-making and provision are organized into 4 categories: (1) cost and clinical operations; (2) adolescent awareness and attitudes; (3) confidentiality, consent, and parental attitudes; and (4) health care provider knowledge, attitudes, and counseling. Knowledge deficits and misconceptions among adolescents and their health care providers are key barriers to adolescent LARC use.

Assessing Program Coverage of Two Approaches to Distributing a Complementary Feeding Supplement to Infants and Young Children in Ghana

The work reported here assesses the coverage achieved by two sales-based approaches to distributing a complementary food supplement (KOKO Plus™) to infants and young children in Ghana. Delivery Model 1 was conducted in the Northern Region of Ghana and used a mixture of health extension workers (delivering behavior change communications and demand creation activities at primary healthcare centers and in the community) and petty traders recruited from among beneficiaries of a local microfinance initiative (responsible for the sale of the complementary food supplement at market stalls and house to house). Delivery Model 2 was conducted in the Eastern Region of Ghana and used a market-based approach, with the product being sold through micro-retail routes (i.e., small shops and roadside stalls) in three districts supported by behavior change communications and demand creation activities led by a local social marketing company. Both delivery models were implemented sub-nationally as 1-year pilot programs, with the aim of informing the design of a scaled-up program. A series of cross-sectional coverage surveys was implemented in each program area. Results from these surveys show that Delivery Model 1 was successful in achieving and sustaining high (i.e., 86%) effective coverage (i.e., the child had been given the product at least once in the previous 7 days) during implementation. Effective coverage fell to 62% within 3 months of the behavior change communications and demand creation activities stopping. Delivery Model 2 was successful in raising awareness of the product (i.e., 90% message coverage), but effective coverage was low (i.e., 9.4%). Future programming efforts should use the health extension / microfinance / petty trader approach in rural settings and consider adapting this approach for use in urban and peri-urban settings. Ongoing behavior change communications and demand creation activities is likely to be essential to the continued success of such programming.

Household Coverage of Fortified Staple Food Commodities in Rajasthan, India.

A spatially representative statewide survey was conducted in Rajasthan, India to assess household coverage of atta wheat flour, edible oil, and salt. An even distribution of primary sampling units were selected based on their proximity to centroids on a hexagonal grid laid over the survey area. A sample of n = 18 households from each of m = 252 primary sampling units PSUs was taken. Demographic data on all members of these households were collected, and a broader dataset was collected about a single caregiver and a child in the first 2 years of life. Data were collected on demographic and socioeconomic status; education; housing conditions; recent infant and child mortality; water, sanitation, and hygiene practices; food security; child health; infant and young child feeding practices; maternal dietary diversity; coverage of fortified staples; and maternal and child anthropometry. Data were collected from 4,627 households and the same number of caregiver/child pairs. Atta wheat flour was widely consumed across the state (83%); however, only about 7% of the atta wheat flour was classified as fortifiable, and only about 6% was actually fortified (mostly inadequately). For oil, almost 90% of edible oil consumed by households in the survey was classified as fortifiable, but only about 24% was fortified. For salt, coverage was high, with almost 85% of households using fortified salt and 66% of households using adequately fortified salt. Iodized salt coverage was also high; however, rural and poor population groups were less likely to be reached by the intervention. Voluntary fortification of atta wheat flour and edible oil lacked sufficient industry consolidation to cover significant portions of the population. It is crucial that appropriate delivery channels are utilized to effectively deliver essential micronutrients to at-risk population groups. Government distribution systems are likely the best means to accomplish this goal.

Crippling Violence: Conflict and Incident Polio in Afghanistan

Background Designing effective public health campaigns in areas of armed conflict requires a nuanced understanding of how violence impacts the epidemiology of the disease in question. Methods We examine the geographical relationship between violence (represented by the location of detonated Improvised Explosive Devices) and polio incidence by generating maps of IEDs and polio incidence during 2010, and by comparing the mean number of IED detonations in polio high-risk districts with non polio high-risk districts during 2004–2009. Results We demonstrate a geographic relationship between IED violence and incident polio. Districts that have high-risk for polio have highly statistically significantly greater mean numbers of IEDs than non polio high-risk districts (p-values 0.0010–0.0404). Conclusions The geographic relationship between armed conflict and polio incidence provides valuable insights as to how to plan a vaccination campaign in violent contexts, and allows us to anticipate incident polio in the regions of armed conflict. Such information permits vaccination planners to engage interested armed combatants to co-develop strategies to mitigate the effects of violence on polio.

Partner approval and intention to use contraception among Zanzibari women presenting for post-abortion care.

OBJECTIVE We examined the effect of partner approval of contraception on intention to use contraception among women obtaining post-abortion care in Zanzibar. STUDY DESIGN Our data source was a 2010 survey of 193 women obtaining post-abortion care at a large public hospital in Zanzibar. We used multivariable logistic regression analysis to assess associations between partner approval and intention to use contraception. RESULTS Overall, 23% of participants had used a contraceptive method in the past, and 66% reported intending to use contraception in the future. We found that partner approval of contraception and ever having used contraception in the past were each associated with intending to use contraception in the future. In the multivariable model, adjusting for past contraception use, partner approval of contraception was associated with 20 times the odds of intending to use contraception (odds ratio, 20.25; 95% confidence interval, 8.45-48.56). CONCLUSIONS We found a strong association between partner approval and intention to use contraception. Efforts to support contraceptive use must include both male and female partners. IMPLICATIONS Public health and educational efforts to increase contraceptive use must include men and be targeted to both male and female partners. Given that male partners are often not present when women obtain health care, creative efforts will be required to meet men in community settings.

Fertility desires, unmet need for family planning, and unwanted pregnancies among HIV-infected women in care in Kinshasa, DR Congo.

Introduction We assessed the fertility desires, utilization of family planning (FP) methods, and incidence of pregnancies among HIV-infected women receiving care in an HIV clinic with an onsite FP services in Kinshasa, Democratic Republic of Congo. Methods Between November 2011 and May 2012, all HIV-infected women who attended a routine visit at the clinic were interviewed about their fertility desires and utilization of contraceptive methods using a structured questionnaire. Routine follow-up visit data were used to identify pregnancies recorded between the interview and June 2013. Results Overall, of the 699 HIV-infected women interviewed. 249 (35.7%) reported not wanting another child. Of the 499 (72.2%) participants who were sexually active at the time of interview, 177 (35.5%) were using an effective contraceptive method, including 70 (14.0%) women who reported using condoms consistently and 104 (20.8%) who were using injectable contraception. Overall, 88 (17.6%) sexually active participants who did not want another child were not using an effective FP method, and thus are considered to have had unmet need. During the median follow-up time of 22.2 (IQR: 20.2, 23.6) months, among all women interviewed, 96 (14.1%) became newly pregnant [pregnancy rate 9.3 (95%CI: 7.6, 11.4) per 100 women-years] including 21 (8.7%) among women who initially reported not wanting another child [unwanted pregnancy rate 5.8 (95%CI: 3.6, 9.3) per 100 women-years]. Conclusion The persistence of relatively high unmet need among women receiving HIV care in a clinic with onsite FP services suggests the existence of barriers that must be identified and addressed.

Prostate-specific antigen is unlikely to be a suitable biomarker of semen exposure from recent unprotected receptive anal intercourse in men who have sex with men.

A biomarker of unprotected receptive anal intercourse could improve validity of sexual behavior measurement. We quantified prostate-specific antigen (PSA) from rectal swabs from men who have sex with men (MSM). One swab was PSA positive. Using current methods, PSA is an inadequate biomarker of recent unprotected receptive anal intercourse in men who have sex with men.

Prevalence of sexually transmitted infections among Tanzanian migrants: a cross-sectional study

For the many millions of migrants, mobility creates vulnerabilities and elevates risk for sexually transmitted infections (STIs). We document, among Tanzanian agricultural plantation residents, migrant characteristics and test associations between migrant status and prevalent STI (HSV-2, syphilis, and HIV). From 623 plantation resident participants, we limit this analysis to participants about whom we know migration status (migrants n = 242, non-migrants n = 291). We collected behavioral data via audio-computer assisted self-interview survey, and clinical data via STI testing. We used multivariate Poisson regression models, stratified by gender and controlling for behavioral risk factors, to measure associations between migrant status and STI. In men, HIV prevalence was 9% for migrants, and 6% for non-migrants. HSV-2 prevalence was 57% for migrants, and 32% for non-migrants. Syphilis prevalence was 12% for migrants, and 3% for non-migrants. Among women, there were few differences in STI prevalence by migrant status: prevalence of HIV was 6% vs. 5% (migrants vs. non-migrants); HSV-2 prevalence was 68% vs. 65%; and syphilis prevalence was 11% vs. 8%. Being a male migrant was significantly associated with increased prevalence of any STI after controlling for sociodemographic and behavioral characteristics (APR = 1.53, 95% CI 1.23–5.25). Migrant women did not have increased prevalence of STI as compared to non-migrant women (APR = 1.03, 95% CI 0.85–1.24). Amongst Tanzanian agricultural workers, male migrants experienced elevated risk for prevalent STI as compared to male non-migrants. We suggest structural interventions to reduce risks associated with migration, especially in male migrants, including workplace-based STI prevention programs, and connecting migrants to resources and support within new communities. The key messages are: migrant men experience significantly elevated risk for prevalent STI, above and beyond sociodemographic and behavioral risk factors, as compared to their non-migrant peers; women in this Tanzanian agricultural plantation community overall had higher prevalence of some STIs than men, migrant women had similar STI risk as non-migrant women; and migration for work, an economic strategy for millions, also creates vulnerabilities, so workplace-based STI prevention programs and connecting migrants to community resources are essential.