Ashley Fraser

Gender and Relationship Differences in Condom Use Among 15-24-Year-Olds in Angola

CONTEXT The sexual behavior of young people in Angola will play a major role in the future spread of HIV, yet few young people use condoms consistently, and reported rates of condom use are low. It is important to identify determinants of condom use among Angolan adolescents and young adults. METHODS Data for analysis came from 1,995 sexually experienced youth aged 15-24 who participated in a 2001 knowledge, attitudes and practices survey in Luanda, Angola. Logistic regression analysis was performed to identify predictors of consistent condom use by gender and determinants of condom use at last intercourse by type of relationship. RESULTS For both males and females, consistent condom use was positively associated with higher levels of education (odds ratios, 1.7-2.6) and believing that condoms did not diminish sexual pleasure (1.8 for both genders). It was negatively associated with being married or in a cohabiting relationship (0.1-0.5). Females who equated condom use with lack of trust were less likely to use condoms consistently (0.5), and males who believed that condoms were safe and those who had multiple partners were more likely to be consistent users (1.6 and 1.7, respectively). Urban residence, higher education, being in school and not equating condom use with lack of trust were important predictors of use at last intercourse in regular and casual relationships, whereas access to condoms was the most important factor in spousal relationships (4.5). CONCLUSIONS Intervention programs aimed at less educated, periurban and unemployed young people should be part of an effective HIV-prevention strategy. Such programs must address misperceptions among youth about condom use and the need for protection from HIV and other STIs.

Community mobilization to reduce postpartum hemorrhage in home births in northern Nigeria

The purpose of this study is to demonstrate the importance of community mobilization in the uptake of a health intervention, namely, community-based distribution of misoprostol to prevent postpartum hemorrhage. Community mobilization to increase access to misoprostol for postpartum hemorrhage prevention was implemented in northwestern Nigeria in 2009. Theories of community participation and the current near-epidemic maternal mortality conditions underpin an approach using modest levels of community involvement. The study was undertaken in five communities around Zaria, Nigeria. Community leaders and selected community members participated in a series of dialogs. Additionally, community education, information and dramas sessions were held. Twenty nine community oriented resource persons (CORPs), 27 drug keepers and 41 traditional birth attendants (TBAs) were involved in the intervention. Postpartum interviews were used to assess the impact of community mobilization efforts and to track use of misoprostol. Multiple logistic regression was used to examine the association between correct use and receiving information regarding misoprostol from TBAs or CORPs. A total of 1875 women were enrolled in the study in 2009. Most women delivered at home (95%) and skilled attendance at delivery was low (7%). Community mobilization efforts reached most women with information about postpartum hemorrhage and misoprostol (88%), resulting in high comprehension of intervention messages. Women identified TBAs and CORPs as the single most important source of information about misoprostol 41% and 31% of the time, respectively. Availability of misoprostol at the community level gave 79% of enrolled women some protection against postpartum hemorrhage which they otherwise would not have had. Although high level community participation in health care interventions is the ideal, this study suggests that even in circumstances where only modest levels of participation can realistically be achieved, community mobilization can have a significant impact on the successful distribution and uptake of a potentially life-saving health intervention, in turn helping promote policy change.

Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents

OBJECTIVE To determine whether community-based health workers in a rural region of Ethiopia can provide injectable contraceptives to women with similar levels of safety, effectiveness and acceptability as health extension workers (HEWs). METHODS This was a prospective non-randomized community intervention trial designed to test the provision of injectable contraceptives by community-based reproductive health agents (CBRHAs). Effectiveness, safety, acceptability and continuation rates were the outcomes of interest. The outcomes observed when injectable contraceptives were administered by HEWs in health posts and when they were administered by CBRHAs were compared by means of χ(2) tests for association among categorical variables and t-tests for independent samples to determine differences between group means. FINDINGS A total of 1062 women participated in the study. Compared with health post clients, the clients of CBRHAs were, on average, slightly older, less likely to be married and less educated, and they had significantly more living children. Women seeking services from CBRHAs were also significantly more likely to be using injectable contraceptives for the first time; health post clients were more likely to have used them in the past. In addition, clients of CBRHAs were less likely to discontinue using injectable contraceptives over three injection cycles than health post clients. CONCLUSION Receiving injectable contraceptives from CBRHAs proved as safe and acceptable to this sample of Ethiopian women as receiving them in health posts from HEWs. These findings add to the growing body of evidence supporting the development, introduction and scale up of programmes to train community-based health workers such as CBRHAs to safely administer injectable contraceptives.

Concepts of Infidelity Among African American Emerging Adults Implications for HIV/STI Prevention

In this study, we used an exploratory methodology to determine what cultural models African American emerging adults use to understand infidelity/cheating. Cultural models are defined as “cognitive schema[s] that [are] intersubjectively shared by a social group” (D’Andrade, 1987, p. 112). We interviewed 144 participants ages 19-22 from three geographically distal sites. Qualitative analysis was conducted using NUDIST and In Vivo Analysis, a form of Grounded Theory. Among those in a main (dyadic) relationship, 37% of females and 57% of males stated they had been unfaithful to their main partner during the past month. We identify five cultural models defining 1) the nature of infidelity, 2) reasons for infidelity, 3) techniques for managing side (extra-dyadic) partners, 4) means of investigating suspected infidelity, and 5) condom use in main and side relationships. Our findings suggest that stressing condom use in side partner relationships may be a particularly effective means of HIV/STI prevention in this high-risk population.

Primary relationship scripts among lower-income, African American young adults.

Research on romantic relationships among lower income, African American young adults has mostly focused on problem behaviors, and has infrequently documented nonpathological relationship processes that are widely studied among middle-class college students, their wealthier and largely European American counterparts [Journal of Black Studies 39 (2009) 570]. To identify nonpathological cultural concepts related to heterosexual romantic relationships, we interviewed 144 low to low-mid income, African American young adults aged 19-22 from the San Francisco Bay Area, CA, metropolitan Chicago, IL, and Greater Birmingham, AL. We identified 12 gender-shared scripts related to the romantic relationship in areas of (1) defining the relationship, (2) processes of joining, (3) maintaining balance, and (4) modulating conflict. Understanding romantic relationship scripts is important as successful romantic relationships are associated with improved mental and physical health among lower income individuals as compared with individuals without romantic partners [Social Science & Medicine 52 (2001) 1501].

Women’s empowerment and family planning: A review of the literature

This paper reviews the literature examining the relationship between womens empowerment and contraceptive use, unmet need for contraception and related family planning topics in developing countries. Searches were conducted using PubMed, Popline and Web of Science search engines in May 2013 to examine literature published between January 1990 and December 2012. Among the 46 articles included in the review, the majority were conducted in South Asia (n=24). Household decision-making (n=21) and mobility (n=17) were the most commonly examined domains of womens empowerment. Findings show that the relationship between empowerment and family planning is complex, with mixed positive and null associations. Consistently positive associations between empowerment and family planning outcomes were found for most family planning outcomes but those investigations represented fewer than two-fifths of the analyses. Current use of contraception was the most commonly studied family planning outcome, examined in more than half the analyses, but reviewed articles showed inconsistent findings. This review provides the first critical synthesis of the literature and assesses existing evidence between womens empowerment and family planning use.

Meeting rural demand: a case for combining community-based distribution and social marketing of injectable contraceptives in Tigray Ethiopia.

Background In Sub-Saharan Africa, policy changes have begun to pave the way for community distribution of injectable contraceptives but sustaining such efforts remains challenging. Combining social marketing with community-based distribution provides an opportunity to recover some program costs and compensate workers with proceeds from contraceptive sales. This paper proposes a model for increasing access to injectable contraceptives in rural settings by using community-based distributers as social marketing agents and incorporating financing systems to improve sustainability. Methods This intervention was implemented in three districts of the Central Zone of Tigray, Ethiopia and program data has been collected from November 2011 through October 2012. A total of 137 Community Based Reproductive Health Agents (CBRHAs) were trained to provide injectable contraceptives and were provided with a loan of 25 injectable contraceptives from a drug revolving fund, created with project funds. The price of a single dose credited to a CBRHA was 3 birr (

Criticism of misguided Chu et al. article

0.17) and they provide injections to women for 5 birr (

Women's empowerment and fertility: a review of the literature.

0.29), determined with willingness-to-pay data. Social marketing was used to create awareness and generate demand. Both quantitative and qualitative methods were used to examine important feasibility aspects of the intervention. Results Forty-four percent of CBRHAs were providing family planning methods at the time of the training and 96% believed providing injectable contraceptives would improve their services. By October 2012, 137 CBRHAs had successfully completed training and provided 2541 injections. Of total injections, 47% were provided to new users of injectable contraceptives. Approximately 31% of injections were given for free to the poorest women, including adolescents. Conclusions Insights gained from the first year of implementation of the model provide a framework for further expansion in Tigray, Ethiopia. Our experience highlights how program planners can tailor interventions to match family planning preferences and create more sustainable contraceptive service provision with greater impact.

Contraceptive Use among Women Seeking Repeat Abortion in Addis Ababa, Ethiopia

Chu, Brhlikova and Pollocks article suggests the WHO rethink its decision to include misoprostol on the Essential Medicines List. Their paper is a sad example of workers in an elite setting advocating policies with the potential to endanger the lives of thousands of vulnerable women in low-resource settings. The self-administration of misoprostol, or use by traditional birth attendants, is the most immediate and practical solution to help the least developed countries move towards achieving Millennium Development Goal 5.1 It is true that in some studies oxytocin performs marginally better than misoprostol,2 but as mentioned by Chu et al., oxytocin administration is not currently feasible in most low-resource settings. Misoprostol presents an opportunity to achieve some semblance of health equity.3 The paper is also methodologically and ethically flawed. It reviews the 172 published papers on the use of misoprostol to control postpartum haemorrhage (PPH) in the framework of high-quality obstetric services and it explicitly omits studies that are not randomized controlled trials (RCTs). However, RCTs are often impossible to conduct in most low-resource settings where maternal death rates are highest. The paper by Prata et al4. included in the review, in fact, was not an RCT. In the case of misoprostol, an undisputed powerful uterotonic, the most practical RCT would compare misoprostol to a placebo, since the reality in low-resource settings leaves only these two options. Consequently, a RCT would randomly allocate the risk of death to women in the control arm when we know that misoprostol might have the potential to save their lives. Since Chu et al. conducted their review; a RCT in Belgaum India found 400 μg sublingual misoprostol to be more effective than 10 IU intramuscular oxytocin, as measured by blood loss (mean blood loss 192 ± 124 mL with misoprostol and 366 ± 136 mL blood loss with oxytocin).5 These data, together with compelling literature from non-RCTs in low-resource settings, strongly endorse the WHOs decision, which weighed all of the evidence, with considerations of the larger context and implications. A reversal of their decision would only hurt the very women that Chu et al. purport to be helping.