Beth A. Brown

Access and Attitudinal Factors Related to Breast and Cervical Cancer Rescreening: Why are Latinas Still Underscreened?

To identify access, attitudes, and health practices of Latina women undergoing regular mammography and Pap smear screening, 977 Latinas aged 40 to 74, residing in four California cities, answered a telephone interview. Forty-one percent of women had regular mammography, and 73% had regular Pap smear screening. Cancer screening maintenance was associated with having health insurance, a regular place of care, and fewer fatalistic attitudes about cancer. Regular mammography and Pap smear screening were also associated with ever being married, attending church, and having taken hormone replacement therapy. Being older than 50, residing in the United States a long time, and having had a hysterectomy predicted mammography maintenance. Pap smear screening maintenance was negatively associated with poverty, old age, and negative attitudes toward physicians. There are structural and attitudinal barriers to regular cancer screening among Latinas. Interventions that increase access to care and address womens attitudes about cancer are needed.

One-Year Contraceptive Continuation and Pregnancy in Adolescent Girls and Women Initiating Hormonal Contraceptives

OBJECTIVE: To assess contraceptive discontinuation, switching, factors associated with method discontinuation, and pregnancy among women initiating hormonal contraceptives. METHODS: This was a 12-month longitudinal cohort study of adolescent girls and women (n=1,387) aged 15 to 24 years attending public family planning clinics who did not desire pregnancy for at least 1 year and selected to initiate the patch, ring, depot medroxyprogesterone acetate, or pills. Participants completed follow-up assessments at 3, 6, and 12 months after baseline. Life table analysis was used to estimate survival rates for contraceptive continuation. Cox proportional hazards models were used to estimate factors associated with method discontinuation. RESULTS: The continuation rate (per 100 person-years) at 12 months was low for all methods; however, it was lowest for patch and depot medroxyprogesterone acetate initiators, 10.9 and 12.1 per 100 person years, respectively (P≤.003); continuation among ring initiators was comparable to pill initiators, 29.4 and 32.7 per 100 person-years, respectively (P=.06). Discontinuation was independently associated with method initiated and younger age. The only factors associated with lower risk of discontinuation were greater intent to use the method and being in school or working. The pregnancy rate (per 100 person-years) was highest for patch and ring initiators (30.1 and 30.5) and comparable for pill and depot medroxyprogesterone acetate initiators (16.5 and 16.1; P<.001). CONCLUSION: The patch and the ring may not be better options than the pill or depot medroxyprogesterone acetate for women at high risk for unintended pregnancy. This study highlights the need for counseling interventions to improve contraceptive continuation, education about longer-acting methods, and developing new contraceptives that women may be more likely to continue. LEVEL OF EVIDENCE: II

Hormonal contraceptive method choice among young, low-income women: how important is the provider?

OBJECTIVES Several new methods are available, but we know little about successful integration of contraceptive technologies into services. We investigated provider factors associated with the initiation of new hormonal methods among women at high risk of unintended pregnancy. METHODS This cohort study enrolled 1387 women aged 15-24 starting hormonal contraception (vaginal ring, transdermal patch, oral contraceptive, or injectable) at four family planning clinics in low-income communities. We measured provider factors associated with method choice, using multinomial logistic regression. RESULTS Ring and patch initiators were more likely than women starting oral contraceptives to report that they chose their method due to provider counseling (p<0.001). Contraceptive knowledge in general was low, but initiation of a new method, the ring, was associated with higher knowledge about all methods after seeing the provider (p<0.001). Method initiated varied with provider site (p<0.001). These associations remained significant, controlling for demographics and factors describing the provider-patient relationship, including trust in provider and continuity of care. CONCLUSION Womens reports of provider counseling and of their own contraceptive knowledge after the visit was significantly associated with hormonal method initiated. PRACTICE IMPLICATIONS More extensive counseling and patient education should be expected for successful integration of new hormonal methods into clinical practice.

Contraceptive decision-making in sexual relationships: young men's experiences, attitudes and values

Much attention has been focused on efforts to reduce unintended pregnancy by improving contraceptive use among high-risk women; however, there is limited information to guide interventions to engage young men in contraceptive decision-making. We conducted focus groups of young men, aged 19–26, from diverse racial backgrounds from low-income communities in the San Francisco Bay Area to examine social norms about sexual relationships and how they impact on contraceptive use. The data were analysed using content analysis. A range of relationships were described, however casual relationships predominated. While young men expressed strong desires to avoid pregnancy in casual relationships, the unpredictable nature of relationships, together with low communication and regard for the women involved, made stressing consistent contraceptive use among partners unlikely. The themes expressed by these young men about sex and behaviour in different relationships illustrate a spectrum of decision-making dilemmas and illustrate the inherent difficulty in fully engaging young men in contraceptive decision-making. A strategy is needed to address relationship values, dynamics and condom use beyond STI-prevention frameworks and young womens ability to make appropriate contraceptive choices in light of the inherent difficulties and uncertainty associated with casual relationships.

Does partner selection contribute to sex differences in sexually transmitted infection rates among African American adolescents in San Francisco

Introduction: Little is known regarding whether partner characteristics explain sex differences in sexually transmitted infection (STI) rates in nonclinic-based, school-aged African American youth. Materials and Methods: A random digit dial household sample of 14- to 19-year-old youth in San Francisco reported the total number, age, race, and perceived history of incarceration, gang membership, and level of sexual activity of their partners. Youth were tested for gonorrhea and chlamydia. Results: Female participants were more likely than male participants to have a partner who was older or had been incarcerated and less likely to have a non-African American partner. Controlling for partner number, females odds ratio (OR) for having an STI was 1.39 (95% confidence interval [CI] = 0.98–1.98; P = 0.07). Controlling for partner incarceration and number of partners, the borderline sex difference was eliminated (OR = 1.07; 95% CI = 0.70–1.63). Conclusion: Sex differences in STI rates among African American adolescents may be determined more by the risk of the partner than the risk of the individual.

Contraceptive discontinuation and repeat unintended pregnancy within 1 year after an abortion.

BACKGROUND We examined 12-month hormonal contraceptive continuation and pregnancy rates by abortion history. STUDY DESIGN Women who wanted to avoid pregnancy for at least 1 year were recruited at four San Francisco Bay area family planning clinics on regular service days and on abortion care days. Participants completed baseline and follow-up questionnaires. Multivariable Cox models assessed the factors associated with method discontinuation and pregnancy. RESULTS Women who were enrolled into the study on the day of their abortion were 20% more likely to discontinue their contraceptive method than women who never had an abortion [adjusted hazard ratio (AHR)=1.21, 95% confidence interval (CI)=1.03-1.42]. Women who had a recent abortion or previous abortion were 60% more likely to have a pregnancy during follow-up than women who never had an abortion (AHR=1.63, 95% CI =1.21-2.20, and AHR=1.66, 95% CI=1.18-2.33, respectively). CONCLUSION The experience of having an unintended pregnancy and abortion does not lead to behavioral changes that protect against another unintended pregnancy.

Sexual network position and risk of sexually transmitted infections

Objectives: A population-based sexual network study was used to identify sexual network structures associated with sexually transmitted infection (STI) risk, and to evaluate the degree to which the use of network-level data furthers the understanding of STI risk. Methods: Participants (n = 655) were from the baseline and 12-month follow-up waves of a 2001–2 population-based longitudinal study of sexual networks among urban African–American adolescents. Sexual network position was characterised as the interaction between degree (number of partners) and two-reach centrality (number of partners’ partners), resulting in the following five positions: confirmed dyad, unconfirmed dyad, periphery of non-dyadic component, centre of star-like component and interior of non-star component. STI risk was measured as laboratory-confirmed infection with gonorrhoea and/or chlamydia. Results: Results of logistic regression models with generalised estimating equations showed that being in the centre of a sexual network component increased the odds of infection at least sixfold compared with being in a confirmed dyad. Individuals on the periphery of non-dyadic components were nearly five times more likely to be infected than individuals in confirmed dyads, despite having only one partner. Measuring network position using only individual-based information led to twofold underestimates of the associations between STI risk and network position. Conclusions: These results demonstrate the importance of measuring sexual network structure using network data to fully capture the probability of exposure to an infected partner.

What’s to know about study recruitment? We asked recruiters

To address the historic lack of research on womens health and womens exclusion from many significant clinical trials, governmental mandates have been implemented to increase their participation. To accomplish recruitment goals, it is imperative that a better understanding is reached about womens attitudes about research. In an effort to contribute information about recruitment, focus groups with study recruiters from San Francisco Bay Area research facilities were convened. Study recruiters provide a unique perspective on womens decision-making processes. The focus group discussions provided information on successful recruitment techniques employed by research recruiters that may be replicated across research studies.

Evaluation of e-mail contact to conduct follow-up among adolescent women participating in a longitudinal cohort study of contraceptive use.

BACKGROUND The purpose of this study was to determine whether e-mail contact is a viable method for gathering information from adolescent women about contraceptive use. STUDY DESIGN Adolescent women initiating contraception followed in a prospective longitudinal cohort study and who had access to the Internet were randomized to the control or intervention arm and were contacted at 3, 6 and 12 months after enrollment. The control arm completed follow-up surveys in-person or by telephone. The intervention arm received Web-based surveys via e-mail. RESULTS There were 46 women in each group. Women in both groups were approximately 20 years old, were sexually active minority women, and were in school or employed. While participants in the intervention group initially had lower response rates than those in the control group (59% vs. 91%, respectively), with the addition of traditional follow-up methods, the overall response rates were comparable (94% vs. 91%, respectively). CONCLUSIONS E-mail follow-up with Web-based surveys was effective amongst adolescent women at risk for unintended pregnancy. This indicates that e-mail contact could be used as a preliminary follow-up strategy to capture a substantial proportion of participants and that standard follow-up can be used as a second-line approach. A two-pronged approach with initial e-mail contact and traditional follow-up for participants who do not respond may be a viable method when evaluating sensitive areas such as contraceptive use.

Older male partners, high rates of incarceration and marginal economic activities in the sexual networks of a random digit dial sample of 14–19 year old economically disadvantaged African American youth

Conclusions: To the extent that incarceration is correlated with STD risk the presence of a large percentage of male sex partners with a history of incarceration suggests that improved screening and treatment of incarcerated adolescents and young adults could benefit the reproductive health of all youth in the community. The disproportionate rates of STDs among African American female adolescents cannot be explained by their rates of high-risk sexual behaviors. Geographic segregation and partner selection may be more important determinants of their STD risk. (excerpt)