Michele G. Shedlin

Continuation of Prescribed Compared With Over-the-Counter Oral Contraceptives

OBJECTIVE: To estimate differences in continuation of oral contraceptive pills (OCPs) between U.S. resident women obtaining pills in U.S. family planning clinics compared with over-the-counter in Mexican pharmacies. METHODS: In El Paso, Texas, we recruited 514 OCP users who obtained pills over the counter from a Mexican pharmacy and 532 who obtained OCPs by prescription from a family planning clinic in El Paso. A baseline interview was followed by three consecutive surveys over 9 months. We asked about date of last supply, number of pill packs obtained, how long they planned to continue use, and experience of side effects. Retention was 90%, with only 105 women lost to follow-up. RESULTS: In a multivariable Cox proportional hazards model, discontinuation was higher for women who obtained pills in El Paso clinics compared with those who obtained their pills without a prescription in Mexico (hazard ratio 1.6, 95% confidence interval [CI] 1.1–2.3). Considering the number of pill packs dispensed to clinic users, discontinuation rates were higher (hazard ratio 1.8, 95% CI 1.2–2.7) for clinic users who received one to five pill packs. However, there was no difference in discontinuation between clinic users receiving six or more pill packs and users obtaining pills without a prescription. CONCLUSION: Results suggest providing OCP users with more pill packs and removing the prescription requirement would lead to increased continuation. LEVEL OF EVIDENCE: II

Research Participant Recruitment in Hispanic Communities: Lessons Learned

Hidden/special populations such as new immigrants are hard-to-reach due to issues such as stigma, discrimination, fear of immigration authorities, and cultural norms. Such factors can affect the recruitment of participants for behavioral research, especially research which addresses stigmatizing conditions such as HIV/AIDS. This research involved a qualitative approach and methods. The study identified contextual factors as well as attitudes, experiences and beliefs affecting HIV risk among recent Hispanic immigrants in New York. During the course of this research, challenges to participant recruitment were identified which were related to the environments, characteristics of the populations, and the sensitive nature of the topic to be studied. Strategies including exploratory fieldwork and sensitivity to participants’ fear of “the system” were effective in recruiting individuals from this population. The authors discuss the strategies which facilitated recruitment of research subjects from these new Hispanic immigrant communities and the importance of behavioral research among these vulnerable communities.

Contraindications to Combined Oral Contraceptives Among Over-the-Counter Compared With Prescription Users

OBJECTIVE: To compare the estimated proportion of contraindications to combined oral contraceptives between women who obtained combined oral contraceptives in U.S. public clinics compared with women who obtained combined oral contraceptives over the counter (OTC) in Mexican pharmacies. METHODS: We recruited a cohort of 501 women who were residents of El Paso, Texas, who obtained OTC combined oral contraceptives in Mexico and 514 women who obtained combined oral contraceptives from family planning clinics in El Paso. Based on self-report of World Health Organization category 3 and 4 contraindications and interviewer-measured blood pressure, we estimated the proportion of contraindications and, using multivariable-adjusted logistic regression, identified possible predictors of contraindications. RESULTS: The estimated proportion of any category 3 or 4 contraindication was 18%. Relative contraindications (category 3) were more common among OTC users (13% compared with 9% among clinic users, P=.006). Absolute contraindications (category 4) were not different between the groups (5% for clinic users compared with 7% for OTC users, P=.162). Hypertension was the most prevalent contraindication (5.6% of clinic users and 9.8% of OTC users). After multivariable adjustment, OTC users had higher odds of having contraindications compared with clinic users (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.11–2.29). Women aged 35 years or older (OR 5.30, 95% CI 3.59–7.81) and those with body mass index 30.0 or more (OR 2.24, 95% CI 1.40–3.56) also had higher odds of having contraindications. CONCLUSION: Relative combined oral contraceptive contraindications are more common among OTC users in this setting. Progestin-only pills might be a better candidate for the first OTC product given their fewer contraindications. LEVEL OF EVIDENCE: II

Frustrated Demand for Sterilization Among Low-Income Latinas in El Paso, Texas

CONTEXT Sterilization is the most commonly used contraceptive in the United States, yet access to this method is limited for some. METHODS A 2006-2008 prospective study of low-income pill users in El Paso, Texas, assessed unmet demand for sterilization among 801 women with at least one child. Multivariable logistic regression analysis identified characteristics associated with wanting sterilization. In 2010, at an 18-month follow-up, women who had wanted sterilization were recontacted; 120 semistructured and seven in-depth interviews were conducted to assess motivations for undergoing the procedure and the barriers faced in trying to obtain it. RESULTS At baseline, 56% of women wanted no more children; at nine months, 65% wanted no more children, and of these, 72% wanted sterilization. Only five of the women interviewed at 18 months had undergone sterilization; two said their partners had obtained a vasectomy. Women who had not undergone sterilization were still strongly motivated to do so, mainly because they wanted no more children and were concerned about long-term pill use. Among womens reasons for not having undergone sterilization after their last pregnancy were not having signed the Medicaid consent form in time and having been told that they were too young or there was no funding for the procedure. CONCLUSIONS Because access to a full range of contraceptive methods is limited for low-income women, researchers and providers should not assume a womans current method is her method of choice.

Dominican, Mexican, and Puerto Rican Prostitutes: Drug Use and Sexual Behaviors

Although Hispanics are overrepresented in AIDS cases in the United States, little information is available to help understand differences in drug and sex risk behaviors in Hispanic subgroups, needed to develop appropriate prevention programs. This study reports on HIV-related risk behaviors in three groups of Hispanic prostitutes recruited in the United States: Dominican (77), recruited in Washington Heights, NY, Mexican (151), recruited in El Paso, 7X; and Puerto Rican (48), recruited in East Harlem, NY Ethnographic interviews were conducted with a subsample of subjects to examine cultural meaning of risk behaviors; structured interviews were conducted with subjects to describe demographic characteristics and summarize levels of risk behaviors. Results indicated that the labels Hispanic and prostitute obfuscated important differences related to geographic and cultural factors. To be effective for diverse Hispanic groups, HIV prevention efforts and interventions must be based on knowledge of these differences.

Prevalence, patterns and predictors of substance use among Latino migrant men in a new receiving community

BACKGROUND The purpose of this study was to evaluate the prevalence, patterns and predictors (individual, social, cultural, and environmental) of illicit drug use and binge drinking in a cohort of Latino migrant men (LMM) in a new receiving community. METHODS A cohort of LMM in New Orleans (n=125) was assembled in 2007 using respondent driven sampling and interviewed quarterly for 18 months regarding past month substance use and other potential covariates. Baseline frequencies were weighted using RDSAT and longitudinal analyses included generalized estimating equations (GEE) and the Cochran-Armitage test for trends. RESULTS At baseline, substance use behaviors were: drug use 15.0% (range 7.3-25.0%) and binge drinking 58.3% (range 43.6-74.6%). All three of these behaviors decreased over follow-up (P<0.01). Baseline alcohol dependence and drug problem were 11.8% (range 5.6-24.3%) and 0.08% (range 0.00-2.7%) and both remained the same over time. Baseline rate of chlamydia was 9% (range 0.00-22.4%); all men tested negative for gonorrhea, HIV, and syphilis. For both binge drinking and drug use, having sex with a female sex worker was associated with increased risk, whereas belonging to a club or organization was associated with less risk. Additional factors associated with increased drug use were: having a friend in New Orleans upon arrival, symptoms of depression, and working in construction. An additional factor associated with less binge drinking was having family in New Orleans upon arrival. CONCLUSION Among LMM, substance use is influenced by social and environmental factors. Interventions increase community connectedness may help decrease usage.

Latino Gay and Bisexual Men's Relationships with Non-Gay-Identified Men Who Have Sex With Men

This study investigated relationships between Latino gay-identified men in metropolitan New York City and their non-gay-identified male partners. Phase 1 consisted of in-depth interviews (N = 33), and Phase 2 consisted of quantitative surveys (N = 120) with Brazilian, Colombian, and Dominican men who have sex with men (MSM). A majority of participants reported having had sex with heterosexually identified men, and in many cases, the relationship was sustained over time. We found mixed results concerning an attitude sometimes attributed to Latinos that sexual orientation is defined by sexual role, with receptive MSM seen as gay and insertive MSM seen as straight. Although there were no significant associations between partner sexual orientation and unprotected anal intercourse, gay men were less likely to take the insertive role in oral or anal sex with straight-identified male partners than with gay partners.

HIV Risk and Prevention Among Hispanic Immigrants in New York: The Salience of Diversity

The importance of identifying differences in HIV risk between Hispanic subgroups is the focus of this article. Data are drawn from two New York–based HIV-related studies: among Puerto Rican drug users and among new immigrants from Central America, the Dominican Republic, and Mexico. Results indicated that intercultural individuals (i.e., those involved in both Puerto Rican and mainland cultures) were less risky in terms of injection- and sex-related risk behaviors and that geographic and other contextual factors, along with cultural norms, influence risk behaviors for immigrants. Both studies indicate the need to differentiate subgroup factors affecting HIV risk and prevention behaviors to develop appropriate and effective community-based interventions. The studys limitations are noted.

Use of Complementary and Alternative Medicines and Supplements by Mexican-Origin Patients in a U.S.-Mexico Border HIV Clinic

&NA; This article draws from a study investigating the influence of institutional and psychosocial factors on adherence to antiretroviral (ARV) medications by Mexican‐origin persons living with HIV (PWLH) on the U.S.–Mexico border and seeking treatment at a clinic in El Paso, Texas. Among 113 participants, many individuals reported using complementary and alternative medicines (CAM) to support general health and their immune systems and to address symptoms of HIV‐related diseases and ARV side effects. CAM were seen as complementing ARV treatment; however, CAM use was often not reported to health care providers out of concern about disapproval and loss of care privileges. This finding challenges researchers and providers to consider seriously how Hispanic populations, with their CAM use, may exhibit the hybridization of health and healing. Information on CAM use needs to be available to providers to assess the benefits and contraindications of use and to develop realistic and effective care strategies.

Knowledge and beliefs about reproductive anatomy and physiology among Mexican-Origin women in the USA: implications for effective oral contraceptive use.

Inherent in many reproductive health and family planning programmes is the problematic assumption that the body, its processes and modifications to it are universally experienced in the same way. This paper addresses contraceptive knowledge and beliefs among Mexican-origin women, based upon data gathered by the qualitative component of the Border Contraceptive Access Study. Open-ended interviews explored the perceived mechanism of action of the pill, side-effects, non-contraceptive benefits, and general knowledge of contraception. Findings revealed complex connections between traditional and scientific information. The use of medical terms (e.g. ‘hormone’) illustrated attempts to integrate new information with existing knowledge and belief systems. Conclusions address concerns that existing information and services may not be sufficient if population-specific knowledge and beliefs are not assessed and addressed. Findings can contribute to the development of effective education, screening and reproductive health services.