Rebecca Cabral

The measurement and meaning of unintended pregnancy.

Unintended pregnancy combines two aspects of fertility: unwanted and mistimed pregnancies. The personal partnership social and political realities of these two aspects are different and the use of separate categories may better reflect the way women think about a pregnancy. A better understanding of the multiple dimensions of unintended pregnancy also may lead to a better understanding of the consequences of these pregnancies. Likewise better knowledge of the extent of mistiming and perhaps the strength of intentions may be important in understanding health impact. Effective programs to prevent unintended pregnancy must use terms that are familiar to women and must build upon cultural understanding of the problem to be prevented. Research should focus on the meaning of pregnancy intentions to women and the processes women and their partners use in making fertility decisions. It should prospectively address the impact of pregnancy intentions on contraceptive use. Both qualitative and quantitative research have contributed to our understanding of fertility decisionmaking; both will be essential to the creation of more effective prevention programs. (excerpt)

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

Women at risk of HIV / STD: the importance of male partners as barriers to condom use.

Womens perceptions of power in their relationship with their main partner, control over condom use, concerns about potential partner retribution, condom requests, and condom use were assessed by interviewing a group of women attending two urban public clinics for sexually transmitted diseases in Alabama. Only 5% reported that they had no control over condom use by their partner. Fears of catastrophic partner reactions to condom use requests (sexual coercion, abuse, or abandonment) and experiences of partner objections were also uncommon. Women did not perceive themselves to be powerless. Inconsistent condom use was associated with wanting condom use but not asking and with perceived consequences of relationship loss, however, most power-related measures, including physical abuse, were not related to condom use in the 30 days prior to the interview.

Female Condom Use Among Women at High Risk Of Sexually Transmitted Disease

CONTEXT Whereas the female condom has been evaluated in many hypothetical acceptability or short-term use studies, there is little information about its suitability for the prevention of sexually transmitted diseases (STDs) or HIV over extended periods of time. METHODOLOGY As part of a six-month prospective follow-up study of 1,159 STD clinic patients, clients were interviewed during their initial visit, exposed to a behavioral intervention promoting condoms, given a physical examination and provided with instructions on completing a sexual diary. Potential predictors of trying the female condom were evaluated using logistic regression, and three condom-use groups (exclusive users of female condoms, exclusive users of male condoms and users of both types of condoms) were compared using multinomial regression. RESULTS Among 895 women who reported having engaged in vaginal intercourse during the study period, one-half had sex with only one partner, while one-quarter each had two partners or three or more partners. A total of 731 women reported using the female condom at least once during the follow-up period--85% during the first month of follow-up. Multiple logistic regression analyses indicated that employed women and those with a regular sexual partner at baseline were significantly more likely to try the female condom. By the end of the follow-up period, 8% of participants had used the female condom exclusively, 15% had used the male condom exclusively, 73% had used both types of condom and 3% had used no condoms. Twenty percent of women who tried the female condom used it only once and 13% used it twice, while 20% used 5-9 female condoms and 32% used 10 or more. Consistent condom users (N=309) were predominantly users of both types of condom (75%), and were less often exclusive users of the male condom (18%) or the female condom (7%). According to a multivariate analysis, women who used the female condom exclusively or who mixed condom types were more likely to be black, were more likely to be employed and were more likely to have a regular partner than were users of the male condom. CONCLUSIONS Women at risk of STDs find the female condom acceptable and will try it, and some use it consistently. Mixing use of female condoms and male condoms may facilitate consistent condom use. The female condom may improve an individuals options for risk reduction and help reduce the spread of STDs.

The link between the use of crack cocaine and the sexually transmitted diseases of a clinic population : A comparison of adolescents with adults

Background and Objectives: To determine whether personal and/or a partners use of crack cocaine is associated with the diagnosis of early syphilis or gonorrhea independent of high‐risk sex behaviors, and to determine whether the relationships between crack cocaine and associated sexually transmitted diseases (STDs) are similar for adolescents and adults. Study Design: A cross‐sectional behavioral survey of heterosexual males and females attending public STD clinics in three cities. Logistic regression was used to identify risk behavior patterns associated with each STD compared with no STD. Results: Multivariate analysis revealed that men who were high on drugs, including crack cocaine, before or during sex were more likely to be diagnosed with syphilis (Odds Ratio [OR] = 1.49; Confidence Intervals [CI] = 1.06, 2.13). Males more likely to be diagnosed with gonorrhea were younger (OR = 0.94; CI = 0.92, 0.96), had sex with a crack cocaine user (OR = 1.99; CI = 1.36, 2.91), did not use condoms last time they had sex with a nonmain partner (OR = 1.59; CI = 1.09, 2.13), and did not have sex with an intravenous drug user (OR = 0.45; CI = 0.22, 0.95). For women, there were no independent risk factor for syphilis but younger age was a risk factor for gonorrhea (OR = 0.95; CI = 0.91, 0.99). The associations between crack cocaine and syphilis and gonorrhea in men and between crack cocaine and syphilis in women were not significant among adolescents in this study. Conclusion: The results of this study highlight the differences in the crack cocaine‐related behaviors of adults and adolescents at risk for gonorrhea and syphilis. The nature of these differences support the use of distinct intervention strategies for each STD and for adolescents and adults.

Promoting condom use with main partners: A behavioral intervention trial for women

The Stages of Change (SOC) model was used to implement and evaluate a condom promotion intervention for HIV-positive and at-risk women who were recruited from clinic and community settings in Baltimore and Philadelphia. Participants were assigned to receive standard reproductive health services or enhanced services (standard plus SOC peer advocate intervention). Women who had a main partner at baseline and at a 6-month follow-up were included in the analysis (70 HIV positive, 471 at risk). Compared with the standard group, HIV-positive women in the enhanced group were significantly more likely to have progressed in the SOC model or to have maintained consistent condom use, and less likely to have relapsed or stayed in the precontemplation stage. Among the at-risk women, exposure to the intervention was associated with being at a higher SOC and being less likely to relapse relative to the standard group. The SOC model has promise for use in social and public health service settings that serve women at risk or living with HIV.

Psychosocial factors associated with self-reported male condom use among women attending public health clinics

Background Previousresearch has identified factors associated with condom use. However, lessinformation exists on the impact that a history of sexually transmitteddisease (STD) has on condomuse. Goal Toidentify factors associated with self-reported male condom use that relate toa history of STD. StudyDesign Women attending STD clinics completed a survey thatassessed sexual behavior, STD history, and psychosocial characteristics.Binomial regression was used to estimate the association between these factorsand condomuse. Results Ofthe 12 factors included in the regression model, 11 were significant for allwomen. When the analysis was stratified by STD history, high condom useself-efficacy, high convenience of condom use, and high frequency of condomuse requests were significantly associated with increased condom use amongwomen with or without a history of STD. Factors such as greater perceivedcondom use norms, higher perceived level of risk, and greater need for condomuse in long-term relationships were significantly associated with increasedcondom use among women with a history of STD. Factors such as shorter durationof a relationship, less violence in the relationship, and lifetime drug usewere associated with increased condom use among women with no history ofSTD. Conclusions Thepattern of psychosocial factors determining condom use is modified by apositive history of STD. These findings suggest that a history of STD could bean important factor in targeting condom useinterventions.

Reproductive and contraceptive attitudes as predictors of condom use among women in an HIV prevention intervention.

ABSTRACT This study prospectively evaluates the effect of child-bearing motivation and contraceptive attitudes on consistency of condom use among at-risk women enrolled in an HIV prevention intervention. Women (age 15–40, 85% African-American) were recruited from homeless shelters, drug treatment facilities, and public housing developments and assigned to standard or enhanced intervention conditions. Among the eligible study group of nonsterilized women with a main partner (n = 312), 24.4% wanted to have a baby at baseline; 43.5% believed their partner wanted them to have a baby. Women who reported a desire for a baby, compared to all others, were less likely to be at a higher level of condom consistency six months later (OR = 0.66; .48–.90). Women who perceived partner support for contraceptive use showed a higher level of condom consistency (OR = 1.20; 1.03–1.41) at 6-month follow-up. Many women in this study wanted to have a baby and this desire interfered with subsequent consistency of condom use. We also found that condom use increased toward consistency of use among women whose partner supported contraceptive use. HIV prevention interventions should include screening for reproductive motivation, so that prevention messages can be tailored to the realities of womens lives. Women who want a baby can be educated about disease prevention in the context of pregnancy planning and linked with appropriate services. Women who want to avoid childbearing can be given messages that emphasize the contraceptive benefits of condom use and that help strengthen partner support.

Do main partner conflict, power dynamics, and control over use of male condoms predict subsequent use of the female condom?

ABSTRACT This study assessed hypotheses that measures of power and control over male condom (MC) use would predict use of the female condom (FC) among women with main partners from two public STD clinics (n = 616). The women (mean age 24 years, 87% African American) were enrolled in an intervention study to promote barrier contraceptive use and were interviewed at baseline and at 6 monthly follow-up visits. Seven baseline predictor variables were assessed: her having requested MC use, his having objected, her having wanted a MC used but not asking, percentage of MC use, perceived control over MC use, anticipated consequences of refusing unprotected sex, and physical violence. In the first Poisson regression analysis, none of the hypothesized predictors was significantly associated with FC use during follow up. In the second regression analysis, which assessed the influence of the hypothesized set of predictors on follow-up FC use in situations when MCs were not used, we found two effects. Either no or inconsistent MC use before study entry was associated with less subsequent FC use; women who reported, at study entry, having more control over MC use were more likely to use FCs during follow up. We found no evidence of adoption of the FC by women in relationships marked by history of conflict over the MC, circumstances in which alternatives are most needed. On the contrary, we found that women with a history of control and consistent use of MCs were the most likely users of FCs when MCs were not used.

Early Identification and Linkage to Care for People with Chronic HBV and HCV Infection: The HepTLC Initiative

Objective. In 2012, CDCs Division of Viral Hepatitis launched a public health initiative to increase hepatitis B virus (HBV) and hepatitis C virus (HCV) infection testing for those at risk and to improve linkage to medical care for those infected. We describe testing outcomes of previously unidentified people at risk for HBV and HCV infection and the lessons learned while linking patients to care. Methods. CDCs Hepatitis Testing and Linkage to Care (HepTLC) initiative provided 34 financial awards to U.S. organizations that serve people at risk for viral hepatitis, 25 of which focused on HCV and nine of which focused on HBV. Grantees offered testing and test result notification to people at risk for HBV and/or HCV infection, as well as counseling, referral, and verification or notification of linkage to care for people with positive test results. We entered demographic data, self-reported risk factors, country of origin (for HBV), and testing outcomes into a confidential database. Results. The 34 grantees tested 87,860 people at more than 260 sites in 17 states. Of the 23,144 people tested for HBV, 1,317 (6%) were positive. Of the 64,716 people tested for HCV, 57,570 (89%) received an HCV antibody (anti-HCV) test, of whom 7,580 (13%) tested anti-HCV positive. Of the 4,765 people who received an HCV RNA test, 3,449 (72%) tested positive. Of the 4,766 people who tested positive for either HBV or HCV infection, 2,116 (44%) were linked to care. Conclusion. Interventions targeting people at risk for HBV and HCV infection reached a substantial number of people for whom testing is recommended and identified a large proportion of those who had previously unrecognized infection. Patient navigation was critical for follow-up and linkage to care.