Susie Hoffman

Risk Factors for Falls as a Cause of Hip Fracture in Women

BACKGROUND Although even in the elderly most falls are not associated with fractures, over 90 percent of hip fractures are the result of a fall. Few studies have assessed whether the risk factors for falls are also important risk factors for hip fracture. METHODS To examine the importance of risk factors for falls in the epidemiology of hip fracture, we performed a case-control study of 174 women (median age, 80 years) admitted with a first hip fracture to 1 of 30 hospitals in New York and Philadelphia. Controls, matched to the case patients according to age and hospital, were selected from general surgical and orthopedic surgical hospital services. Information was obtained by direct interview. RESULTS As measured by the odds ratio, increased risks for hip fracture were associated with lower-limb dysfunction (odds ratio = 1.7; 95 percent confidence interval, 1.1 to 2.8), visual impairment (odds ratio = 5.1; 95 percent confidence interval, 1.9 to 13.9), previous stroke (odds ratio = 2.0; 95 percent confidence interval, 1.0 to 4.0), Parkinsons disease (odds ratio = 9.4; 95 percent confidence interval, 1.2 to 76.1), and use of long-acting barbiturates (odds ratio = 5.2; 95 percent confidence interval, 0.6 to 45.0). Of the controls, 44 (25 percent) had had a recent fall. The case patients were more likely than these controls to have fallen from a standing height or higher (odds ratio = 2.4; 95 percent confidence interval, 1.0 to 5.7). Of those with hip fracture the younger patients (less than 75 years old) were more likely than the older ones (greater than or equal to 75 years old) to have fallen on a hard surface (odds ratio = 1.9; 95 percent confidence interval, 1.04 to 3.7). CONCLUSIONS A number of factors that have been identified as risk factors for falls are also associated with hip fracture, including lower-limb dysfunction, neurologic conditions, barbiturate use, and visual impairment. Given the prevalence of these problems among the elderly, who are at highest risk, programs to prevent hip fracture should include measures to prevent falls in addition to measures to slow bone loss.

Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.

The relationship between depressive symptom scores on the Center for Epidemiological Studies Depression Scale (CES-D; L. S. Radloff, 1977) at each trimester of pregnancy and a decrement in either fetal growth or gestational duration was evaluated among 666 pregnant women. There was no association overall, but among 222 women from lower occupational status households, each unit increase on the CES-D at 28 weeks gestation was associated with a reduction of 9.1 g (95% confidence interval [CI] = -16.0, -2.3) in gestational-age-adjusted birth weight. When missing data were multiply imputed, the estimate was -4.6 g (95% CI = - 10.7, 1.5). CES-D score was unrelated to fetal growth or gestational duration in analyses among other potentially high-risk subgroups: smokers, women with a history of adverse outcome, and women with social vulnerabilities. These results raise the possibility that among lower status women, depressive mood may be associated with restricted fetal growth.

Rethinking Gender, Heterosexual Men, and Women's Vulnerability to HIV/AIDS

Most HIV prevention literature portrays women as especially vulnerable to HIV infection because of biological susceptibility and mens sexual power and privilege. Conversely, heterosexual men are perceived as active transmitters of HIV but not active agents in prevention. Although the womens vulnerability paradigm was a radical revision of earlier views of women in the epidemic, mounting challenges undermine its current usefulness. We review the etiology and successes of the paradigm as well as its accruing limitations. We also call for an expanded model that acknowledges biology, gender inequality, and gendered power relations but also directly examines social structure, gender, and HIV risk for heterosexual women and men.

Structural barriers to ART adherence in Southern Africa: Challenges and potential ways forward

Abstract Structural barriers to antiretroviral therapy (ART) adherence are economic, institutional, political and cultural factors, that collectively influence the extent to which persons living with HIV follow their medication regimens. We identify three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, limited access to mental health services and difficulties in ensuring adequate counselling. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, migration, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, we identify ways in which individuals, communities and health care systems may overcome some of these structural barriers. Finally, we make recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.

A gender-specific HIV/STD risk reduction intervention for women in a health care setting: Short- and long-term results of a randomized clinical trial

This study assessed the short- and long-term effect of a gender-specific group intervention for women on unsafe sexual encounters and strategies for protection against HIV/STD infection. Family planning clients (N = 360) from a high HIV seroprevalence area in New York City were randomized to an eight-session, a four-session or a control condition and followed at one, six and 12 months post-intervention. Using an intention-to-treat analysis, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls at one month (OR = 1.93, 95% confidence interval [CI] = 1.07, 3.48, p = 0.03) and at 12-month follow-up (OR = 1.65, 95% CI = 0.94, 2.90, p = 0.08). Relative to controls, women assigned to the eight-session condition reported during the previous month approximately three-and-a-half (p = 0.09) and five (p < 0.01) fewer unprotected sex occasions at one- and 12-month follow-up, respectively. Women in the eight-session group also reduced the number of sex occasions at both follow-ups, and had a greater odds of first time use of an alternative protective strategy (refusal, outercourse, mutual testing) at one-month follow-up. Results for the four-session group were in the expected direction but overall were inconclusive. Thus, gender-specific interventions of sufficient intensity can promote short- and long-term sexual risk reduction among women in a family planning setting.

The future of the female condom.

More than 10 years have elapsed since the female condom became widely available, and it remains the only femaleinitiated means of preventing both pregnancy and sexually transmitted infections (STIs), including HIV. The female condom was developed as an alternative to the male condom, and it was hailed as a method that would enable women to have greater control over their own protection from disease. With the support of the Joint United Nations Programme on HIV/AIDS (UNAIDS), public and private funders, and the manufacturer, more than 90 developing countries have introduced the method through public distribution, social marketing campaigns or commercial outlets. In several countries that have actively promoted its use, such as South Africa, Brazil, Ghana and Zimbabwe, steadily increasing female condom sales to the government suggest that effective programs can generate demand. At the same time, there have been disappointments. Uptake in the West and in some developing countries has been lower than was initially anticipated, demonstrating that successful introduction will not be as straightforward as was hoped. 1 A study by Kulczycki and colleagues published earlier this year shows that the method is not popular among some women. 2 Indeed, there are still gaps in knowledge about how acceptable the female condom is for long-term use and whether promoting it can help reduce STI rates. Despite both successes and disappointments, promotion of the female condom remains important, especially in the face of heterosexually acquired HIV infection rates that are soaring globally. It is unfortunate, therefore, that a discourse has emerged recently that marginalizes the female condom as a viable prevention option, out of concerns about its high cost and the need for women to obtain their partner’s cooperation in order to use it. 3 Such a conclusion is premature, as the picture is far more complex. In this viewpoint, we review what has been learned about the female condom over the past decade, and argue for a renewed commitment to behavioral intervention research and the implementation and evaluation of large-scale female condom programs.

HIV risk behaviors and the context of sexual coercion in young adults' sexual interactions: results from a diary study in rural South Africa.

Background: Gender inequalities in relationship power may promote unprotected sexual intercourse. Goals: The goal of this study was to gain insight into the specific gender dynamics in the intimate relationships of rural South African young adults that contribute to risk for HIV infection. Study: Using diary methods, 25 female and 25 male secondary school students in rural South Africa provided daily reports (N = 1000) over a 3-week timeframe, including details regarding 466 sexual interactions. Results: Inconsistent condom use was more likely in relationships in which the male partner had ever used threat or force to engage in sex during this period (unadjusted odds ratio, 13.4; 95% confidence interval, 1.57–114.26). Male sexual coercion was more likely in relationships in which alcohol was ever used in conjunction with sex and when a man’s desire to engage in sex was perceived as greater than the woman’s. Conclusion: This study adds to the growing evidence that sexual relationships characterized by gender inequality and sexual coercion are contexts of sexual risk.

Parity, lactation and hip fracture

The relationship between parity, lactation and the occurrence of hip fracture was investigated in a case-control study of white women. The cases were patients (n=174) aged 45 years and over with a radiologically confirmed first hip fracture sampled from among admissions to 30 hospitals in New York and Philadelphia between September 1987 and July 1989. Controls (n=174) were selected from general surgical and orthopedic services during the same time period and were frequency-matched to cases by age and hospital. Ever having a live birth was associated with reduced odds of hip fracture, controlling for age and hospital of recruitment (odds ratio =0.65; 95% confidence interval =0.41–1.04). When body mass index was also controlled, each birth was associated on average with a 9% reduction in the odds of hip fracture (odds ratio =0.92 [0.78–1.08]), although the trend was not statistically significant. After adjusting for number of births, lactation was not associated with hip fracture (adjusted odds ratio for 12 months of lactation or less =0.80 [0.42–1.55]; adjusted odds ratio for more than 12 months =1.08 [0.45–2.60]).

Intimate Partner Violence and Safer Sex Negotiation: Effects of a Gender-Specific Intervention

This study examined the effects of a gender-specific HIV/STD prevention intervention with two dosage levels (four-session, eight-session) among women reporting physical abuse by a current or recent (past year) intimate partner. From 360 women included in the full randomized trial, we conducted subgroup analyses among 152 women who experienced partner physical abuse within the past year. Unprotected vaginal and anal sex occasions and negotiation skills were examined as outcomes. We also assessed whether the intervention increased previously abused womens subsequent risk of physical abuse. Among abused women, those in the eight-session, but not the four-session, intervention decreased their unprotected sex occasions or maintained consistent safer sex at both 1-month (OR = 3.63, 95% CI = 1.50–8.80) and 1-year (OR = 2.88, 95% CI = 1.17–7.10) postintervention. In the short-term, abused women in both the four- and eight-session groups had a greater odds of using an alternative strategy (e.g., refusal, “outercourse,” or mutual testing) and of having a safer sex discussion with their partners relative to their controls, and they scored higher on intention to negotiate safer sex. The intervention did not increase or decrease the incidence of subsequent abuse during the 1-year follow-up period. A gender-specific intervention that focuses on negotiation skills in the context of potentially abusive partners benefits, and does not appear to harm, recently abused women.

Beyond the Male Condom: The Evolution of Gender-Specific HIV Interventions for Women

Abstract As the number of HIV infections in women has increased, there has been a concomitant recognition that prevention efforts to reduce sexual transmission must address the gendered context in which risk behavior occurs. This paper provides a longitudinal perspective on the emergence of the HIV epidemic in U.S. women and the parallel development of interventions to reduce risk. In the first portion of this paper, we briefly discuss the growth of the epidemic among women and how public health responses reflected the early discourse about infected women. We also address methods of protection available to women, and the emerging recognition of the importance of gender relations. In the second half of this paper, we show how gender-specificity in prevention efforts has evolved, using a framework developed by Geeta Gupta (2001) and relying on published reviews of the intervention literature in the past 10 years. Finally, we discuss in detail several recent examples. We conclude with a discussion of future directions.