Microbial Primer: Phase variation - survival and adaptability by generation of a diverse population.

Phase variation is defined as the rapid and reversible switching of gene expression, and typically occurs in genes encoding surface features in small genome bacterial pathogens. Phase variation has evolved to provide an extra survival mechanism in bacteria that lack multiple 'sense-and-respond' gene regulation systems. Many bacterial pathogens also encode DNA methyltransferases that are phase-variable, controlling systems called 'phasevarions' (phase-variable regulons). This primer will summarize the current understanding of phase variation, describing the role of major phase-variable factors, and phasevarions, in bacterial pathobiology.

Main and interactive effects of discrimination, parent racial/ethnic socialization, and internalizing symptomology on BIPOC teens' ethnic-racial identity.

Research suggests that BIPOC (Black, Indigenous, People of Color) adolescents have the best developmental outcomes when strong, positive ethnic-racial identity (ERI) is acknowledged and embraced. This study investigated whether discrimination, internalizing symptomology, parent socialization, and/or interactions of these variables were associated with adolescent ERI, specifically in exploration, resolution, and affirmation, to illuminate nuanced ways BIPOC youth can achieve positive ERI. Recruited from third-party research panels, surveyed participants were adolescents (Mage = 15.28; 51.6% male) of diverse ethnic/racial groups and socioeconomic backgrounds from all regions of the United States. Overall, results showed that there were four significant main effects on ERI: a negative relation between internalizing symptomology and exploration, a positive relation between parent socialization and exploration, a positive relation between parent socialization and resolution, and a negative relation between internalizing symptomology and affirmation. There were also two significant interactive effects such that (1) discrimination had a stronger negative relation with affirmation under condition of high internalizing, and (2) parent socialization had a stronger positive relation with affirmation under condition of high internalizing. Results show development of ERI in adolescence is subject to multiple, interactive influences. Main and interactive effects highlight the contextual role that mental health implicates for youth of color. Implications for parents and practitioners are discussed.

Trajectories of parents' gendered play attitudes during early childhood and implications for children's gender development.

This study examined associations between parents' gendered attitudes about play and children's gender development. The sample was 501 families from a large US city followed annually for 4 years (501 mothers, 383 fathers; 69% White, 16% Latinx, 8% African American; children Mage = 5.67 months, 53% boys). Latent trajectories examined change in parents' attitudes toward same- and other-gender play during first 4 years of the child's life. On a subsample (n = 252), trajectories were examined in relation to children's later gender-typed preferences and gender constancy. Parents grew more gender-flexible in their attitudes, particularly parents of boys. Trajectories reflecting more stereotypic attitudes showed some associations (small in magnitude) with children's gender-typed preferences and gender constancy by age 4.

Longitudinal associations between parents' prosocial behavior and media use and young children's prosocial development: The mediating role of children's media use.

Research has found that media is associated with children's prosocial behavior (PB) from an early age, and that parents play a key role in children's media use and behavior. However, few studies explore these relations as early as infancy while also controlling for well-established predictors of PB (e.g., empathic concern). Thus, the present study examined longitudinal associations between parents' PB and media use, and prosocial development during early childhood, mediated by children's own media use. Participants were 519 children (M age at Time 1 = 17.77 months) and parents who participated in three timepoints of an ongoing, longitudinal study. A longitudinal path model suggested that children's media use was still significantly associated with PB 1 year later after accounting for factors such as parents' PB, media use, and empathy. These findings have important implications for the early development of behaviors that serve as a foundation for social and moral development.

Toddlers and the Telly: A latent profile analysis of children's television time and content and behavioral outcomes one year later in the U.S.

Despite the ubiquity of tablets and smartphones, television remains the most frequently used screen media consumed by young children. However, it is likely that variability exists in how young children use media; for example, while some may view small amounts of aggressive content, others may view many hours each day of aggressive and prosocial media content. It is possible that differences in toddler television time and content also impact behavioral outcomes. The aims of this study were two-fold; first, we examined profiles of children's time spent watching television and media content viewed. Second, we examined longitudinal relations between media use profiles and outcomes including aggression, prosocial behavior, and problematic media use. Results suggested a three-profile solution of children's television time and content, including "Low TV content," "High child-centered content," and "High aggressive content" profiles. The "High aggressive content" group experienced higher levels of problematic media use and aggressive behavior one year later compared to other classes. The discussion focuses on implications of these findings. We urge parents to become aware of both television time and media content as they may relate to problematic media use behaviors in young children.

White children's empathy-related responding and prosocial behavior toward White and Black children.

Relations among White (non-Latinx) children's empathy-related responding, prosocial behaviors, and racial attitudes toward White and Black peers were examined. In 2017, 190 (54% boys) White 5- to 9-year-old children (M = 7.09 years, SD = 0.94) watched a series of videos that depicted social rejection of either a White or Black child. Empathy-related responses, prosocial behaviors, and racial attitudes were measured using multiple methods. Results showed that younger children showed less facial concern toward Black than White peers and greater increases with age in concern and prosocial behaviors (sharing a desirable prize) for Black, compared to White, targets. Children's facial anger increased with age for White but not Black targets. The findings can extend our understanding children's anti-racism development.

Variability in infant helping and sharing behaviors across the second and third years of life: Differential roles of target and socialization.

Infants can help and share in the second year of life. However, there is limited knowledge as to variability in these behaviors as a function of target (e.g., caregiver vs. unfamiliar adult) and the influence of caregiver support on infant prosocial behavior. Infants (N = 268, 124 female) at 1-2 years of age (M = 1.47, SD = .27) and again at 2-3 years of age (M = 2.48, SD = .26) participated in a helping task (with the caregiver or unfamiliar experimenter), a sharing task (with either target), and a free-play observation with their primary caregiver from which caregiver support was coded. The racial and ethnic composition of the sample consisted of 3% Asian, 10% Black, 20% Hispanic, 59% White, 1% mixed race, and 6% "other." Median family annual income was $50,000 to $59,000, and median caregiver education level was "some college." Infant helping favored caregivers at both time points. However, infant sharing did not differ by target for 1-2-year-olds, but 2-3-year-olds shared more with their caregivers than an unfamiliar experimenter. Additionally, infants' behaviors antecedent to the act of helping or sharing (e.g., latency to respond, checking behaviors, and looking duration toward the target) differed by target. Concurrent relations between caregiver support and helping and sharing were moderated by age and differed by time point. Caregiver support for 1-2-year-olds also longitudinally predicted an age-moderated relation with 2-3-year-olds' helping toward an unfamiliar experimenter. Theoretical implications for the role of socialization in the emergence of helping and sharing behaviors are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Parents' color-blind racial ideology and implicit racial attitudes predict children's race-based sympathy.

We examined the relation of White parents' color-blind racial attitudes (a global composite score and its subscales) and their implicit racial attitudes to their young children's race-based sympathy toward Black and White victims. One hundred and nighty non-Hispanic White children (54% boys, Mage = 7.13 years, SD = 0.92) reported their sympathy in response to short films depicting bullying toward White or Black children. Their primary caregivers' (mostly mothers') color-blind racial ideology (CBRI) was assessed through a questionnaire (reflecting global color blindness, as well as denial of institutional racism, White privilege, and blatant racial issues), and their implicit racial attitudes were assessed with a computerized test. Children's sympathy toward Black victims and their equitable sympathy (difference score toward Black vs. White victims) was predicted by parents' color blindness, implicit racial attitudes, and their interaction. Results indicated several interaction effects, such that parents' denial of blatant racial attitudes and global CBRI were negatively related to children's sympathy toward Black victims and equitable sympathy toward Black versus White victims, only when the parents held implicit racial attitudes that favored White people. In addition, parents' denial of White privilege was negatively related to children's sympathy toward Black victims. The findings are discussed in terms of potential ways to shape children's race-based sympathy and compassion, particularly with an eye toward ways White parents might socialize sympathy toward historically marginalized youth. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Immunostimulants versus placebo for preventing exacerbations in adults with chronic bronchitis or chronic obstructive pulmonary disease.

BACKGROUND: Individuals with chronic obstructive pulmonary disease (COPD) or chronic bronchitis may experience recurrent exacerbations, which negatively impact prognosis and quality of life, and can impose a significant socioeconomic burden on the individual and wider society. Immunostimulants are a broad category of therapies that may theoretically enhance non-specific immunity against several respiratory insults, thereby reducing exacerbation risk and severity. However, evidence to date for their use in this population is limited. OBJECTIVES: To determine the efficacy of immunostimulants in preventing respiratory exacerbations in adults with chronic obstructive pulmonary disease, chronic bronchitis, or both. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest literature search was conducted on 25 January 2022.  SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) that compared immunostimulant therapy, administered by any method and with the intention of preventing (rather than treating) exacerbations, with placebo for a minimum treatment duration of one month in adults with chronic bronchitis or COPD, or both. We excluded participants with other respiratory conditions.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were number of participants with no exacerbations during the study period and all-cause mortality, secondary outcomes were respiratory-related mortality, quality of life, number of participants requiring antibiotics, exacerbation duration, respiratory-related hospitalisation duration and adverse events/side effects. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS: This review included 36 studies involving 6192 participants. Studies were published between 1981 and 2015. Duration ranged from three to 14 months. The mean age of study participants varied between 35.2 and 82 years. Twelve studies examined participants with COPD only. Seventeen studies reported baseline lung function values; most indicated a moderate-to-severe degree of airflow limitation. Nineteen studies indicated inclusion of participants with a mean baseline exacerbation frequency of two or more in the preceding year. Immunostimulants investigated were OM-85, AM3, RU41740 (Biostim), Ismigen, Diribiotine CK, thymomodulin, pidotimod, D53 (Ribomunyl), Lantigen B, Symbioflor, and hyaluronan; routes of administration were oral, sublingual, and subcutaneous. The risk of bias of the included studies was mostly low or unclear. Participants receiving immunostimulants for a mean duration of six months were slightly more likely to be free of exacerbations during that time (odds ratio (OR) 1.48, 95% confidence interval (CI) 1.15 to 1.90; 15 RCTs, 2961 participants; moderate-certainty evidence). The overall number needed to treat with immunostimulants for a mean of six months, to prevent one participant from experiencing an exacerbation, was 11 (95% CI 7 to 29). This outcome was associated with a moderate degree of unexplained heterogeneity (I2 = 53%). Type of immunostimulant, baseline lung function, baseline exacerbation frequency, treatment duration, and follow-up duration did not modify the effect size, although due to heterogeneity and limited study and participant numbers within some subgroups, the validity of the subgroup treatment effect estimates were uncertain. Immunostimulants probably result in little to no difference in all-cause mortality (OR 0.64, 95% CI 0.37 to 1.10; 5 RCTs, 1558 participants; moderate-certainty evidence) and respiratory-related mortality (OR 0.40, 95% CI 0.15 to 1.07; 2 RCTs, 735 participants; low-certainty evidence) compared to placebo; however, the effects were imprecise and data quality limited the certainty of these results.  There was a small improvement in health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), with immunostimulant compared to placebo (mean difference -4.59, 95% CI -7.59 to -1.59; 2 RCTs, 617 participants; very-low certainty evidence). The effect estimate just met the minimum clinically important difference (MCID) score of 4 units; however, the CI width means the possibility of a non-meaningful difference cannot be excluded. The pooled result from five studies indicated that immunostimulants likely reduce the number of participants requiring antibiotics over a mean duration of six months (OR 0.34, 95% CI 0.18 to 0.63; 542 participants; moderate-certainty evidence). This outcome had a low-to-moderate degree of heterogeneity (I2 = 38%), but the direction of effect was consistent across all studies. There was no evidence of a difference in the odds of experiencing an adverse event with immunostimulant compared to placebo, over a mean duration of six months (OR 1.01, 95% CI 0.84 to 1.21; 20 RCTs, 3780 participants; high-certainty evidence). The CI limits for the associated risk ratio (RR) did not cross thresholds for appreciable harm or benefit (RR 1.02, 95% CI 0.92 to 1.13). An additional seven studies reported no events rates in either study arm. Meta-analyses were not performed for the outcomes of exacerbation duration and respiratory-related hospitalisation duration, due to high levels of heterogeneity across the included studies (exacerbation duration: I2 = 92%; respiratory-related hospitalisation duration: I2 = 83%). Results from an effect direction plot and binomial probability test for exacerbation duration indicated that a significant proportion of studies (94% (95% CI 73% to 99%); P = 0.0002) favoured intervention, possibly indicating that immunostimulants are efficacious in reducing the mean exacerbation duration compared to placebo. However, the degree of uncertainty associated with this estimate remained high due to data quality and heterogeneity. Three studies reported mean duration of respiratory-related hospitalisation, two of which demonstrated a direction of effect that favoured immunostimulant over placebo. AUTHORS' CONCLUSIONS: In participants with chronic bronchitis or COPD, we are moderately confident that treatment with immunostimulants is associated with a small reduction in the likelihood of having an exacerbation and a moderate reduction in the requirement for antibiotics. Low numbers of events limit interpretation of the effect of immunostimulants on all-cause and respiratory-related mortality. We are uncertain whether immunostimulants improve quality of life, and whether they are associated with a reduction in exacerbation and respiratory-related hospitalisation durations, although immunostimulants were generally associated with a positive effect direction in the studies that examined these outcomes. Immunostimulants appear to be safe and well-tolerated, and are not associated with an increased risk of adverse events.

Students' perceptions, educational challenges and hope during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has disrupted the lives of US students both at home and at school. Little is known regarding how adolescents perceive COVID-19 has impacted (both positively and negatively) their academic and social lives and how protective factors, such as hope, may assist with resilience. Importantly, not all pandemic experiences are necessarily negative, and positive perceptions, as well as potential protective factors, are key to understanding the pandemic's role in students' lives. METHOD: Utilizing quantitative and qualitative approaches, the present study descriptively examined 726 6th through 12th grade (51% female, 53% White) students' perceptions of how COVID-19 related to educational and life disruptions, and positive aspects of their lives, within the United States. Analyses additionally explored the role of pre-pandemic hope in improving feelings of school connectedness during the pandemic. RESULTS: Results showed that most students felt that switching to online learning had been difficult and their education had suffered at least moderately, with a sizeable proportion of students feeling less academic motivation compared with last year. When asked to share qualitative answers regarding perceived challenges and positive aspects of life, themes were consistent with quantitative perceptions. Students' pre-pandemic hope positively predicted students' feelings of school connectedness. CONCLUSIONS: Findings paint a complex picture of youth's COVID-19 experiences and have implications for proactive ways to support students as COVID-19 continues to affect daily life and educational structures and practices.

"Feeling It": Links between elements of compassion and sexual well-being.

Introduction: Compassion may be a particularly important component of a sexual relationship as it facilitates needed self-awareness, understanding, and connection to frame deeply intimate expressions of sexual emotion and vulnerability. Given the lack of research on how broad concepts of compassionate elements may be linked to sexual well-being, we examine how mindfulness (an ability to maintain awareness in the present moment), compassionate relational attitudes (i.e., accessibility, responsiveness, and engagement), and compassionate relational behaviors (i.e., forgiveness and gratitude), are linked to sexual well-being (sexual harmony, orgasm consistency, and sexual frequency), and sexual mindfulness (a state of being mindful during sex) for oneself and one's partner. Methods: We constructed an actor partner structural equation model with newly married couples (n = 2,111) and regressed sexual outcomes at time 1 and time 2 on each partner's compassionate attitudes, behaviors and mindfulness reported at time 1. Results: Results showed that cross-sectionally, nearly all elements of one's compassion related to one's own sexual well-being for both partners. Strongest paths included positive significant relations for women between mindfulness and non-judgment and from compassionate relational attitudes and behaviors to sexual harmony. Men's compassionate behaviors were positively related to their own sexual awareness. Perhaps more importantly, women's and men's compassionate behaviors had significant effects on their partner's sexual well-being longitudinally. Discussion: Implications include an emphasis on compassion as a key mechanism that can increase sexual satisfaction and strengthen relationships, particularly in the critical time of early marriage where patterns of interconnectedness are being established.

A Person-centered Approach to Violence Exposure in Postwar Colombian Youth: Demographic Covariates and Positive Youth Development Outcomes.

While the negative impact of extensive exposure to community violence and armed conflict is known, less emphasis has been focused on outcomes supportive of resilience. It is critical to begin exploring these constructs to both promote healing from decades-long conflict and to inform targeted interventions that focus on positive youth development in contexts of adversity. This study thus utilized a person-centered approach to estimate violence exposure profiles among 3,443 Colombian youth to explore what demographic covariates and positive youth development outcomes, such as school engagement, hope, goals, social competence, future expectations, and barriers to education were associated with each violence exposure profile. Four profiles emerged: a low exposure profile, a high community violence profile, a some combined exposure profile, and a high combined exposure profile, each with various levels of community violence witnessing and victimization as well as armed conflict exposure. Demographic covariance results showed older, urban, male youth were more likely to be in the high violence exposure profiles compared to the low exposure group. Youth in the high combined exposure profile were more likely to have lower hope, educational expectations, and social competence compared to the low exposure group. Findings highlight that a person-centered approach provides a more multidimensional view of adolescent violence exposure. Demographic differences suggested the importance of tailoring violence prevention initiatives to the local context. Finally, results concerning positive youth development outcomes suggest that resiliency-oriented constructs, which can be instrumental toward youth's postwar healing and growth, should be emphasized among populations who experience high levels of co-occurring exposure.

Hope levels across adolescence and the transition to high school: Associations with school stress and achievement.

INTRODUCTION: Feeling hopeful is an important condition for adolescents' health, well-being, and educational success and attainment, yet limited research has examined hope at different ages throughout adolescence. Information regarding hope levels across grade could help educators know when to capitalize on goal-setting behaviors, and when to intervene should hope levels be low. Additionally, hope could help with the middle to high school transition because it presents opportunities and challenges, including school-related stress, as students adjust to new environments and expectations. METHODS: To investigate hope levels across adolescence, inter- and intra-personal analyses examined hope levels across grade-level in two cohorts of southwestern U.S. students (n = 1,018, 6th-10th grade students, 47% female, 55% White/45% non-White, (predominately Latinx)). The study used online self-report surveys to collect data. Next, longitudinal regression analyses across one year investigated relations of school stress and hope, and hope and achievement across the transition to high school. RESULTS: Students in both cohorts reported relatively stable hope levels from 6th to 10th grade, except for large decreases in hope during 8th grade, which recovered during 9th grade. For longitudinal analyses across the high school transition, student stress about school performance primarily influenced 8th graders who had relatively low hope. Eighth grade hope predicted 9th grade academic achievement. CONCLUSION: Findings regarding hope across adolescence show that hope is similar across grade, except for a large decrease in hope that may occur before the transition to high school. Longitudinal analyses showed that school performance stress may contribute to this decrease but may also assist in hope recovery after the transition. Findings support educational practices and policies that target student hope before the high school transition to potentially buffer student stress and promote high school achievement.

Emotion-related socialization in the classroom: Considering the roles of teachers, peers, and the classroom context.

The goal of this study was to apply aspects of the heuristic model advanced by Eisenberg, Cumberland, and Spinrad (1998) to the study of socialization that takes place in preschool and elementary school classrooms. Investigating socialization in this context is important given the number of hours students spend in school, the emotional nature of social interactions that take place involving teachers and students, and the emotions students often experience in the context of academic work. Guided by Eisenberg, Cumberland, et al.'s (1998) call to consider complex socialization pathways, we focus our discussion on ways teachers, peers, and the classroom context can shape students' emotion-related outcomes (e.g., self-regulation, adjustment) and academic-related outcomes (e.g., school engagement, achievement) indirectly and differentially (e.g., as a function of student or classroom characteristics). Our illustrative review of the intervention literature demonstrates that the proposed classroom-based socialization processes have clear applied implications, and efforts to improve socialization in the classroom can promote students' emotional and academic competence. We conclude our discussion by outlining areas that require additional study. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Children's mu suppression is sensitive to witnessing others' social victimization.

Empathy has been a key focus of social, developmental, and affective neuroscience for some time. However, research using neural measures to study empathy in response to social victimization is sparse, particularly for young children. In the present study, 58 children's (White, non-Hispanic; five to nine years old) mu suppression was measured using electroencephalogram methods (EEG) as they viewed video scenarios depicting social injustices toward White and Black children. We found evidence of increased mu suppression in response to social victimization; however, contrary to well-documented findings of ingroup racial bias in empathic responses among adults, we found no evidence of racial bias in mu suppression in young children. Implications of these findings for neuroscience research on empathy and the development of ingroup bias are discussed.

WOMEN'S EMPOWERMENT AND FAMILY PLANNING: A REVIEW OF THE LITERATURE.

This paper reviews the literature examining the relationship between women's 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 women's 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 women's empowerment and family planning use.

Partner Support for Family Planning and Modern Contraceptive Use in Luanda, Angola.

Husband's/partner's support for family planning may influence a women's modern contraceptive use. Socio-demographic factors, couple communication about family planning, and fertility preferences are known to play a role in contraceptive use. We conducted logistic regression analysis to investigate the relationship between perceived husband's/partner's approval and husband's/partner's encouragement of modern contraceptive use, adjusting for socio-demographic factors and recent couple communication about family planning. We also examined mediating roles potentially played by perceived contraceptive accessibility and contraceptive self-efficacy (using index created by principal component analysis). Perceived husband's/partner's approval was associated with triple the odds of women's modern contraceptive use and remained significantly associated with 1.6 times the odds, after controlling for contraceptive accessibility and contraceptive self-efficacy. Husband's/partner's encouragement, while initially significantly associated with contraceptive use, became non-significant after adjustments for socio-demographic factors and couple communication. Perceived husband's/partner's approval, separate from a woman's sense of self-efficacy and perceived accessibility of contraceptives, appears strongly and positively associated with current modern contraceptive use. Increased couple communication may help women identify their husband's/partner's approval. Difference between the meaning of approval and encouragement should be explored. Interventions involving information education and communication campaigns geared to men and promoting male involvement in family planning could increase contraceptive prevalence.

How much is it going to cost me? Bidirectional relations between adolescents' moral personality and prosocial behavior.

The current study examined bidirectional relations between adolescents' moral personality (prosocial values, self-regulation, and sympathy) and low- and high-cost prosocial behavior toward strangers. Participants included 682 adolescents (M age of child = 14.31, SD = 1.07, 50% female) who participated at two time points, approximately one year apart. Cross-lag analyses suggested that adolescents' values were associated with both low- and high-cost prosocial behavior one year later, self-regulation was associated with high-cost prosocial behavior, and sympathy was associated with low-cost prosocial behavior. Findings also suggested that low-cost prosocial behavior was associated with sympathy one year later, and high-cost prosocial behavior was associated with values. Discussion focuses on reciprocal relations between moral personality and prosocial behavior, and the need to consider a more multidimensional approach to prosocial development during adolescence.

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

Women's empowerment has become a focal point for development efforts worldwide and there is a need for an updated, critical assessment of the existing evidence on women's empowerment and fertility. We conducted a literature review on studies examining the relationships between women's empowerment and several fertility-related topics. Among the 60 studies identified for this review, the majority were conducted in South Asia (n = 35) and used household decision-making as a measure of empowerment (n = 37). Overall, the vast majority of studies found some positive associations between women's empowerment and lower fertility, longer birth intervals, and lower rates of unintended pregnancy, but there was some variation in results. In many studies, results differed based on the measure of empowerment used, sociopolitical or gender environment, or sub-population studied. This article is one of the first evaluations of the literature assessing the relationships between women's empowerment and fertility. We identify several key issues that merit further investigation.

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