Male-female concordance in reported involvement of women in contraceptive decision-making and its association with modern contraceptive use among couples in rural Maharashtra, India.

OBJECTIVE: Women's involvement in contraceptive decision-making increases contraceptive use and reduces unmet need, but study of this has been limited to women's self-reports. Less research is available examining couple concordance and women's involvement in contraceptive decision-making as reported by both men and women. STUDY DESIGN: We carried out a cross-sectional study using data from rural India (N = 961 young married couples). Using multivariable regression we examined the association between concordance or discordance in spousal reports of wife's involvement in contraceptive decision-making and modern contraceptive use, adjusting for demographics, intimate partner violence, and contraceptive use discussion. RESULTS: More than one third (38.3%) of women reported current modern contraceptive use. Report of women's involvement in contraceptive decision-making showed 70.3% of couples agreed that women were involved, jointly or alone (categorized as Concordant 1), 4.2% agreed women were not involved (categorized at Concordant 2), 13.2% had women report involvement but men report women were uninvolved (categorized as Discordant 1), and 12.2% had women report uninvolvement but men report that women were involved (categorized as Discordant 2). Discordant 2 couples had lower odds of modern contraceptive use relative to Concordant 1 couples (adjusted RR = 0.61, 95% CI 0.45-0.83). No other significant differences between Concordant 1 couples and other categories were observed. CONCLUSION: One in four couples indicated discordance on women's involvement in contraceptive decision making, with Discordant 2 category having lower odds of contraceptive use. Couples' concordance in women's involvement in contraceptive decision-making offers a target for family planning research and interventions to better meet their needs. Trial registration ClinicalTrial.gov, NCT03514914. https://clinicaltrials.gov/ct2/show/NCT03514914.

Evidence on women's involvement in decision-making are limited to women's self reports and often not specific to contraceptive decision-making. This study uses couples dyadic data to assess male­female concordance on women's involvement in contraceptive decision-making and contraceptive use outcomes. Couple's concordance on women's involvement in contraceptive decision-making is associated with contraceptive use. There is potential in couple-focused family planning counseling that enhances women's contraceptive decision-making agency to improve women's contraceptive use.

Disrupting gender norms in health systems: making the case for change.

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

A gender synchronized family planning intervention for married couples in rural India: study protocol for the CHARM2 cluster randomized controlled trial evaluation.

BACKGROUND: Prior research from India demonstrates a need for family planning counseling that engages both women and men, offers complete family planning method mix, and focuses on gender equity and reduces marital sexual violence (MSV) to promote modern contraceptive use. Effectiveness of the three-session (two male-only sessions and one couple session) Counseling Husbands to Achieve Reproductive Health and Marital Equity (CHARM) intervention, which used male health providers to engage and counsel husbands on gender equity and family planning (GE + FP), was demonstrated by increased pill and condom use and a reduction in MSV. However, the intervention had limited reach to women and was therefore unable to expand access to highly effective long acting reversible contraceptives such as the intrauterine device (IUD). We developed a second iteration of the intervention, CHARM2, which retains the three sessions from the original CHARM but adds female provider- delivered counseling to women and offers a broader array of contraceptives including IUDs. This protocol describes the evaluation of CHARM2 in rural Maharashtra. METHODS: A two-arm cluster randomized controlled trial will evaluate CHARM2, a gender synchronized GE + FP intervention. Eligible married couples (n = 1200) will be enrolled across 20 clusters in rural Maharashtra, India. Health providers will be gender-matched to deliver two GE + FP sessions to the married couples in parallel, and then a final session will be delivered to the couple together. We will conduct surveys on demographics as well as GE and FP indicators at baseline, 9-month, and 18-month follow-ups with both men and women, and pregnancy tests at each time point from women. In-depth interviews will be conducted with a subsample of couples (n = 50) and providers (n = 20). We will conduct several implementation and monitoring activities for purposes of assuring fidelity to intervention design and quality of implementation, including recruitment and tracking logs, provider evaluation forms, session observation forms, and participant satisfaction surveys. DISCUSSION: We will complete the recruitment of participants and collection of baseline data by July 2019. Findings from this work will offer important insight for the expansion of the national family planning program and improving quality of care for India and family planning interventions globally. TRIAL REGISTRATION: ClinicalTrial.gov, NCT03514914 .

Sex Trade and Health Care Utilization Among People Living with HIV/AIDS.

People living with HIV/AIDS (PLWH) are more likely to have a history of trading sex, but little research has examined whether trading sex is associated with lower health care utilization amongst PLWH. This study assesses this association with PLWH (N = 583) recruited and surveyed from seven community sites in six US cities participating in a multi-site community-based HIV test and treat initiative. Participants were 90.6% Black or Latino, 30.4% homeless, and 9.0% (1 in 11) sold sex (past 90 days). Most reported receiving HIV clinical care (63.9%, past 6 months) and HIV case management (68.9%, past year), but 35.7% reported a missed health care appointment (past 3 months). In adjusted regression models, trading sex was associated with a missed health care appointment (OR = 2.44) and receiving psychological assistance (OR = 2.31), past 90 days, but not receipt of HIV care or supportive HIV services. Trading sex may compromise consistent health care utilization among PLWH.

Assessing the Relationship Between Mental Distress and Tobacco Use in Post-Katrina and Rita Louisiana.

BACKGROUND: The relationship between mental health status and smoking is complicated and often confounded by bi-directionality, yet most research on this relationship assumes exogeneity. OBJECTIVES: The goal of this article is to implement an instrumental variable approach to (1) test the exogeneity assumption and (2) report on the association between mental health status and smoking post-disaster. METHODS: This analysis utilizes the 2006 and 2007 Louisiana Behavioral Risk Factor Surveillance Survey to examine the link between mental distress and smoking in areas affected by Hurricanes Katrina and Rita. Residence in a hurricane-affected parish (county) was used as an instrumental variable for mental distress. RESULTS: Just over 22% of the sample resided in a hurricane-affected parish. Residents of hurricane-affected parishes were significantly more likely to report occasional and frequent mental distress. Residence in a hurricane-affected parish was not significantly associated with smoking status. With residence established as a salient instrumental variable for mental distress, the exogeneity assumption was tested and confirmed in this sample. A dose-response relationship existed between mental distress and smoking, with smoking prevalence increasing directly (and non-linearly) with mental distress. CONCLUSIONS: In this sample, the relationship between mental distress and smoking status was exogenous and followed a dose-response relationship, suggesting that the disasters did not result in an uptake of smoking initiation, but that the higher amounts of mental distress may lead to increased use among smokers. The findings suggest that tobacco control programs should devise unique strategies to address mentally distressed populations.

CHARM, a gender equity and family planning intervention for men and couples in rural India: protocol for the cluster randomized controlled trial evaluation.

BACKGROUND: Globally, 41% of all pregnancies are unintended, increasing risk for unsafe abortion, miscarriage and maternal and child morbidities and mortality. One in four pregnancies in India (3.3 million pregnancies, annually) are unintended; 2/3 of these occur in the context of no modern contraceptive use. In addition, no contraceptive use until desired number and sex composition of children is achieved remains a norm in India. Research shows that globally and in India, the youngest and most newly married wives are least likely to use contraception and most likely to report husband's exclusive family planning decision-making control, suggesting that male engagement and family planning support is important for this group. Thus, the Counseling Husbands to Achieve Reproductive Health and Marital Equity (CHARM) intervention was developed in recognition of the need for more male engagement family planning models that include gender equity counseling and focus on spacing contraception use in rural India. METHODS/DESIGN: For this study, a multi-session intervention delivered to men but inclusive of their wives was developed and evaluated as a two-armed cluster randomized controlled design study conducted across 50 mapped clusters in rural Maharashtra, India. Eligible rural young husbands and their wives (N = 1081) participated in a three session gender-equity focused family planning program delivered to the men (Sessions 1 and 2) and their wives (Session 3) by village health providers in rural India. Survey assessments were conducted at baseline and 9&18 month follow-ups with eligible men and their wives, and pregnancy tests were obtained from wives at baseline and 18-month follow-up. Additional in-depth understanding of how intervention impact occurred was assessed via in-depth interviews at 18 month follow-up with VHPs and a subsample of couples (n = 50, 2 couples per intervention cluster). Process evaluation was conducted to collect feedback from husbands, wives, and VHPs on program quality and to ascertain whether program elements were implemented according to curriculum protocols. Fidelity to intervention protocol was assessed via review of clinical records. DISCUSSION: All study procedures were completed in February 2015. Findings from this work offer important contributions to the growing field of male engagement in family planning, globally. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01593943.

The EMERGE framework to measure empowerment for health and development.

RATIONALE: Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed. OBJECTIVE: We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development. METHOD: We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures. RESULTS: Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights. CONCLUSION: The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

The associations of everyday and major discrimination exposure with violence and poor mental health outcomes during the COVID-19 pandemic.

Research on discrimination and risks for violence and mental health issues under the pandemic is notably absent. We examined the relative effects of perceived everyday discrimination (e.g., poorer service, disrespectful treatment in a typical week) and major experiences of race-based discrimination (e.g., racial/ethnic discrimination in housing or employment at any point in the lifetime) on experiences of violence and the PHQ-4 assessment of symptoms of depression and anxiety under the pandemic. We analyzed state-representative cross-sectional survey data from California adults (N = 2114) collected in March 2021. We conducted multivariate regression models adjusting for age, race/ethnicity, gender, sexual identity, income, and disability. One in four Californians (26.1%) experienced everyday discrimination in public spaces, due most often to race/ethnicity and gender. We found that everyday discrimination was significantly associated with past year physical violence (single form Adjusted Odds Ratio [AOR] 5.0, 95% CI 2.5-10.3; multiple forms AOR 2.6, 95% CI 1.1-5.8), past year sexual violence (multiple forms AOR 2.5, 95% CI 1.4-4.4), and mental health symptoms (e.g., severe symptoms, multiple forms AOR 3.3, 95% CI 1.6-6.7). Major experiences of race-based discrimination (reported by 10.0% of Californians) were associated with past year sexual violence (AOR 2.0, 95% CI 1.1-3.8) and severe mental health symptoms (AOR 2.7, 95% CI 1.2-6.2). Non-race-based major discrimination (reported by 23.9% of Californians) was also associated with violence and mental health outcomes Everyday discrimination, more than major experiences of discrimination, was associated with higher risk for violence and poor mental health outcomes during the pandemic. Non-race-based forms of major discrimination independently were also associated with these negative outcomes. Findings indicate that efforts to reduce and ultimately eliminate discrimination should be a focus of public health and COVID-19 rebuilding efforts.

The Role of Theory in the Prevention of Sexual Violence in Sport.

Sexual violence (SV) remains at epidemic proportions in the U.S. and growing evidence demonstrates that youth and adults engaged in sport are at increased risk of victimization and perpetration of SV. Unfortunately, sport SV prevention strategies are rarely built on theory or theoretically grounded evidence, despite demonstrated effectiveness of such approaches. This study aimed to answer to questions: 1) Which theories are relevant to the development of effective SV prevention strategies in sport?; and 2) How has theory been incorporated into existing SV prevention literature on sport safety? A scoping review of the literature plus expert input identified 29 theories pertinent to SV prevention in sport. A systemized review of the literature regarding SV prevention in sport resulted in the identification and characterization of 41 published articles. Authors then examined theory's role in prevention literature. This study identified 29 theories pertinent to SV prevention in sports and applicable across the behavioral spectrum. Most theories were rooted in the Behavioral (41%), Situational (24%) or Social/Attitudinal (21%) areas. Less common were theories grounded in Feminist (14%) domains. Theories were predominantly focused at the individual (42%), organizational (29%), and interpersonal (18%) ecological levels. Of the 41 sport prevention articles, 33 (83%) referred to a theory either explicitly or implicitly. Though most theories have been incorporated into prevention efforts, closer examination indicates that the majority were descriptive, unlikely to use a sophisticated methodology (10%; e.g., experimental, quasi-experimental), and rarely intended to assess a specific prevention program/strategy or policy (21%). Strong theoretical foundations are available for SV prevention research focused on sports, and their application appears to show value across the developmental spectrum of athletes. There remains a need for greater focus on theory-driven research intended to develop prevention strategies and policies designed to enhance athlete safety.

Erratum to "Sport as a vehicle of change for livelihoods, social participation and marital health for the youth: Findings from a prospective cohort in Bihar, India" [EClinicalMedicine 20 (2020) 100302].

[This corrects the article DOI: 10.1016/j.eclinm.2020.100302.].

Sport as a vehicle of change for livelihoods, social participation and marital health for the youth: Findings from a prospective cohort in Bihar, India.

BACKGROUND: Adolescent participation in pro-social activities such as sport can promote identity formation, self-efficacy and social support, but its benefits in India remain unassessed. We examined longitudinal effects of adolescent sport participation on economic, social and political engagement, marital health and family planning among young adults in India. METHODS: We analyzed prospective data from unmarried adolescents (n = 2,322, ages 15-19) who participated in the Youth in India 2007-8 study (wave 1) and were followed in the UDAYA study 2015-16 (wave 2), in Bihar, India. Sport participation was assessed in wave 1. Outcomes assessed in wave 2 were economic engagement (vocational training, past year paid employment), social group participation, political participation, marriage (any and prior to 18), and among those married, marital violence [MV] and contraceptive use. We used logistic and multinomial models to assess longitudinal associations between sport and our outcomes, adjusting for age, residence and wealth at baseline and secondary schooling completion at follow-up. RESULTS: In multivariate models for males, adolescent sport participation was associated with higher odds of vocational training [AOR: 1.92, 95% CI: 1.17, 3.15], social program engagement [AOR: 1.89, 95% CI: 1.14, 3.15], and a trend effect for political participation [AOR: 1.47, 95% CI: 0.97, 2.24]. Among females, sport in adolescence was associated with lower child marriage [ARRR = 0.67, 95% CI: 0.48, 0.96], and higher vocational training [AOR = 1.28, 95% CI: 1.03, 1.16] and family planning use [AOR = 1.31, 95% CI: 1.05, 1.63]. Crude effects were noted for delayed marriage, paid work and perpetration of marital violence among males. INTERPRETATION: Evidence from India shows that sport can be an instrument supporting pro-social engagement for boys and girls. Further understanding of the gendered nature of sport and the mechanisms linking sport to agency among youth is needed. FUNDING: This work was supported by the David and Lucile Packard Foundation (Grant number: 2017-66705).

Associations between village-level norms on marital age and marital choice outcomes among adolescent wives in rural Niger.

Social norms, the often unspoken rules that dictate behavior, are increasingly understood to play a role in child, early and forced marriage (CEFM) practices, but are less frequently examined in quantitative research on CEFM. No research on this topic has focused on Niger, despite the country having the highest prevalence of child marriage in the world. This study examines the associations of community and individual-level norms on marital age and marital choice with the outcomes of girls' age at marriage and choice in marriage. We used data from a family planning evaluation trial conducted in three districts within the Dosso region of Niger. Survey data were collected from adolescent wives and their husbands (N = 582) on demographics, normative beliefs regarding girls' age at marriage and marital choice, and among wives, age at marriage and engagement in marital choice. We developed our community-level norm variables by using the aggregate data from husbands' and wives' norms and wives' CEFM experiences. Using crude and adjusted regression models, we assessed the associations between our norms variables and our CEFM outcomes. In this context of very high prevalence of CEFM, we found that village-level norms related to marital choice, particularly the norms of men, are associated with younger age of girls at marriage. We also found that younger age of girls at marriage is positively associated with lower likelihood of their engagement in marital choice. Further, we find that village-level norms related to a later age of marriage and support for marital choice, as well as adolescent wives' perceptions of community norms related to a higher age of marriage, are associated with higher odds of a wife having had marital choice. These findings suggest the value of community level social norms change on CEFM in Niger, and the importance of focusing on child marriage and girls' marital choice simultaneously given their interconnection.

Evaluation of the Making Employment Needs (MEN) Count Intervention to Reduce HIV/STI Risk for Black Heterosexual Men in Washington DC.

The primary aim of this study was to evaluate the impact of MEN Count, a race- and gender-tailored three-session counseling intervention, on HIV/STI incidence as well as housing and employment. A two-armed quasi-experimental design was used to compare MEN Count to an attention comparison condition focused on stress reduction, from March 2014 to April 2017. Participants (N = 454) were Black heterosexual men in Washington DC, largely recruited from an STI clinic. Multivariate difference-in-difference regressions assessed whether the intervention was associated with significant changes in the outcomes set, which included nonviral STI incidence, sexual risk categorization, housing, and employment. Significant improvements over time were observed across both treatment arms for all outcomes (p < .05). Reductions in unemployment were significantly greater for intervention than for control participants (AOR unemployment = 0.48, 95% CI [0.23, 0.99]). Improvements in other outcomes did not differ significantly by treatment group. In dose analyses, participants receiving all intervention sessions were significantly less likely than control participants to have experienced homelessness in the 90 days prior (AOR= 0.31, 95% CI [0.10, 0.96]) and to be unemployed (AOR = 0.37, 95% CI [0.14, 0.96]). The MEN Count intervention offers a promising approach to address structural risk factors for STI, but not STI itself, among this largely STI clinic-based sample.

Multi-Site Evaluation of Community-Based Efforts to Improve Engagement in HIV Care Among Populations Disproportionately Affected by HIV in the United States.

This study assesses effects of a community-based intervention across seven sites in the United States on HIV care utilization and study retention, among people living with HIV (PLWH). A two-armed study was conducted from 2013 to 2016 in each of seven community-based agencies across the United States. Each site conducted interventions involving community engagement approaches in the form of case management or patient navigation. Control conditions were standard of care involving referral to HIV clinical care. Participants (N = 583) were adults reporting erratic or no HIV care in the past 6 months. Longitudinal survey data on demographics, behavioral risks, and HIV care were collected from participants at baseline, before service delivery, and at 6-month follow-up. Unadjusted and adjusted generalized linear mixed models were used to assess the intervention effects on HIV care utilization and study retention. Participants were majority black (75.5%), cisgender male (55.1%), and heterosexual (55.4%). No significant intervention effect was observed on HIV care utilization, although both groups improved significantly over time [adjusted odds ratio (AOR): 2.09, 95% confidence interval (CI): 1.30-3.37]. Intervention participants were more likely to be retained in the study (AOR: 1.50, 95% CI: 1.03-2.20). Community intervention did not affect HIV care utilization more than standard of care, but intervention participants were more likely to be retained in the study, suggesting that such approaches support relationship building in ways that can facilitate follow-up of socially vulnerable PLWH. More research is needed to understand how such community efforts can support better HIV care utilization in these populations.

Impact of Sexual Violence Across the Lifespan on HIV Risk Behaviors Among Transgender Women and Cisgender People Living With HIV.

BACKGROUND: To examine sexual violence across the lifespan among transgender and cisgender people living with HIV and its associations with recent risk behaviors. SETTING: Seven community-based sites serving priority populations disproportionately affected by HIV in the United States, including major metropolitan areas in the West and East Coast, as well as the suburban Mid-Atlantic and rural Southeastern regions. METHODS: From 2013 to 2016, baseline survey data were collected from participants (N = 583) of a multisite community-based HIV linkage to/retention in care study conducted at 7 sites across the United States. Adjusted mixed-effects logistic regression models with random effect for site-assessed associations of sexual violence and gender identity with risk outcomes including condomless sex, sex trade involvement, and substance use-related harms. RESULTS: One-third of participants reported a history of sexual violence; transgender [adjusted odds ratio (AOR) = 5.1, 95% confidence interval (CI): 2.6 to 10.1] and cisgender women (AOR = 3.8, 95% CI: 2.3 to 6.4) were more likely than cisgender men to experience sexual violence. Sexual violence was associated with experiencing drug-related harms (AOR = 2.6, 95% CI: 1.2 to 5.5). Transgender women were more likely than cisgender men to have sold sex (AOR = 9.3, 95% CI: 1.7 to 50.0). CONCLUSIONS: A history of sexual violence is common among transgender and cisgender women PLWH, and it increases risk for drug-related harms. Transgender women are also more likely to report selling sex.