Longitudinal examination of changing fertility intentions and behaviors over a four-year period in urban Senegal.

BACKGROUND: Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use. METHODS: Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods. RESULTS: Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon. CONCLUSIONS: These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.

Assessing the sustainability of the Nigerian urban reproductive health initiative facility-level programming: longitudinal analysis of service quality.

BACKGROUND: To date, there is little information on the sustainability of family planning (FP) service quality after completion of a donor-funded program. This paper examines the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI) program on quality of FP services in two cities: Ilorin, where the program ended in March 2015 and Kaduna where the program continued. METHODS: Data come from three time periods: 2011, before program implementation; 2014, near Phase 1 completion; and 2017, two-years post Phase 1. In 2011, we undertook a facility audit and provider surveys in all public sector facilities in each city as well as all private facilities mentioned as the source for FP or maternal, newborn, and child health services in a 2010 women's household survey. In 2014 and 2017, we returned to the same facilities to undertake the facility audit and provider surveys. Quality is measured from principal component analyses of 30 items from the facility audit and provider surveys. Service use outcomes are measured as the ratio of FP clients (total and new) to the number of reproductive health staff members. Multivariate random effect models are estimated to examine changes in the outcomes over time, between NURHI and non-NURHI facilities and by city. RESULTS: We demonstrate that NURHI facilities had better quality and higher service use than non-NURHI facilities. Further, while quality of services was higher in Ilorin in 2011, by 2014 and three years later (2017), the quality was better in Kaduna where the program continued. In addition, while no difference was found in service utilization between Ilorin and Kaduna in 2014, by 2017, Kaduna had significantly more new FP users than Ilorin. CONCLUSIONS: In Ilorin, quality of services did not continue its strong upward trend after the program ended. Programs need to consider long-term strategies that support continuation of program components post program implementation. This may include ensuring continued training of providers and addressing equipment and commodity stock-outs through system changes rather than specific facility-level changes. The findings from this study can be used to inform future programs seeking to improve quality of FP services in a sustainable manner.

Inactivation of Adenomatous Polyposis Coli Reduces Bile Acid/Farnesoid X Receptor Expression through Fxr gene CpG Methylation in Mouse Colon Tumors and Human Colon Cancer Cells.

BACKGROUND: The farnesoid X receptor (FXR) regulates bile acid (BA) metabolism and possesses tumor suppressor functions. FXR expression is reduced in colorectal tumors of subjects carrying inactivated adenomatous polyposis coli (APC). Identifying the mechanisms responsible for this reduction may offer new molecular targets for colon cancer prevention. OBJECTIVE: We investigated how APC inactivation influences the regulation of FXR expression in colonic mucosal cells. We hypothesized that APC inactivation would epigenetically repress nuclear receptor subfamily 1, group H, member 4 (FXR gene name) expression through increased CpG methylation. METHODS: Normal proximal colonic mucosa and normal-appearing adjacent colonic mucosa and colon tumors were collected from wild-type C57BL/6J and Apc-deficient (Apc(Min) (/+)) male mice, respectively. The expression of Fxr, ileal bile acid-binding protein (Ibabp), small heterodimer partner (Shp), and cyclooxygenase-2 (Cox-2) were determined by real-time polymerase chain reaction. In both normal and adjacent colonic mucosa and colon tumors, we measured CpG methylation of Fxr in bisulfonated genomic DNA. In vitro, we measured the impact of APC inactivation and deoxycholic acid (DCA) treatment on FXR expression in human colon cancer HCT-116 cells transfected with silencing RNA for APC and HT-29 cells carrying inactivated APC. RESULTS: In Apc(Min) (/+) mice, constitutive CpG methylation of the Fxrα3/4 promoter was linked to reduced (60-90%) baseline Fxr, Ibabp, and Shp and increased Cox-2 expression in apparently normal adjacent mucosa and colon tumors. Apc knockdown in HCT-116 cells increased cellular myelocytomatosis (c-MYC) and lowered (∼50%) FXR expression, which was further reduced (∼80%) by DCA. In human HCT-116 but not HT-29 colon cancer cells, DCA induced FXR expression and lowered CpG methylation of FXR. CONCLUSIONS: We conclude that the loss of APC function favors the silencing of FXR expression through CpG hypermethylation in mouse colonic mucosa and human colon cells, leading to reduced expression of downstream targets (SHP, IBABP) involved in BA homeostasis while increasing the expression of factors (COX-2, c-MYC) that contribute to inflammation and colon cancer.

Using a Quality Improvement Approach in the Prevention of Mother-to-Child HIV Transmission Program in Uganda Improves Key Outcomes and Is Sustainable in Demonstration Facilities: Partnership for HIV-Free Survival.

BACKGROUND: The Partnership for HIV-Free Survival (PHFS) in Uganda used a quality improvement (QI) approach to integrate the prevention of mother-to-child transmission (MTCT) of HIV, maternal and child health, and nutrition services, with the goal of increasing the retention of mother-baby pairs in care and decreasing vertical transmission of HIV. METHODS: This evaluation of PHFS used a retrospective longitudinal design to assess the program's association with 4 outcomes. Data were extracted from patient records from 2011 (before the program) to 2018 (after the program) at 18 demonstration, 18 scale-up, and 24 comparison facilities. Difference-in-differences analyses were conducted with significance set at P < 0.15 during and P > 0.15 or a significant continued improvement after PHFS. RESULTS: PHFS was associated with an increase in exclusive breastfeeding (EBF) (P = 0.08), 12-month retention in care (P < 0.001), and completeness of child 18-month HIV test results (P = 0.13) at demonstration facilities during program implementation. MTCT at 18 months decreased, but did not differ between groups. Increases in EBF (P = 0.67) and retention in care (P = 0.16) were sustained, and data completeness (P = 0.10) continued to increase at demonstration facilities after the program. PHFS was associated with an increase in EBF (P < 0.001) at scale-up facilities, but there was no difference between groups for retention in care, MTCT, or data completeness. Gains in EBF were lost (P = 0.08) and retention in care declined (P < 0.001) at scale-up facilities after the program. CONCLUSION: PHFS' quality improvement approach increased EBF, retention in care, and data completeness in demonstration facilities during the program and these benefits were sustained.

On the sustainability of a family planning program in Nigeria when funding ends.

Few studies have examined the sustainability of family planning program outcomes in the post-program period. This article presents the results of a natural experiment where the Nigerian Urban Reproductive Health Initiative Phase I programming ended in early 2015 and Phase II activities continued in a subset of cities. Using data collected in 2015 and 2017, we compare contraceptive ideation and modern family planning use in two cities: Ilorin where program activities concluded in 2015 and Kaduna where program activities continued. The results demonstrate that exposure to program activities decreased in Ilorin but for those individuals reporting continuing exposure, the effect size of exposure on modern family planning use remained the same and was not significantly different from Kaduna. Modern family planning use continued to increase in both cites but at a lower rate than during Phase I. The results are useful for designing family planning programs that sustain beyond the life of the program.

The Mayer Hashi Large-Scale Program to Increase Use of Long-Acting Reversible Contraceptives and Permanent Methods in Bangladesh: Explaining the Disappointing Results. An Outcome and Process Evaluation.

BACKGROUND: Bangladesh has achieved a low total fertility rate of 2.3. Two-thirds of currently married women of reproductive age (CMWRA) want to limit fertility, and many women achieve their desired fertility before age 30. The incidence of unintended pregnancy and pregnancy termination is high, however. Long-acting reversible contraceptives (LARCs), consisting of the intrauterine device and implant, and permanent methods (PM), including female sterilization and vasectomy, offer several advantages in this situation, but only 8% of CMWRA or 13% of method users use these methods. PROGRAM: The Mayer Hashi (MH) program (2009-2013) aimed to improve access to and the quality of LARC/PM services in 21 of the 64 districts in Bangladesh. It was grounded in the SEED (supply-enabling environment-demand) Programming Model. Supply improvements addressed provider knowledge and skills, system strengthening, and logistics. Creating an enabling environment involved holding workshops with local and community leaders, including religious leaders, to encourage them to help promote demand for LARCs and PMs and overcome cultural barriers. Demand promotion encompassed training of providers in counseling, distribution of behavior change communication materials in the community and in facilities, and community mobilization. METHODS: We selected 6 MH program districts and 3 nonprogram districts to evaluate the program. We used a before-after and intervention-comparison design to measure the changes in key contraceptive behavior outcomes, and we used a difference-in-differences (DID) specification with comparison to the nonprogram districts to capture the impact of the program. In addition to the outcome evaluation, we considered intermediate indicators that measured the processes through which the interventions were expected to affect the use of LARCs and PMs. RESULTS: The use of LARCs/PMs among CMWRA increased between 2010 and 2013 in both program (from 5.3% to 7.5%) and nonprogram (from 5.0% to 8.9%) districts, but the rate of change was higher in the nonprogram districts. Client-provider interaction and exposure to LARCs/PMs were lower in the program than nonprogram districts, and the MH program districts had higher vacancies of key providers than the nonprogram areas, both indications of a more difficult health system environment. CONCLUSION: The weaknesses in the health system in the MH districts apparently undermined the effectiveness of the program. More attention to system weaknesses, such as additional supportive supervision for providers, might have improved the outcome.

Impact evaluation of the Urban Health Initiative in urban Uttar Pradesh, India.

OBJECTIVES: The Urban Health Initiative (UHI) was initiated in 2009 with the goal of increasing family planning (FP) use among the poor in urban areas of Uttar Pradesh, India. The Measurement, Learning & Evaluation project (MLE) was tasked with rigorous impact evaluation of the UHI. This paper presents the impact evaluation findings of the UHI program. STUDY DESIGN: The MLE design includes a longitudinal sample of women and health facilities with baseline (2010) and endline (2014) data collection in six cities in Uttar Pradesh, India. At baseline, samples representative of women in each city were selected with oversampling of the poor. Eighty-four percent of women interviewed at baseline were reinterviewed 4 years later at endline. The longitudinal data support a within/fixed-effects approach to identification of program impact on changes in modern FP use. RESULTS: Impact evaluation results show significant effects of exposure to both demand and supply side program activities. In particular, women exposed to brochures (marginal effect: 6.96, p<.001), billboards/posters/wall hangings (marginal effect: 2.09, p<.05), and FP on the television (marginal effect: 2.46, p<.001) were significantly more likely to be using a modern method at endline. In addition, we found borderline significance for being exposed to a community health worker (marginal effect: 1.66, p<.10) and living close to an improved public and private supply environment where UHI undertook activities (marginal effects and p values: 2.48, p<.05 and 1.56, p<.10, respectively). CONCLUSIONS: UHI program activities were designed to complement the Government of India's strategies aimed at ensuring access to and provision of FP to urban poor populations. The effective demand- and supply-side strategies of the UHI program are therefore likely to be sustainable and scalable to other urban areas in India. IMPLICATIONS STATEMENT: Findings from this study are important for designing sustainable and scalable FP strategies for urban India where increases in FP use will be relevant for meeting international FP targets.

Is cigarette smoking in poorer nations highly sensitive to price? Evidence from Russia and China.

We examine cigarette demand in China and Russia using longitudinal micro-level household and community surveys. Previous developing-country price elasticity estimates of around -0.75 have been larger than United States estimates of about -0.4, but the former have relied primarily on aggregate data. In contrast, our micro-level price elasticity estimates in China and Russia range from 0 to -0.15. Thus, raising prices in poorer countries may not reduce smoking to the degree previously suggested.

Did the distribution of health insurance in China continue to grow less equitable in the nineties? Results from a longitudinal survey.

This paper examines changes in the distribution of health insurance across socioeconomic groups in China over the 1989-1997 period. The analysis is based on the China Health and Nutrition Survey (CHNS), a unique micro-level longitudinal survey of households in eight Chinese provinces. Findings indicate that while aggregate insurance coverage rates in the sample changed little over this period, certain previously noted differences in coverage rates across socioeconomic groups narrowed significantly. These findings bring into question the presumption that continued market-oriented reform would lead to increased differences in coverage across those groups. The results, in fact, suggest exactly the opposite, that as the market oriented changes have occurred important disparities in health insurance coverage have been reduced. If these reductions are occurring there are important implications for policy. The groups normally targeted for equity reasons seem to be making progress over time but continued improvements are needed for these groups to reach the levels of coverage enjoyed by more fortunate subgroups.

Prevalence and correlates of physical spousal violence against women in slum and nonslum areas of urban Bangladesh.

This study explores the prevalence and correlates of past-year physical violence against women in slum and nonslum areas of urban Bangladesh. The authors use multivariate logistic regression to analyze data from the 2006 Urban Health Survey, a population-based survey of 9,122 currently married women aged between 15 and 49 who were selected using a multistage cluster sampling design. The prevalence of reported past-year physical spousal violence is 31%. Prevalence of past-year physical spousal violence is higher in slums (35%) than in nonslums (20%). Slapping/arm-twisting and pushing/shaking/ throwing something at the women are the most commonly reported acts of physical abuse. Multivariate analysis shows that the risk of physical spousal abuse is lower among older women, women with post-primary education, and those belonging to rich households and women whose husbands considered their opinion in decision making. Women are at higher risk of abuse if they had many children, believe that married woman should work if the husband is not making enough money, and approve wife-beating norms. This study serves to confirm the commonness of physical spousal abuse in urban Bangladesh, demonstrating the seriousness of this multifaceted phenomenon as a social and public health issue. The present findings suggest the need for comprehensive prevention and intervention strategies that capitalize on the interplay of individual and sociocultural factors that cause physical spousal violence. Our study adds to a growing literature documenting domestic violence against women in urban areas of developing south Asian nations.

Physical and sexual abuse of wives in urban Bangladesh: husbands' reports.

Using data from 8,320 husbands'self reports for the 2006 Urban Health Survey, this article examines the prevalence of physical and sexual intimate partner violence (IPV) perpetrated by husbands against their wives in Bangladesh and identifies risk markers associated with such violence. Of the men included in the sample for this study, 55 percent reported perpetrating physical IPV against their wives at some point in their married lives, 23 percent reported perpetrating physical IPV in the past year, 20 percent reported ever perpetrating sexual IPV, and 60 percent reported ever perpetrating physical or sexual IPV. Bivariate analyses revealed that men residing in slums had a greater likelihood than those residing in nonslum areas and in district municipalities of perpetrating lifetime and past-year physical IPV, and any lifetime (physical or sexual) IPV. Lifetime sexual IPV prevalence, by contrast, was highest in district municipalities (26 percent), followed by slum (20 percent) and nonslum (17 percent) areas. Net of other factors, low socioeconomic levels were associated with men's increased likelihood of perpetrating IPV. Alcohol and drug use, sexually transmitted disease infection, poor mental health, and holding attitudes supportive of wife beating were predictive of IPV perpetration. These results suggest that IPV-prevention programs targeting men should consider spousal abuse, substance use, and sexual risk behaviors as social and public health problems and should also consider the sociocultural context within which men who abuse their partners are embedded.

Changes in access to health care in China, 1989-1997.

The post-1979 period in China has seen the implementation of reforms that dismantled much of the Maoist era social welfare system and permitted a significant reallocation of society's resources. The result has been rapid but uneven economic development that has profoundly altered the environment within which consumers make health investment decisions. Many studies report significant and apparently non-random reductions in health care utilization during this period. Scholars have tended to focus on the loss of insurance coverage and the growth of fees for services in explaining such reductions. An alternative explanation is growing inequality in access to care. This possibility has not received much research attention. As a result, our understanding of the patterns of changes in health care access, and of the types of populations that have been most adversely affected, has been rather limited. This research examines the distribution of the changes in several indicators of access to health care across communities during the period 1989 to 1997. We find evidence of relatively uneven changes to these indicators. Money charges for routine services increased consistently, though this trend was less pronounced in lower-income communities. Most communities experienced reductions in travel distance to clinics but increases in distance to hospitals. There were major improvements to the quality of care in wealthier rural areas, but not in poorer villages. Wealthier villages experienced less improvement in waiting time and drug availability. These trends appear to be closely associated with changing economic circumstances during the reform era.