Estimating the changing burden of disease attributable to interpersonal violence in South Africa for 2000, 2006 and 2012.

BACKGROUND: South Africa (SA)'s high rate of interpersonal violence persists as a leading public health problem for the country. The first South African Comparative Risk Assessment Study (SACRA1) in 2000 quantified the long-term mental and physical health burden attributable to interpersonal violence by supplementing the direct injury burden of disease attributable to interpersonal violence injuries with the substantial contribution of mental health, behavioural and reproductive health consequences accruing from exposure to intimate partner violence (IPV) and child sexual abuse. OBJECTIVES: To revise and improve these estimates by including the additional burden from other forms of child maltreatment, community violence, sexual violence by non-partners, and bullying victimisation in SA for 2000, 2006 and 2012, and trends over time. METHODS: We used comparative risk assessment methods to calculate population attributable fractions (PAFs) for interpersonal violence. This method requires inputs on the prevalence of exposure to the interpersonal violence risk factor subtypes, namely child maltreatment, bullying, IPV, sexual violence by non-partners and other community violence; the burden of related health outcomes (mortality and morbidity); and relative risks of health outcomes in individuals exposed to the risk factor v. those unexposed. We estimated the PAF for the combinations of all interpersonal violence subtypes together to estimate the burden attributable to interpersonal violence overall for 2000, 2006 and 2012. RESULTS: Between 2000 and 2012, there was a decrease in interpersonal violence age-standardised attributable death rates from 100 to 71 per 100 000. In the second South African Comparative Risk Assessment Study (SACRA2), estimates of the attributable disability-adjusted life years (DALYs) for interpersonal violence for the year 2000 were revised, from 1.7 million to 2 million DALYs, taking into account attributable mortality and disability from additional forms of violence. There was a decrease in DALYs attributable to interpersonal violence from 2 million in 2000 to 1.75 million in 2012, accounting for 8.5% of the total burden for SA, ranking second highest, after unsafe sex, among 18 risk factors evaluated in 2012. CONCLUSION: Overall, interpersonal violence-attributable DALYs decreased substantially but remain high. The reduction in age-standardised attributable death rates indicates that some policy and social intervention aspects are effective. Further strengthening of existing laws pertaining to interpersonal violence, and other prevention measures, are needed to intensify the prevention of violence, particularly gender-based violence. Additional forms of violence included in this analysis have improved our understanding of the interpersonal violence burden, but the attributable burden in males, although exceedingly high, remains an underestimate. There is a need to improve the epidemiological data on prevalence and risks for the different types of interpersonal violence, particularly for males.

Sexual and gender-based violence and HIV in South Africa: An HIV facility-based study.

BACKGROUND: South Africa (SA) is known to have high levels of sexual and gender-based violence (SGBV) and HIV. Studies that explore the intersections of the two phenomena tend to be done at sites that provide services for survivors of SGBV, but few have explored experiences of SGBV of individuals attending HIV testing and treatment health facilities. Although HIV voluntary counselling and testing (VCT) services are generally well practised at ensuring pre- and-post-test counselling, there is little evidence that SGBV is included in routine screening. There is therefore a gap in knowledge of the prevalence of SGBV among patient populations in HIV testing and treatment settings. OBJECTIVES: To assess levels of SGBV in a patient population of an HIV facility in SA. METHODS: This cross-sectional study used a screening tool and a longer in-depth questionnaire on the prevalence of SGBV. A random sample of VCT clients were screened. Prevalence questionnaires were administered to a convenience sample of patients attending treatment literacy classes. RESULTS: A total of 1 936 VCT clients completed the screening tool, of whom 2% reported forced sex without a condom or rape. Of the 436 patients who completed the in-depth prevalence questionnaire, 71% were women; 12% of women had been forced to have sex the last time that they had sexual intercourse. The lifetime prevalence of sexual violence was 14% and the lifetime prevalence of physical violence was 16%. CONCLUSIONS: Levels of SGBV are high among populations attending HIV testing and treatment facilities. Healthcare providers need to be able to identify SGBV and provide appropriate services to survivors of SGBV who are seen at HIV testing and treatment facilities.

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

BACKGROUND: Previous research has identified factors associated with condom use. However, less information exists on the impact that a history of sexually transmitted disease (STD) has on condom use. GOAL: To identify factors associated with self-reported male condom use that relate to a history of STD. STUDY DESIGN: Women attending STD clinics completed a survey that assessed sexual behavior, STD history, and psychosocial characteristics. Binomial regression was used to estimate the association between these factors and condom use. RESULTS: Of the 12 factors included in the regression model, 11 were significant for all women. When the analysis was stratified by STD history, high condom use self-efficacy, high convenience of condom use, and high frequency of condom use requests were significantly associated with increased condom use among women with or without a history of STD. Factors such as greater perceived condom use norms, higher perceived level of risk, and greater need for condom use in long-term relationships were significantly associated with increased condom use among women with a history of STD. Factors such as shorter duration of a relationship, less violence in the relationship, and lifetime drug use were associated with increased condom use among women with no history of STD. CONCLUSIONS: The pattern of psychosocial factors determining condom use is modified by a positive history of STD. These findings suggest that a history of STD could be an important factor in targeting condom use interventions.

Female condom use among women at high risk of sexually transmitted disease.

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

Partner type and condom use.

OBJECTIVES: To examine the association between type of sexual partnership and condom use consistency. DESIGN: A prospective follow-up study of women attending two urban clinics for sexually transmitted diseases (STD). METHODS: Sexual diaries recording barrier method, partner initials and partner type for each act of intercourse were kept by 869 women. Condom use by partner type was evaluated in three ways in the entire group: among women who encountered multiple partners, during months in which women encountered multiple partners, and within sexual partnerships that changed status during the study. RESULTS: Consistency of condom use was higher with new and casual partners than with regular partners in the entire group and among women who encountered multiple partners. In months in which partners of different types were encountered, condom-use consistency was higher with new and casual partners than with regular partners. Consistent condom use decreased in partnerships that changed status from new to regular. The female condom was used more often with regular partners than with new or casual partners in the entire study group, among women who encountered multiple partners, and during months in which a woman achieved consistent use with her regular partner. CONCLUSIONS: This study provides strong evidence that condom use behavior is modified by partner type. Observations about condom use and partner type made in cross-sectional or retrospective surveys also hold in the present longitudinal analyses of individual women and of partnerships that change status. The female condom may be an important option for achieving consistent protection within stable partnerships.

Effectiveness of an intervention promoting the female condom to patients at sexually transmitted disease clinics.

OBJECTIVES: This study evaluated a behavioral intervention designed to promote female condoms and reduce unprotected sex among women at high risk for acquiring sexually transmitted diseases (STDs). METHODS: The effect of the intervention on barrier use was evaluated with a pretest-posttest design with 1159 female STD clinic patients. RESULTS: Among participants with follow-up data, 79% used the female condom at least once and often multiple times. More than one third of those who completed the study used female condoms throughout follow-up. Use of barrier protection increased significantly after the intervention, and high use was maintained during a 6-month follow-up. To account for attrition, the use of protection by all subjects was projected under 3 conservative assumptions. The initial visit and termination visit projections suggest that use increased sharply after the intervention and declined during follow-up but remained elevated compared with the baseline. CONCLUSIONS: Many clients of public STD clinics will try, and some will continue, to use female condoms when they are promoted positively and when women are trained to use them correctly and to promote them to their partners. A behavioral intervention that promotes both female and male condoms can increase barrier use.

Mechanical failure of the latex condom in a cohort of women at high STD risk.

BACKGROUND AND OBJECTIVES: Mechanical failure may reduce the efficacy of condoms. Little is known about frequency and determinants of condom failure in groups at high risk of sexually transmitted diseases (STD). GOAL: To measure condom breakage and slippage rates and evaluate potential determinants of failure among women attending a public STD clinic. STUDY DESIGN: Women attending an STD clinic participated in a 6-month prospective study of barrier contraception for the prevention of STD. They completed sexual diaries that were reviewed at monthly follow-up visits. No data were collected from the male partners. Baseline characteristics of the participants and time-dependent behaviors were evaluated as potential determinants of condom failure. RESULTS: Of 21,852 condoms used by 892 women, 500 broke during intercourse (2.3%) and 290 slipped (1.3%). Breakage was more common among young, black, single nulliparae who engaged in high-risk behavior. Slippage was more common among married women with children. Failure rates decreased with condom use, with coital frequency, and with use of spermicides. CONCLUSION: User characteristics and experience are determinants of breakage and slippage, which are often regarded only as the effect of product design flaws. Attention to modifiable determinants of failure may improve user counseling and product labeling.

PIP: This paper presents information obtained from a large prospective study of a cohort of women at high risk who used condoms for protection against sexually transmitted diseases (STDs). The objectives of the study were to measure condom breakage and slippage rates, and to examine the possible determinants of failure. The participants were women aged 18-34 years who attended an STD clinic 6 months prior to the study. They were asked to record information about all sexual activities and barriers used in a sexual diary, which was then reviewed in a monthly follow-up visit. A total of 21,852 condoms were used by 892 women, of which 500 broke during intercourse (2.3%) and 290 slipped off (1.3%). Breakage was more common among young, Black, single nulliparas who engaged in high-risk behavior. The failure rate decreased with condom use, with coital frequency, and with use of spermicides. In conclusion, condom breakage and slippage were generally low in women at high risk for STDs. Both indices of condom failure decreased significantly with increasing condom use during the study, and both were associated with specific user characteristics.

Prospective study of barrier contraception for the prevention of sexually transmitted diseases: study design and general characteristics of the study group.

BACKGROUND AND OBJECTIVES: The AIDS epidemic has brought barrier contraceptives to the forefront of public health research. A comprehensive evaluation of the efficacy of barrier contraceptive use in preventing sexually transmitted diseases (STDs), including AIDS, is necessary to inform both potential users and public health policy makers. This study was undertaken to evaluate the efficacy of condoms and vaginal spermicide products, used alone or in combination, in preventing gonorrhea and chlamydia among women attending an STD clinic. GOAL OF THIS STUDY: To describe the general characteristics of the study group and its follow-up experience. STUDY DESIGN: Women who met the eligibility criteria were invited to participate. The initial visit included an interview, a behavioral intervention promoting barrier methods, a physical examination, and instructions to complete a sexual diary. Participants received free barrier contraceptives and returned for six monthly follow-up visits. DESIGN RESULTS: Participants (n = 1,122) were low income, single (74%) black (89%) women with a median age of 24. The behavioral intervention led to the use of barrier protection in more than 70% of reported acts of vaginal intercourse. Barriers were used consistently (100% of sexual acts) during 51% of the months of follow-up. A total of 148 cases of gonorrhea (28 per 1,000 months) and 122 cases of chlamydia infection (23 cases per 1,000 months) were diagnosed during follow-up. CONCLUSION: This study represents a practical solution to a complex set of design considerations. The study protocol was successful in promoting consistent and proper use of barrier methods.

Health education for pregnant smokers: its behavioral impact and cost benefit.

OBJECTIVES: A randomized trial (the Birmingham Trial II) was conducted to evaluate the behavioral impact of health education methods among 814 female smokers at four public health maternity clinics. METHODS: Four hundred patients were randomly assigned to an Experimental (E) Group, and 414 were assigned to a Control (C) Group. Self-reports and saliva cotinine tests confirmed smoking status at the first visit, at midpregnancy, and at end of pregnancy. RESULTS: The E Group exhibited a 14.3% quit rate and the C Group an 8.5% quit rate. A Historical Comparison (C) Group exhibited a 3.0% quit rate. Black E and C Group patients had higher quit rates than White E and C Group patients. A cost-benefit analysis found cost-to-benefit ratios of $1:$6.72 (low estimate) and $1:$17.18 (high estimate) and an estimated savings of $247,296 (low estimate) and $699,240 (high estimate). CONCLUSION: Health education methods are efficacious and cost beneficial for pregnant smokers in public health maternity clinics.

Multivariate evaluation of health attitudes and behaviors: development and validation of a method for health promotion research.

Many self-reported measures of health status, attitudes, and knowledge used by clinicians and researchers suffer from a variety of shortcomings, including limited empirical justification, excessive complexity, assessments of nonmodifiable historic or hereditary factors, and limited utility for public health program planning. The Health Attitudes and Behavior Scale is an instrument designed to overcome many of these shortcomings and direct public health professionals toward more efficacious interventions. One hundred sixty-four subjects responded to true-false and Likert scale items related to health beliefs, attitudes, and behavioral practices. A principal component analysis of the Likert items yielded six components, tentatively labeled (a) Lack of Social Support, (b) Hurdles to Health, (c) Health Attitudes/Weight Concerns, (d) Positive Environment, (e) Disease Concerns, and (f) Time and Work Pressure. Analyses of these scales using coefficient alpha indicated adequate internal consistency for each of them. These scales were then related to demographic variables of age, educational level, sex, and marital status. Next, these scales were correlated with individual true-false items reflecting self-reported behavioral practices or health histories. A component analysis of the true-false items yielded four principal components labeled (a) Organizational Health Concerns, (b) Smoking and Exercise Concerns, (c) Coronary and Weight Concerns, and (d) Blood Pressure and Risk Factor Programs. Finally, a cluster analysis yielded six typical profiles reflecting different levels of the original six components. Of interest is the fact that the Lack of Social Support and Time and Work Pressure scales had a very limited integration into the overall patterns. The assumption that organizational and environmental factors can have an important impact on health was supported. The need for further research in this area is also discussed.

Community change agents and health interventions: hypertension screening.

This study explores a community-based approach to health care. Community volunteers were trained and then conducted door-to-door screening for hypertension. Three large apartment complexes were selected for screening. In the two experimental communities, a letter was sent to each household soliciting volunteers who were then trained to measure blood pressure, complete data sheets, gain admittance to houses, and make appropriate recommendations for medical consultation. The residents in the control community received letters informing them of the hours during which they could have their blood pressure checked free of charge in the apartment complex rental office. Chi-square tests on number of apartments screened indicated the experimental door-to-door screening methods was significantly more effective than the control central site method. These results demonstrate that the experimental screening project was a highly effective and inexpensive technique for hypertension screening.

The effects of instructions, incentive, and feedback on a community problem: dormitory noise.

A reinforcement system utilizing instructions, modelling, feedback, and group reinforcement was employed in an attempt to reduce disruptive noise on three university residence halls. A fourth hall received the same treatment program without the reinforcement component. Noise scores were determined by recording the number of discrete noise occurrences over a criterion decibel level. On all four residential floors, noise scores during treatment conditions were lower than initial and final baseline levels. Additionally, periods of noise reduction corresponded to the changing criterion multiple-baseline and reversal designs utilized. Pre- and posttreatment questionnaire responses from the three reinforcement floors paralleled changes in objective noise data. At posttreatment, residents reported less noise disturbance of study and sleep and more control over the noise situation and floor problems in general. These results indicated that a comprehensive behavior-modification treatment package was effective in reducing disruptive noise in university residence halls. Difficulties in data collection and anomalies in the data are discussed. Future directions for field-based behavior-modification research are outlined.