Contraception coverage and methods used among women in South Africa: A national household survey.

BACKGROUND: Globally, family planning services are being strengthened and the range of contraceptive choices expanded. Data on contraceptive coverage and service gaps could help to shape these initiatives. OBJECTIVE: To assess contraception coverage in South Africa (SA) and identify underserved populations and aspects of programming that require strengthening. METHODS: Data from a 2012 SA household survey assessed contraception coverage among 6 296 women aged 15 - 49 years and identified underserved populations. RESULTS: Two-thirds had an unintended pregnancy in the past 5 years, a quarter of which were contraceptive failures. Most knew of injectable (92.0%) and oral contraception (89.9%), but fewer of intrauterine devices (56.1%) and emergency contraception (47.3%). Contraceptive prevalence was 49.1%, and 41.8% women used modern non-barrier methods. About half had ever used injectable contraception. Contraception was lower in black Africans and younger women, who used a limited range of methods. CONCLUSION: Contraception coverage is higher than many previous estimates. Rates of unintended pregnancy, contraceptive failure and knowledge gaps, however, demonstrate high levels of unmet need, especially among black Africans and young women.

Longitudinal predictors of depressive symptoms among low income injection drug users.

Effects of changes in physical health status and drug use, and prior social support on depressive symptoms were assessed in low income injection drug users. Data are from participants (n = 503) enrolled at baseline (1994-1995) who remained at one-year follow-up (79%), of whom 37% were HIV-positive and 36% female. Physical health was measured by HIV symptoms, AIDS, CD4 count and functional limitation (IADLs). One-third scored high on depressive symptoms (CES-D > or = 16) at one-year follow-up, representing no statistically significant change from baseline (38%). In multiple logistic regression, after controlling for baseline depression scores (OR = 6.11, p < 0.001) and drug use (OR = 1.20, p = 0.192), baseline functional limitation (OR = 3.28, p < 0.001) and declining functioning (OR = 3.60, p < 0.001) were positively, and quitting drug use was negatively, associated with depressive symptoms at follow-up. Low social support at baseline (OR = 0.58, p < 0.10) was marginally predictive of depressive symptoms. Depressive symptoms did not differ by gender. For HIV-positive respondents, functional limitation was predictive of depressive symptoms, but HIV illness and drug use were not. Facilitating drug treatment and preventive medical care may aid in reducing depression in this population. For HIV-positive drug users, drug treatment prior to AIDS may help reduce depressive symptoms, with potential implications for HIV service utilization and medical adherence.

Children of injection drug users: impact of parental HIV status, AIDS, and depression.

We investigated the association between parental factors (including infection with human immunodeficiency virus [HIV], acquired immunodeficiency syndrome [AIDS] diagnosis, parental medical illness, and depression) and children's behavioral and emotional problems among children of injection drug users (IDUs). IDUs were recruited through community outreach. The sample included 73 parents of 73 children, aged 4 to 12 years. Parental depression (odds ratio [OR] = 4.61) and medical illness (OR = 4.70) were found to be significantly associated with internalizing (depressive and anxiety-related symptoms), but not with externalizing (aggressive and disruptive behaviors) symptoms in the children of IDUs. The clinical implications are that children of IDUs are known to be at high risk for psychiatric symptoms and disorders; these data suggest that children of depressed and/or medically ill IDU parents may be at even higher risk of internalizing symptoms (depression and anxiety symptoms) than children of IDUs who do not suffer from these conditions.

Characteristics of injection drug using parents who retain their children.

While it is known that injection drug users (IDUs) often have their children removed or place them voluntarily, little is known about factors associated with whether IDU parents live with their children. We identified a community sample of 391 IDU parents with at least one child under age 14 (index IDU parents). For these IDU parents, 62% did not have any of their children under age 14 living with them. We assessed whether certain health factors, risk related behaviors, social indicators, and active drug use were related to whether children of IDUs were living with the index IDU parent. IDU parents who were living with their children were overwhelmingly more likely to be female, more likely to have health insurance, and engage in no-risk or low-risk drug practices, as compared to moderate/high-risk practices. Additionally, HIV negative and HIV positive asymptomatic parents were about three times more likely to be living with their children than HIV positive parents with clinical symptoms commonly seen among those suffering from HIV-related illnesses. HIV-related clinical symptoms, rather than HIV status per se, seem to be associated with retention of children.

Correlates of condom use stage of change: implications for intervention.

A telephone survey was used to collect data on attitudes, beliefs, and practices concerning condom use among 812 African Americans with regular sex partners and of reproductive age in Baltimore. Condom use was "staged" according to Prochaska's model of stage of behavioral change. Characteristics of the respondents' sexual relationships, peer characteristics, and demographic and psychosocial characteristics were examined for their association with the stage of condom use. Multiple logistic regression analysis revealed that a partner's reaction to condom use, condom use self-efficacy with the partner, condom use outcome expectancy with the partner, perceived partner risk, length of relationship, sterility, cohabitation, perceived vulnerability to HIV infection and perceived peer norms about condom use were each independently related to staged condom use. Gender differences in the relationship of these independent variables with stages of change were found. Implications for intervention include differential treatment by gender and stage of change. Couples should also be considered for intervention.

PIP: According to 1996 US Centers for Disease Control data, HIV/AIDS has become the second and third leading cause of death for Black and Hispanic women, respectively, in the US aged 25-44 years. The main risks for infection among minority women are IV drug use and sexual contact with IV drug users. Findings are presented from a telephone survey conducted to collect data on the attitudes, beliefs, and practices concerning condom use among 812 reproductive-age African Americans with regular sex partners in Baltimore. Condom use was "staged" according to Prochaska's model of stage of behavioral change, while characteristics of the respondents' sexual relationships, peer characteristics, and demographic and psychosocial characteristics were examined for their association with the stage of condom use. Multiple logistic regression analysis found that a partner's reaction to condom use, condom use self-efficacy with the partner, condom use outcome expectancy with the partner, perceived partner risk, length of relationship, sterility, cohabitation, perceived vulnerability to HIV infection, and perceived peer norms about condom use were each independently related to staged condom use. Gender differences in the relationship of those independent variables with stages of change were found. Implications for intervention include differential treatment by gender and stage of change. Couples should also be considered for intervention.

Multiple condom use in commercial sex in Lamphun Province, Thailand: a community-generated STD/HIV prevention strategy.

BACKGROUND AND OBJECTIVE: In an investigation of condom breakage in commercial sex, we found a high proportion of multiple condoms use. This study sought to ascertain the characteristics of brothel-based commercial sex workers (CSWs) and their clients; to identify the decision makers (clients and/or CSWs) active in choosing multiple condom use; and to determine whether there is an implicit hierarchy of condom use negotiation. GOALS: To identify factors associated with multiple condom use in commercial sex and to provide an understanding of how this innovation developed in this setting. STUDY DESIGN: Sixty-seven brothel-based CSWs in Lamphun Province who participated in a study of condom breakage participated in a case-control study of multiple versus single condom use, which determined CSW and client characteristics for evidence of multiple condom use. Interviews and focus groups were used to determine decision making for condom use and the contexts for multiple use. Association between characteristics of CSWs/clients and multiple condom use was analyzed using X2 for trend. RESULTS: No official program encouraged multiple condom use; this appeared to be a community-devised strategy to increase protection from human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). CSWs working in daytime brothels had significantly greater multiple condom use than those working in nighttime brothels; mean percentages + SD of multiple simultaneous use were 57.5% + 28.6 and 35.5% + 22.4, respectively (p < 0.001). Day CSWs were older, had more pregnancies, reported higher frequency of STD symptoms and history of pelvic inflammatory disease, and had more clients per day but had a lower number of sex acts per client than night CSWs. Among factors associated with multiple condoms, only age was significant. The decision to use single or multiple condoms for a sex act was primarily (78.2% in single and 79.3% in multiple) made by the CSW herself. The main reason given for multiple condom use was protection from HIV/STD. CONCLUSIONS: There is high compliance between CSWs in Lamphun province and the Ministry of Public Health-sponsored 100% condom use campaign, and CSWs are attempting to further reduce their risks of HIV/STD exposure by using multiple condoms for sex with their clients.

Stage of behavior change for condom use: the influence of partner type, relationship and pregnancy factors.

A theoretical model was used to examine the influence of relationship factors, pregnancy intentions, contraceptive behavior and other psychosocial characteristics on stages of behavior change in condom use among heterosexual black women of reproductive age. Data from an inner-city street survey compared women who were not contemplating condom use, women who were attempting to use condoms or had used them consistently for short periods of time, and those who had achieved long-term consistent use. Women's relationship with their main partner appears to be an important factor in understanding their use of condoms both with main partners and with other partners. For condom use with the main partner, factors such as emotional closeness and partner support were significant predictors of the likelihood that women would be attempting to use condoms rather than not contemplating use. Cohabitation and the belief that condom use builds trust were significant predictors of long-term consistent condom use. Having a regular or main partner was strongly associated with intentions to use condoms with other partners. Women who wanted to become pregnant were much less likely to intend to use condoms with their main partner, and women using oral contraceptives were less likely to be long-term consistent condom users.

PIP: This study examines the influence of five groups of factors on the stages of change in condom use among Black women in Baltimore, Maryland, in 1993. The stages of change included: precontemplation, contemplation, ready for action, action, and maintenance. Interviews were obtained from women aged 17-35 years in designated neighborhoods. The sample included 625 women equally divided among age groups 17-20 years, 20-24 years, and 25-35 years. 63% of the 625 women had a main sexual partner and 42% had other partners, of which 33% had a main partner and other partners. Most women with main partners were in the precontemplation stage (50%) and most women with other partners were in the maintenance stage (41%). Women with main and other partners were primarily in the maintenance stage (37%). Few were classified as being in the contemplation or action stages. Changes between the precontemplation stage and the middle stage are viewed as "developing intentions." Changes between the middle stage and maintenance stage are viewed as "using consistently." Condom use with a main partner was associated with all five groups of factors: demographic, social, pregnancy intentions, outcome expectations or HIV risk, and efficacy. Having a regular partner who supported condom use significantly increased the odds of developing intentions to use condoms and of using condoms consistently. Friends support of condom use and condom use among friends raised the odds of becoming a consistent condom user. Having two or more partners and having one or more HIV risk factors was positively associated with the likelihood of consistent condom use. The strongest effects on developing intentions to use condoms with a main partner were emotional closeness, partner support for condom use, and women's potential happiness if pregnancy was an outcome. Consistent condom use with a main partner was predicted best by cohabitation with the main partner, use of the pill at the last intercourse, and the belief in condoms as a means of building trust. Prediction among other partners was more difficult.

The cost of a preventable disease: estimated U.S. national medical expenditures for congenital syphilis, 1990.

Reported cases of congenital syphilis have increased rapidly in recent years. The purpose of this study was to estimate first-year medical care expenditures among 1990 incident cases of infants diagnosed with congenital syphilis. The authors used a synthetic estimation model to calculate expenditures for congenital syphilis as the number of treated cases multiplied by cost per case. The number of cases was derived from surveillance data adjusted for underreporting and presumptive (false-positive) treatment. Cost per case was based on expected hospital and physician charges applied to case treatment protocols appropriate to case severity. Base-case estimated first-year medical expenditure for 1990 treated cases (N = 4,400) in 1990 was +12.5 million. In sensitivity analysis, estimates ranged from +6.2 million to +47 million. Substantial reduction in congenital syphilis treatment costs could be achieved through targeted public health interventions consisting of prenatal maternal screening and contact tracing of males testing positive for syphilis. Physicians should be aggressive in presumptive treatment of newborns, since this usually prevents future disability but represents a small portion of total national expenditure for congenital syphilis. More precise data on severe cases resulting in long-term disability are needed to make reliable cost estimates.

Inner-city women at risk for cervical cancer: behavioral and utilization factors related to inadequate screening.

This study investigated the relationships between health care utilization, knowledge, attitudes, sociodemographic characteristics, and adequacy of cervical cancer screening among a random sample of women from inner-city neighborhoods with high rates of cervical cancer mortality. Of 416 women interviewed, 30.3% reported hysterectomies; women with intact uteri (N = 290) are the subjects of this analysis. Over two-fifths (44.1%) reported not receiving adequate Pap testing during the previous 4 years. Compared with adequately screened women, they were more likely to be 45 years or older, have no medical insurance, report never having been to an obstetrician-gynecologist, recall never having been told by a medical provider how often to get a Pap test, rely on providers for adequate screening, report not seeking care as often as they think they should, have less knowledge of risk factors for cervical cancer, and believe that women should get Pap tests less than yearly. Separate models for younger and older women showed that these factors vary by age, demonstrating the need for interventions to be sensitive to age subgroups. These findings suggest that cancer control activities should place more emphasis on motivating women as well as influencing the health care delivery system to maximize reductions in cervical cancer.

Social network structure and prenatal care utilization.

The associations between social network structural characteristics, sociodemographic factors, and prenatal care utilization were examined in a sample of 185 low-income, inner-city, maternity patients. It was predicted that the networks of women who underutilized care would be larger and of higher density than those of women who utilized care appropriately. They were also expected to be less disperse, with members living near one another; less diverse, with members drawn mainly from immediate family and extended kin; and composed primarily of strong relational ties between members. Findings indicated that women were more likely to underutilize care if they were embedded in strong-tie, nondisperse networks where most members were immediate family or relatives. Of the sociodemographic variables, only parity was associated with prenatal care utilization. The findings support the underlying assumption that social networks have a significant influence on individuals' utilization of prenatal services. This suggests that providers of services to pregnant women may need to revise their current strategies for bringing women into care and their methods of delivering educational services to women already in care.

Practice changes in response to the malpractice litigation climate. Results of a Maryland physician survey.

Data from a 1987 survey of Maryland physicians in three specialties (internal medicine, family or general practice, and obstetrics-gynecology) were used to study the types of changes physicians have made in their practices during the last 2 years as a result of the current malpractice litigation climate. Overall, 51% reported making some type of practice change. The practice changes that physicians reported reflect both risk-reduction (e.g., increased use of tests) and risk-avoidance (e.g., cutting back high-risk patients) strategies, although risk-reduction actions were reported more frequently. Raising patient fees was also reported. Specialty predicts whether or not physicians make each type of change; in particular, obstetrician-gynecologists are more likely to report practice changes of all types. Prior litigation experience does not, in general, predict practice changes. The implications of the types of changes reported for access to care and costs of care were considered.

Assessment of cervical cancer screening and follow-up programs.

There is essentially no debate about the benefits of cervical cancer screening. The current debate centers around periodicity, the appropriate interval for repeated testing, and the age at which screening should be discontinued. As the frequency of screening is increased within a defined population, there is a gain in survival (life-years) depending upon the risk status of the population segment screened. However, each increment in survival comes at an increasingly high cost. Significant gains have been made in improving screening and detection services through widespread availability of the Papanicolaou test. However, there has been concern raised that the cost-effectiveness of cervical cancer screening has not been clearly demonstrated. This report analyzes the current status of the literature on screening for cervical cancer with a focus on cost-effectiveness and cost-benefit analyses of screening using the Pap test. A relatively small group of studies was located which directly addressed the cost-effectiveness question. All of the studies cited attempted in some manner to describe the relationship between benefits of cervical cancer screening and costs. Two studies reported a program design with net positive monetary benefits, while one estimated that the direct cost of medical care avoided through screening was approximately equal to the cost of the screening program. In general, however, screening for cervical cancer is viewed as an investment in extending life (a net cost per year of life gained). Most analysts ascribe a net monetary cost to cervical cancer screening programs. Then the question becomes one of cost-effectiveness--designing a program so as to optimize the result obtained. With respect to optimizing screening, the literature leaves no doubt of the value of cervical cancer screening in general. From a cost-effectiveness perspective, screening no more frequently than every 3-5 years appears reasonable. It is important to think in terms of a total program and how effectively the population at risk is being reached. The literature reviewed spans a period of more than twenty years and reflects studies across the globe. While the quality is uneven, from this body of work a consensus emerges: screening is effective, but the frequency of screening in the United States is probably too high. In addition, those who are most intensively screened are probably at the lowest risk. Outreach and targeting of at-risk population groups needs to be addressed in order to improve cost-effectiveness of cervical cancer screening. The effectiveness of the screening technology (the Pap test) is taken for granted, but this may be a mistake.(ABSTRACT TRUNCATED AT 400 WORDS)