Perceptions of Partners' Fertility Preferences and Women's Covert Contraceptive Use in Eight Sub-Saharan African Countries.

Covert use of contraception is a common but underreported and understudied phenomenon where one partner uses contraception without the other's knowledge. We used Demographic and Health Survey couple data to examine the relationship between wives' perceptions of husbands' fertility preferences and type of contraceptive use (overt vs. covert) in Benin, Ethiopia, Kenya, Mali, Nigeria, Sierra Leone, Uganda, and Zambia using logistic regression. Wives who perceived that their husbands wanted more children than them had increased odds of using covertly, compared to those who perceived that husbands wanted the same number of children in all countries except Benin, and the strength of the relationships ranged from adjusted odds ratio (aOR) 2.89 (95 percent confidence interval (CI) 1.75-4.76) in Zambia to aOR 4.01 (95 percent CI 1.68-9.58) in Mali. Wives who reported not knowing their husbands' fertility preferences had increased odds of using covertly compared to wives who perceived that their husbands wanted the same number of children in all countries except Zambia, ranging from aOR 2.02 (95 percent CI 1.11-3.69) in Ethiopia to aOR 3.82 (95 percent CI 2.29-6.37) in Kenya. Our findings indicate that efforts to increase partner engagement to align couple's fertility preferences may encourage overt use.

Family Planning Beliefs and Their Association with Contraceptive Use Dynamics: Results from a Longitudinal Study in Uganda.

Norms and beliefs toward contraception, both positive and negative, motivate contraceptive use; however, they have seldom been explored longitudinally in low- and middle-income countries, limiting our understanding of their influence on contraceptive dynamics. We used PMA2020 Uganda national longitudinal data of reproductive aged women in 2018 (baseline) and 2019 (follow-up) to explore discontinuation and switching among modern contraceptive users at baseline (n = 688) and contraceptive use at follow-up among nonusers at baseline (n = 1,377). Multivariable simple and multinomial logistic regressions assessed the association of individual and community-level contraceptive beliefs with contraceptive uptake, discontinuation and switching. One-quarter of nonusers at baseline were using contraception at follow-up, while 37 percent of users at baseline had discontinued and 28 percent had switched methods at follow-up. The odds of contraceptive uptake were lower among women who strongly agreed that contraception impacted future fertility or caused conflict within a couple, relative to those who strongly disagreed (adjusted odds ratio (aOR): 0.7 and aOR: 0.6, respectively), but higher among women who strongly agreed that contraception preserved beauty (aOR: 1.6). Women who strongly agreed that it was acceptable to use contraception before having children were less likely to discontinue their method than those who strongly disagreed (adjusted relative risk ratio (aRRR): 0.5), though living in a community where more women agreed with this statement was associated with higher discontinuation (aRRR: 6.0). Family planning programs that promote positive beliefs toward family planning could improve contraceptive uptake and continuation. More research is needed to understand how contraceptive beliefs shape contraceptive decisions across the life course.

A Panel Study of Fertility Preferences and Contraceptive Dynamics in the Presence of Competing Pregnancy Risks in Uganda.

Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.

Association between experience of specific side-effects and contraceptive switching and discontinuation in Uganda: results from a longitudinal study.

BACKGROUND: There is substantial evidence that contraceptive side-effects are a major deterrent to consistent use of contraception but few studies in low- or middle-income countries explore the role of specific side-effects on contraceptive use dynamics. This study used population-based, longitudinal data to explore the effect of specific side-effects on contraceptive continuation, discontinuation, and switching in Uganda. METHODS: Data for this study come from two rounds of survey data collection in Uganda: PMA2020's sixth cross-sectional survey and a follow-up survey conducted 1 year later. The main outcomes of interest were discontinuation and switching among users of hormonal contraceptive methods (implants, injectables and oral pill) and the IUD at baseline (n = 560). Multivariable logistic regressions assessed the association of experiencing specific side-effects (more bleeding, less bleeding, irregular bleeding, increased dryness/reduced libido, and physical discomfort) with discontinuation and switching 1 year later, adjusting for socio-demographic characteristics, type of method, and length of use. We also examined the differential effects of side-effects between discontinuation and switching risks. RESULTS: About 23% of hormonal and IUD contraceptive users reported experiencing side-effects at baseline survey. Overall, discontinuation and switching were higher among injectables and pill users, compared to IUD and implants users. Reporting more bleeding or less bleeding increased the odds of discontinuation and switching by 2.74 (95% CI 1.00-7.51) and 1.86 (1.04-3.34), respectively. There was no significant difference in discontinuation and switching by side-effects. CONCLUSIONS: Greater attention should be paid to understanding the unique contributions of side-effects to contraceptive behavior using population-based data. While about a quarter of women reported experiencing side effects, those who experienced bleeding specific side effects were at higher risk of contraceptive discontinuation and switching. Providing greater individualized care that includes information and counseling about common side-effects, how they may impact daily life, and how tolerable these effects may be is necessary.

Research has shown that experiencing side-effects is related to stopping use of contraception, even when women wish to avoid pregnancy. Most research, however, does not differentiate between distinct side-effects, such as increased bleeding or changes to sexual experience, and instead combined all into "side-effects or health concerns". We used data from 560 women in Uganda, who were interviewed twice, 1 year apart, to see if women who reported different side-effects at the first interview were more likely to stop using contraception or switch to a different contraceptive method than women who did not report experiencing side-effects. We found that increased or decreased menstrual bleeding was associated with a higher odds of contraceptive discontinuation and switching, Contraceptive discontinuation or switching was not different by women's reporting of vaginal dryness/reduced libido or physical discomfort, such as cramping. It is important to understand what side-effects are likely to motivate stopping or switching contraception so that education and counseling can inform women of side-effects they may experience, help them choose the best method based on what side-effects they deem important, and if necessary, aid in switching contraceptive methods.

Paying for Prescription Drugs Around the World: Why Is the U.S. an Outlier?

Issue: Compared with other high-income countries, the United States spends the most per capita on prescription drugs. Goal: To compare drug spending levels and trends in the U.S. and nine other high-income countries ­ Australia, Canada, France, Germany, the Netherlands, Norway, Sweden, Switzerland, and the United Kingdom; consider potential explanations for higher U.S. spending; and explore patients' exposure to pharmaceutical costs. Method: Analysis of health data from the Organisation for Economic Co-operation and Development, the 2016 Commonwealth Fund International Health Policy Survey, and other sources. Findings and Conclusions: Various factors contribute to high per capita drug spending in the U.S. While drug utilization appears to be similar in the U.S. and the nine other countries considered, the prices at which drugs are sold in the U.S. are substantially higher. These price differences appear to at least partly explain current and historical disparities in spending on pharmaceutical drugs. U.S. consumers face particularly high out-of-pocket costs, both because the U.S. has a large uninsured population and because cost-sharing requirements for those with coverage are more burdensome than in other countries. Most Americans support reducing pharmaceutical costs. International experience demonstrates that policies like universal health coverage, insurance benefit design that restricts out-of-pocket spending, and certain price control strategies, like centralized price negotiations, can be effective.

How High-Need Patients Experiences the Health Care System in Nine Countries.

U.S. health care costs are disproportionately concentrated among older adults with multiple chronic conditions or functional limitations--a population often referred to as "high-need" patients. This analysis uses data from the Commonwealth Fund 2014 International Health Policy Survey of Older Adults to investigate health care use, quality, and experiences among high-need patients in nine countries compared with other older adults. High-need patients use a greater amount of health care services and also experience more coordination problems and financial barriers to care compared with other older adults. Disparities are particularly pronounced in the United States. The comparative success of other countries, particularly in reducing financial barriers to care, may be a product of policies that specifically target high-need patients. Similarly focusing on these populations in the U.S. and effectively managing their care may improve their health status while reducing overall costs.

Prevalence and characteristics of covert contraceptive use in the Performance Monitoring for Action multi-country study.

Objectives: A more nuanced understanding of contributors to covert contraceptive use remains critical to protecting covert users and reducing its necessity. This study aimed to examine the overall prevalence of covert use, and sociodemographic characteristics associated with covert vs overt use across multiple geographies in sub-Saharan Africa and Asia. Study Design: Performance Monitoring for Action (PMA) is one of the few nationally representative surveys that measures covert use across socially diverse contexts via a direct question. Utilizing PMA 2019-2020 phase 1 data from Burkina Faso, Côte D'Ivoire, Kenya, Democratic Republic of Congo (DRC; Kinshasa and Kongo Central regions), Uganda, Nigeria (Kano and Lagos), Niger, and Rajasthan, we estimated overall prevalence of covert use. We conducted bivariate analyses and multivariate logistic regressions for 6 sites, comparing the odds of covert use with overt use among users of contraception by sociodemographic characteristics. Results: Covert use ranged from 1% in Rajasthan to 16% in Burkina Faso. Marital status was the only sociodemographic characteristic consistently associated with type of use across sites. Specifically, polygynous marriage (compared to monogamous) increased odds of using covertly, ranging from adjusted odds ratio (aOR) of 1.8 [95% confidence interval (CI) 1.2-2.7] in Burkina Faso to 6.2 [95% CI 2.9-13.3] in Kinshasa. Unmarried women with partners or boyfriends were also more likely to be using covertly compared with their monogamously married counterparts in all sites (aORs ranged from 2.2 [95% CI 1.0-4.7] in Uganda to 4.4 [95% CI 1.7-11.0] in Kinshasa). Conclusion: Understanding factors associated with covert use has programmatic and policy implications for women's reproductive autonomy. Implications: Covert use is a common phenomenon across most sites, representing a small but programmatically important contingent of users. Family planning providers and programs must protect access to and maintain privacy of reproductive services to this population, but should also focus on creating interventions and environments that support overt use.

Measuring experiences and concerns surrounding contraceptive induced side-effects in a nationally representative sample of contraceptive users: Evidence from PMA Ethiopia.

Objective: Our objectives were to assess the prevalence of specific side-effects experienced by current and recent contraceptive users, describe patterns of side-effects that users were concerned about, and share measurement lessons learned. Study design: Data come from the PMA Ethiopia 2019 nationally-representative, cross-sectional survey. Our analytic sample included women who were current (weighted n = 2190; unweighted n = 2020) or recent (past 24 months; weighted n = 627; unweighted n = 622) users of a hormonal method or IUD. We provide descriptive statistics of the percentage of current/recent users who report currently/ever experiencing specific side-effects, not experiencing but being concerned about experiencing specific side-effects, and both currently experiencing and being concerned about experiencing specific side-effects. All analyses are stratified by method type (implant, injectable, pill) to explore variation by method. Results: Among current users, 648/2190 women (30%) reported experiencing any side-effect, while 252/644 (40%) of recent users reported ever experiencing any side-effect. Bleeding changes were reported most frequently and were higher among implant and injectable users. More recent users reported side-effects that were associated with physical discomfort, such as headaches, than current users. About one-third of current and recent users reported being concerned about at least one side-effect that they had not experienced, with about 15% of current and recent users reporting concerns about bleeding changes (307/2190 and 112/627, respectively) and concerns about physical discomfort (334/2019 and 98/627, respectively). Conclusions: While bleeding changes are common, users report a range of side-effects related to physical discomfort underscoring the need for comprehensive counseling. We highlight challenges in measuring side-effects using quantitative tools and pose recommendations for future research and measurement efforts. Implications: : Experiencing and fearing contraceptive-induced menstrual bleeding changes and physical discomfort, particularly headaches, is high among hormonal contraceptive and IUD users in Ethiopia. counseling that addresses an array of side-effects is needed. Additional research is also needed to disentangle the effect of experiencing versus fearing side-effects on contraceptive use.

The role of partner influence in contraceptive adoption, discontinuation, and switching in a nationally representative cohort of Ugandan women.

BACKGROUND: Understanding contraceptive use dynamics is critical to addressing unmet need for contraception. Despite evidence that male partners may influence contraceptive decision-making, few studies have prospectively examined the supportive ways that men influence women's contraceptive use and continuation. OBJECTIVE: This study sought to understand the predictive effect of partner influence, defined as partner's fertility intentions and support for contraception, and discussions about avoiding pregnancy prior to contraceptive use, on contraceptive use dynamics (continuation, discontinuation, switching, adoption) over a one-year period. METHODS: This study uses nationally representative longitudinal data of Ugandan women aged 15-49 collected in 2018-2019 (n = 4,288 women baseline; n = 2,755 women one-year follow-up). Two analytic sub-samples of women in union and in need of contraception at baseline were used (n = 618 contraceptive users at baseline for discontinuation/switching analysis; n = 687 contraceptive non-users at baseline for adoption analysis). Primary dependent variables encompassed contraceptive use dynamics (continuation, discontinuation, switching, and adoption); three independent variables assessed partner influence. For each sub-sample, bivariate associations explored differences in sociodemographic and partner influences by contraceptive dynamics. Multinomial regression models were used to examine discontinuation and switching for contraceptive users at baseline; logistic regression identified predictors of contraceptive adoption among non-users at baseline. RESULTS: Among users at baseline, 26.3% of women switched methods and 31.5% discontinued contraceptive use by follow-up. Multinomial logistic regression, adjusting for women's characteristics, indicated the relative risk of contraceptive discontinuation doubled when women did not discuss pregnancy avoidance with their partner prior to contraceptive use. Partner influence was not related to method switching. Among non-users at baseline, partner support for future contraceptive use was associated with nearly three-fold increased odds of contraceptive adoption. SIGNIFICANCE: These results highlight the potentially supportive role of male partners in contraceptive adoption. Future research is encouraged to elucidate the complex pathways between couple-based decision-making and contraceptive dynamics through further prospective studies.

Older Americans Were Sicker And Faced More Financial Barriers To Health Care Than Counterparts In Other Countries.

High-income countries are grappling with the challenge of caring for aging populations, many of whose members have chronic illnesses and declining capacity to manage activities of daily living. The 2017 Commonwealth Fund International Health Policy Survey of Older Adults in eleven countries showed that US seniors were sicker than their counterparts in other countries and, despite universal coverage under Medicare, faced more financial barriers to health care. The survey's findings also highlight economic hardship and mental health problems that may affect older adults' health, use of care, and outcomes. They show that in some countries, one in five elderly people have unmet needs for social care services-a gap that can undermine health. New to the survey is a focus on the "high-need" elderly (those with multiple chronic conditions or functional limitations), who reported high rates of emergency department use and care coordination failures. Across all eleven countries, many high-need elderly people expressed dissatisfaction with the quality of health care they had received.

In New Survey Of Eleven Countries, US Adults Still Struggle With Access To And Affordability Of Health Care.

Surveys of patients' experiences with health care services can reveal how well a country's health system is meeting the needs of its population. Using data from a 2016 survey conducted in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-we found that US adults reported poor health and well-being and were the most likely to experience material hardship. The United States trailed other countries in making health care affordable and ranked poorly on providing timely access to medical care (except specialist care). In all countries, shortfalls in patient engagement and chronic care management were reported, and at least one in five adults experienced a care coordination problem. Problems were often particularly acute for low-income adults. Overall, the Netherlands performed at the top of the eleven-country range on most measures of access, engagement, and coordination.

Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs.

Industrialized countries face a daunting challenge in providing high-quality care for aging patients with increasingly complex health care needs who will need ongoing chronic care management, community, and social services in addition to episodic acute care. Our international survey of primary care doctors in the United States and nine other countries reveals their concern about how well prepared their practices are to manage the care of patients with complex needs and about their variable experiences in coordinating care and communicating with specialists, hospitals, home care, and social service providers. While electronic information exchange remains a challenge in most countries, a positive finding was the significant increase in the adoption of electronic health records by primary care doctors in the United States and Canada since 2012. Finally, feedback on job-related stress, perceptions of declining quality of care, and administrative burden signal the need to monitor front-line perspectives as health reforms are conceived and implemented.