Men's perceptions of HIV self-testing in Eswatini: a qualitative study.

Men in Eswatini test for HIV at lower rates compared to women despite the widespread availability of HIV testing services in the country. HIV self-test kits have been proposed as an HIV testing model to reach more men by bypassing the health facility, which is known to be a barrier for men using HIV testing services. In this study, we sought to understand men's perspectives on HIV self-testing in Eswatini. We conducted semi-structured interviews with 22 men, recruited from a rural community and from an urban men's clinic, to assess their awareness of HIV self-testing and their perceptions of it as an alternative HIV testing option. Findings show that men were aware of HIV self-testing but had concerns that left most feeling hesitant about adopting it. Many men expressed doubts about the accuracy of self-testing and their own technical competence to use the kit without supervision. They also expressed fears about testing, and possibly learning they were HIV positive, without adequate pre - and post-HIV test counseling. To allay men's fears and improve uptake of HIV self-testing, practitioners might consider innovative methods such as virtual counseling services and linking HIV self-testing to other community-based HIV care services.

Changes in contraceptive method mix following the Colorado Family Planning Initiative.

OBJECTIVES: To describe the changes in contraceptive method use and mix among Colorado Title X clients following the 2009 Colorado Family Planning Initiative (CFPI), which allowed Colorado Title X providers to offer all contraceptive methods without medically unnecessary barriers. STUDY DESIGN: Using data on all visits to Colorado Title X clinics between 2007 and 2016 for women aged 10-49 years, we described trends in contraceptive method use by age group and race/ethnicity prior to and following the implementation of CFPI. RESULTS: The implementation of CFPI saw an abrupt increase in Title X visits. Visits subsequently declined steeply for non-Hispanic White clients while visits by Hispanic clients remained at elevated levels. During CFPI, the use of long-acting reversible contraceptives increased while the use of oral contraceptive pills decreased. Nonetheless, oral contraceptive pills remained the most common method used by Title X clients throughout the study period. Changes in the method mix varied by age and race/ethnicity. Method switching was relatively uncommon among established Title X clinic users. CONCLUSIONS: CFPI, which removed financial barriers to the most expensive methods, was associated with increases in the use of long-acting reversible contraceptives and changes in method mix that varied by age group and race/ethnicity. IMPLICATIONS: CFPI removed barriers to previously inaccessible methods that contributed to changes in the method mix at Title X clinics. That these changes were not uniform across ages and race/ethnicities emphasize that subgroup variation in family planning policy impact stems from heterogeneity in barriers to care and method-specific unmet demand.

U.S. Fertility in Life Course Context: A Research Note on Using Census-Held Linked Administrative Records for Geographic and Sociodemographic Subgroup Estimation.

Fertility is a life course process that is strongly shaped by geographic and sociodemographic subgroup contexts. In the United States, scholars face a choice: they can situate fertility in a life course perspective using panel data, which is typically representative only at the national level; or they can attend to subnational contexts using rate schedules, which do not include information on life course statuses. The method and data source we introduce here, Census-Held Linked Administrative Records for Fertility Estimation (CLAR-FE), permits both. It derives fertility histories and rate schedules from U.S. Census Bureau-held data for the nation and by state, racial and ethnic subgroups, and the important life course status of parity. We generate three types of rates for 2000-2020 at the national and state levels by race and ethnicity: age-specific rates and both unconditional and conditional parity- and age-specific rates. Where possible, we compare these rates with those produced by the National Center for Health Statistics. Our new rate schedules illuminate state and racial and ethnic differences in transitions to parenthood, providing evidence of the important subgroup heterogeneity that characterizes the United States. CLAR-FE covers nearly the entire U.S. population and is available to researchers on approved projects through the Census Bureau's Federal Statistical Research Data Centers.

A partner-specific critique of mistimed and unwanted fertility: Results from an analysis of the 2017-2019 United States National Survey of Family Growth.

CONTEXT: Despite substantial critiques of retrospective measures of fertility intentions, researchers widely use the metrics of unwanted and mistimed pregnancies as tools for monitoring patterns and trends in reproductive health. However, in focusing exclusively on the timing and numeric elements of fertility these constructs ignore partner-specific desires, which may lead to considerable measurement error and threaten their validity. METHODOLOGY: We use data on births in the last 5 years from the 2017-2019 United States National Survey of Family Growth to compare responses to the standard retrospective measure of fertility intentions with responses to a partner-specific question that asks respondents about whether they had ever desired a child with that partner. RESULTS: We find that women's responses to questions on retrospective fertility desires with and without reference to a particular partner vary in ways that suggest that women and researchers interpret these questions differently. DISCUSSION: Despite a long history in fertility research, the standard approach to measuring mistimed and unwanted fertility is both conceptually and operationally flawed. In the context of complicated sexual and reproductive lives that do not start and end with a single partner, researchers should reevaluate the usefulness of the constructs of mistimed and unwanted fertility. We conclude by offering recommendations for analysts and survey designers as well as by calling for a move away from the terms entirely to focus instead on the pregnancies that women themselves view as most problematic.

Men's Endorsement of Intimate Partner Violence and HIV Testing Behavior Across Sub-Saharan Africa.

Despite an upward trend in HIV testing across sub-Saharan Africa, men continue to lag women in the use of HIV testing services. Inequitable gender attitudes held by some men may be implicated in their suboptimal HIV testing behaviors. We sought to ascertain the relationship between men?s endorsement of intimate partner violence (IPV), which is one manifestation of inequitable gender attitudes, and their lifetime and recent HIV testing, using nationally representative Demographic and Health Survey data from 23 sub-Saharan African countries. In a pooled analysis, we found that a unit increase in the IPV index scale is associated with 8% lower odds of lifetime HIV testing, and 6% lower odds of recent HIV testing. The strength of this relationship, however, varied across countries and regions. Our findings suggest that efforts to increase men?s HIV testing in the region should address the inequitable gender attitudes underpinning men?s endorsement of IPV, but that it is important to consider contextual variation.

Expanded Contraceptive Access Linked To Increase In College Completion Among Women In Colorado.

Public subsidies for contraception are often justified by assertions regarding their benefits for women's lives, yet there is limited contemporary evidence supporting these assertions. Beginning in 2009 the Colorado Family Planning Initiative abruptly expanded access to the full range of contraceptive methods through Colorado's Title X family planning clinics. Using eleven years of American Community Survey data linked to data from two decennial censuses, we assessed whether exposure to the program led to improvements in college completion among women. Exposure to the Colorado Family Planning Initiative at high school ages was associated with a population-level increase of 1.8-3.5 percentage points in women's on-time bachelor's degree attainment, which represents a 6-12 percent increase in women obtaining their degrees compared with earlier cohorts. Federal and state policies restricting or expanding access to the full range of contraceptive methods can affect women's attainment of higher education in addition to their reproductive health.

Women's Life Experiences and Shifting Reports of Pregnancy Planning.

BACKGROUND: Unplanned pregnancy is associated with adverse consequences for women. Yet, these associations are typically based on women's reports of pregnancy planning provided post birth. Therefore, women's recollection of their pregnancy planning may be influenced by their adverse life circumstances following the pregnancy, artificially driving these associations. METHODS: To understand how post-birth experiences pattern women's recall of their pregnancy planning, we conducted 17 in-depth interviews with young women (24-34 years old) enrolled in a longitudinal study in southern Malawi. Respondents who were pregnant at the time of data collection in 2015 answered close-ended questions about the planning of their pregnancy. During in-depth interviews three years later, women discussed their life experiences since the pregnancy and were re-asked a subset of the same questions about the planning of the 2015 pregnancy. We thematically coded respondents' narratives about their relationships, parenting, and economic situations in the three years following their pregnancy and mapped these onto changes in women's pre- and post-birth reports of their pregnancy planning. RESULTS: More than one-half of respondents recalled their pregnancy planning differently than they did pre-birth-some as more planned, others as less planned. The presence and direction of women's changing reports were patterned by the quality of their relationship with the child's father, the father's involvement as a partner and parent, and their economic situation. CONCLUSIONS: Women's life experiences following a birth correspond with changes in their pregnancy planning reports, emphasizing the limitations of using retrospective measures to study the consequences of unplanned fertility.

Life After Loss: A Prospective Analysis of Mortality Exposure and Unintended Fertility.

The relationship between mortality and fertility is a key component of demographic transition theory, placing it at the center of extensive inquiry. Among other linkages, mortality in women's communities and social networks influences their subsequent fertility. Existing demographic research assumes this is principally due to volitional mechanisms, implying that exposure to mortality consolidates women's desire to become pregnant, leading to intended fertility. Yet, insights from other disciplines suggest that mortality exposure could also increase women's unintended fertility through psychological, relational, and behavioral mechanisms. This study examines the relationships between network mortality exposure and women's hazard of pregnancy, and of unintended pregnancy specifically. We analyze two years (2009-2011) of closely spaced panel data on young Malawian women (N=1,272) enrolled in the Tsogolo la Thanzi study. Our data include information on funeral attendance and fertility desires measured weeks before conception, which is confirmed through frequent pregnancy testing. Hazard models show that the number of funerals women attend corresponds with a higher hazard of pregnancy and of unintended pregnancy specifically. These findings make clear that mortality exposure can influence fertility not by shaping women's desires but by disrupting the realization of those desires.

Contraceptive Access Through School-Based Health Centers: Perceptions of Rural and Suburban Young People.

PURPOSE: School-based health centers (SBHCs) have traditionally been concentrated in urban centers but have increasingly moved to rural and suburban settings. Adolescents living outside urban centers continue to experience barriers accessing contraceptives and reproductive health care. SBHCs are well positioned to reduce these barriers since they often offer convenient, in-school reproductive health care services. We describe the experiences of adolescents and emerging adults as they navigate access to contraceptives at SBHCs and nonschool locations in nonurban, low-income communities. METHOD: We interviewed 30 sexually active individuals aged 15 to 21 living in rural and suburban communities in Colorado where high school SBHCs were recently introduced. Participants reflected on their experiences with or without in-school access to sexual and reproductive health services. RESULTS: Overall, young people supported within-school access to contraceptives, citing convenience, low cost, and greater confidentiality and privacy compared with out-of-school providers, particularly in rural areas. At the same time, findings point to the need for SBHCs to overcome adolescents' and emerging adults' misunderstanding of age requirements to access confidential contraceptive services and their remaining concerns around confidentiality in the school setting. CONCLUSIONS: Our results indicate that SBHCs in low-income rural and suburban areas provide essential contraceptive services that young people access and value. Policy makers in nonurban communities should look to the SBHC model to reduce barriers for young people accessing reproductive health care, and health care providers should work to ensure confidentiality and to correct misinformation about their right to access contraceptive services.

The impact of contraceptive access on high school graduation.

Does access to the full range of contraceptive methods increase young women's educational attainment? Family planning programs are often justified by claims that it does, but contemporary evidence is unexpectedly weak. We use a natural experiment afforded by a 2009 Colorado policy change to assess the impact of expanded access to contraception on women's high school graduation. Linking survey and Census data, we follow a population-representative U.S. sample, including large subsamples of young women living in Colorado in 2010 and in comparison states. Using a difference-in-differences design, we find expansion of access to contraception was associated with a statistically significant 1.66 percentage-point increase in high school graduation. This increase in graduation represents a 14% decrease in the baseline percentage not graduating high school before the policy change. Results are robust to a variety of sensitivity tests. Our findings indicate that improving access to contraception increases young women's human capital formation.

Women's Health Decline Following (Some) Unintended Births: A Prospective Study.

BACKGROUND: As many as one-in-three unintended births occur in Africa. These births have the potential to adversely impact women's health, but data and design limitations have complicated efforts to understand their consequences. Moreover, there is growing evidence that women often feel happy about an unintended pregnancy and this heterogeneity may be important for identifying the births that are - and those that are not - harmful to women's health. OBJECTIVE: To assess whether having an unintended birth precipitates health declines for young women in a high-fertility, high-morbidity context, and whether women's emotional reaction to the pregnancy foreshadows the consequences of the resulting birth. METHODS: We use closely spaced panel data from 896 young women in Malawi that include prospective measures of fertility timing desires captured only months before conception and a contemporaneous measure of emotional reaction to the pregnancy. We run lagged dependent variable regression models of self-rated health that account for health and sociodemographic conditions prior to pregnancy and compare women with unintended births to women with intended births and to an alternative comparison group: women who avoid an unintended birth. We then disaggregate unintended births by women's emotional reaction after learning of the pregnancy. RESULTS: Women who had an unintended birth but initially had a positive reaction to the pregnancy did not experience a decline in health after birth. Women who had a more negative reaction, however, experienced marked reductions in self-rated health, even years after the birth. CONTRIBUTION: Our findings highlight meaningful heterogeneity in the consequences of unintended fertility for women's health and offer insights into the unintended births that put women at greatest risk of health decline.

The Enduring Case for Fertility Desires.

Persistently high levels of unintended fertility, combined with evidence that over- and underachieved fertility are typical and not exceptional, have prompted researchers to question the utility of fertility desires writ large. In this study, we elaborate this paradox: widespread unintendedness and meaningful, highly predictive fertility desires can and do coexist. Using data from Malawi, we demonstrate the predictive validity of numeric fertility timing desires over both four-month and one-year periods. We find that fertility timing desires are highly predictive of pregnancy and that they follow a gradient wherein the likelihood of pregnancy decreases in correspondence with desired time to next birth. This finding holds despite the simultaneous observation of high levels of unintended pregnancy in our sample. Discordance between desires and behaviors reflects constraints to achieving one's fertility and the fluidity of desires but not their irrelevance. Fertility desires remain an essential-if sometimes blunt-tool in the demographers' toolkit.

Gendered health institutions: examining the organization of health services and men's use of HIV testing in Malawi.

INTRODUCTION: Men in sub-Saharan Africa are less likely to use HIV testing services than their female counterparts. Norms of masculinity are frequently cited as the main barrier to men's use of HIV testing services, but very little is known about how health institutions are organized to facilitate or impede men's care. We examined the organization of health institutions in Malawi, and implications for men's use of HIV testing services. METHODS: A mixed methods ethnography was conducted in Malawi between October 2013 and September 2014. National Ministry of Health guidelines from 2012 to 2014 were analysed, counting the frequency of recommended preventative services by sex. In-depth interviews were conducted with 18 healthcare workers and 11 national key informants (29 total). Five rural health facilities participated in direct observation and 52 observational journals were completed to document the structure and implementation of HIV services within local facilities. All data were analysed using the theory of gendered organization. Findings were grouped into one of the three theoretical levels of organization: (1) organizational policy; (2) organizational practice; and (3) structure of gendered expectations. RESULTS: Health institutions were gendered across three levels. Organizational policy: National guidelines omitted young and adult men's health during reproductive years (176-433 recommended visits for women vs. 32 visits for men). Health education strategies focused on reproductive and child health services, with little education strategies targeting men. Organizational practice: HIV testing was primarily offered during reproductive and child health services and located near female-focused departments within health facilities. As these departments were women's spaces, others could easily tell that men were using HIV services. Structure of gendered expectations: Clients who successfully accessed HIV testing services were perceived as exemplifying characteristics that were traditionally considered feminine: compliance (obeying instructions without explanation); deference (respecting providers regardless of provider behaviour); and patience ("waiting like a woman"). CONCLUSIONS: Health institutions in Malawi were organized in ways that created substantial, multilevel barriers to men's HIV testing and reinforced perceptions of absent, difficult men. Future research should prioritize a gendered organization framework to understand and address the complex realities of men's constrained access to HIV services.

The Influence of School-Based Health Center Access on High School Graduation: Evidence From Colorado.

PURPOSE: To examine the association between the introduction of a school-based health center (SBHC) and high school graduation rates. METHODS: We use school-level longitudinal data from Colorado that combines data on the opening of SBHCs in high schools with 4-year high school graduation rates overall and by gender between 2000 and 2018. The analytic sample consists of high schools without an SBHC in 2000 (n = 132). We compare high schools that opened SBHCs over the period to those that did not and run school-level panel fixed effects models to assess the relationship between opening an SBHC and change in high school graduation rates. RESULTS: Schools that subsequently opened SBHCs had larger minority populations and lower average graduation rates in 2000. Opening an SBHC was associated with a 4.1 percentage point increase in the overall graduation rate (p = .077). The gender-stratified analyses indicate young men's graduation rates were most sensitive to the presence of an SBHC, increasing 4.8 percentage points (p = .051), compared to young women's graduation rates increasing 3.0 percentage points (p = .163). CONCLUSIONS: Our findings suggest that the benefits of SBHC access may extend beyond health-specific outcomes to graduation rates.

Perceived Infertility Among Young Adults in Balaka, Malawi.

CONTEXT: Perceived infertility-an individual's belief that she or he is unable to conceive or impregnate a partner-may lead to contraceptive nonuse and unintended pregnancy, among other concerns, but has not been widely studied in low-income settings. METHODS: A measure of perceived infertility previously used in the United States was included in a 2015 survey of young adults in Balaka, Malawi. The prevalence of potential perceived infertility (i.e., believing it is a little or substantially likely that one is infertile, or would have difficulty getting pregnant or impregnating a partner; PPI) was estimated among the analytic sample of 1,064 women and 527 men aged 21-29. Multivariable logistic regression was used to identify variables associated with PPI; respondents' reasons for PPI and their estimates of the probability of pregnancy after unprotected sex were also investigated. RESULTS: The prevalence of PPI was 8% overall, and 20% among nulliparous women. Factors associated with PPI and reasons for PPI varied by gender. For women, PPI was significantly associated with age, education, an interaction term between age and education, number of sexual partners, feelings if she were to become pregnant next month, parity and contraceptive use. For men, PPI was associated with an interaction term between age and education, number of sex partners and marital status. Respondents tended to overestimate the probability of pregnancy after unprotected sex. CONCLUSIONS: Perceived infertility was lower in Malawi than in the United States, although substantial among certain subgroups. Educational interventions aimed at increasing knowledge about pregnancy probabilities and the return of fertility after contraceptive discontinuation may reduce concerns around perceived infertility.

RESUMEN Contexto: La infecundidad percibida ­ la creencia de una persona de que ella o él no puede concebir o embarazar a una pareja ­ podría conducir a la falta de uso de anticonceptivos y al embarazo no planeado, entre otras preocupaciones, pero esto no se ha estudiado ampliamente en entornos de bajos ingresos. Métodos: Una medida de la infecundidad percibida utilizada anteriormente en los Estados Unidos se incluyó en una encuesta de 2015 aplicada a adultos jóvenes en Balaka, Malawi. La prevalencia de infecundidad potencial percibida (es decir, creer que es poco o muy probable que una persona es infecunda, o que tendría dificultades para quedar embarazada o para embarazar a una pareja; IPP) se estimó entre la muestra analítica de 1,064 mujeres y 527 hombres de 21 a 29 años de edad. Se usó regresión logística multivariable para identificar variables asociadas con la IPP; también se investigaron las razones de las personas encuestadas para experimentar IPP y sus estimaciones de la probabilidad de embarazo después de tener relaciones sexuales sin protección. Resultados: La prevalencia de IPP fue del 8% en general y del 20% entre mujeres nulíparas. Los factores asociados con la IPP y las razones para experimentar IPP variaron según el género. Para las mujeres, la IPP se asoció significativamente con la edad, la escolaridad, un período de interacción entre la edad y la escolaridad, el número de parejas sexuales, los sentimientos si quedara embarazada el próximo mes, la paridad y el uso de anticonceptivos. Para los hombres, la IPP se asoció con un período de interacción entre edad y escolaridad, número de parejas sexuales y estado conyugal. Las personas encuestadas tendieron a sobreestimar la probabilidad de embarazo después de tener relaciones sexuales sin protección. Conclusiones: La infecundidad percibida fue menor en Malawi que en los Estados Unidos, aunque fue sustancial entre ciertos subgrupos. Las intervenciones educativas destinadas a aumentar el conocimiento sobre las probabilidades de embarazo y el retorno de la fecundidad después de la interrupción de los anticonceptivos pueden reducir las preocupaciones sobre la infecundidad percibida.

RÉSUMÉ Contexte: L'infertilité perçue ­ le fait de croire, pour une personne, qu'elle ne peut pas concevoir ou causer une grossesse ­ peut conduire, entre autres préoccupations, à l'absence de contraception et à la grossesse non planifiée, sans toutefois avoir été largement étudiée dans les contextes à faible revenu. Méthodes: Une mesure de l'infertilité perçue utilisée précédemment aux États-Unis a été incluse dans une enquête menée en 2015 auprès de jeunes adultes de Balaka (Malawi). La prévalence d'une éventuelle infertilité perçue (c'est-à-dire croire qu'il est légèrement ou fortement probable qu'on soit infertile, ou qu'on aurait des difficultés à concevoir ou à causer la grossesse d'une partenaire; IPP) a été estimée dans l'échantillon analytique de l'étude, composé de 1 064 femmes et de 527 hommes âgés de 21 à 29 ans. Les variables associées à l'IPP ont été identifiées par régression logistique multivariable. Les raisons d'IPP données par les répondants et leurs estimations de la probabilité d'une grossesse après un rapport sexuel non protégé ont aussi été étudiées. Résultats: La prévalence de l'IPP était de 8% au total, et de 20% parmi les femmes nullipares. Les facteurs associés à l'IPP et les raisons de l'IPP variaient suivant le sexe. Pour les femmes, l'IPP était significativement associée à l'âge, à l'éducation, à un terme d'interaction entre l'âge et l'éducation, au nombre de partenaires sexuels, aux sentiments que susciterait la découverte d'une grossesse le mois suivant, à la parité et à la pratique contraceptive. Pour les hommes, l'IPP était associée à un terme d'interaction entre l'âge et l'éducation, au nombre de partenaires sexuelles et à la situation matrimoniale. Les répondants tendaient à surestimer la probabilité d'une grossesse après un rapport sexuel non protégé. Conclusions: L'infertilité perçue s'est révélée inférieure au Malawi, par rapport aux États-Unis, bien qu'elle soit apparue considérable dans certains sous-groupes. Les interventions éducatives visant à accroître les connaissances sur les probabilités de grossesse et le retour à la fertilité après l'arrêt de la contraception peuvent réduire les préoccupations concernant l'infertilité perçue.

Unrealized Educational Expectations and Mental Health: Evidence from a Low-Income Country.

The rapid expansion of schooling across low-income countries, combined with intensive governmental and nongovernmental efforts to promote education, has encouraged youth in these contexts to form exceptionally high educational expectations, despite immense structural barriers to achieving them. Consequently, many young people's educational expectations go unmet, driving concerns over the possible unintended consequences, including their elevated risk of mental health problems. At the same time, role transitions (e.g., marriage, parenthood) remain important elements of the transition to adulthood in many low-income countries, and may be a source of resilience-allowing youth to shift their identity away from education towards a new role. In this study, we explore the mental health implications of young women's unmet educational expectations, and the possible buffering impact of motherhood, in a low-income community in Malawi, in southeast Africa. Analyses of six years of longitudinal data show that young women's unmet expectations to continue school are associated with multiple indicators of mental health disadvantage across two points in time. In the short term, however, this is only true of young women who did not enter motherhood in the midst of their educational plans going unrealized: young women who became mothers-and thus achieved a key element of the transition to adulthood in this setting-experience fewer mental health disadvantages. The findings demonstrate the potential mental health consequences of young adults' expectations exceeding their outcomes while also highlighting a source of resilience.

Changing Childbearing Norms During an Era of ART Expansion in Malawi, 2009 to 2015.

Community norms shape the childbearing goals and behaviors of persons living with HIV/AIDS (PLWHA) but little is known about how norms around HIV-positive childbearing have changed with expanded access to antiretroviral treatment (ART). We analyze data collected in 2009 and 2015 by the Tsogolo la Thanzi (TLT) project-a longitudinal, population-based study of young adults in southern Malawi. Respondents were asked about the acceptability of childbearing using vignettes that varied a hypothetical couple's HIV status and number of children. We assess mean differences in support for childbearing over time and by respondent gender and serostatus. The acceptability of childbearing for PLWHA increased dramatically over the 6-year period; however, support levels varied based on a couple's current number of children and whether they were seropositive concordant or discordant. Differences in attitudes by gender and HIV status diminished over time, pointing to a population-level convergence in norms about acceptable childbearing.

Evaluating Sampling Biases from Third-party Reporting as a Method for Improving Survey Measures of Sensitive Behaviors.

Survey participants often misreport their sensitive behaviors (e.g., smoking, drinking, having sex) during interviews. Several studies have suggested that asking respondents to report the sensitive behaviors of their friends or confidants, rather than their own, might help address this problem. This is so because the "third-party reporting" (TPR) approach creates a surrogate sample of alters that may be less subject to social desirability biases. However, estimates of the prevalence of sensitive behaviors based on TPR assume that the surrogate sample of friends is representative of the population of interest. We used sociometric data on social networks in Likoma, Malawi to examine this assumption. Specifically, we use friendship network data to investigate whether friends have similar socio-economic characteristics as index respondents, and to measure possible correlations between the likelihood of inclusion in the surrogate sample and sensitive behaviors. From these results, we suggest approaches to strengthen estimates of the prevalence of sensitive behaviors obtained from TPR.

Tsogolo la Thanzi: A Longitudinal Study of Young Adults Living in Malawi's HIV Epidemic.

Tsogolo la Thanzi (TLT) was designed to study how young adults navigate sexual relationships and childbearing during a generalized HIV epidemic. TLT began in 2009 with a population-representative sample of 1,505 women and 574 men between the ages of 15 and 25 living in Balaka, southern Malawi, where regional adult HIV prevalence then stood at 15 percent. The first phase (2009-11) included a series of eight interviews, spaced four months apart. During this time, women's romantic and sexual partners enrolled in the study on an ongoing basis. A refresher sample of 315 women was added in 2012. Seventy-eight percent of respondents were re-interviewed in the second phase of TLT (2015), which consisted of follow-up interviews approximately 3.5 years after the previous interview (ages 21-31). At each wave, detailed information about fertility intentions and behaviors, relationships, sexual behavior, health, and a range of sociodemographic and economic traits was gathered by means of face-to-face surveys. Biomarkers for HIV and pregnancy were also collected. Distinguishing features include: a population-representative sample, closely spaced data collection, dyadic data on couples over time, and an experimental approach to HIV testing and counseling. Data are available through restricted data-user agreements managed by Data Sharing for Demographic Research (DSDR) at the University of Michigan.

Data Collection as Disruption: Insights from a Longitudinal Study of Young Adulthood.

Research disrupts the social world, often by making respondents aware that they are being observed or by instigating reflection upon particular aspects of life via the very act of asking questions. Building on insights from the first Hawthorne studies, reflexive ethnographers, and methodologists concerned with panel conditioning, we draw on six years of research within a community in southern Malawi to introduce a conceptual framework for theorizing disruption in observational research. We present a series of poignant-yet-typical tales from the field and two additional tools-the refresher-sample-as-comparison and study-focused ethnography-for measuring disruption empirically in a longitudinal study. We find evidence of study effects in many domains of life that relate directly to our scope of inquiry (i.e., union formation, fertility) and in some that extend beyond it (i.e., health). Moreover, some study effects were already known and discussed in the broader community, which was also affected by our research in unintended ways. We conclude that the assumption of non-interactivity in observational research is shaky at best, urging data-gatherers and users to think more seriously about the role of disruption in their work.