Mixed-Method Quasi-Experimental Study of Outcomes of a Large-Scale Multilevel Economic and Food Security Intervention on HIV Vulnerability in Rural Malawi.

The objective of the Savings, Agriculture, Governance, and Empowerment for Health (SAGE4Health) study was to evaluate the impact of a large-scale multi-level economic and food security intervention on health outcomes and HIV vulnerability in rural Malawi. The study employed a quasi-experimental non-equivalent control group design to compare intervention participants (n = 598) with people participating in unrelated programs in distinct but similar geographical areas (control, n = 301). We conducted participant interviews at baseline, 18-, and 36-months on HIV vulnerability and related health outcomes, food security, and economic vulnerability. Randomly selected households (n = 1002) were interviewed in the intervention and control areas at baseline and 36 months. Compared to the control group, the intervention led to increased HIV testing (OR 1.90; 95 % CI 1.29-2.78) and HIV case finding (OR = 2.13; 95 % CI 1.07-4.22); decreased food insecurity (OR = 0.74; 95 % CI 0.63-0.87), increased nutritional diversity, and improved economic resilience to shocks. Most effects were sustained over a 3-year period. Further, no significant differences in change were found over the 3-year study period on surveys of randomly selected households in the intervention and control areas. Although there were general trends toward improvement in the study area, only intervention participants' outcomes were significantly better. Results indicate the intervention can improve economic and food security and HIV vulnerability through increased testing and case finding. Leveraging the resources of economic development NGOs to deliver locally-developed programs with scientific funding to conduct controlled evaluations has the potential to accelerate the scientific evidence base for the effects of economic development programs on health.

Women's narratives of living in polygamous marriages: Rural Malawian experience distilled and preserved in poetic constructions.

Polygamy in sub-Saharan Africa has been linked to poverty, infant mortality, and HIV; however, it is unknown how interpersonal dynamics within polygamous households may influence population health outcomes. Findings from this postcolonial feminist study derive from interview data in a larger mixed-methods study in rural Malawi. We used thematic narrative analysis to probe 25 women's stories and applied an arts-based research technique, poetic construction, to present the results. Participants' evocative expressions, distilled and preserved in poetic form, illustrate themes of perseverance, grief, agency, and reflection. We discuss how gender relations, childrearing, tradition, economics, and health intersect in polygamous households.

The Survey of the Health of Wisconsin (SHOW), a novel infrastructure for population health research: rationale and methods.

BACKGROUND: Evidence-based public health requires the existence of reliable information systems for priority setting and evaluation of interventions. Existing data systems in the United States are either too crude (e.g., vital statistics), rely on administrative data (e.g., Medicare) or, because of their national scope (e.g., NHANES), lack the discriminatory power to assess specific needs and to evaluate community health activities at the state and local level. This manuscript describes the rationale and methods of the Survey of the Health of Wisconsin (SHOW), a novel infrastructure for population health research. METHODS/DESIGN: The program consists of a series of independent annual surveys gathering health-related data on representative samples of state residents and communities. Two-stage cluster sampling is used to select households and recruit approximately 800-1,000 adult participants (21-74 years old) each year. Recruitment and initial interviews are done at the household; additional interviews and physical exams are conducted at permanent or mobile examination centers. Individual survey data include physical, mental, and oral health history, health literacy, demographics, behavioral, lifestyle, occupational, and household characteristics as well as health care access and utilization. The physical exam includes blood pressure, anthropometry, bioimpedance, spirometry, urine collection and blood draws. Serum, plasma, and buffy coats (for DNA extraction) are stored in a biorepository for future studies. Every household is geocoded for linkage with existing contextual data including community level measures of the social and physical environment; local neighborhood characteristics are also recorded using an audit tool. Participants are re-contacted bi-annually by phone for health history updates. DISCUSSION: SHOW generates data to assess health disparities across state communities as well as trends on prevalence of health outcomes and determinants. SHOW also serves as a platform for ancillary epidemiologic studies and for studies to evaluate the effect of community-specific interventions. It addresses key gaps in our current data resources and increases capacity for etiologic, applied and translational population health research. It is hoped that this program will serve as a model to better support evidence-based public health, facilitate intervention evaluation research, and ultimately help improve health throughout the state and nation.

Rural Malawian Women's Resistance to Systematic Oppression, Violence, and Abuse by Their Husbands.

In Malawi, 41% of women aged 15 to 49 report ever experiencing intimate partner violence (IPV). Although there is evidence of the pervasiveness of IPV in Malawian society, the context in which it occurs and how women respond is not well described. The purpose of this study was to describe experiences of IPV of rural Malawian women. In-depth interviews were conducted with 55 rural Malawian women aged 21 to 75 years (M = 39) as part of a larger, mixed-methods study. This qualitative thematic analysis highlights husbands' IPV against wives and women's actions to protect themselves and their children, and to thrive despite the violence. Our use of a postcolonial feminist perspective led us to acknowledge Malawian women's acts of resistance in the midst of the harsh realities of IPV and gender inequality. We contend women's resilience and resistance against oppression within intimate relationships are critical tools in the process of reducing IPV. Structural interventions that (a) address the multiple distal and proximal factors affecting IPV, (b) are tailored to and owned by local populations, and (c) involve both men and women as architects and active participants, we believe, hold the greatest promise for reducing IPV in Malawi.

Active consent in urban elementary schools: an examination of demographic differences in consent rates.

The consent process is an integral piece of research and evaluation studies, especially when conducted within a school setting. The challenge of reaching parents of students to obtain consent is an issue with which those conducting school-based studies grapple. The literature suggests that the success of the consent process can affect the representativeness of the sample. This study describes one consent approach and examines the demographic differences between the eligible population, the consenters and the refusers. Demographic differences were found between consenters and refusers and suggestions are offered for further research and for other researchers who conduct school-based projects.

Setting a goal to reduce teen births in Milwaukee by 2015.

INTRODUCTION: Although teen birth rates have declined significantly since 1991, teen pregnancy remains a significant public health problem in Milwaukee, Wis. Using historical teen birth data trends, this study sets a birth rate reduction goal by the year 2015 for Milwaukee teenagers between the ages of 15 and 17. METHODS: Birth counts and birth rates for teenagers between the ages of 15 and 17 were obtained from the Wisconsin Interactive Statistics on Health (WISH). Trend analyses were performed on teen birth rate data gathered between 1991 and 2006 in an effort to forecast and set a birth rate goal for the year 2015. RESULTS/DISCUSSION: Trend analyses yielded a predicted birth rate projection of 35.9 (Adjusted R2 = .95, P < .001) births per 1000 females. Using the exponential function estimate as well as national and state goals, Milwaukee community leaders set a feasible goal of 30 births per 1000 teens aged 15-17 years for the year 2015, which represents a 46% reduction of the 2006 rate of 55/1000.

"He won't use condoms": HIV-infected women's struggles in primary relationships with serodiscordant partners.

We investigated the sexual behaviors of 55 HIV-infected women in Wisconsin who narrated their lives in 10 interviews over 2 years during 2000 to 2003. We sought to examine the interpersonal situations in which sexual risk occurred. During the prospective period, 58% (32) were abstinent and 24% (13) practiced safe sex exclusively. The remaining 18% (10) engaged in unprotected sexual intercourse, but only in primary partnerships, almost all of which were with serodiscordant partners. We focused on experiential detail and narrative depth of 10 women who had sex without condoms. These narratives demonstrate how the women attempted to initiate condom use but engaged in unprotected sexual intercourse regularly at the insistence of their partners. Consequently, these women lived in trepidation of causing their partners' sickness and death.

Effectiveness of female and male condoms in preventing exposure to semen during vaginal intercourse: a randomized trial.

OBJECTIVES: Comparison of male condom (MC) vs. female condom (FC) with respect to self-reported mechanical and acceptability problems and semen exposure using prostate-specific antigen (PSA) as an objective biological marker and evaluation of the effect of an educational intervention on self-reported problems and semen exposure, by condom type. DESIGN: Randomized crossover trial. METHODS: Four hundred women attending a family planning clinic in Brazil were randomized and either received in-clinic instruction or were encouraged to read the condom package insert; all used two FCs and two MCs. We measured the rates of self-reported user problems with MC and FC use and the rates of semen exposure during use (assessed by testing vaginal fluid for PSA). RESULTS: The educational intervention group reported fewer problems with either condom as compared with the control group (p = .0004, stratified by condom type). In both groups, self-reported problems were more frequent with FC use than with MC use (p < .0001, stratified by intervention). The educational intervention did not significantly reduce semen exposure. Overall, semen exposure occurred more frequently with FC use (postcoital PSA, > 1 ng/mL; 22%) than with MC use (15%); the difference, however, was small and nonsignificant for high PSA levels (> or = 150 ng/mL; 5.1% for FC vs. 3.6% for MC). CONCLUSIONS: In this study, the FC was less effective than the MC in preventing semen exposure during use and led more frequently to self-reported user problems. Both devices were highly protective against "high-level" semen exposure, as measured by postcoital PSA levels in vaginal fluid. In-clinic education may reduce user problems and increase acceptability and use of both devices.

Methods and protocol of a mixed method quasi-experiment to evaluate the effects of a structural economic and food security intervention on HIV vulnerability in rural Malawi: The SAGE4Health Study.

BACKGROUND: Poverty and lack of a predictable, stable source of food are two fundamental determinants of ill health, including HIV/AIDS. Conversely, episodes of poor health and death from HIV can disrupt the ability to maintain economic stability in affected households, especially those that rely on subsistence farming. However, little empirical research has examined if, and how, improvements in people's economic status and food security translate into changes in HIV vulnerability. METHODS: In this paper, we describe in detail the methods and protocol of an academic-NGO collaboration on a quasi-experimental, longitudinal study of the mechanisms and magnitude of the impact of a multilevel economic and food security program (Support to Able-Bodied Vulnerable Groups to Achieve Food Security; SAFE), as implemented by CARE. Primary outcomes include HIV vulnerability (i.e., HIV risk behaviors, HIV infection), economic status (i.e., income, household assets) and food security (including anthropometric measures). We recruited participants from two types of areas of rural central Malawi: traditional authorities (TA) selected by CARE to receive the SAFE program (intervention group) and TAs receiving other unrelated CARE programming (controls). In the intervention TAs, we recruited 598 program participants (398 women, 200 men) and interviewed them at baseline and 18- and 36-month follow-ups; we interviewed 301 control households. In addition, we conducted random surveys (n = 1002) in the intervention and control areas with a 36-month assessment interval, prior to and after implementation of SAFE. Thus, we are examining intervention outcomes both in direct SAFE program participants and their larger communities. We are using multilevel modeling to examine mediators and moderators of the effects of SAFE on HIV outcomes at the individual and community levels and determine the ways in which changes in HIV outcomes feed back into economic outcomes and food security at later interviews. Finally, we are conducting a qualitative end-of-program evaluation consisting of in-depth interviews with 90 SAFE participants. DISCUSSION: In addition to examining pathways linking structural factors to HIV vulnerability, this research will yield important information for understanding the impact of a multilevel environmental/structural intervention on HIV, with the potential for other sustainable long-term public health benefits.

Perceived neighborhood quality, sleep quality, and health status: evidence from the Survey of the Health of Wisconsin.

Why does living in a disadvantaged neighborhood predict poorer mental and physical health? Recent research focusing on the Southwestern United States suggests that disadvantaged neighborhoods favor poor health, in part, because they undermine sleep quality. Building on previous research, we test whether this process extends to the Midwestern United States. Specifically, we use cross-sectional data from the Survey of the Health of Wisconsin (SHOW), a statewide probability sample of Wisconsin adults, to examine whether associations among perceived neighborhood quality (e.g., perceptions of crime, litter, and pleasantness in the neighborhood) and health status (overall self-rated health and depression) are mediated by overall sleep quality (measured as self-rated sleep quality and physician diagnosis of sleep apnea). We find that perceptions of low neighborhood quality are associated with poorer self-rated sleep quality, poorer self-rated health, and more depressive symptoms. We also observe that poorer self-rated sleep quality is associated with poorer self-rated health and more depressive symptoms. Our mediation analyses indicate that self-rated sleep quality partially mediates the link between perceived neighborhood quality and health status. Specifically, self-rated sleep quality explains approximately 20% of the association between neighborhood quality and self-rated health and nearly 19% of the association between neighborhood quality and depression. Taken together, these results confirm previous research and extend the generalizability of the indirect effect of perceived neighborhood context on health status through sleep quality.

Self-reported mechanical problems during condom use and semen exposure. Comparison of two randomized trials in the United States of America and Brazil.

OBJECTIVES/GOAL: To compare self-reported condom use problems and objectively determined semen exposure in 2 populations. STUDY DESIGN: Two randomized crossover trials in the United States and Brazil compared the failure rates of the female condom (FC) and male condom (MC). Participants used both condom types, completed condom-specific questionnaires to report problems, and collected precoital and postcoital samples of vaginal fluid. Prostate-specific antigen (PSA) was detected by immunoassay. RESULTS: Problems with condom use were reported less frequently in the Brazilian study (rate difference: FC = 24%, P <0.0001, MC = 5%, P = 0.003). By contrast, the PSA detection rates were similar for both the FC and the MC (rate difference: FC = 2%, MC = 1%, not significant). These results suggest that the PSA detection rate was similar in the 2 study groups and that self-reported problems may be a less reliable measure of condom failure. CONCLUSIONS: Use of biomarkers of condom failure like PSA may help to strengthen the validity of studies promoting behavior change for the prevention of sexually transmitted diseases.

Características reprodutivas de mulheres de 15 a 49 anos: estudos comparativos e planejamento de açöes / Reproductive charactistics of women from 15 to 49 years of age: comparative studies and planning for actions

A disponibilidade de dados sobre o perfil socioeconomico, demográfico e reprodutivo das mulheres tanto em nível nacional, regional e municipal permite comparaçöes entre regiöes além de oferecer subsídios para o planejamento de açöes do Programa de Assistência Integral à Saúde da Mulher. Foi realizado um estudo transversal de base-populacional com uma amostra de 3.002 mulheres de 15 a 49 anos residindo na zona urbana da cidade de Pelotas, RS. As informaçöes socioeconômicas, demográficas e reprodutivas foram obtidas através de um questionário estruturado. A análise foi realizada através da comparaçäo estatística de médias e proporçöes. Na análise da esterilizaçäo os dados foram controlados para a idade. Cerca de 56 por cento das mulheres eram casadas/em uniäo e 35 por cento solteiras. Um terço das mulheres eram donas-de-casa e 50 por cento tinham trabalho remunerado. Cerca da metade das adolescentes tinham vida sexual ativa, e dessas, 33 por cento já tinham estado grávidas. Observou-se elevado percentual de gravidez indesejada principalmente entre as jovens. O número médio de filhos entre as mulheres de 45 a 49 anos - final da vida reprodutiva - foi de 2,4. Os métodos contraceptivos mais prevalentes foram a pílula e a esterilizaçäo. Entre as mulheres casadas/em uniäo, 15 por cento estavam esterilizadas. Cerca de 25 por cento das mulheres acima de 35 anos haviam feito ligadura tubária. Entre as mulheres esterilizadas, 29,6 por cento tinham tido perda fetal e 18,3 por cento haviam tido peo menos um filho prematuro. Entre o total de maridos/companheiros, 20 por cento näo aceitavam o uso de pelos menos um método contraceptivo. Os resultados confirmam a necessidade de uma maior atençäo e desenvolvimento de programas especiais para adolescentes, de melhorias no acesso aos serviços de expansäo do uso das opçöes anticoncepcionais disponíveis e de açöes programáticas e pesquisas sobre o tema "homem/saúde reprodutiva"

Análise retrospectiva de quatro anos do dispositivo intra-uterino T de cobre 200 B / Four year retrospective study with the copper T 200 B IUD

oitocentas e vinte e cinco pacientes usuárias de DIU T de Cobre 200 B foram observadas quanto à aceitaçåo, eficácia e efeitos colaterais, durante 7.590 meses/uso. A maior aceitaçåo foi entre as mulheres que já haviam tido filhos. Os efeitos colaterais mais encontrados foram fluxo vaginal, dor e hipermenorréia. A taxa de gestaçåo foi 2,2. As extraçöes ocorreram principalmente pelo desejo de gestar