Randomized trial outcomes of a TTM-tailored condom use and smoking intervention in urban adolescent females.

Smoking and sexual risk behaviors in urban adolescent females are prevalent and problematic. Family planning clinics reach those who are at most risk. This randomized effectiveness trial evaluated a transtheoretical model (TTM)-tailored intervention to increase condom use and decrease smoking. At baseline, a total of 828 14- to 17-year-old females were recruited and randomized within four urban family planning clinics. Participants received TTM or standard care (SC) computerized feedback and stage-targeted or SC counseling at baseline, 3, 6 and 9 months. Blinded follow-up telephone surveys were conducted at 12 and 18 months. Analyses revealed significantly more consistent condom use in the TTM compared with the SC group at 6 and 12, but not at 18 months. In baseline consistent condom users (40%), significantly less relapse was found in the TTM compared with the SC group at 6 and 12, but not at 18 months. No significant effects for smoking prevention or cessation were found, although cessation rates matched those found previously. This TTM-tailored intervention demonstrated effectiveness for increasing consistent condom use at 6 and 12 months, but not at 18 months, in urban adolescent females. This intervention, if replicated, could be disseminated to promote consistent condom use and additional health behaviors in youth at risk.

Basic body knowledge in street-recruited, active drug-using women enrolled in a "body empowerment" intervention trial.

BACKGROUND: Drug-using women remain at high risk for HIV infection. Female condoms (FC) have proven potential and cervical barriers have promise to reduce HIV risk; their effective use may be boosted by familiarity and confidence about female anatomy. Women with high levels of crack cocaine use were assessed for their knowledge about reproductive anatomy, HIV/STI risk, as well as cancer screening behaviors. METHODS: Women were recruited for a randomized trial of a behavioral intervention via mobile vans in Philadelphia known for high crack use and sex exchange. Knowledge and behavioral data on 198 women were collected via interviewer-administered questionnaire. Women were randomized into control (n=99) and intervention (n=99) arms. Five weekly, small-group, intervention sessions stressed "body empowerment" and teaching use of female-initiated barrier methods. Follow-up body knowledge data were collected at 12 months. Changes in and correlates of body knowledge were analyzed and compared. RESULTS: Most participants were African-American (66%); their mean age was 39.6 years. At baseline, 44% of the sample erroneously believed women have sex and urinate from the same place; 62% erroneously believed that tampons could get lost in the abdominal cavity. Only 27% knew douching increased STI transmission risk; only 10% knew condoms reduce cervical cancer risk. At follow-up, overall body knowledge improved substantially, across both arms. Race was associated with high body knowledge at baseline but not at follow-up. CONCLUSIONS: Knowledge favoring use of women-initiated methods and cervical cancer prevention was very low in this hard-to-reach sample. Body knowledge improved substantially with enhanced voluntary counseling and testing (VCT) as well as the women-focused intervention. Body knowledge education must be targeted and tailored to drug-using women.

Correlates of trichomonas prevalence among street-recruited, drug-using women enrolled in a randomized trial.

OBJECTIVES: Substance-using women need prevention technologies and programs to reduce risk of HIV/sexually transmitted infection (STI). We examined STI prevalence and identified risk correlates for female drug users. METHODS: We used interviewer-administered and computer-assisted surveys, and tested specimens for four, treatable STIs (trichomonas, early syphilis, gonorrhea, chlamydia) on 198 HIV-seronegative, street-recruited, substance-using women enrolled in a randomized trial to reduce HIV/STI risk. RESULTS: Most women were crack users (88%), reported sex exchange (80%) and were not in drug user treatment (74%). Two-thirds were African-American and nearly all were unemployed. Protection during sex was infrequent. African-American women reported fewer unprotected sex acts and fewer sexual partners, but greater crack use and more sex-for exchange, than whites or Hispanics. Trichomonas prevalence (36.9%) exceeded that for chlamydia (3.5%), syphilis (1.5%), and gonorrhea (0%). In multivariate logistic regression, having a primary and casual partner more than doubled (AOR 2.86) the risk of having trichomonas and being African-American raised the risk by more than 8 times (AOR 8.45). CONCLUSIONS: African-American, drug-using women, and women with multiple partner types, are in urgent need of effective STI/HIV prevention interventions.

The green choices project: integrating environmental health education into reproductive health care settings.

A national reproductive health organization developed the Green Choices project to educate staff and clients about how to live in healthier environments by reducing potentially harmful environmental exposures to toxicants. An advisory group, comprised of experts in environmental and reproductive health and literacy, defined the project's scope and common environmental exposures to address. The following educational materials were developed: an online staff environmental health 101 curriculum, an environmental health assessment tool for clients to identify their potential risks, and information sheets for each environmental exposure that described potential risks and ways to reduce risks. Beta-testing methods included baseline and follow-up surveys, one-on-one interviews, focus groups, and recommendations from experts. Staff and client feedback on the educational materials resulted in increased clarity, sensitivity, relevancy, and appeal. Environmental health experts ensured accuracy of information, and reading experts lowered the reading level from 12th to 6th grade. A campaign to disseminate environmental health information and educational materials nationally is under way.

Implementing an advance emergency contraception policy: what happens in the real world?

CONTEXT: Advance provision of emergency contraception increases the likelihood of its use, yet little is known about the factors that influence successful implementation of an advance provision policy in publicly funded family planning clinics. METHODS: Data on knowledge of, attitudes toward and use of emergency contraception were collected from 211 patients attending four Title X-funded clinics in Pennsylvania in 2001-2002. In addition, 22 staff from the four clinics were interviewed regarding barriers to and facilitators of advance provision in 2004-2005, and 111 staff from 46 clinics completed related surveys in 2005. Qualitative data underwent content analysis, and frequencies and bivariate associations between variables were calculated for the survey data. RESULTS: Most patients said they would use emergency contraception (80%) and believed it should be easy to obtain (93%), although 46% thought it is a form of abortion. Patients' familiarity with the method, attitudes toward it and self-efficacy regarding its use were not associated with most demographic or reproductive health characteristics. While nearly all interviewed staff endorsed routine advance provision, only about half of survey respondents offered it "very often" at patients' initial or annual visits. Barriers to advance provision included staff prejudgment of patients' needs and ability to use the method, time constraints and inefficiencies in clinic procedures. CONCLUSIONS: Strategies that may facilitate advance provision of emergency contraception include emphasizing the need for staff to offer it during all patient visits, providing patient-friendly information and streamlining clinic procedures.

Characteristics associated with emergency contraception use by family planning patients: a prospective cohort study.

CONTEXT: Little is known about how written family planning clinic policy regarding emergency contraception, as well as personal characteristics, behaviors and attitudes, may influence a woman to use emergency contraception. METHODS: Between June 2001 and July 2002, women attending publicly funded family planning clinics in Pennsylvania were enrolled in an 18-month longitudinal study. Half attended clinics with a policy of offering emergency contraception in advance; the remainder had only emergent access to the drug. After providing baseline data, women completed monthly automated phone surveys about recent sexual activity, contraceptive use and attitudes toward pregnancy. Characteristics associated with recent use of emergency contraception were examined using multivariate logistic regression. RESULTS: Responses to 3,700 phone surveys from 729 women showed that 25% of those who attended clinics offering advance access used emergency contraception at least once during the study, compared with 8% who attended emergent access clinics. Women attending advance access clinics had significantly elevated odds of having used emergency contraception in the past month (odds ratio, 2.6). Other characteristics positively associated with the likelihood of recent emergency contraception use were familiarity with the drug, having a new sex partner and having unprotected sex at least once (2.0 each); negative feelings toward pregnancy (1.4); and using condoms as one's main contraceptive method (1.8). CONCLUSIONS: In addition to discussing and offering advance emergency contraception, providers should further explore specific behaviors and attitudes associated with emergency contraception use.

Improving patient educational literature: an understandable patient package insert for "the pill".

The objective of this project was to develop a simpler, more understandable, and accurate patient package insert (PPI) for inclusion in all packs of oral contraceptives (OCs). The project involved field-testing, using focus groups and semistructured cognitive interviews with family planning patients, a self-administered survey of clinic staff, and written recommendations from oral contraceptive and readability experts. The revision and field-testing of the PPI reduced its length by one third, lowered its reading level from the 10th to 1 2th grade down to 6th grade, included lay as well as medical terminology, and reorganized the information to make it easier to find and easier to use. The revised PPI, as submitted to the FDA in February 2001, could increase patient knowledge of safe and effective pill use and would be a valuable educational tool for providers of oral contraceptives. The FDA is currently updating the OC product labeling to reflect the most recent safety data and will then issue the labeling, including the field-tested patient package insert, for public comment.

Active Drug-Using Women Use Female-Initiated Barrier Methods to Reduce HIV/STI Risk: Results from a Randomized Trial.

UNLABELLED: Background. We tested an original, woman-focused intervention, based on body empowerment, and female-initiated barrier methods, including the female condom (FC) and cervical barriers. Methods. Eligible women were >= 18 years of age, HIV seronegative, and active drug users, reporting 30% or greater unprotected sex acts. Both controls (C) and intervention (I) participants received enhanced HIV/STI harm reduction counseling. I participants underwent 5 additional weekly group sessions. We compared change in frequency of unprotected vaginal intercourse across arms at 12 months. Results. Among 198 enrolled women, over 95% completed followup. Two-thirds were African-American; most of them used crack, had a primary partner, and reported sex exchange. In paired t-tests from baseline to followup, the frequency of unprotected vaginal sex dropped significantly for I (primary P < 0.00, nonprimary P < 0.002) and C (primary P < 0.008, nonprimary P < 0.000) arms with all partners. The difference in change across arms was of borderline significance for primary partner (P = 0.075); no difference was seen for nonprimary partner (P = 0.8). Use of male condom and FC increased with both partner types over time, but more consistently among I women. CONCLUSION: The "value-added" impact of the intervention was observed mainly with primary partners. Body knowledge with routine FC counseling should be incorporated into interventions for drug-using women.

Young unmarried men's understanding of female hormonal contraception.

BACKGROUND: A better understanding of men's attitudes, norms and behaviors regarding women's use of hormonal contraception is needed. STUDY DESIGN: We conducted contraceptive life-history interviews with 41 ethnically diverse males ages 18-25 years which detailed up to six heterosexual relationships, focusing on knowledge, attitudes, norms and behaviors regarding hormonal contraception use, decision making and communication. RESULTS: Men's attitudes, norms and behaviors associated with hormonal contraceptive decisions and use varied greatly across participants and their relationships. Findings suggest a mixture of attitudes and practices regarding the importance of communication around contraception influenced by sexual experiences, age and relationship type. Many men demonstrated limited knowledge about contraceptives and identified improving contraceptive knowledge as an essential step in facilitating contraceptive communication. CONCLUSIONS: Increased awareness about young men's understanding of and perceived roles regarding hormonal contraception will help in designing services that address contraceptive adherence, contraceptive communication and incorrect or inadequate contraceptive knowledge.