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Data from the Demographic and Health Surveys for Namibia, Swaziland, and Zambia and the AIDS Indicator Survey from Tanzania were used to examine the influence of marital status and number of partners on consistent condom use among men with casual sexual partnerships in four generalized HIV epidemic settings. We restrict the sample to the 26% (Zambia), 29% (Tanzania), 35% (Swaziland), and 42% (Namibia) of men, who, in the last 12 months before the survey, had any non-marital/non-cohabiting (i.e., casual) sexual partners. We use "condom always used with any partner in the last 12 months" as a dichotomous-dependent measure of consistent condom use. Analyses were stratified by country. Of men with casual partners, 41% (Zambia) to 70% (Namibia) used a condom every time with at least one partner. The majority of men were unmarried/non-cohabiting with one casual partner in the last year. In Swaziland and Zambia, multivariate results suggest that unmarried/non-cohabiting men with one casual partner had significantly lower odds than married/cohabiting men with casual partners to use condoms consistently (odds ratio [OR]=0.56, p=0.01 and OR=0.41, p<0.001, respectively.). In Namibia, unmarried/non-cohabiting men with two or more casual partners had significantly greater odds than married/cohabiting men with casual partners to use condoms consistently (OR=2.80, p<0.01). With some exceptions by country, higher education, religious group, wealth, having no children, knowing HIV results, having an STI, having one lifetime partner, and positive condom knowledge and beliefs also were significantly associated with using a condom every time with any partner. We conclude that consistent condom use remains an elusive goal even among men with casual sexual relationships. Condom use messages should be refined and targeted to men based on their number and types of relationships and combined with other messages to decrease concurrent relationships.

Abstinence-until-marriage (AUM) - strongly supported by religious conservatives in the USA - became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the President's Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.

Family planning has widespread positive impacts for population health and well-being; contraceptive use not only decreases unintended pregnancies and reduces infant and maternal mortality and morbidity, but it is critical to the achievement of Millennium Development Goals. This study uses baseline, representative data from six cities in Uttar Pradesh, India to examine family planning use among the urban poor. Data were collected from about 3,000 currently married women in each city (Allahabad, Agra, Varanasi, Aligarh, Gorakhpur, and Moradabad) for a total sample size of 17,643 women. Participating women were asked about their fertility desires, family planning use, and reproductive health. The survey over-sampled slum residents; this permits in-depth analyses of the urban poor and their family planning use behaviors. Bivariate and multivariate analyses are used to examine the role of wealth and education on family planning use and unmet need for family planning. Across all of the cities, about 50% of women report modern method use. Women in slum areas generally report less family planning use and among those women who use, slum women are more likely to be sterilized than to use other methods, including condoms and hormonal methods. Across all cities, there is a higher unmet need for family planning to limit childbearing than for spacing births. Poorer women are more likely to have an unmet need than richer women in both the slum and non-slum samples; this effect is attenuated when education is included in the analysis. Programs seeking to target the urban poor in Uttar Pradesh and elsewhere in India may be better served to identify the less educated women and target these women with appropriate family planning messages and methods that meet their current and future fertility desire needs.

Measurement of condom use is important to assess progress in increasing use. Since 2003, the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) have included new measures of self-reported condom use. We use data from Namibia, Swaziland, Tanzania, and Zambia to compare measures of condom use accounting for type of sexual partner. Condom use at last sex ranged from 20% in Tanzania to 57% in Namibia for men, and from 12% in Tanzania to 41% in Namibia for women. Reported condom use was lower in response to questions about condom use every time with last partner (from 13 to 47% for men and from 8 to 33% for women). Condom use was highest among people with two or more partners in the last year and lowest with marital partners. Overall, the prevalence of condom use was low, and there was wide variability across the various measures, countries, sexes, and types of partner. Promotion of condom use in all partnerships, but especially in non-marital relationships and among individuals with multiple partners, remains a critical strategy. New condom use questions in the DHS and AIS expand options for measuring and studying condom use.

Purpose: Gender inequity is a risk factor for intimate partner violence (IPV), although there is little research on this relationship that focuses on youth or males. Using survey data collected from 240 male and 198 female youth aged 15-24 in Rio de Janeiro, Brazil, we explore the association between individual-level support for gender equity and IPV experiences in the past 6 months and describe responses to and motivations for IPV., Methods: Factor analysis was used to construct gender equity scales for males and females. Logistic and multinomial logistic regression models were used to examine the relationship between gender equity and IPV., Results: About half of female youth reported some form of recent IPV, including any victimization (32%), any perpetration (40%), and both victimization and perpetration (22%). A total of 18% of male youth reported recently perpetrating IPV. In logistic regression models, support for gender equity had a protective effect against any female IPV victimization and any male IPV perpetration and was not associated with female IPV perpetration. Female victims reported leaving the abusive partner, but later returning to him as the most frequent response to IPV. Male perpetrators said the most common response of their victims was to retaliate with violence. Jealousy was the most frequently reported motivation of females perpetrating IPV., Conclusion: Gender equity is an important predictor of IPV among youth. Examining the gendered context of IPV will be useful in the development of targeted interventions to promote gender equity and healthy relationships and to help reduce IPV among youth., (Copyright © 2011 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Most studies on HIV risk in sub-Saharan Africa focus on individual-level sociodemographic and behavioral correlates of risk. Only recently have researchers and programmers considered the context within which individuals live. This study uses the 2005-6 Zimbabwe Demographic and Health Survey to examine the correlation between the prevalence of HIV at the community level and the prevalence of HIV risk-taking behaviors. Results show that women and men living in communities with higher HIV prevalence in the opposite sex are at increased risk of HIV. In addition, rural women and men living in communities with greater premarital and nonmarital sex are at greater risk of HIV. Finally, HIV prevalence is higher among women and men living in urban areas with higher intimate partner violence. Programs should address community-level social norms that make high-risk behaviors acceptable and thus increase all women and men's risk of HIV, not just those engaged in high-risk behaviors.

The relationship between intimate partner violence (IPV) and early marriage is explored using the 2005-2006 India National Family Health Survey (NFHS-3). The NFHS-3 collected data from a representative sample of women and men in India with a large enough sample size to have a representative sample at the state level. The focus is on youth from Bihar and Rajasthan, two states with high IPV and early marriage. Multivariate logistic regression analyses demonstrate that women aged 20 to 24 who married before age eighteen, the legal age at marriage in India, are more likely to have ever experienced IPV in their lifetime and recently experienced IPV (in the last 12 months) than their counterparts who married later. The results were significant in Rajasthan but not in Bihar. To reduce IPV, targeted efforts must be made to decrease the proportion of India's girls who are married under the legal age of marriage.

This study presents findings from a systematic review of evaluations of family planning interventions published between 1995 and 2008. Studies that used an experimental or quasi-experimental design or used another approach to attribute program exposure to observed changes in fertility or family planning outcomes at the individual or population levels were included and ranked by strength of evidence. A total of 63 studies met the inclusion criteria. The findings from this review are summarized in tabular format by the type of intervention (classified as supply-side or demand-side). About two-thirds of the studies found were evaluations of programs focusing on demand generation. Findings from all programs revealed significant improvements in knowledge, attitudes, discussion, and intentions. Program impacts on use of contraceptives and use of family planning services were less consistently found, and fewer than half of the studies that measured fertility or pregnancy-related outcomes found an impact. Based on the review findings, we identify promising programmatic approaches and propose directions for future evaluation research of family planning interventions.

A panel study examining the effects of women's individual characteristics, side effects experienced, and service quality on their contraceptive discontinuation was undertaken in four urban areas of Honduras. Data were collected from October 2006 to December 2007. The baseline sample consisted of 800 women aged 15-44 who were new or continuing users of an injectable contraceptive, the IUD, or an oral contraceptive. A total of 671 women (84 percent) were reinterviewed after one year. Life tables and Cox proportional hazards models were used to present discontinuation rates and factors associated with contraceptive discontinuation. Among new users, discontinuation of the baseline method at 12 months was high (45 percent), especially for users of an injectable method (50 percent). In the hazards model, service quality had little effect on discontinuation, whereas individual characteristics and the experience of specific side effects showed significant effects. The results suggest that programs should emphasize continuous contraceptive coverage rather than continuous use of a particular method.

Context: In Cambodia, unmet need for contraception is high. Studies suggest that social support and parity each play a role in contraceptive decision making., Methods: A representative sample of 706 married women aged 15-49 from two rural provinces in Cambodia who wished to delay childbirth were interviewed about their contraceptive use and their perceptions of their husband's, peers' and elders' support of contraception. Multivariate analyses examined associations between support measures and women's current use of modern methods, among all women and by parity., Results: Overall, 43% of women were currently using a modern method. Women who believed that their husband had a positive attitude toward contraception were more likely than those who did not to use a method (odds ratio, 3.4), whereas women who were nervous about talking with their husband about contraception were less likely than others to use a method (0.6); these associations remained in analyses by parity. Among all women and high-parity women, those whose husband made the final decision about contraception were less likely than other women to use a method (0.6 and 0.4, respectively). Perceiving that most of one's peers practice contraception was strongly associated with method use among low-parity women (4.4). Among all groups, women who agreed that one should not practice contraception if an elder says not to had decreased odds of method use (0.5 each)., Conclusions: To promote contraceptive use, family planning programs should focus on increasing men's approval of contraception, improving partner communication around family planning and bolstering women's confidence in their reproductive decision making.

This study examines intimate partner violence (IPV) attitudes and experience among women and men in Uganda to inform IPV-prevention programs in the region. Nationally representative population-based data from women aged 15 to 49 and men aged 15 to 54 were collected between May and October 2006 as part of the Uganda Demographic and Health Survey. The survey included questions on women's and men's attitudes toward wife beating and information on IPV victimization (women) and perpetration (men). More than half of men and nearly three quarters of women have attitudes supportive of wife beating in Uganda. More than half of married women report IPV victimization, and 40% of married men report perpetration. Women and men who reported witnessing their fathers beating their mothers were more likely to report IPV victimization (perpetration for men). Witnessing violence was also associated with positive attitudes toward wife beating among men. IPV-prevention programs need to address the important role of having witnessed wife beating between the mother and the father on men's subsequent attitudes and behaviors. Women who witnessed wife beating are also the most likely to have supportive attitudes and IPV experience, possibly indicating that their relationship expectations are different than women who did not witness violence. Community-based prevention programs targeting men and women are needed in Uganda and elsewhere in sub-Saharan Africa where gender norms that justify IPV prevail.

Background: Gender-based violence is an important risk factor for adverse reproductive health (RH). Community-level violence may inhibit young women's ability to engage in safer sexual behaviors due to a lack of control over sexual encounters. Few studies examine violence as a contextual risk factor., Methods: Using nationally representative data from five African countries, the association between community-level physical or sexual intimate partner violence (IPV) and the circumstances of first sex (premarital or marital) among young women (ages 20-29) was examined., Results: In Mali, and Kenya bivariate analyses showed that young women who had premarital first sex were from communities where a significantly higher percentage of women reported IPV experience compared to young women who had marital first sex. Multivariate analyses confirmed the findings for these two countries; young women from communities with higher IPV were significantly more likely to have had premarital first sex compared to first sex in union. In Liberia, community-level IPV was associated with a lower risk of premarital sex as compared to first sex in union at a marginal significance level. There was no significant relationship between community-level IPV and the circumstances of first sex in the Democratic Republic of Congo or Zimbabwe., Conclusion: These findings indicate that context matters for RH. Individualized efforts to improve RH may be limited in their effectiveness if they do not acknowledge the context of young women's lives. Programs should target prevention of violence to improve RH outcomes of youth.

Context: Most studies on pregnancy ambivalence are based on data from women and depend on the women's perceptions to measure their partner's pregnancy intentions. Because these perceptions may not be accurate, data collected directly from men are needed to understand the role of couple dynamics in fertility behavior., Method: Matched couple data from the 2002-2003 Indonesia Demographic and Health Survey were used to examine contraceptive use, fertility desires and attitudes about becoming pregnant in the next few weeks-whether it would be a big problem, a small problem or no problem. Concordance between partners on these issues was evaluated. Inconsistent fertility desires and responses to the problem question are used to define ambivalence within couples. Multivariate logistic regression analyses were used to assess whether couples' pregnancy ambivalence was associated with contraceptive use., Results: Seventy-one percent of husbands and 54% of wives reported that a pregnancy in the next few weeks would be "no problem"; couples' concordance on this question was 64% among contraceptive users and 61% among nonusers. In the multivariate analysis, couples who were discordant on the issue of a pregnancy in the near future had 26% lower odds of using contraceptives than couples in which both partners agreed a pregnancy would be a big or small problem. Contraceptive use was also less likely for couples in which one partner wanted to delay or stop childbearing and the other wanted more children or was undecided (odds ratio, 0.4)., Conclusions: Husbands and wives influence each other's fertility attitudes and family planning use. Both husbands' and wives' pregnancy attitudes should be taken into account at the time of screening and method selection.

Context: Compared with the Latin American average, adolescent fertility is high in El Salvador, Guatemala, Honduras and Nicaragua, countries that also have high poverty levels and poor access to reproductive health care., Methods: For each country, data were drawn from four national health surveys conducted between 1987 and 2007, and analysis focused on trends in sexual and reproductive behavior among adolescent females aged 15-19. Event history analysis examined transitions to first sexual intercourse, first union and first live birth across survey years; Cox hazard and logistic regression analyses assessed associations between selected demographic characteristics and these outcomes, as well as ever-use of a modern contraceptive method., Results: The likelihood that adolescent females have initiated sexual intercourse has increased over time in El Salvador, Honduras and Nicaragua, and has remained stable in Guatemala. Meanwhile, the odds of having entered their first union have declined in Nicaragua and risen in El Salvador, but have not changed in Honduras or Guatemala. Notably, the likelihood that adolescents have ever used a modern contraceptive method has increased in all four countries over the survey years. Nicaraguan adolescents became significantly less likely to have had their first live birth over the study period. Finally, urban residence, education level and socioeconomic status were important predictors of adolescents' sexual and reproductive outcomes., Conclusions: Programmatic and policy initiatives should focus on improving adolescents' education and socio- economic prospects, and efforts are especially needed to help adolescents delay the age at which they become sexually active and enter their first union.

No previous published research has examined the applicability of varying methods for identifying young people who are at high risk of experiencing unintended pregnancy and acquiring HIV infection. This study compares three surveys of young people aged 15-24 in Port-au-Prince, Haiti, in terms of their sociodemographic characteristics and sexual behaviors and the surveys'usefulness for identifying young people at high risk and for program planning. The surveys consist of responses from: a representative sample of young people in the 2005-06 Haiti Demographic and Health Survey (HDHS), a 2004 facility-based study, and a 2006-07 venue-based study that used the Priorities for Local AIDS Control Efforts (PLACE) method. The facility-based and PLACE studies included larger proportions of single, sexually experienced young people and people who knew someone with HIV/ AIDS than did the HDHS. More respondents in the PLACE sample had multiple sex partners in the past year and received money or gifts in return for sex, compared with respondents in the facility study. At first and last sex, more PLACE respondents used contraceptives, including condoms. Experience of pregnancy was most commonly reported in the data from the facility-based sample; however, more ever-pregnant PLACE respondents than others reported ever having terminated a pregnancy. Program managers seeking to implement prevention activities should consider using facility- or venue-based methods to identify and understand the behaviors of young people at high risk.

Background: Recent studies have demonstrated that it is common for women to report inconsistent fertility motivations and family planning behaviors. This study examines these inconsistencies among urban Honduran women interviewed at two points in time and presents reasons for inconsistent fertility motivations and contraceptive behaviors at follow-up., Methods: Data come from a one-year panel study conducted in Honduras from October 2006 to December 2007. A total of 633 women aged 15-44 years were interviewed at baseline and follow-up and have non-missing information on the key variables of interest. At baseline and follow-up, women were asked how much of a problem it would be (no problem/small problem/big problem) if they got pregnant in the next couple of weeks. At follow-up, women were asked an open-ended question on reasons it would be no problem, a small problem, or a big problem. The open-ended question was recoded into a smaller set of response categories. Univariate and bivariate analyses are presented to examine inconsistencies and reasons for stated inconsistencies., Results: At follow-up, over half the women using a contraceptive method said that it would be no problem if they got pregnant. Nearly half of the women changed their perceptions between baseline and follow-up. Common reasons for reporting no problem among contraceptive users were that they accepted a child as God's will or that children are a blessing, their last child was old enough and they wanted another child. Common reasons for reporting a big/small problem among non-users of family planning (who have an unmet need for family planning) were that they were not in a stable relationship, the husband was not present, and they would expect a negative response from their family., Conclusion: Inconsistent fertility motivations and contraceptive behaviors are common among effective contraceptive users. Women who are using contraception and become pregnant will not necessarily report the pregnancy as unintended, given the widespread acceptance of unintended pregnancies in Honduras. Family planning providers need to recognize that fertility motivations vary over time and that women may not have firm motivations to avoid a pregnancy.

Objectives: We studied whether female youths from communities with higher sexual violence were at greater risk of negative reproductive health outcomes., Methods: We used data from a 2003 nationally representative household survey of youths aged 15-24 years in South Africa. The key independent variable was whether a woman had ever been threatened or forced to have sex. We aggregated this variable to the community level to determine, with control for individual-level experience with violence, whether the community-level prevalence of violence was associated with HIV status and adolescent pregnancy among female, sexually experienced, never-married youths., Results: Youths from communities with greater sexual violence were significantly more likely to have experienced an adolescent pregnancy or to be HIV-positive than were youths from communities experiencing lower sexual violence. Youths from communities with greater community-level violence were also less likely to have used a condom at their last sexual encounter. Individual-level violence was only associated with condom nonuse., Conclusions: Programs to reduce adolescent pregnancies and HIV risk in South Africa and elsewhere in sub-Saharan Africa must address sexual violence as part of effective prevention strategies.

Objectives: Strong linkages exist between childhood abuse and adult intimate partner violence (IPV) among women in developed countries. Few studies examine this pattern in developing nations. This study explores the effect of childhood physical and/or psychological abuse on the likelihood of IPV among a national sample of Ecuadorian women of reproductive age., Methods: Secondary data analysis was conducted on a subsample of 9,077 Ecuadorian women, utilizing the 2004 Encuesta Demografía y de Salud Materna e Infantil survey. Cross-tabulations and multivariate logistic regression models were utilized to assess whether women who report childhood abuse had a higher likelihood of reporting sexual, physical or psychological IPV during their lifetimes or within the past year., Results: Levels of abuse were high. More than 30% of women reported childhood psychological or physical abuse, and 21% experienced both types of abuse. Forty percent of women reported sexual, physical or psychological IPV during their lifetimes, while 15% reported any form of IPV in the past year. The co-occurrence of childhood psychological and physical abuse was highly predictive of all forms of IPV, with less consistent associations for women who reported only physical or only psychological childhood abuse., Conclusions: This study suggests that childhood abuse is an important risk factor for IPV victimization among Ecuadorian women. While this analysis supports findings from developed countries, more cross-cultural research about patterns of violence throughout the life course is needed to develop relevant prevention programs.

We examine sexual violence and reproductive health outcomes among sexually experienced youth in Port-au-Prince, Haiti, using the Priorities for Local AIDS Control methodology to identify participants in locations where sexual partnerships are formed. Our findings indicated that sexual violence is common and is significantly associated with condom use, pregnancy experience, and recent sexually transmitted infection symptoms.

Although unwanted pregnancies can cause social and economic problems for Sub-Saharan African youth, the consequences of intended adolescent pregnancies have gone unnoticed. Rarely do studies recognize that youth who desire a pregnancy are less likely to practice safe sex and, therefore, are at greater risk of contracting sexually transmitted infections (STIs), including HIV. This study uses data from the 2003 Mozambique Demographic and Health Survey to explore youth fertility desires and condom use. In multivariate analyses, controlling for other factors associated with condom use, female youth who want to get pregnant soon are significantly less likely (odds ratio: 0.35; 95% confidence interval: 0.22-0.55) to use condoms with nonmarital partners than youth who want to delay childbearing. Programs for sexually active youth should recognize the importance of fertility desires as a potential moderator of condom use, even if the woman is at risk of HIV or STI. Recommendations are provided for HIV prevention counseling for youth who want to get pregnant and youth who are ambivalent about a future pregnancy.

Background: Experiences at sexual debut may be linked to reproductive health later in life. Additionally, young women with older sexual partners may be at greater risk for HIV and sexually transmitted infections. This study examines sexual debut with an older partner and subsequent reproductive health outcomes among 599 sexually experienced women aged 15-24 who utilized voluntary counseling and testing or reproductive health services in Port-au-Prince, Haiti., Methods: Logistic regression models, controlling for socioeconomic and demographic factors, examined whether age differences at first sex were significantly associated with STI diagnosis in the previous 12 months and family planning method use at last intercourse., Results: Sixty-five percent of women reported sexual initiation with a partner younger or less than 5 years older, 28% with a partner 5 to 10 years older, and 7% with a partner 10 or more years older. There was a trend towards decreased likelihood of recent use of family planning methods in women who had first sexual intercourse with a partner 5 to 9 years older compared to women with partners who were younger or less than 5 years older. Age differences were not linked to recent STI diagnosis., Conclusion: Programs focusing on delaying sexual debut should consider age and gender-based power differentials between younger women and older men. Future research should examine whether wide age differences at sexual debut are predictive of continued involvement in cross-generational relationships and risky sexual behaviors and explore the mechanisms by which cross-generational first sex and subsequent reproductive health may be connected.

Objective: Adolescence is a period characterized by increased exploration and exposure to risk-taking behaviors, including unsafe sex. This study examines prior contraceptive method use by pregnant or recently pregnant adolescents in Teresina-Piauí, Brazil., Design: Cross-sectional study., Setting: Four hospital maternity units., Participants: Two-hundred and seventy-eight adolescents aged 15-19 admitted in four hospital maternity units for clinical treatment or for pregnancy resolution were interviewed., Methods: The sample was stratified proportional to the number of adolescents who visit each hospital. Chi-square and Fisher exact test are used to analyze differences between contraceptive users and non-users., Results: Half of interviewed adolescents used some form of contraception at first intercourse (53.2%) and 40.3% used contraception at intercourse leading to the current pregnancy. Male condom was the most common method at first intercourse (96.6% among users of a method) and at the time of pregnancy (58.9%). The main reasons for contraceptive nonuse were that the adolescent had not thought about contraception at the time of first sex (36.1%) and the adolescent wished for a baby at the time of pregnancy (26.5%). About 57% of girls who did not want the pregnancy reported that they did not use any contraceptive method right before the pregnancy. Among pregnant adolescents with an unwanted pregnancy, a greater percentage who had access to health services reported contraceptive use (48%) compared to only 16.7% of those with no access to health services., Conclusions: Contraceptive method use by adolescents was unsatisfactory as indicated by unwanted pregnancies among both users and nonusers of contraception. Prevention of unintended pregnancies requires greater information and access to contraceptives among all sexually active youth.

Objective: This study determines which adolescent girls are becoming pregnant., Design: Cross-sectional study., Sample: Pregnant or puerpera adolescents in Teresina, Brazil (278), aged 15-19 years., Measurements: Comparisons were made between the older and younger age groups of the Teresina sample and between the socioeconomic and demographic characteristics of the Teresina sample and ever-pregnant adolescents from the 1996 Demographic and Health Survey (DHS) sample. Descriptive analyses and Pearson's chi-square tests were performed., Results: Compared with the 1996 DHS sample, there has been a social improvement manifested by a higher proportion attending school and a lower proportion of adolescent workers in the 2006 Teresina sample. In the 2006 sample, 60.2% of those attending school were below their grade for age level. The principal reason for school abandonment 10 years ago was marriage (24.4%) and that among the 2006 Teresina sample was pregnancy (44.9%). Girls who were 15-17 years old in the 2006 sample experienced menarche and sexual debut earlier than those who were 18-19 years old in the same sample., Conclusions: Adolescent pregnancies are likely to have an unfavorable long-term impact on adolescent mothers' lifestyle, even with some improvement since 1996. Effective programs for adolescent pregnancy prevention are needed to reduce the possibility of continuance of these trends for another 10 or more years in the future.

Objective: To examine correlates of perceived access to cigarettes at home, school, and the store among youth., Methods: Virginia middle school youth were surveyed before beginning tobacco prevention programs. Multivariate analyses examined household smoking, peer smoking, and perceived community tobacco use for their relationship to perceived access at home, school, and the store., Results: Perceived access at home was associated with parent, sibling, and friend smoking. Perceived access at school and stores was associated with perceived peer and community smoking., Conclusions: Youth tobacco prevention programs should target the commercial and social sources of tobacco access to reduce experimentation, adoption, and addiction among youth.

Objectives: To determine whether contraceptive discontinuation is associated with pregnancies that are conceived earlier than desired (mistimed) or are not wanted at the time of conception (unwanted)., Methods: Data were obtained from the 2002 Guatemala National Maternal and Child Health Survey. Pregnancies within the three years prior to and at the time of the survey (April 1999-November 2002) were classified as either "intended," "mistimed," or "unwanted." The key independent variable was whether the woman had used contraception within 12 months of the pregnancy and, for those who had used it, the reason for discontinuation (either to get pregnant or for another reason). A multinomial logistic analysis was used to determine the degree of association of discontinuation with pregnancy intentions., Results: One of every five mistimed pregnancies and one of every six unwanted pregnancies followed discontinuations that were for reasons other than to become pregnant (e.g., contraceptive failure, side effects, and health concerns). Discontinuations for reasons other than to become pregnant were shown to be positively and significantly associated with a reported mistimed pregnancy (coefficient = 2.15; standard error = 0.27) or unwanted pregnancy (2.68; 0.37) compared to an intended pregnancy. Pregnancies preceded by discontinuations for reasons other than to become pregnant were also more likely to be reported as mistimed or unwanted than pregnancies of women who were not using contraception during the year prior to pregnancy., Conclusions: There is a need to increase contraceptive continuation. Any program should include an increased effort to reduce contraceptive failure and better address the side effects and the health concerns that women have that can lead to discontinuation. Non-users who want to delay or limit births should also be identified and targeted for outreach in order to reduce unintended pregnancies.

Objective: Severe physical punishment of children is an important issue in international child health and welfare. This study examines such punishment in Guatemala and El Salvador., Methods: Data came from nationally representative surveys of women aged 15-49 and men aged 15-59 residing in Guatemala (2002) and El Salvador (2002-2003). The surveys included questions about punishment experienced during childhood, with response options ranging from verbal scolding to beating. In Guatemala, parents were asked how they disciplined their children; questions allowed them to compare how they were punished in their childhood with how they punished their own children. Bivariate and multivariate analyses are presented., Results: In Guatemala, 35% of women and 46% of men reported being beaten as punishment in childhood; in El Salvador, the figures were 42% and 62%, respectively. In both countries, older participants were relatively more likely than younger participants to have been beaten as children. Witnessing familial violence was associated with an increased risk of being beaten in childhood. In Guatemala, having experienced physical punishment as a child increased the chance that parents would use physical punishment on their own children. Multivariate analyses revealed that women who were beaten in childhood were significantly more likely in both countries to be in a violent relationship., Conclusions: The use of beating to physically punish children is a common problem in Guatemala and El Salvador, with generational and intergenerational effects. Its negative and lingering effects necessitate the introduction of policies and programs to decrease this behavior.

Objective: The prevalence of sexual abuse during childhood or adolescence varies depending on the definitions and age categories used. This study examines the first national, population-based data available on child sexual abuse that occurs before age 15 in three countries: El Salvador, Guatemala, and Honduras. This study uses comparable indicators and measures of sexual abuse for the three countries to document the prevalence of abuse, types of perpetrators, and the association of child sexual abuse with recent intimate partner violence., Methods: Child sexual abuse was defined as sexual abuse that first occurs before age 15. Nationally representative data from El Salvador, Guatemala, and Honduras were used. In El Salvador, separate questions on forced intercourse and non-penetrative sexual abuse were asked. Bivariate and multivariate analyses were performed using STATA Version 8SE., Results: The prevalence of child sexual abuse varied from 7.8% in Honduras to 6.4% in El Salvador and 4.7% in Guatemala. In all three countries, the overwhelming majority of women who reported child sexual abuse first experienced the abuse before age 11. Perpetrators tended to be a family member, a neighbor, or an acquaintance. Bivariate and multivariate analyses indicated that women who experienced child sexual abuse in Guatemala and Honduras were about two times more likely to be in violent relationships as women who did not experience abuse. This relationship was not significant in multivariate analyses for El Salvador where the prevalence of intimate partner violence was the lowest., Conclusions: Child sexual abuse in Central America is clearly a problem with the prevalence between 5% and 8%. Child sexual abuse can have long-term negative health impacts including exposure to intimate partner violence in adulthood. Programs to prevent abuse and treat victims of child sexual abuse are needed in Central America.

Perceptions that smoking contributes to weight loss are widespread among youth. We examined the association between weight loss and smoking to determine whether supportive attitudes were associated with smoking status and whether this is a particular problem in rural areas. High school students (N=730) completed a survey assessing smoking-related characteristics and behaviors. Attitudes assessed included perceptions of whether weight concerns were the reasons others smoke and personal beliefs about tobacco's effect on weight gain. Smoking status was categorized as never (44%), experimental (42%), and current (14%). Multinomial logistic regressions investigated relationships between attitudes and smoking, adjusting for weight goals, gender, ethnicity, parent/peer smoking, and body mass index. Both attitudinal measures were associated with smoking (p< .05). Nonsmokers and experimental smokers were more likely than current smokers to believe that people smoke to lose weight. Although current smokers were less likely to report that others smoke for weight control, they believed they would gain weight if they quit. Conversely, nonsmokers and experimental smokers were less likely to believe they would gain weight if they do not smoke compared with current smokers. Thus personal attitudes differ from attitudes toward others with respect to weight loss and smoking. Moreover, endorsement of these attitudes can reliably distinguish current versus experimental smokers and may help better clarify the transition to current smoker. Because weight concerns are a significant factor in youth smoking, these issues should be included in intervention efforts, particularly in rural communities where smoking rates are higher and age at initiation is earlier.

Background: Zambia experienced declining aggregate fertility and increasing aggregate contraceptive use from 1990 to 2000. Yet, in rural Zambia, progress in family planning has lagged far behind the advances made in Zambia's urban areas. The contraceptive prevalence rate in Lusaka and other urban areas outstripped the rate in rural Zambia by nearly 25 percentage points (41.2 percent versus 16.6 percent) in 2001. The total fertility rate varied between urban and rural areas by 2.5 children (4.3 versus 6.9 children). This paper considers the urban-rural differentials in Zambia and assesses family planning outreach as a tool to narrow this divide., Methods: This study uses the Zambia Demographic and Health Survey (DHS) data, collected between 2001 and 2002. Logistic regression techniques were employed to examine factors associated with contraceptive use. The first analysis tested modern contraceptive use versus traditional method use and no use. In addition, separate models were run for samples stratified by type of residence (rural or urban) to determine if different factors were associated with use by residence. A simulation determined the effect of all women receiving at least one household visit from a health worker if all other variables were held constant., Results: Differences in modern contraceptive use between urban and rural areas persist (OR: 1.56, 95 percent CI: 1.24-1.96) even after adjusting for a number of demographic, socioeconomic, cognitive, and attitudinal factors. Household visits by a community health worker significantly increased the likelihood of modern contraceptive use among rural women (OR: 1.83; 95 percent CI: 1.29-2.58). If all rural women received at least one outreach visit per year, the prevalence rate for modern contraceptive methods would be expected to increase for this group by 5.9 percentage points, a marked increase but less than one-quarter of the total urban-rural differential., Conclusion: Outreach in the form of health worker visits can improve access to family planning services, but it does not eliminate barriers to access or address continued high-fertility desires in Zambia. Until policymakers consider strategies that address both family planning demand creation and supply of services, progress in Zambia and the rest of sub-Saharan Africa will continue to lag behind the rest of the world.

Smoking is the most preventable cause of death in the United States. Most adult smokers began smoking during adolescence, making youth tobacco prevention an especially important public health goal. Guided by an extension of the theory of planned behavior (TPB), this study examined the role of psychosocial factors in accounting for adolescents' smoking intentions. Participants from three high schools (n = 785) were surveyed to assess smoking-related characteristics and behaviors as part of a statewide evaluation of tobacco prevention programming. Attitudes, subjective norms (and other normative factors) and perceived behavioral control were all associated with non-smokers' intentions to smoke. Having more favorable attitudes toward remaining tobacco free and perceiving that friends would not be supportive of smoking were both associated with decreased likelihood of intending to smoke. Normative influence and peer use were significant factors, such that having more friends who smoke was associated with increased odds of intent to smoke. Lastly, perceived difficulty to quit was related to smoking intentions, with higher confidence to quit significantly associated with intentions to smoke. Findings are consistent with the TPB--attitudes, normative factors and perceived behavioral control each helped account for non-smoking adolescents' intentions to smoke. Implications for theory and intervention building are discussed.

Context: Use of unmet need for family planning to identify prospective clients may misrepresent the actual family planning needs of a population, given that a large proportion of women have ambivalent fertility desires., Methods: Survey data for 1998 and 2003 from Burkina Faso, Ghana and Kenya were used to examine the fertility desires and motivations of women who said they wanted to delay or limit childbearing. A question on how much of a problem it would be if women found out they were pregnant in the next few weeks measured the strength of their fertility motivations., Results: In Burkina Faso and Ghana, about a quarter of women who said they wanted to delay or limit childbearing also reported that it would be no problem or a small problem if they became pregnant soon. This response pattern was equally common among contraceptive users and nonusers. In Kenya, more than four in 10 women gave such ambivalent responses. Among women with an unmet need for means of delaying or limiting childbearing, 16-31% of those in Burkina Faso and Ghana, and 30-56% of those in Kenya, said that getting pregnant in the next few weeks would be no problem or a small problem., Conclusions: It is critical to consider the strength of fertility motivations when determining which women have family planning needs. Targeting women who are the most motivated to avoid childbearing will likely have the greatest impact on reducing unintended pregnancy in Sub-Saharan Africa.

Objectives: We examined pregnancy decisionmaking among women seeking abortion or prenatal care., Methods: Conventional measures of pregnancy intentions were compared with newer measures in 1017 women seeking abortion. A reduced sample of abortion patients (142 African American women from New Orleans) was compared with 464 similar women entering prenatal care., Results: Virtually all abortion patients reported the pregnancy as unintended; two thirds of prenatal patients reported the pregnancy as unintended. Reasons for seeking abortion related to life circumstances, including cost, readiness, not wanting any more children, marital status, relationship stability, and being too young. Abortion patients were more likely to report trying hard to avoid a pregnancy and not being in a relationship. They were less likely to report that their partner wanted a baby (odds ratio=0.10) or that they wanted a baby with their partner (odds ratio=0.13) than prenatal patients., Conclusions: Traditional measures of pregnancy intentions did not readily predict a woman's choice to continue or abort the pregnancy. Relationship with male partners, desire for a baby with the partner, and life circumstances were critical dimensions in pregnancy decisionmaking.

Objective: To examine reasons for contraceptive nonuse at first sex and subsequent unintended pregnancy among women attending family planning and prenatal clinics., Methods: Data come from the Determinants of Unintended Pregnancy Risk in New Orleans study. Reasons for nonuse by age, partner's age, and pregnancy status are compared., Results: Concern about parents' finding out about sexual activity was a common reason for nonuse at first sex and first unintended pregnancy. Problems accessing and discontinuation of contraception were reasons given at second or higher-order unintended pregnancy., Conclusions: Reasons for nonuse vary by event and age at event. Providers should consider various reasons when counseling patients on contraceptive options.

Context: In El Salvador, fathers less commonly say that pregnancies are unintended than mothers do. However, men's pregnancy intentions are not understood as well as women's., Methods: Data from 425 fathers participating in the 2003 National Male Reproductive Health Survey of El Salvador were analyzed to examine their intentions in regard to partners' pregnancies that had ended in a live birth in the last five years. They were asked whether they had been trying to avoid pregnancy at the time of conception, whether they had been trying to get their partner pregnant, how they had felt about the pregnancy and what they thought their partner's pregnancy intentions had been. Descriptive analyses were based on the most recent pregnancy reported by each man., Results: A quarter of the pregnancies had been unintended from the men's perspective--13% had been mistimed and 11% had been unwanted. Almost half (46%) of unintended pregnancies had been conceived when the father was trying to avoid pregnancy. However, 36% of men reporting an unintended pregnancy said they had been happy when they found out about it. For 20% of all pregnancies, men perceived that their partner's pregnancy intentions differed from their own., Conclusions: Family planning services in El Salvador need improvement, and services and outreach should target men. Men's experiences with unintended pregnancies--in particular, contraceptive failure and discordance within couples about pregnancy intention--are complex and merit further investigation.

Context: Gender differences influence decision making about reproductive health. Most information on reproductive health decision making in Latin America has come from women's reports of men's involvement., Methods: Data were collected in Honduras in 2001 through two national surveys that used independent samples of men aged 15-59 years and women aged 15-49. Bivariate and multivariate analyses were used to identify factors associated with male-centered decision-making attitudes and behaviors regarding family size and family planning use., Results: Overall, 25% of women and 28% of men said that men alone should be responsible for at least one of these reproductive decisions, and 27% of women and 21% of men said that the man in their household made one or both decisions. For women, having no children and being in a consensual union were each associated with holding male-centered decision-making attitudes; having less than a secondary education, being of medium or low socioeconomic status and living in a rural area were each associated with male-centered decision making. Among men, having less than secondary education and being in a consensual union were each associated with male-centered decision-making attitudes and behavior. Women who had ever used or were currently using modern methods were significantly less likely to hold attitudes supporting male-centered decision-making than were those who relied on traditional methods and those who had never used a modern method., Conclusions: Programs should recognize power imbalances between genders that affect women's ability to meet their stated fertility desires. In rural areas, programs should target men, encouraging them to communicate with their wives on reproductive decisions.

Background: Smoking, diet, and lack of exercise are the top preventable causes of death in the United States. Some 23% of high school students currently smoke and many teens do not meet Healthy People 2010 standards for healthy eating or physical activity. This study examined the relationship between smoking and the consumption of fruit, vegetables, milk/dairy products and the frequency of exercise in 10,635 Virginia youth., Methods: Survey data were collected from middle school (MS; n = 8022) and high school (HS; n = 2613) adolescents participating in youth tobacco prevention/cessation programs. Data were analyzed using chi-square bivariate tests and multivariate regression models., Results: Smokers were significantly less likely than nonsmokers to exercise > or = 3x week and to consume > or = 1 serving/day of vegetables or milk/dairy products. This was more evident in high school than middle school students and in females compared to males. In both HS and MS, a dose-response relationship was detected with higher level smoking associated with lower frequency of eating specified food and exercise., Conclusions: Smoking is associated with compromised intake of healthy food and exercise. To decrease incident cases of chronic disease later in life, new tailored, innovative interventions are needed that address multiple health behaviors in youth.

In 1998, the Association Togolaise Pour le Bien Etre Familiale launched a youth centre in Lomé, Togo. To evaluate the centre, a three-year panel study was undertaken. Three years after being launched, about 10% of surveyed youth had visited the centre. Youth who lived close to the centre had contact with a peer educator and were exposed to television were more likely to have visited the youth centre than all others. Visiting the youth centre and having contact with a peer educator were associated with greater contraceptive use in the matched sample. Youth centre clinical users were younger, less likely to be married and less likely to have ever been pregnant than clinical users of other sites. The youth centre is meeting its goal of providing services to high-risk youth in Lomé. To increase youth centre access for all youth, it will be necessary to increase the number of youth centres.

Context: Unintended pregnancy is associated with poor health outcomes for mothers and infants, and is indicative of gaps in family planning services. Conventional measures of pregnancy intendedness do not reflect the multiple factors affecting a woman's pregnancy-related intentions and attitudes., Methods: Data collected between March 2002 and February 2003 from 701 women in a public family planning clinic and 671 women in a public prenatal clinic in New Orleans were analyzed to examine factors underlying intendedness (including attitudes toward pregnancy and motivations to achieve or avoid pregnancy)., Results: In factor analyses, variables measuring pregnancy intendedness were represented by a single latent factor, pregnancy desirability. For first pregnancy, variables that best captured desirability were those measuring happiness, effort in achieving the pregnancy, extent of looking forward to telling friends, whether the pregnancy was intended (i.e., came at the right time or later), and whether the woman wanted to have a baby with her partner. For last or current pregnancies that were second or higher order ones, they were happiness, pregnancy wantedness, effort in achieving the pregnancy, whether the pregnancy was planned and whether the woman wanted to have a baby with her partner. Among women younger than 18 at first pregnancy, happiness and whether a woman wanted a baby with her partner were the only items that captured pregnancy desirability., Conclusions: Future surveys on pregnancy intendedness could reduce the number of questions used to capture pregnancy desirability. This should help standardize surveillance systems and permit better assessment of trends in pregnancy desirability over time.

This study assesses the impact of the Prevention du SIDA sur les Axes Migratoires de l'Afrique de l'Ouest Roulez Protege mass media campaign in Burkina Faso on truckers' likelihood of talking with colleagues about HIV/AIDS, using condoms with an occasional sexual partner, and intending to use a condom in the future. A total of 764 and 1,032 truckers were interviewed in 1997 and 2000 along the Ouagadougou-Niangoloko trucking route. Truckers' exposure to the program has been high and the main message promoted has been greatly understood among those exposed. Logistic regression analyses suggest that the campaign did not have direct behavioral impacts. Exposure to radio spots and participation in group discussions were found to be significantly associated with truckers discussing AIDS with peers or reporting intentions to use a condom in the future. Exposure to Roulez Protege messages through television or billboards was not found to be significantly associated with interpersonal discussion or condom use intentions. Programs should seek to sustain and expand the indirect effects of these types of programs in West Africa. Reinforcing interpersonal counseling interventions should, down the road, lead to overall knowledge and behavior changes among the high-risk trucker population.

A population-based sample study of adolescent women and men from Lomé, Togo, was conducted to examine their responses to personal experiences with AIDS. Information was obtained on youth reproductive health knowledge, attitudes and practices, including attitudes towards HIV/AIDS and personal experience with AIDS. Multivariate results demonstrate that an important factor that distinguishes adolescent male condom users from non-users of condoms is the knowledge of someone who died of AIDS. Conversely, personal experience with AIDS was unrelated to reported condom use among adolescent women. The results illustrate that reproductive health programmes directed towards adolescents need to target men with messages different from women. Sexually active men respond to personal experience with AIDS by adopting condoms whereas women may have less control over condom use and have other strategies such as abstinence and fidelity to protect themselves from AIDS and unintended pregnancies.