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ObjectiveTo gain in-depth understanding of the caregiver experience when navigating urban immunisation services for their children.DesignAn exploratory qualitative assessment comprising 16 in-depth interviews using an interpretative phenomenology approach.SettingCaregivers were purposively recruited from slums (n=8) and other urban communities (n=8) in the capital city of Sierra Leone.ParticipantsCaregivers of children ages 6–36 months old who were fully vaccinated (n=8) or undervaccinated (n=8).ResultsEmotional enablers of vaccination were evident in caregivers’ sense of parental obligation to their children while also anticipating reciprocal benefits in children’s ability to take care of their parents later in life. Practical enablers were found in the diversity of immunisation reminders, information access, information trust, getting fathers more involved, positive experiences with health workers and postvaccination information sharing in the community. Underlying barriers to childhood vaccination were due to practical constraints such as overcrowding and long waiting times at the clinic, feeling disrespected by health workers, expecting to give money to health workers for free services and fear of serious vaccine side effects. To improve vaccination outcomes, caregivers desired more convenient and positive clinic experiences and deeper community engagement.ConclusionsHealth system interventions, community engagement and vaccination outreach need to be tailored for urban settings. Vaccine communication efforts may resonate more strongly with caregivers when vaccination is framed both around parental responsibilities to do the right thing for the child and the future benefits to the parent.

Introduction Experimental Ebola vaccines were introduced during the 2014–2015 Ebola outbreak in West Africa. Planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) was underway in late 2014. We examined hypothetical acceptability and perceptions of experimental Ebola vaccines among health care workers (HCWs), frontline workers, and the general public to guide ethical communication of risks and benefits of any experimental Ebola vaccine. Methods Between December 2014 and January 2015, we conducted in-depth interviews with public health leaders (N = 31), focus groups with HCWs and frontline workers (N = 20), and focus groups with members of the general public (N = 15) in Western Area Urban, Western Area Rural, Port Loko, Bombali, and Tonkolili districts. Themes were identified using qualitative content analysis. Results Across all participant groups, not knowing the immediate and long-term effects of an experimental Ebola vaccine was the most serious concern. Some respondents feared that experimental vaccines may cause Ebola, lead to death, or result in other adverse events. Among HCWs, not knowing the level of protection provided by experimental Ebola vaccines was another concern. HCWs and frontline workers were motivated to help find a vaccine for Ebola to help end the outbreak. General public participants cited positive experiences with routine childhood immunization in Sierra Leone. Discussion Our formative assessment prior to STRIVE’s implementation in Sierra Leone helped identify concerns, motivations, and information gaps among potential participants of an experimental Ebola vaccine trial, at the time when an unprecedented outbreak was occurring in the country. The findings from this assessment were incorporated early in the process to guide ethical communication of risks and benefits when discussing informed consent for possible participation in the vaccine trial that was launched later in 2015.

Quantitative and qualitative assessments have revealed diverse factors that influence the uptake of childhood immunisation services and shed light on reasons for vaccination delays and refusals. UNICEF and partner organisations developed the Immunisation Caregiver Journey Framework as a novel way to understand caregiver experiences in accessing and receiving immunisation services for children. This framework aims to help immunisation programmes identify vaccination barriers and opportunities to improve vaccination uptake by enhancing the overall caregiver journey in a systems-focused manner, using human-centred design principles. In this paper, we adapt the framework into a flexible qualitative inquiry approach with theoretical guidance from interpretative phenomenology. We draw from the implementation experiences in Sierra Leone to inform methodological guidance on how to design and implement the Immunisation Caregiver Journey Interviews (ICJI) to understand the lived experiences of caregivers as they navigate immunisation services for their children. Practical guidance is provided on sampling techniques, conducting interviews, data management, data analysis and the use of data to inform programmatic actions. When properly implemented, the ICJI approach generates a rich qualitative understanding of how caregivers navigate household and community dynamics, as well as primary healthcare delivery systems. We argue that understanding and improving the caregiver journey will enhance essential immunisation outcomes, such as the completion of the recommended vaccination schedule, timeliness of vaccination visits and reduction in dropouts between vaccine doses.

CDC recommends a number of mitigation behaviors to prevent the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Those behaviors include 1) covering the nose and mouth with a mask to protect others from possible infection when in public settings and when around persons who live outside of one's household or around ill household members; 2) maintaining at least 6 feet (2 meters) of distance from persons who live outside one's household, and keeping oneself distant from persons who are ill; and 3) washing hands often with soap and water for at least 20 seconds, or, if soap and water are not available, using hand sanitizer containing at least 60% alcohol (1). Age has been positively associated with mask use (2), although less is known about other recommended mitigation behaviors. Monitoring mitigation behaviors over the course of the pandemic can inform targeted communication and behavior modification strategies to slow the spread of COVID-19. The Data Foundation COVID Impact Survey collected nationally representative data on reported mitigation behaviors during April-June 2020 among adults in the United States aged ≥18 years (3). Reported use of face masks increased from 78% in April, to 83% in May, and reached 89% in June; however, other reported mitigation behaviors (e.g., hand washing, social distancing, and avoiding public or crowded places) declined marginally or remained unchanged. At each time point, the prevalence of reported mitigation behaviors was lowest among younger adults (aged 18-29 years) and highest among older adults (aged ≥60 years). Lower engagement in mitigation behaviors among younger adults might be one reason for the increased incidence of confirmed COVID-19 cases in this group, which have been shown to precede increases among those >60 years (4). These findings underscore the need to prioritize clear, targeted messaging and behavior modification interventions, especially for young adults, to encourage uptake and support maintenance of recommended mitigation behaviors to prevent the spread of COVID-19.

Introduction The WHO Regional Office for Europe developed the Guide to tailoring immunization programmes (TIP) , offering countries a process through which to diagnose barriers and motivators to vaccination in susceptible low vaccination coverage and design tailored interventions. A review of TIP implementation was conducted in the European Region. Material and methods The review was conducted during June to December 2016 by an external review committee and was based on visits in Bulgaria, Lithuania, Sweden and the United Kingdom that had conducted a TIP project; review of national and regional TIP documents and an online survey of the Member States in the WHO European Region that had not conducted a TIP project. A review committee workshop was held to formulate conclusions and recommendations. Results The review found the most commonly cited strengths of the TIP approach to be the social science research as well as the interdisciplinary approach and community engagement, enhancing the ability of programmes to “listen” and learn, to gain an understanding of community and individual perspectives. National immunization managers in the Region are generally aware that TIP exists and that there is strong demand for the type of research it addresses. Further work is needed to assist countries move towards implementable strategies based on the TIP findings, supported by an emphasis on enhanced local ownership; integrated diagnostic and intervention design; and follow-up meetings, advocacy and incentives for decision-makers to implement and invest in strategies. Conclusions Understanding the perspectives of susceptible and low-coverage populations is crucial to improving immunization programmes. TIP provides a framework that facilitated this in four countries. In the future, the purpose of TIP should go beyond identification of susceptible groups and diagnosis of challenges and ensure a stronger focus on the design of strategies and appropriate and effective interventions to ensure long-term change.

Background In November 2017, the World Health Organization received initial reports of suspected diphtheria cases in camps established for displaced Rohingyas in Cox’s Bazar district, Bangladesh. By January 11, 2018, over 4,000 suspected cases of diphtheria and 30 deaths were reported. The Bangladesh government and partners implemented a diphtheria vaccination campaign in December 2017. Outbreak response staff reported anecdotal evidence of vaccine hesitancy. Our assessment aimed to understand vaccination barriers and opportunities to enhance vaccine demand among displaced Rohingyas in Bangladesh. Methods In January 2018, we conducted a qualitative assessment consisting of nine focus group discussions and 15 key informant interviews with displaced Rohingyas in three camps. Participants included mothers and fathers with under five-year-old children, community volunteers, majhis (camp leaders), Islamic religious leaders, traditional and spiritual healers, and teachers. We recruited participants using purposive sampling, and analyzed the data thematically. Results Across focus groups and in-depth interviews, trusted information sources cited by participants included religious leaders, elders, village doctors, pharmacists, majhis, and mothers trained by non-governmental organizations to educate caregivers. Treatment of diphtheria and measles was usually sought from multiple sources including traditional and spiritual healers, village doctors, pharmacies, and health clinics. Major barriers to vaccination included: various beliefs about vaccination causing people to become Christian; concerns about multiple vaccines being received on the same day; worries about vaccination side effects; and, lack of sensitivity to cultural gender norms at the vaccination sites. Conclusion Although vaccination was understood as an important intervention to prevent childhood diseases, participants reported numerous barriers to vaccination. Strengthening vaccine demand and acceptance among displaced Rohingyas can be enhanced by improving vaccination delivery practices and engaging trusted leaders to address religious and cultural barriers using community-based channels.

Living with HIV, for many of those infected, has meant adjusting to life with a stigmatised condition and, until recently, the threat of looming death. We explore the adjustment of a group of long-term former clients of The AIDS Support Organisation (TASO) in Uganda who, when tested for HIV during the rollout of antiretroviral therapy in 2004, were found to be HIV negative. In-depth semi-structured interviews with 34 former TASO clients were conducted between 2005 and 2007. Their narratives reveal a great deal about the biographical disruption they have faced, and the biographical work that they have undertaken in both the personal and the social dimensions of their lives in order to manage their new-found HIV-uninfected status. After the negative test result, as they were no longer HIV-infected, they had to leave TASO and that support was sorely missed, as was the friendship of TASO members to whom they often felt reluctant to disclose their new status. The identity 'reversal' or change was often handled privately. Compared with their transition to an HIV-positive identity, they now lacked a social dimension to their identity transformation as they managed their new identity in the face of self- and public doubt.

Objective: To describe sexual behaviour trends in a rural Ugandan cohort in the context of an evolving HIV epidemic, 1993–2006. Methods: Sexual behaviour data were collected annually from a population cohort in which HIV serological surveys were also conducted. Behaviour trends were determined using survival analysis and logistic regression. Trends are reported based on the years in which the respective indicators were collected. Results: Between 1993 and 2006, median age at first sex increased from 16.7 years to 18.2 years among 17–20-year-old girls and from 18.5 years to 19.9 years among boys. Both sexes reported a dip in age at sexual debut between 1998 and 2001. One or more casual partners in the past 12 months among men rose from 11.6% in 1997 to 12.7% in 2004 and then declined to 10.2% in 2006. Among women it increased from 1.4% in 1997 to 3.7% in 2004 and then reduced to 1.4% in 2006. The rise in casual partners between 1997 and 2004 was driven mainly by older age groups. Trends in condom use with casual partners varied by age, increasing among those aged 35+ years, declining in the middle age groups and presenting a dip and then a rise in the youngest aged group (13–19 years). Conclusion: Among youth, risky behaviour declined but increased in the late 1990s/early 2000s. Among those aged 35+ years, condom use rose but casual partners also rose. Several indicators portrayed a temporary increase in risk taking behaviour from 1998 to 2002.

Much research on the impact of HIV and AIDS on older people fails to differentiate between age groups, and treats those aged from 50 years to the highest ages as homogeneous. The ‘oldest old’ or those aged over 75 years may be particularly vulnerable through declining health and independence as a result of the AIDS epidemic, which has forced some to take on roles that younger relatives would have performed had they lived. In this paper we describe the past and current experience of eight people in advanced old age living in rural Uganda who were informants for an ethnographic study of the impact of HIV and AIDS on households during 1991–92 and again in 2006–07. The aim of the study was to understand how they had coped with the impacts of the epidemic. From the eight case studies, it is concluded that family size, socio-economic status and some measure of good fortune in sustained good health enabled these people to live to an advanced age. While we recommend that targeted social protection is important in helping the poorest among the oldest, we suggest that sustaining respect for age and experience, and ensuring that older people do not feel discarded by family and society are as important as meeting their practical needs.

Limited research has been conducted outside Western settings on how HIV-positive parents decide to test and disclose their own HIV status to children. We conducted a qualitative study in 2001 and 2005 to assess parent attitudes and current counselling policy and practice regarding child testing and parental disclosure in Uganda prior to the roll-out of antiretroviral therapy. Parent perspectives were obtained through extended in-depth interviews with 10 HIV-positive parents recruited from The AIDS Support Organization (TASO) Entebbe branch. Counselling policy and practice were explored through key informant interviews with directors and two counsellors from each of five Ugandan counselling institutions with national or regional coverage. Respondents had 51 children ranging from 4 to 36 years with a median age of 13. Five of 10 parents had disclosed their status to their children usually to all and four of these had tested one child for HIV. All those who tested any child had also disclosed their status to some or all of their children. Parents regularly worried that their children may be infected but all preferred to wait for emergence of symptoms before considering HIV tests citing fear of childrens emotional reaction and lack of perceived benefits from knowing status. Counselling policy directors confirmed the absence of policy and training guidelines on the subject of parent-child disclosure. Counsellors reported improvising and giving inconsistent advice on this common concern of clients. Concerns over disclosure to children of parents HIV status and testing children for HIV represent a major psychological burden for HIV-positive parents. Further research is needed but current counselling practice could be improved now by adapting lessons learned from existing research. (authors)

Summary.A characteristic of African pre-transitional fertility regimes is large ideal family size. This has been used to support claims of cultural entrenchment of high fertility. Yet in Kenya fertility rates have fallen. In this paper this fall is explored in relation to trends in fertility norms and attitudes using four sequential cross-sectional surveys spanning the fertility transition in Kenya (1978, 1984, 1989 and 1998). The most rapid fall in the reported ideal family size occurred between 1984 and 1989, whilst the most rapid fall in the total fertility rate occurred 5 to 10 years later, between 1989 and 1998. Thus these data, spanning the fertility transition in Kenya, support the traditional demographic model that demand for fertility limitation drives fertility decline. These data also suggest that the decline in fertility norms over time was partly a period effect, as the reported ideal family size was seen to fall simultaneously in all age cohorts, and partly a cohort effect, as older age cohorts reporting higher ideal family sizes were replaced by younger cohorts reporting lower ideal family sizes. These data also suggest that a new fertility norm of four children may have developed by 1989 and continued until 1998. This is consistent with, and perhaps could have been used to predict, the stall in the Kenyan fertility decline after 1998.

Given improvements in the transport infrastructure and the end of travel restrictions characteristic of the apartheid period, there could be a reasonable expectation that male risk behaviour in sex ...

Women's ability to negotiate the timing and conditions of sex with their partners is central to their ability to control a variety of reproductive health outcomes. Focus group discussions and survey data from 1356 women and their regular male partners in two districts in Uganda were analysed to explore the nature of sexual negotiation and to test hypotheses about the influence of women's work and marriage institutions on norms and behaviour regarding sexual decision making. Sexual negotiation is characterized by four stages starting with normative precedent for decision making about sex and progressing to communication, disagreement, and conflict resolution. Men are generally reported to have more influence over sex in these settings, but women can and do refuse sex under a variety of circumstances. Education and urban residence consistently enhance women's ability to negotiate sex. The effect of marriage and women's work characteristics depends strongly on district context. We speculate that certain type...

Living with HIV, for many of those infected, has meant adjusting to life with a stigmatised condition and, until recently, the threat of looming death. We explore the adjustment of a group of long-term former clients of The AIDS Support Organisation (TASO) in Uganda who, when tested for HIV during the rollout of antiretroviral therapy in 2004, were found to be HIV negative. In-depth semi-structured interviews with 34 former TASO clients were conducted between 2005 and 2007. Their narratives reveal a great deal about the biographical disruption they have faced, and the biographical work that they have undertaken in both the personal and the social dimensions of their lives in order to manage their new-found HIV-uninfected status. After the negative test result, as they were no longer HIV-infected, they had to leave TASO and that support was sorely missed, as was the friendship of TASO members to whom they often felt reluctant to disclose their new status. The identity 'reversal' or change was often handled privately. Compared with their transition to an HIV-positive identity, they now lacked a social dimension to their identity transformation as they managed their new identity in the face of self- and public doubt.

People living with HIV who are taking antiretroviral therapy (ART) are increasingly involved in 'positive prevention' initiatives. These are generally oriented to promoting abstinence, 'being faithful' (partner reduction) and condom use (ABC). We conducted a longitudinal qualitative study with people living with HIV using ART, who were provided with adherence education and counselling support by a Ugandan non-governmental organisation, The AIDS Support Organisation (TASO). Forty people were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic- or home-based) and HIV progression stage (early or advanced) and interviewed at enrollment and at 3, 6, 18 and 30 months. At initiation of ART, participants agreed to follow TASO's positive-living recommendations. Initially poor health prevented sexual activity. As health improved, participants prioritised resuming economic production and support for their children. With further improvements, sexual desire resurfaced and people in relationships cemented these via sex. The findings highlight the limitations of HIV prevention based on medical care/personal counselling. As ART leads to health improvements, social norms, economic needs and sexual desires increasingly influence sexual behaviour. Positive prevention interventions need to seek to modify normative and economic influences on sexual behaviour, as well as to provide alternatives to condoms.

Adherence at the earliest stages of treatment is likely to be influenced by prior illness trajectories and future expectations, best captured (and addressed) before treatment begins. We examined the influence of illness trajectories and treatment expectations on psychosocial readiness to start antiretroviral therapy (ART) in Jinja, Uganda. In-depth interviews were conducted between October 2005 and April 2006 with 41 members of an AIDS support organisation on their first day of treatment. Transcribed texts were translated, coded and analysed thematically using NVIVO-7 software. Results indicated that acute fear of death and progressive withdrawal from social, economic and sexual roles narrowed focus on survival, while efficacy-enhancing experiences with septrin prophylaxis and trust in counsellors reinforced belief in HIV diagnosis and importance of adherence. Most enjoyed supportive home environments after disclosing their serostatus. Lack of money for food and transport was anticipated as the main barriers to future adherence, particularly among women. Integrating strong counselling support with ART provision helped channel the power of shared illness experience into positive motivation to adhere at the onset of treatment.Keywords: HIV, antiretroviral therapy, adherence, qualitative, Africa.

The aims were to investigate community perceptions about the different relationship between alcohol consumption and sexual risk-taking for men and women in a high HIV prevalence African setting. Participatory learning and action (PLA) activities were conducted in five rural villages in south-western Uganda in 2002. For each village discussions and visualization activities over the course of 5 days explored local concepts of fun drinking alcohol and HIV-related behavioural risks. Twelve focus group discussions (FGDs) investigated emerging themes. Analysis is based on visual outputs observation notes and focus group transcripts. Attendance at sex-segregated PLA sessions was open to all village residents. FGDs were purposively sampled from drinkers and general population groups. For men drinking is conducted invariably outside the home usually at night in bars emphasizing independence masculinity and freedom from domestic responsibilities. For women drinking outside male supervision challenges feminine ideals of domesticity and signifies potential sexual vulnerability. Accepting drinks from men was viewed as signifying assent to sex and refusal could justify men resorting to sexual coercion. Even though drinking is seen to promote sexual risk HIV prevention campaigns were considered unwelcome in bars. Communities preferred seminars involving drinkers and non-drinkers alike. Public drinking in this community serves as a marker for men willing to exercise privileges of independence (sexual and otherwise) and women willing to defy gender norms (and risk the sexual consequences). The social and symbolic context of drinking suggests why effective HIV prevention around alcohol should not be limited to drinking environments alone. (authors)

Market trading requires access to cash, independent decision-making, mobility and social interaction. This study sought to explore whether market work empowers women with respect to spending decisions and negotiation over sex and condom-use. A semi-structured questionnaire was administered to 212 market women; and 12 focus group discussions and 52 in-depths interviews were conducted among market women in southwestern Uganda. Market women reported high levels of independence, mobility, assertiveness and social interaction. Access to cash was not synonymous with control over it, however. Spending decisions were limited by men's ability to selectively withdraw finances for expenditures central to women's concerns including household and children's needs. Trading in markets earns women masculine labels such as kiwagi, characterized variously as independent, rebellious and insubordinate. Earning money does not change expectations of correct behaviour for wives, making it difficult for women to initiate, deny sex or ask for condoms. Independence and income from market work may make it easier for women to enter and exit new sexual relationships. However, unable to protect themselves within partnerships, HIV risk may increase as a result.

BACKGROUND Uptake of HIV test results from an annual serosurvey of a population study cohort in rural southwestern Uganda had never exceeded 10% in any given year since inception in 1989. An intervention offering counselling and HIV results at home was conducted in four study villages following the 2001 serosurvey round, and followed by a qualitative evaluation exploring nature of demand and barriers to knowing HIV status. METHODS Data from annual serosurveys and counsellor records are analyzed to estimate the impact of the intervention on uptake of HIV test results. Textual data are analyzed from 21 focus group discussions among counsellors, and men and women who had received HIV test results, requested but not yet received, and never requested; and 34 in-depth interviews equally divided among those who had received test results either from counselling offices and homes. RESULTS Offering HIV results at home significantly increased uptake of results from 10 to 37% for all adults aged 15 (p

This study uses survey and focus-group data from the 1995-96 Negotiating Reproductive Outcomes study in Uganda to describe the nature of the decision to stop childbearing and to question the simplifying assumption of consensus decision-making implicit in much demographic research on unmet need. Negotiation is characterized in four stages, from normative precedent for decision-making to communication, disagreement, and conflict resolution. Indirect forms of communication between partners predominate, contributing to the tendency of both men and women to overestimate each other's demand for additional children. Partner opposition is found to cause a statistically significant increase in unmet need reported by women and a shift in contraceptive mix favoring use of traditional methods over modern methods. For women, partner opposition may account for as much as 20 percent of unmet need in urban areas, 12 percent in rural areas, and 15 percent overall.

Background People living with HIV (PLHIV) taking ART are increasingly involved in positive prevention" initiatives. These are generally oriented to promoting Abstinence, “Being faithful” (partner reduction) and condom use. Methods We conducted a longitudinal qualitative study with PLHIV using ART, who were provided with adherence education and counselling support by a Ugandan non-governmental organisation, The AIDS Service Organisation (TASO). Participants were 40 people selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic- or home-based), and HIV progression stage (early or advanced). At enrolment and 3, 6, 18 and 30 months, semi-structured interviews and home observation visits explored adherence and life changes. Results At initiation of ART, participants agreed to follow TASO9s positive-living (similar to ABC) recommendations. Initially poor health prevented sexual activity. As health improved, participants prioritised resuming economic production and support for their children. With further improvements, sexual desire resurfaced and people in relationships cemented these via sex. Married male participants were able to use condoms with their wives, but married female participants were unable to assure consistent condom use despite serostatus disclosure to their husbands. Several participants sought and some obtained HIV positive partners (serosorting) for emotional security, support in ART adherence, sexual fulfilment, avoidance of stigma and sometimes parenthood. Respondents used condoms in the early period of new relationships, but several did not disclose HIV status to partners at first. Male partners of female respondents stopped using condoms after a variable initial period. This contributed to continued non-disclosure, since the women feared violence or loss of economic security from disclosure. Conclusion Positive prevention interventions continue to concentrate on behavioural outcomes and education and counselling approaches. Our findings show that, as ART leads to health improvements, gender norms, economic needs, sexual desires and a wish for “normalisation” of social roles and relationships increasingly influence sexual behaviour. Positive Health, Dignity and Prevention require combinations of appropriate biological, behavioural and structural interventions tailored to the economic and cultural milieu and informed by an appreciation of the human rights of PLHIV.

Based on a survey of couples in long-term unions in Masaka and Lira districts in Uganda, we critically examine the role of gender inequality in the domain of decision-making about fertility and sex in the discussion and use of condoms. First, we document the sexual context and process of condom negotiation from the perspectives of women and men. Next, we test the hypothesis that increases in the relative influence of women, compared to their male partners, in decision-making about sex and fertility should enhance the likelihood of discussion and use of condoms. The result point to barriers that exist for both men and women but show a clear disadvantage for women. They also suggest that, for both partners, a sense of control over fertility has a positive effect on condom use, and that the effect of women's empowerment does not seem to diminish the effect of men's empowerment.

The Negotiating Reproductive Outcomes study was conducted in the Masaka and Lira districts of Uganda to determine: how reproductive decisions and outcomes are negotiated within sexual unions; which individual household and community characteristics influence negotiation; and how womens status influences their ability to negotiate outcomes. Data collection began in January 1995 and involved a focus group and a survey of 1750 women 20-44 years old and 1356 of their male partners. Separate estimates were made for rural and urban areas within each district. The first chapter of this report provides background information on the study objectives and methodology. Chapter 2 describes the socioeconomic context in the districts. Chapter 3 presents results about negotiating contraceptive use in terms of current knowledge and use reasons for use and nonuse negotiating family planning (FP) with partner and others and concurrence and secret use. Chapter 4 covers negotiations about the number and spacing of children including the ideal number of children and sex balance discussions about spacing and limiting with others nonverbal negotiation evolution of preferences and resolution of conflict. Chapter 5 discusses negotiation of sexual behavior and condom use through a look at sexual norms communication about sex negotiating sex knowledge of AIDS prevention and negotiating condom use. Major conclusions are that couples do negotiate reproductive outcomes that much communication is nonverbal and subject to misinterpretation that men want FP because of economic concerns whereas women also have health concerns and that womens vulnerable status curtails their ability to negotiate and gives men greater authority over reproductive decisions.