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This study was undertaken to evaluate the effect of a reproductive empowerment contraceptive counselling intervention (ARCHES) adapted to private clinics in Nairobi, Kenya on proximal outcomes of contraceptive use and covert use, self-efficacy, awareness and use of intimate partner violence (IPV) survivor services, and attitudes justifying reproductive coercion (RC) and IPV. We conducted a cluster-controlled trial among female family planning patients (N = 659) in six private clinics non-randomly assigned to ARCHES or control in and around Nairobi, Kenya. Patients completed interviews immediately before (baseline) and after (exit) treatment and at three- and six-month follow-up. We use inverse probability by treatment weighting (IPTW) applied to difference-in-differences marginal structural models to estimate the treatment effect using a modified intent-to-treat approach. After IPTW, women receiving ARCHES contraceptive counselling, relative to controls, were more likely to receive a contraceptive method at exit (86% vs. 75%, p

BackgroundNiger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing and high gender inequity. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronized social behavioral intervention designed to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Niger.MethodsWe conducted a four-armed cluster-randomized trial in 48 villages across three districts in Dosso region, Niger. Married adolescent girls (ages 13-19) and their husbands were recruited within selected villages. Intervention arms included home visits by gender-matched community health workers (CHWs) (Arm 1), gender-segregated, group discussion sessions (Arm 2), and both approaches (Arm 3). We used multilevel mixed-effects Poisson regression models to assess intervention effects for our primary outcome, current modern contraceptive use, and our secondary outcome, past year IPV.ResultsBaseline and 24-month follow-up data were collected April-June 2016 and April-June 2018. At baseline, 1072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1080 husbands were interviewed (88% participation), with 72% retention at follow-up. Adolescent wives had higher likelihood of modern contraceptive use at follow-up relative to controls in Arm 1 (aIRR 3.65, 95% CI 1.41-8.78) and Arm 3 (aIRR 2.99, 95% CI 1.68-5.32); no Arm 2 effects were observed. Relative to those in the control arm, Arm 2 and Arm 3 participants were significantly less likely to report past year IPV (aIRR 0.40, 95% CI 0.18-0.88 for Arm 2; aIRR 0.46, 95% CI 0.21-1.01 for Arm 3). No Arm 1 effects were observed.ConclusionsThe RMA approach blending home visits by CHWs and gender-segregated group discussion sessions is the optimal format for increasing modern contraceptive use and decreasing IPV among married adolescents in Niger. Trial registration This trial is retrospectively registered with ClinicalTrials.gov, Identifier NCT03226730.

BackgroundThe field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms.MethodsUsing an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019.ResultsA two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence.ConclusionsThis brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

In India, traditional social practices around marriage, such as non-involvement of prospective brides in choice of partner and timing of marriage, child/early marriage, dowry and purdah, compromise womens agency at the time of marriage and may also affect contraceptive practices in marriage. This paper examines the associations between traditional marital practices and contraceptive behaviours, including womens control over contraceptive decision-making, couples communication about contraception, and ever use of contraceptives, among married women aged 18-29 years (N = 1,200) and their husbands in rural Maharashtra, India. Multivariable logistic regression was used to examine the association between these marginalising social practices and family planning behavioural outcomes, adjusting for demographic and parity confounders. Wives who were the primary decision-makers on who to marry had higher odds of ever having communicated with their husband on pregnancy prevention (AOR 1.76, 95% CI 1.16-2.68), and ever using modern contraceptives (AOR 2.19, 95% CI 1.52-3.16). Wives who were the primary decision-makers on when to marry also had higher odds of ever having used modern contraceptives (AOR 1.86, 95% CI 1.21-2.93). Womens involvement in marital choice may facilitate couples engagement related to family planning, possibly via the establishment of better communication between partners.

Social norms related to fertility may be driving pregnancy desire, timing and contraceptive use, but measurement has lagged. We validated a 10-item injunctive Fertility Norms Scale (FNS) and examined its associations with family planning outcomes among 1021 women and 1020 men in India. FNS captured expectations around pronatalism, childbearing early in marriage and community pressure. We assessed reliability and construct validity through Cronbachs alpha and exploratory factor analysis (EFA) respectively, examining associations with childbearing intention and contraceptive use. FNS demonstrated good reliability (α = 0.65-0.71) and differing sub-constructs by gender. High fertility norm among women was associated with greater likelihood of pregnancy intention [RRR = 2.35 (95% CI: 1.25,4.39); ARRR = 1.53 (95% CI: 0.70,3.30)], lower likelihood of delaying pregnancy [RRR = 0.69 (95% CI: 0.50,0.96); ARRR = 0.72 (95% CI: 0.51,1.02)] and greater ambivalence on delaying pregnancy [RRR = 1.92 (95% CI: 1.18,3.14); ARRR = 1.99 (95% CI: 1.21,3.28)]. Womens higher FNS scores were also associated with higher sterilization [RRR = 2.17 (95% CI: 1.28,3.66); ARRR = 2.24 (95% CI: 1.32,3.83)], but the reverse was noted for men [RRR = 0.61 (95% CI: 0.36,1.04); ARRR = 0.54 (95% CI: 0.32,0.94)]. FNS indicated better predictive value among women compared to men for key reproductive outcomes. This measure may be useful for social norms-focused evaluations in family planning and warrants cross-contextual study.

OBJECTIVES: The CHARM2 (Counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) intervention engages health care providers to deliver gender-equity and family planning sessions to couples using a person-centered shared decision-making approach for contraception counseling. We previously showed that the intervention improved contraceptive use at 9-month follow-up. We sought to assess whether the intervention was further associated with the quality of care reported by participants and whether the quality of care reported mediated the effect of the intervention on contraceptive use. STUDY DESIGN: This is a planned secondary analysis of the effect of the CHARM2 intervention on 1201 married couples in rural Maharashtra, India in a cluster randomized controlled trial completed between 2018 and 2020. We assessed the effect of CHARM2 on perceived quality of care as measured by the Interpersonal Quality of Family Planning (IQFP) scale using a difference-in-differences linear regression approach including a mixed-effects model with nested random effects to account for clustering. We assessed whether the association between CHARM2 and modern contraceptive use was mediated by quality of family planning care. RESULTS: Intervention participants had higher mean IQFP scores than control participants at 9-month follow-up (intervention 3.2, SD 0.6 vs. control 2.3 mean, SD 0.9, p < 0.001). The quality of care reported mediated the effect of the intervention on contraceptive use (indirect effect coefficient 0.29, 95% CI 0.07-0.50). CONCLUSION: Family planning interventions such as CHARM2, which utilize person-centered shared decision-making contraceptive counseling approaches improve womens perceived quality of care. Effects on quality of care mediate observed effects of the intervention on contraceptive use. IMPLICATIONS: Contraceptive interventions should focus on improving person-centered outcomes, such as quality of care, rather than contraceptive use targets. By focusing on improving person-centered care, interventions will improve contraceptive use among those who desire a method while meeting the holistic reproductive health needs of clients and couples.

Research on discrimination and risks for violence and mental health issues under the pandemic is notably absent. We examined the relative effects of perceived everyday discrimination (e.g., poorer service, disrespectful treatment in a typical week) and major experiences of race-based discrimination (e.g., racial/ethnic discrimination in housing or employment at any point in the lifetime) on experiences of violence and the PHQ-4 assessment of symptoms of depression and anxiety under the pandemic. We analyzed state-representative cross-sectional survey data from California adults (N = 2114) collected in March 2021. We conducted multivariate regression models adjusting for age, race/ethnicity, gender, sexual identity, income, and disability. One in four Californians (26.1%) experienced everyday discrimination in public spaces, due most often to race/ethnicity and gender. We found that everyday discrimination was significantly associated with past year physical violence (single form Adjusted Odds Ratio [AOR] 5.0, 95% CI 2.5-10.3; multiple forms AOR 2.6, 95% CI 1.1-5.8), past year sexual violence (multiple forms AOR 2.5, 95% CI 1.4-4.4), and mental health symptoms (e.g., severe symptoms, multiple forms AOR 3.3, 95% CI 1.6-6.7). Major experiences of race-based discrimination (reported by 10.0% of Californians) were associated with past year sexual violence (AOR 2.0, 95% CI 1.1-3.8) and severe mental health symptoms (AOR 2.7, 95% CI 1.2-6.2). Non-race-based major discrimination (reported by 23.9% of Californians) was also associated with violence and mental health outcomes Everyday discrimination, more than major experiences of discrimination, was associated with higher risk for violence and poor mental health outcomes during the pandemic. Non-race-based forms of major discrimination independently were also associated with these negative outcomes. Findings indicate that efforts to reduce and ultimately eliminate discrimination should be a focus of public health and COVID-19 rebuilding efforts.

Womens contraceptive decision-making control is crucial for reproductive autonomy, but research largely relies on the Demographic and Health Survey (DHS) measure which asks who is involved with decision-making. In India, this typically assesses joint decision-making or male engagement. Newer measures emphasize female agency. We examined three measures of contraceptive decision-making, the DHS and two agency-focused measures, to assess their associations with marital contraceptive communication and use in rural Maharashtra, India. We analyzed follow-up survey data from women participating in the CHARM2 study (n = 1088), collected in June-December 2020. The survey included the DHS (measure 1), Reproductive Decision-Making Agency (measure 2), and Contraceptive Final Decision-Maker measures (measure 3). Only Measure 1 was significantly associated with contraceptive communication (adjusted odds ratio [AOR]: 2.75, 95 percent confidence interval [CI]: 1.69-4.49) and use (AOR: 1.73, 95 percent CI: 1.14-2.63). However, each measure was associated with different types of contraceptive use: Measure 1 with condom (adjusted relative risk ratio [aRRR]: 1.99, 95 percent CI: 1.12-3.51) and intrauterine device (IUD) (aRRR: 4.76, 95 percent CI: 1.80-12.59), Measure 2 with IUD (aRRR: 1.64, 95 percent CI: 1.04-2.60), and Measure 3 with pill (aRRR: 2.00, 95 percent CI: 1.14-3.52). Among married women in Maharashtra, India, male engagement in decision-making may be a stronger predictor of contraceptive communication and use than womens agency, but agency may be predictive of types of contraceptives used.

Unmet need for family planning (FP) continues to be high in India, especially among young and newly married women. Mothers-in-law (MILs) often exert pressure on couples for fertility and control decision making and behaviors around fertility and FP, yet there is a paucity of literature to understand their perspectives. Ten focus group discussions (FGDs) were carried out with MILs of young married women (aged 18-29 years) participating in a couple-focused FP intervention as a part of a cluster-randomized intervention evaluation trial (the CHARM2 study) in rural Maharashtra, India. FGDs included questions on their roles, attitudes, and decision making around fertility and FP. Audio-recorded data were translated/transcribed into English and analyzed for key themes using a deductive coding method. MILs reported having social norms of early fertility and son preference. They understood that family size norms are lower among daughters-in-law and that spacing can be beneficial but were not supportive of short-term contraceptives, especially before the first child. They preferred female sterilization, opposed abortion, had apprehensions around side effects from contraceptive use, and had misconceptions about the intrauterine device, with particular concerns around its coercive insertion. MILs mostly believed that decision making should be done jointly by a husband and wife, but that as elders, they should be consulted and involved in the decision-making process. These findings highlight the need for engagement of MILs for FP promotion in rural India and the potential utility of social norms interventions.

BackgroundDespite calls for gender transformative family planning interventions to increase male engagement and female reproductive agency, there is limited research involving rigorous evaluation of the integration of these approaches. CHARM2 (counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) builds upon a prior three-session male engagement intervention by integrating female-focused sessions emphasizing women's choice and agency (i.e., gender synchronization). We hypothesized that CHARM2 participants will be more likely to report marital contraceptive use and communication and women's contraceptive agency, and less likely to report unintended pregnancy, relative to participants in the control condition.MethodsWe conducted a two-armed cluster randomized controlled trial evaluating the effects of CHARM2 on marital contraceptive use, communication, decision-making; women's contraceptive agency, and pregnancy among young married couples in rural Maharashtra, India (ClinicalTrials.gov #NCT03514914, complete). 40 geographic clusters, defined based on the catchment areas of subcenter health facilities (the most proximal level of community health care within India's public health system) were randomized to control (n = 20) and intervention (n = 20). We assigned all participants within that geographic cluster to the corresponding cluster treatment condition; participants, investigators, and study staff were not masked to treatment assignment. Eligibility criteria included wife aged 18-29, couple residing together for at least six months with no plan for migration, and neither spouse sterilized or infertile. The CHARM2 intervention included five provider-delivered sessions on gender equity and family planning, two delivered in parallel to husbands and wives separately by gender-matched providers, and one final joint session, delivered within the four months subsequent to baseline survey. We conducted surveys and pregnancy testing at baseline and 9-month and 18-month follow-up. We used difference-in-differences multilevel mixed effects logistic regressions to assess CHARM2 effects on marital contraceptive use and communication, and women's contraceptive agency; we used single time point mixed effects logistic regressions for pregnancy outcomes. All analyses used an intention-to-treat approach.Findings1201 couples were recruited between September 2018 and June 2019; 600 intervention and 601 control. All couples were included in outcome analyses. Full couple retention was 90·2% (n = 1083) at 9-month follow-up and 90·5% (n = 1087) at 18-month follow-up. Modern contraceptive use was higher among intervention participants at 9-month but not 18-month follow-up (9-month adjusted ratio of odds ratio [AROR] 1·5, 95% CI 1·03-2·3; 18-month AROR 0·8, 95% CI 0·4-1·4). Communication (9-month AROR 1·9, 95% CI 1·0-3·6; 18-month AROR 2·7, 95% CI 1·5-4·8) and agency (9-month AROR 5·1, 95% CI 1·2-22·4; 18-month AROR 8·1, 95% CI 1·4-48·2) both improved at both time points. There was no significant difference in pregnancy between groups over the 18-month period (AOR 0·8, 95% CI 0·7-1.1) However, for women who expressed fertility ambivalence at baseline, unintended pregnancy was marginally less likely among intervention participants (47% vs 19%) (p = 0·07). There were no reported adverse events.InterpretationThe CHARM2 intervention offers a scalable model to improve contraceptive use, communication, and agency and possibly decrease unplanned pregnancies for couples in rural India.

Bullying of sexual minorities in the United States is common and often begins in middle and high school, yet research that examines sexual harassment of sexual minorities is limited. This study examines whether sexual minorities are more likely than straight people to (a) report sexual harassment and (b) report sexual harassment as adolescents at middle or high school. We analyzed survey data from a cross-sectional study of sexual harassment and assault, conducted with nationally representative samples of adults in 2019 (N = 2,205). Sexual harassment was categorized as non-physically aggressive sexual harassment only (NPSH; e.g., verbal or cyber harassment), physically aggressive sexual harassment (PSH; e.g., stalking, rubbing up against you; with or without NPSH), sexual assault (SA; i.e., forced sex; with or without NPSH or PSH), or no sexual harassment (none). In total, 6% of female and male respondents identified as a sexual minority. A history of sexual harassment or assault was reported by 95.0% of sexual minority women and 80.3% of straight women (p = .001), and by 77.3% of sexual minority men and 41.3% of straight men (p = .001). Multivariable multinomial models demonstrate that sexual minorities were more likely than straight individuals to report NPSH (Adjusted Odds Ratio [AOR] = 2.88, 95% [Confidence Interval] CI = [1.33, 6.20]), PSH (AOR = 4.15, 95% CI: [1.77, 9.77]), and SA (AOR = 5.48, 95% CI = [2.56, 11.73]; reference group: no harassment), as well as to report PSH (AOR = 2.67, 95% CI = [1.30, 5.47]) at school in middle or high school. These abuses demonstrate increased risk for sexual harassment among sexual minorities, including increased risk for physically aggressive sexual harassment when in middle and high school.

Much of the research on intimate partner violence (IPV) documents the negative impacts of violence on women, which are substantial. Less attention has been given to perceptions of the marital relationship given these experiences of violence. However, evidence suggests that many women affected by IPV within marriage remain in their relationships, particularly in contexts such as India, where divorce remains highly stigmatized. Understanding and supporting marital quality may need greater prioritization to support women who remain in relationships affected by violence. This study examines the association between IPV and marital quality among young married couples in rural India. We interviewed 1084 women and 1084 men at two time points (baseline, 18 months) in a western state in India and used multilevel mixed effects models to test the association between IPV and marital quality. We found that women's experience of physical and sexual IPV was associated with poor marital quality at 18 months. Women's experience of sexual IPV was also negatively associated with men's self-reported marital quality at 18 months. Among men, spouse's marital quality was positively associated with their own rating of marital quality. We also examined the reciprocal relationship between IPV and marital quality and found that women's report of poor marital quality was associated with their future experience of physical IPV, sexual IPV, and emotional IPV. Taken together, these findings suggest that IPV interventions need to target marital quality to be effective. To do this, we would need to shift our lens from empowering individuals to empowering couples to work together to improve their relationships., Author(s): Sangeeta Chatterji [sup.1] , Nicole Johns [sup.1] , Mohan Ghule [sup.1] , Shahina Begum [sup.2] , Sarah Averbach [sup.1] [sup.3] , Madhusudan Battala [sup.4] , Anita Raj [sup.1] Author [...]

Bullying of sexual minorities in the United States is common and often begins in middle and high school, yet research that examines sexual harassment of sexual minorities is limited. This study examines whether sexual minorities are more likely than straight people to (a) report sexual harassment and (b) report sexual harassment as adolescents at middle or high school. We analyzed survey data from a cross-sectional study of sexual harassment and assault, conducted with nationally representative samples of adults in 2019 (N = 2,205). Sexual harassment was categorized as non-physically aggressive sexual harassment only (NPSH; e.g., verbal or cyber harassment), physically aggressive sexual harassment (PSH; e.g., stalking, rubbing up against you; with or without NPSH), sexual assault (SA; i.e., forced sex; with or without NPSH or PSH), or no sexual harassment (none). In total, 6% of female and male respondents identified as a sexual minority. A history of sexual harassment or assault was reported by 95.0% of sexual minority women and 80.3% of straight women (p = .001), and by 77.3% of sexual minority men and 41.3% of straight men (p = .001). Multivariable multinomial models demonstrate that sexual minorities were more likely than straight individuals to report NPSH (Adjusted Odds Ratio [AOR] = 2.88, 95% [Confidence Interval] CI = [1.33, 6.20]), PSH (AOR = 4.15, 95% CI: [1.77, 9.77]), and SA (AOR = 5.48, 95% CI = [2.56, 11.73]; reference group: no harassment), as well as to report PSH (AOR = 2.67, 95% CI = [1.30, 5.47]) at school in middle or high school. These abuses demonstrate increased risk for sexual harassment among sexual minorities, including increased risk for physically aggressive sexual harassment when in middle and high school.

OBJECTIVE: The purpose of this analysis was to compare and contrast reproductive health (RH), gender equity attitudes, and intimate partner violence (IPV) among married very young adolescent (VYA) girls with married older adolescent girls and young women (AGYW) in rural Niger given limited literature on the topic. METHODS: We conducted an exploratory analysis of baseline data from the Reaching Married Adolescents Trial in Dosso region, Niger. We report counts and percents, by age group (13-14 years (VYA), 15-16 years, 17-19 years), of AGYWs self-efficacy to use family planning (FP), accurate knowledge of FP, current use of modern FP, and unintended last pregnancy (UIP); lifetime reproductive coercion (RC), physical IPV, and sexual IPV; and gender equity attitudes. We also assess whether percents differ between VYA and older groups using Pearsons Chi-Square and Fishers exact p-values. Results are stratified by parity. Finally, we use logistic regression to consider associations. RESULTS: There were 49 VYA, 248 girls aged 15-16, and 775 AGYW aged 17-19 in our sample (n = 1072). Accurate knowledge of FP, self-efficacy to use FP, current use of modern FP, and UIP increased with age; all percents between VYA and AGYW 17-19 were marginally or statistically significantly different. We also saw VYA report higher lifetime RC and sexual IPV versus older groups, with sexual IPV statistically different between VYA and girls 17-19. Parous VYA reported a significantly higher percent of lifetime RC versus older AGYW. Among 17-19 year-olds, odds of current use of FP were higher among AGYW who reported physical IPV, and odds of UIP were higher among those reporting more gender equitable attitudes, both adjusted for parity. CONCLUSIONS: We observed differences in RH, RC, and sexual IPV among married VYA and older AGYW in rural Niger. VYA should be prioritized in research to confirm and further understand their RH needs.

ObjectivesThe provision of high-quality family planning (FP) counseling can both enhance clients' experience of care and improve their ability to make and act on their contraceptive decisions. The Interpersonal Quality of Family Planning (IQFP) scale measures FP counseling quality and has been validated in the United States. We aimed to explore whether it remains appropriate for use in a low-/middle-income country (LMIC).Study designWe surveyed 1201 nonsterilized married women ages 18-29 in Maharashtra, India, between September 2018 and June 2019. Respondents rated their FP provider from "poor" (1) to "excellent" (5) across 11 IQFP items. We assessed scale reliability via Cronbach's α test and used exploratory factor analysis to evaluate unidimensionality and regression models of plausibly related outcomes to assess construct validity.ResultsFive hundred four women (42%) had seen an FP provider within the past year, 491 (97%) of whom answered all items. Mean IQFP score was 2.62 out of 5 (SD 0.94, range 1-5). Scale reliability was high (α = 0.97). Exploratory factor analyses support unidimensionality (all factor loadings > 0.4). A 1-point increase in average IQFP score was associated with nearly double the odds of current modern contraceptive use (adjusted odds ratio = 1.73, 95% confidence interval = 1.36-2.19).ConclusionsThe IQFP scale shows good reliability and construct validity in this context, and its use in LMIC settings should be broadly considered. A higher IQFP score was associated with greater odds of contraceptive use. The reported FP counseling quality was low, so future public health efforts should aim to increase counseling quality to better meet the needs of women in low-resource settings like rural India. Measurement tools like IQFP can support success evaluation of the quality of care provided by family planning programs.ImplicationsThe Interpersonal Quality of Family Planning scale is a useful tool in rural India, a different context than the one in which it was developed. Use of the IQFP scale should be considered in other low-/middle-income countries to better measure the quality of family planning care provided.

BackgroundTo estimate the proportion of pregnant women in Louisiana who do not obtain abortions because Medicaid does not cover abortion.MethodsTwo hundred sixty nine women presenting at first prenatal visits in Southern Louisiana, 2015-2017, completed self-administered iPad surveys and structured interviews. Women reporting having considered abortion were asked whether Medicaid not paying for abortion was a reason they had not had an abortion. Using study data and published estimates of births, abortions, and Medicaid-covered births in Louisiana, we projected the proportion of Medicaid births that would instead be abortions if Medicaid covered abortion in Louisiana.Results28% considered abortion. Among women with Medicaid, 7.2% [95% CI 4.1-12.3] reported Medicaid not paying as a reason they did not have an abortion. Existing estimates suggest 10% of Louisiana pregnancies end in abortion. If Medicaid covered abortion, this would increase to 14% [95% CI 12, 16]. 29% [95% CI 19, 41] of Medicaid eligible pregnant women who would have an abortion with Medicaid coverage, instead give birth.ConclusionsFor a substantial proportion of pregnant women in Louisiana, the lack of Medicaid funding remains an insurmountable barrier to obtaining an abortion. Forty years after the Hyde Amendment was passed, lack of Medicaid funding for abortion continues to have substantial impacts on women's ability to obtain abortions.

The primary aim of this study was to evaluate the impact of MEN Count, a race- and gender-tailored three-session counseling intervention, on HIV/STI incidence as well as housing and employment. A two-armed quasi-experimental design was used to compare MEN Count to an attention comparison condition focused on stress reduction, from March 2014 to April 2017. Participants (N = 454) were Black heterosexual men in Washington DC, largely recruited from an STI clinic. Multivariate difference-in-difference regressions assessed whether the intervention was associated with significant changes in the outcomes set, which included nonviral STI incidence, sexual risk categorization, housing, and employment. Significant improvements over time were observed across both treatment arms for all outcomes (p < .05). Reductions in unemployment were significantly greater for intervention than for control participants (AOR unemployment = 0.48, 95% CI [0.23, 0.99]). Improvements in other outcomes did not differ significantly by treatment group. In dose analyses, participants receiving all intervention sessions were significantly less likely than control participants to have experienced homelessness in the 90 days prior (AOR= 0.31, 95% CI [0.10, 0.96]) and to be unemployed (AOR = 0.37, 95% CI [0.14, 0.96]). The MEN Count intervention offers a promising approach to address structural risk factors for STI, but not STI itself, among this largely STI clinic-based sample.

BackgroundPrior research from India demonstrates a need for family planning counseling that engages both women and men, offers complete family planning method mix, and focuses on gender equity and reduces marital sexual violence (MSV) to promote modern contraceptive use. Effectiveness of the three-session (two male-only sessions and one couple session) Counseling Husbands to Achieve Reproductive Health and Marital Equity (CHARM) intervention, which used male health providers to engage and counsel husbands on gender equity and family planning (GE + FP), was demonstrated by increased pill and condom use and a reduction in MSV. However, the intervention had limited reach to women and was therefore unable to expand access to highly effective long acting reversible contraceptives such as the intrauterine device (IUD). We developed a second iteration of the intervention, CHARM2, which retains the three sessions from the original CHARM but adds female provider- delivered counseling to women and offers a broader array of contraceptives including IUDs. This protocol describes the evaluation of CHARM2 in rural Maharashtra.MethodsA two-arm cluster randomized controlled trial will evaluate CHARM2, a gender synchronized GE + FP intervention. Eligible married couples (n = 1200) will be enrolled across 20 clusters in rural Maharashtra, India. Health providers will be gender-matched to deliver two GE + FP sessions to the married couples in parallel, and then a final session will be delivered to the couple together. We will conduct surveys on demographics as well as GE and FP indicators at baseline, 9-month, and 18-month follow-ups with both men and women, and pregnancy tests at each time point from women. In-depth interviews will be conducted with a subsample of couples (n = 50) and providers (n = 20). We will conduct several implementation and monitoring activities for purposes of assuring fidelity to intervention design and quality of implementation, including recruitment and tracking logs, provider evaluation forms, session observation forms, and participant satisfaction surveys.DiscussionWe will complete the recruitment of participants and collection of baseline data by July 2019. Findings from this work will offer important insight for the expansion of the national family planning program and improving quality of care for India and family planning interventions globally.Trial registrationClinicalTrial.gov, NCT03514914 .

Over the past two decades, US states have enacted legislation regulating ultrasound scanning in abortion care, including mandating that abortion patients view their ultrasound image. Legal scholars have argued that, by constructing ultrasound viewing as a necessary part of patients' abortion decision making, these laws aim to control and constrain how women make personal decisions about their bodies and parenthood. To date, however, the discussion of the impact of ultrasound viewing laws on women's decisional autonomy has occurred in the abstract. Here, we examine the effect of Wisconsin's mandatory ultrasound viewing law on the viewing behavior of women seeking care at a high-volume abortion-providing facility. Drawing both on chart data from patients before and after the law went into effect and on in-depth interviews with women subject to the mandatory viewing law, we found that the presence of the law impacted patients' viewing decision making. Moreover, we documented a differential effect of the law by race, with larger impacts on the viewing behavior of black women compared with white women. Our findings call for renewed attention to the coercive power of laws regulating abortion on a macrolevel, investigating not only how they affect individuals' behavior and experience but also which individuals are impacted.

BackgroundMedia depictions and laws passed in state legislatures regulating abortion suggest abortion-related medical emergencies are common. An accurate understanding of abortion-related emergencies is important for informing policy and practice. We assessed the incidence of abortion-related emergency department (ED) visits in the United States (U.S.).MethodsWe used a retrospective observational study design using 2009-2013 data from the Nationwide Emergency Department Sample, a nationally representative sample of U.S. ED visits from 947 to 964 hospitals across the U.S. per year. All ED visits among women of reproductive age (15-49) were included. We categorized ED visits by abortion relatedness and treatments received, and assessed whether the visit was for a major incident (defined as requiring blood transfusion, surgery, or overnight inpatient stay). We estimated the proportion of visits that were abortion-related and described the characteristics of patients making these visits, the diagnoses and subsequent treatments received by these patients, the sociodemographic and hospital characteristics associated with the incidents and observation care only (defined as receiving no treatments), and the rate of major incidents for all abortion patients in the U.S.ResultsAmong all ED visits by women aged 15-49 (189,480,685), 0.01% (n = 27,941) were abortion-related. Of these visits, 51% (95% confidence interval, 95% CI 49.3-51.9%) of the women received observation care only. A total of 20% (95% CI 19.3-21.3%) of abortion-related ED visits were for major incidents. One-fifth (22%, 95% CI 20.9-23.0%) of abortion-related visits resulted in admission to the same hospital for abortion-related reasons. Of the visits, 1.4% (n = 390, 95% CI 1.1-1.7%) were potentially due to attempts at self-induced abortion. In multivariable models, women using Medicaid (adjusted odds ratio, AOR 1.28, 95% CI 1.08-1.52) and women with a comorbid condition (AORs 2.47-4.63) had higher odds of having a major incident than women using private insurance and those without comorbid conditions. During the study period, 0.11% of all abortions in the U.S. resulted in major incidents as seen in EDs.ConclusionsAbortion-related ED visits comprise a small proportion of women's ED visits. Many abortion-related ED visits may not be indicated or could have been managed at a less costly level of care. Given the low rate of major incidents, perceptions that abortion is unsafe are not based on evidence.

ContextRecent legislation in states across the United States has required governmental health agencies to take on new and different roles in relation to abortion. While there has been media attention to health department roles in regulating abortion providers, there has been no systematic investigation of the range of activities in which state and local health departments are engaged.ObjectiveTo systematically investigate health department activities related to abortion.MethodsWe searched state health department Web sites of the 50 states and District of Columbia using key words such as "abortion" and "pregnancy termination". Two trained coders categorized 6093 documents using the 10 Essential Public Health Services (EPHS) framework. We then applied these methods to 671 local health department documents.SettingState and local health department Web sites.ParticipantsN/A.ResultsOn average, states engaged in 5.1 of 10 Essential Services related to abortion. Most (76%-98%) state health departments engaged in activities to Monitor Health Status (EPHS1), Enforce Laws (EPHS6), and Evaluate Effectiveness, Accessibility, and Quality (EPHS9). Many (47%-69%) engaged in activities to Inform and Educate (EPHS3), Develop Policies (EPHS5), and Link to Services (EPHS7). A minority (4%-29%) engaged in activities to Diagnose and Investigate Health Problems (EPHS2), Mobilize Community Partnerships (EPHS4), and Assure Competent Workforce (EPHS8). No state engaged in Innovative Research (EPHS10). Few local health departments engaged in abortion-related activities.ConclusionsWhile most state health departments engage in abortion-related activities, they appear to reflect what the law requires rather than the range of core public health activities. Additional research is needed to assess whether these services meet quality standards for public health services and determine how best to support governmental health agencies in their growing tasks. These findings raise important questions about the role of public health agencies and professionals in defining how health departments should be engaging with abortion.

OBJECTIVES:We know little about women's interest in and experiences with a printout of their preabortion ultrasound image. METHODS:We conducted a mixed-methods study at a large-volume abortion-providing facility where patients are offered the opportunity to receive their ultrasound printout, using 2 years of abstracted medical chart data on demographics and printout acceptance and interviews with patients about whether they took a printout and, if they did, why and what they did with it. We analyzed chart data using multivariable logistic regression to examine predictors of printout acceptance and interviews using elaborative coding and modified grounded theory. RESULTS:We abstracted data from 5342 charts and interviewed 23 women. Thirty-eight percent of all patients and 61% of interviewees accepted the printout. Predictors of accepting the printout included being younger, being nonwhite, having a partner who is a boyfriend or friend, and not having a support person at the visit. Interviewees reported that they accepted the printout simply because it was offered, out of curiosity and as part of confirming their abortion decision. They described various uses for the printout, including sharing with others, consulting before their abortion appointment, retaining as a keepsake and nothing at all. CONCLUSIONS:Some abortion patients are interested in receiving a printout of their ultrasound image and find it useful. Women accept a printout for a range of reasons and use it in various ways; there is no singular experience or use of the printout. IMPLICATIONS:We find no evidence that taking a printout of the preabortion ultrasound image causes emotional distress, nor did we find that it was expressly important for any patient's experience. Providers should consider providing interested patients with a printout, if they have the capability to do so, when they request one.

BackgroundAccess to abortion care in the United States is limited by the availability of abortion providers and their geographic distribution. We aimed to assess how far women travel for Medicaid-funded abortion in California and identify disparities in access to abortion care.MethodsWe obtained data on all abortions reimbursed by the fee-for-service California state Medicaid program (Medi-Cal) in 2011 and 2012 and examined distance traveled to obtain abortion care by several demographic and abortion-related factors. Mixed-effects multivariable logistic regression models were constructed to examine factors associated with traveling 50 miles or more. County-level t-tests and linear regressions were conducted to examine the effects of a Medi-Cal abortion provider in a county on overall and urban/rural differences in utilization.Results11.9% (95% CI: 11.5-12.2%) of women traveled 50 miles or more. Women obtaining second trimester or later abortions (21.7%), women obtaining abortions at hospitals (19.9%), and rural women (51.0%) were most likely to travel 50 miles or more. Across the state, 28 counties, home to 10% of eligible women, did not have a facility routinely providing Medi-Cal-covered abortions.ConclusionsEfforts are needed to expand the number of abortion providers that accept Medi-Cal. This could be accomplished by increasing Medi-Cal reimbursement rates, increasing the types of providers who can provide abortions, and expanding the use of telemedicine. If national trends in declining unintended pregnancy and abortion rates continue, careful attention should be paid to ensure that reduced demand does not lead to greater disparities in geographic and financial access to abortion care by ensuring that providers accepting Medicaid payment are available and widely distributed.

BackgroundSince mid-2013, Wisconsin abortion providers have been legally required to display and describe pre-abortion ultrasound images. We aimed to understand the impact of this law.MethodsWe used a mixed-methods study design at an abortion facility in Wisconsin. We abstracted data from medical charts one year before the law to one year after and used multivariable models, mediation/moderation analysis, and interrupted time series to assess the impact of the law, viewing, and decision certainty on likelihood of continuing the pregnancy. We conducted in-depth interviews with women in the post-law period about their ultrasound experience and analyzed them using elaborative and modified grounded theory.ResultsA total of 5342 charts were abstracted; 8.7% continued their pregnancies pre-law and 11.2% post-law (p = 0.002). A multivariable model confirmed the law was associated with higher odds of continuing pregnancy (aOR = 1.23, 95% CI: 1.01-1.50). Decision certainty (aOR = 6.39, 95% CI: 4.72-8.64) and having to pay fully out of pocket (aOR = 4.98, 95% CI: 3.86-6.41) were most strongly associated with continuing pregnancy. Ultrasound viewing fully mediated the relationship between the law and continuing pregnancy. Interrupted time series analyses found no significant effect of the law but may have been underpowered to detect such a small effect. Nineteen of twenty-three women interviewed viewed their ultrasound image. Most reported no impact on their abortion decision; five reported a temporary emotional impact or increased certainty about choosing abortion. Two women reported that viewing helped them decide to continue the pregnancy; both also described preexisting decision uncertainty.ConclusionsThis law caused an increase in viewing rates and a statistically significant but small increase in continuing pregnancy rates. However, the majority of women were certain of their abortion decision and the law did not change their decision. Other factors were more significant in women's decision-making, suggesting evaluations of restrictive laws should take account of the broader social environment.

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time. [ABSTRACT FROM AUTHOR]

BackgroundIn February 2011, an Ohio law took effect mandating use of the United States Food and Drug Administration (FDA)-approved protocol for mifepristone, which is used with misoprostol for medication abortion. Other state legislatures have passed or enacted similar laws requiring use of the FDA-approved protocol for medication abortion. The objective of this study is to examine the association of this legal change with medication abortion outcomes and utilization.Methods and findingsWe used a retrospective cohort design, comparing outcomes of medication abortion patients in the prelaw period to those in the postlaw period. Sociodemographic and clinical chart data were abstracted from all medication abortion patients from 1 y prior to the law's implementation (January 2010-January 2011) to 3 y post implementation (February 2011-October 2014) at four abortion-providing health care facilities in Ohio. Outcome data were analyzed for all women undergoing abortion at ≤49 d gestation during the study period. The main outcomes were as follows: need for additional intervention following medication abortion (such as aspiration, repeat misoprostol, and blood transfusion), frequency of continuing pregnancy, reports of side effects, and the proportion of abortions that were medication abortions (versus other abortion procedures). Among the 2,783 medication abortions ≤49 d gestation, 4.9% (95% CI: 3.7%-6.2%) in the prelaw and 14.3% (95% CI: 12.6%-16.0%) in the postlaw period required one or more additional interventions. Women obtaining a medication abortion in the postlaw period had three times the odds of requiring an additional intervention as women in the prelaw period (adjusted odds ratio [AOR] = 3.11, 95% CI: 2.27-4.27). In a mixed effects multivariable model that uses facility-months as the unit of analysis to account for lack of independence by site, we found that the law change was associated with a 9.4% (95% CI: 4.0%-18.4%) absolute increase in the rate of requiring an additional intervention. The most common subsequent intervention in both periods was an additional misoprostol dose and was most commonly administered to treat incomplete abortion. The percentage of women requiring two or more follow-up visits increased from 4.2% (95% CI: 3.0%-5.3%) in the prelaw period to 6.2% (95% CI: 5.5%-8.0%) in the postlaw period (p = 0.003). Continuing pregnancy was rare (0.3%). Overall, 12.6% of women reported at least one side effect during their medication abortion: 8.4% (95% CI: 6.8%-10.0%) in the prelaw period and 15.6% (95% CI: 13.8%-17.3%) in the postlaw period (p < 0.001). Medication abortions fell from 22% (95% CI: 20.8%-22.3%) of all abortions the year before the law went into effect (2010) to 5% (95% CI: 4.8%-5.6%) 3 y after (2014) (p < 0.001). The average patient charge increased from US$426 in 2010 to US$551 in 2014, representing a 16% increase after adjusting for inflation in medical prices. The primary limitation to the study is that it was a pre/post-observational study with no control group that was not exposed to the law.ConclusionsOhio law required use of a medication abortion protocol that is associated with a greater need for additional intervention, more visits, more side effects, and higher costs for women relative to the evidence-based protocol. There is no evidence that the change in law led to improved abortion outcomes. Indeed, our findings suggest the opposite. In March 2016, the FDA-protocol was updated, so Ohio providers may now legally provide current evidence-based protocols. However, this law is still in place and bans physicians from using mifepristone based on any new developments in clinical research as best practices continue to be updated.

BACKGROUND: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimers disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION: Population growth, increased average age of the worlds population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING: Bill & Melinda Gates Foundation.

This study aimed to assess couple concordance in attitudes toward intimate partner violence (IPV) and its association with physical IPV against women. A cross-sectional survey was conducted with 1,201 nonsterilized women aged 18–29 years and their husbands. It was found that husbands were significantly more likely (69.9%, 95% confidence interval [CI]: 67.3%, 72.5%) to justify IPV than wives (56.5%, 95% CI: 53.7%, 59.3%). Couples who both hold attitudes justifying IPV against women (adjusted odds ratio [AOR]: 3.5; 95% CI: 1.57%–8.00%) and couples where women hold these attitudes, but men do not (AOR: 2.93; 95% CI: 1.18–7.28), were more likely to report male-perpetrated IPV against women in the prior 12 months. [ABSTRACT FROM AUTHOR]