A qualitative study of the perceptions of dissatisfied Norplant users

BACKGROUND

The purpose of this study was to examine specific factors that motivated the request for early removal of Norplant among a group of young, low-income women who were dissatisfied with this contraceptive method.

METHODS

Focus groups were conducted to obtain qualitative in-depth attitude and opinion data about Norplant from women who had used this method of contraception for a period ranging from 2 months to 25 months and had requested its removal because of side effects.

RESULTS

Patient motivation for requesting Norplant removal was based on side effects. No other reason for early removal requests emerged from the focus group discussions. However, the comments of many participants raised questions about the psychosocial context in which patients obtain information about Norplant and request early removal. Many participants mentioned having felt pressured to accept Norplant and not being fully informed about possible side effects. All but two said they were encouraged to "wait out" side effects and that physicians were reluctant to remove the Norplant capsules. Many participants recalled that they had to request removal several times before their physicians complied with their wishes.

CONCLUSIONS

The results of this study suggest that there is a need to review the process of educating patients about Norplant, the situational context of Norplant counseling, and physician practices related to patients' requests for early removal.

Maternal influence on the decision to adopt Norplant

PURPOSE

To examine maternal influence and related variables on adolescents' decision to adopt Norplant.

METHODS

A prospective study of 121 adolescent females who received Norplant through a hospital-based outpatient adolescent gynecology service. Each patient completed self-report questionnaires about her decision process, sexual behaviors and standardized measures of depression and anxiety at their insertion appointment or first-follow-up appointment.

RESULTS

Almost 40% of the sample reported that their mother significantly influenced their decision to use Norplant and 61% of all patients stated that they had informed their mother of their choice of this contraceptive method. Through logistic regression, six variables were found to be significantly associated with mother as the most important decision source. These included: obtaining information about Norplant from a parent, maintaining the same sexual partner, past pill use, and not knowing other adolescents who boast about using the Norplant system.

CONCLUSION

These data suggest that when parental consent is not required, adolescent females disclose sensitive information regarding choice-making to their mothers when they decided to adopt Norplant.

The relational determinants of condom use with commercial sex partners in Thailand

OBJECTIVE

To analyze the extent and determinants of condom use with commercial sex partners among lower socioeconomic status groups in the Thai population.

DESIGN

Respondents were sampled in Udon Thani, Saraburi and Bangkok in 1992. Completed sample size was 678 women in brothels, 330 male truck drivers and 1,075 men aged 17-45 years. Behavioral data and local sexual network information were collected using structured questionnaires (face-to-face interviews), focus groups and in-depth unstructured interviews.

METHODS

Data were analyzed using univariate and multivariate logistic regression.

RESULTS

Condom use with commercial partners remains inconsistent. Consistent use was reported by 61% of women in brothels, 25% of truck drivers, and 29% of men in the low-income population. The single strongest predictor of consistent condom use for all groups is type of partnership. Consistent use drops significantly with regular (multivisit) commercial sex partners compared with casual (single visit) commercial partners; adjusted odds of consistent use are 0.22 for women and 0.25 for men. Brothel women report that one in five of their commercial partners is a 'regular', and 20% of the young men who report a commercial partner report a 'regular'.

DISCUSSION

The strongest determinant of consistent condom use is the nature of the relational bond between the partners, rather than their individual characteristics, knowledge or attitudes. To raise condom use further, programs will have to move beyond the standard knowledge-attitudes-practices paradigm focus on individual attributes to address the contextual determinants of behavior.

The epidemiology of HIV and syphilis among male commercial sex workers in northern Thailand

OBJECTIVE

To examine the prevalence and incidence of HIV and syphilis, and risk behaviors for these infections, among 1,172 male commercial sex workers (CSW) followed prospectively from 1989 to 1994 in Chiang Mai, northern Thailand.

METHODS

Twice yearly visits were conducted by the Thai Ministry of Public Health at all cooperating gay bars and clubs (17 sites) in Chiang Mai City as part of a national HIV sentinel surveillance. Men and boys who agreed were followed prospectively. Sentinel visits included an interview, HIV pre-test counseling, HIV and syphilis serology, condom distribution, and referral for post-test counseling. Participation was voluntary, confidential, and individual HIV results were available only to participating subjects. A total of 219 CSW were seen at least twice, allowing for incidence estimates based on 100 person-years (PY).

RESULTS

Median age of male CSW was 20 years. Median time of work as a CSW was 4 months. Most men (57.6%) described themselves as heterosexual. Median number of clients was 2.5 per week, and reported condom use with clients was low: 42% reported inconsistent or no condom use, while 58% reported always using condoms. Reactive Venereal Disease Research Laboratory results were 7.6%, overall, but showed a declining trend. HIV prevalence was 1.4% in June 1989, 13.9% in June 1990, and 20.1% in December 1993, and showed a significant increasing trend. There were 27 incident HIV infections in 227.3 PY of observation, for an overall incidence during the 4.5-year period of 11.9 per 100 PY (95% confidence interval, 7.42-16.38).

CONCLUSION

Male CSW in northern Thailand are at high risk for HIV despite current prevention efforts. The majority are heterosexual, which may be an important epidemiologic link in the spread of HIV between male CSW users and heterosexual women in Thailand.

Student opinions of condom distribution at a Denver, Colorado, high school

Over the past two decades, the reported number of women and men who have had intercourse by age 18 has increased by approximately 20%. Concomitant increases occurred in the incidence of teen-age pregnancies and sexually transmitted diseases (STDs), including HIV. Increasing condom availability within schools has been proposed as one means of preventing the serious potential consequences of unprotected sexual intercourse. Although published surveys report 68% to 75% of adults have supported distributing condoms in schools, little is known about what students think about making condoms available at school. In this survey, high school students in Denver initiated and helped conduct a school-wide survey to assess student opinions about condom distribution in their school. Of 931 high school students responding to the survey, 85% replied that condoms should be distributed in their school, and 76% believed making condoms more accessible would not change the frequency of sexual activity among teens.

Adolescent girls' attitudes toward contraceptive subdermal implants

Norplant, which has been shown to be a highly effective and acceptable contraceptive for adult women, may also be a very useful contraceptive for adolescents. This study is designed to determine the level of interest in Norplant for adolescent girls with and without children, their attitudes toward various features of Norplant, and the demographic and psychosocial factors predictive of their interest. A self-administered questionnaire was given to 112 adolescents attending our pediatric or adolescent clinic. Data from 28 adolescent mothers and 79 nulliparous adolescents were analyzed. Fifty-six percent of the subjects had heard of Norplant prior to the survey. The overall level of interest in Norplant was high; 70% of the adolescents without children, and 79% of the adolescent mothers were interested. In comparison to oral contraceptives, 73% of those without children and 89% of those with children thought Norplant would be a better contraceptive. The specific features of Norplant liked by 87% and 81% of the subjects, respectively, were not needing to take pills every day and its effectiveness in preventing pregnancy. The characteristics seen as most undesirable related to potential side effects with acne being mentioned by 87% of the subjects. Recursive partitioning analysis demonstrates that more than one prior pregnancy was the main characteristic predictive of very high levels of interest. In summary, this study demonstrates high levels of interest in Norplant by adolescents and suggests that it should be offered as a contraceptive option, especially to those girls who have previously been pregnant.

Using an ovarian monitor as an adjunct to natural family planning

The need to identify a reliable ovulation predictor has received attention by the scientific community in recent years. For couples practicing natural family planning, a more precise identification of the fertile phase would be a welcome adjunct to their method. A home ovarian monitor invented by Professor J. B. Brown of Melbourne, Australia, enables couples to measure the principal urinary metabolite of ovarian estrogen and progesterone. The charted results reveal the hormonal pattern of the menstrual cycle and thus identify the beginning, peak, and end of the fertile period. A study involving 21 couples was conducted with the purpose of assessing overall acceptability, including ease of use, motivation, and client satisfaction. At the completion of the study, 12 couples indicated a high degree of motivation and satisfaction with the monitor. None reported difficulty with the test procedure. Increased confidence in natural family planning was cited as the most positive evaluation and the time required to perform the test, as the most negative.

Simultaneous introduction of distinct HIV-1 subtypes into different risk groups in Russia, Byelorussia and Lithuania

OBJECTIVE

To investigate genotypes and serotypes of HIV-1 variants in Russia, Byelorussia and Lithuania.

PATIENTS AND METHODS

Sera from 20 HIV-1-infected individuals were tested in an enzyme-linked immunosorbent assay (ELISA) with 19 V3 synthetic peptides, and serum HIV-1 V3 RNA was amplified and sequenced.

RESULTS

Sequence comparison of the envelope V3 region among specimens tested revealed a 2-29% range nucleotide divergence, with a mean of 19%. Phylogenetic analysis from the homosexual men were shown to belong to subtype B, and all of the heterosexually infected individuals to subtype C. Sequences from the parenterally infected individuals were more heterogeneous. IOn the peptide ELISA three reactivity patterns were found. Serum samples from six out of seven homosexual men showed reactivity to peptides p108 or p110 representing V3 amino-acid sequences found in US/West European HIV-1 isolates. Serum samples from six of seven individuals who had acquired HIV-1 through heterosexual contacts were reactive to peptide p169. Four out of six parenterally infected patients had peak reactivity to p168.

CONCLUSION

Distinct HIV-1 variants were found in Russia, Byelorussia and Lithuania, which were introduced simultaneously in the mid-1980s. This diversity was shown to be associated with the route of transmission. Homosexual men appeared to be infected with subtype B and heterosexually infected individuals with subtype C HIV-1 variants. HIV-1 subtypes A, C, D and G were found among parenterally infected individuals.

A comparative evaluation of oral contraceptive use and associated compliance issues in a rural population

One hundred thirty-three patients were enrolled in a study designed to evaluate and compare oral contraceptive use in three rural communities. The patients averaged 31 years old (range, 13 to 49 years); 92% were white, 4.5% Hispanic, and 3% Native American. Genora, Ortho-Novum, and Triphasil were the most frequently prescribed oral contraceptives. Triphasic oral contraceptives accounted for one third (n = 64) of 203 prescriptions, and conventional monophasic preparations accounted for two thirds. Twenty percent (n = 26) of the patients studied were non-compliant. The most frequent causes of noncompliance cited were cost and inconvenience. However, generic alternatives were requested in only 43% of the cases for which generic equivalents were available. Less-expensive alternatives (eg, generic products, medroxyprogesterone acetate injection) should be advocated to deter patient noncompliance because of cost issues. Drug interactions and adverse effects were not reported in our patient population and thus did not contribute to noncompliance.

The desire for a son is the father of many daughters: a sex ratio paradox

"This paper investigates the impact of preferences for male offspring to female offspring upon the sex ratio of the population. Asymmetric procreation behaviour of this kind is modelled by assuming that a female's procreation ceases only after at least one son or n daughters are born. It is shown that such asymmetric procreation behaviour has no effect on the sex ratio of the society, but influences rather the growth rate of the population. Finally, problems concerning the interrelationship between the sex ratio, the pattern of procreation, and the marriage regime in stationary populations are investigated."

The impact of oral contraception on vulvovaginal candidiasis

To evaluate risk factors related to sociodemographic and clinical variables, oral contraception and sexual behavior of women with recurrent vulvovaginal candidiasis, we conducted a case-control study comparing 153 patients with recurrent vulvovaginal candidiasis with both asymptomatic women with negative vaginal cultures and patients with nonrecurrent symptomatic vulvovaginal candidiasis. In logistic regression analysis, patients with recurrent Candida vaginitis were more likely than negative controls to have used any contraceptive method in the year before evaluation, to have used antibiotics in the month preceding the visit, and to have a higher number of lifetime sex partners. Compared to patients with nonrecurrent Candida vaginitis, patients with recurrent infection were more likely to use oral contraception and to have a higher frequency of monthly intercourse. The proportion of recur rent disease attributable to the pill averages 11-12%. We conclude that oral contraceptives may influence the recurrence of symptomatic vulvovaginal candidiasis.

Predictors of AIDS knowledge, condom use and high-risk sexual behaviour among women in Dar-es-Salaam, Tanzania

Reducing the number of sex partners and using condoms are the major means for individuals to protect themselves from STDs and AIDS in sub-Saharan Africa. To identify predictors of having only one sex partner in the last year and to assess knowledge and use of condoms among women of reproductive age in Dar-es-Salaam, Tanzania, we interviewed 2285 women at 3 representative family planning clinics between February 1991 and June 1992. After interview, blood and genital specimens were collected for laboratory diagnosis of HIV and other sexually transmitted diseases (STDs). Although knowledge of sexual transmission of AIDS was very high, less than a half of the respondents (42.8%) mentioned use of condoms as an AIDS preventive measure. Younger and more educated women were more likely to mention use of condoms for AIDS prevention, however only 4.6% of women interviewed were regular users of condoms, while 19.8% were occasional users. The majority of women who had never used a condom (57.5%) reported not using condoms because 'men did not like them'. Condom use was positively associated with increasing level of education and increasing number of sexual partners. 14.8% of women reported having more than one sex partner in the last year; this behaviour was more likely among cohabiting women (increased by 210%); HIV-positives (increased by 120%); and among women with STDs (increased by 50%).(ABSTRACT TRUNCATED AT 250 WORDS)

Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation

The contraceptive efficacy of oral contraceptives (OCs) depends on their proper and continued use, particularly with lower estrogen preparations. However, few studies have examined why women miss pills or discontinue OCs, and those that do tend to be small and to focus on adolescents. To address the issues of poor OC compliance and early OC discontinuation, we analyzed OC use in a convenience sample of 6,676 women between the ages of 16 and 30 from Denmark, France, Italy, Portugal, and the United Kingdom. Logistic regression was used to examine the independent effect of each factor. Poor compliance was associated with a lack of established routine for pill-taking (relative risk [RR] = 3.3), failure to read and understand written materials that came with the OC package (RR = 2.2), not receiving adequate information or help about OCs from their health care provider (RR = 1.5), and occurrence of certain side effects, including hirsutism (RR = 2.1), nausea (RR = 1.4), bleeding irregularities (RR = 1.3), and breast tenderness (RR = 1.2). Women who were inconsistent OC users, missing one or more pills per cycle, were almost three times as likely to experience an unintended pregnancy while using OCs than were women who took their OCs consistently. Factors that predicted early discontinuation (women who wished to continue contraceptive protection but discontinued OC use) were primarily side effects, including nausea (RR = 2.1), bleeding (RR = 1.9), breast tenderness (RR = 1.8), mood changes (RR = 1.8), and weight gain (RR = 1.4).(ABSTRACT TRUNCATED AT 250 WORDS)

Contraceptive implant use among inner city teens

PURPOSES

This study develops a clinical profile of urban teens who selected Norplant for contraception; determines which variables identify the subjects most likely to be compliant with the method; and determines the most common reasons for early termination of use.

METHODS

Demographic and health history data and reasons for termination of use were collected prospectively for 122 inner city teens who received Norplant. Life table analysis and the Mantel-Haenszel procedure were used to investigate differences between Norplant retainers and terminators.

RESULTS

The sample consisted of black and Hispanic teens between the ages of 13-19 years, the majority of whom had one or more children and were in school. One and two year retention rates were 71% and 62%. The highest removal rates occurred during the 3-6 month interval after insertion. A significant finding was that teens who have experienced induced abortion were more likely to retain Norplant. Common reasons for termination of use included general and social concerns, including pregnancy desire.

CONCLUSIONS

Norplant retention rates for this teen sample were greater than the compliance rates reported for other conventional methods. Similar to noncompliance with oral contraceptives, discontinuance of the method was most likely to occur in the first 6 months of use. A history of induced abortion identifies those teens most likely to retain Norplant, suggesting that these teens might evaluate contraceptive risks and benefits differently than those with no abortion history. Pregnancy desire was a common reason for terminating Norplant use.

Withdrawal: a review of the literature and an agenda for research

A review to evaluate available literature about withdrawal (coitus interruptus) reveals a dearth of research on the current prevalence, acceptability, use-effectiveness, service-delivery issues, and safety of this ancient and widely used temporary contraceptive method. Population and family planning professionals are shown to have neglected withdrawal in favor of modern, female-controlled methods. This neglect is founded largely upon the popular belief that fertile levels of viable sperm are present in pre-ejaculatory fluid, despite data to the contrary. The validity of existing data on the prevalence of withdrawal is questioned because of the methodological bias inherent in most studies. The use-effectiveness of the practice and its relationship to sexually transmitted diseases have not been adequately investigated. A detailed research agenda on numerous topics concerning withdrawal is proposed.