1
|
Wesche R, Toman M, Grafsky EL, Gupta S, Tarantino MR. Developing an Inclusive Model of Young Heterosexual and Sexual Minority Women's Sexual Decision-Making. JOURNAL OF SEX RESEARCH 2024:1-15. [PMID: 38687300 DOI: 10.1080/00224499.2024.2320260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Efforts to improve sexual health outcomes among young cisgender women require in-depth understanding of how women with diverse sexual identities make decisions about their sexual health. We conducted semi-structured interviews with 31 young cisgender women with diverse sexual identities and histories (age range 18-29 (M = 23.32); 81% White; 29% bisexual, 26% heterosexual, 16% lesbian, 13% queer, 10% pansexual, 3% gay, 3% demisexual) about their decision-making surrounding sexual risk reduction. By conducting thematic analysis, we found that, regardless of partner sex or gender, women adapted sexual health strategies based on how much commitment, trust, and communication existed in their relationships. Because heteronormative structural influences limited access to information and safer sex options, women had to rely on trust and communication more with other women and partners with vaginas, compared to men and partners with penises. Women did not consider safer sex strategies with partners with vaginas (e.g. hand washing) risk-reduction techniques; instead, they considered them general hygiene or a way to take care of a partner. We propose that an inclusive model of young women's sexual decision-making should: (a) highlight the influence of relationships; (b) frame prevention in terms of overall health instead of pregnancy and STIs; and (c) acknowledge that structural factors, such as heteronormativity and sex-negativity, constrain women's decisions.
Collapse
Affiliation(s)
- Rose Wesche
- Department of Human Development and Family Science, Virginia Polytechnic Institute and State University
| | - Madelyn Toman
- Department of Human Development and Family Science, Virginia Polytechnic Institute and State University
| | - Erika L Grafsky
- Department of Human Development and Family Science, Virginia Polytechnic Institute and State University
| | - Shivangi Gupta
- Department of Human Development and Family Science, Virginia Polytechnic Institute and State University
| | - Mari R Tarantino
- Department of Human Development and Family Science, Virginia Polytechnic Institute and State University
| |
Collapse
|
2
|
Kraus EM, Chavan NR, Whelan V, Goldkamp J, DuBois JM. Reproductive decision making in women with medical comorbidities: a qualitative study. BMC Pregnancy Childbirth 2023; 23:848. [PMID: 38082419 PMCID: PMC10712035 DOI: 10.1186/s12884-023-06093-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND A growing number of reproductive-age women in the U.S. have chronic medical conditions, increasing their risk of perinatal morbidity and mortality. Still, they experience unintended pregnancies at similar rates to low-risk mothers. We have limited understanding of how these individuals consider decisions about pregnancy and contraceptive use. The purpose of this study was to understand factors that influence reproductive decision-making among pregnant women with chronic medical conditions. METHODS We conducted 28 semi-structured interviews with pregnant women with pre-existing medical conditions admitted to a tertiary maternal hospital to examine factors influencing reproductive decision making. Maternal demographic characteristics, medical history, and pregnancy outcome data were obtained through participant surveys and abstraction from electronic health records. Interview transcripts were coded and analyzed using Dedoose® with both deductive and inductive content analysis. RESULTS Out of 33 eligible participants, 30 consented to participate and 28 completed interviews. The majority of participants identified as black, Christian, made less than $23,000 yearly, and had a variety of preexisting medical conditions. Overarching themes included: 1) Perceived risks-benefits of pregnancy, 2) Perceived risks-benefits of birth control, 3) Determinants of contraceptive utilization, and 4) Perceived reproductive self-agency. Contraception was viewed as acceptable, but with concerning physical and psychological side effects. Although some considered pregnancy as a health threat, more experienced pregnancy as positive and empowering. Few planned their pregnancies. CONCLUSIONS Preexisting health conditions did not significantly influence reproductive decision-making. Barriers to birth control use were generally based in patient value-systems instead of external factors. Interventions to improve uptake and use of birth control in this cohort should focus on improving care for chronic health conditions and influencing patient knowledge and attitudes toward contraception.
Collapse
Affiliation(s)
- Elena M Kraus
- Department of Obstetrics, Gynecology and Women's Health, Maternal Fetal Medicine, Saint Louis University School of Medicine, St. Louis, MO, 63117, USA.
- Department of Obstetrics & Gynecology, Creighton University School of Medicine, Omaha, NE, 68178, USA.
| | - Niraj R Chavan
- Department of Obstetrics, Gynecology and Women's Health, Maternal Fetal Medicine, Saint Louis University School of Medicine, St. Louis, MO, 63117, USA
| | - Victoria Whelan
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jennifer Goldkamp
- Mercy Clinic Maternal and Fetal Medicine, Saint Louis, MO, 63141, USA
| | - James M DuBois
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, 63110, USA
| |
Collapse
|
3
|
Delaney DJ, Stein LAR, Bassett SS, Clarke JG. Motivational interviewing for family planning and reducing risky sexual behavior among incarcerated men nearing release: A randomized controlled pilot study. Psychol Serv 2023; 20:538-552. [PMID: 34735198 PMCID: PMC10354667 DOI: 10.1037/ser0000552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Incarcerated men are at high risk for sexually transmitted infections (STIs) and unintended partner pregnancy postrelease. Limited research has been invested in developing and testing treatments targeting risky sexual behavior and unwanted pregnancy for this at-risk population. Motivational interviewing (MI) is a promising behavioral intervention for decreasing risky sexual behaviors. This study assessed the feasibility and acceptability of MI for family planning and risky sexual behaviors with incarcerated men nearing release. Preliminary efficacy of the MI intervention was also compared to an educational control group. Thirty-two men were assessed at baseline and randomized to one 90-min session. Assessment occurred 2 months after release. MI was feasibly administered, and participants were highly satisfied with both treatments. In addition, those who received MI reported higher rates of condom use with casual partners, higher rates of partner use of hormonal contraceptives, and slightly higher rates of sex that was protected against pregnancy. Increases are readiness to discuss family planning with sexual partners, as well as reported frequency of these discussions, and increases in family planning knowledge were also found in those randomized to MI. The findings from this study indicate the need to further assess MI with this population with a full-scale clinical trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Collapse
Affiliation(s)
- Daniel J Delaney
- Department of Psychology, Chafee Social Science Center, University of Rhode Island
| | - L A R Stein
- Department of Psychology, Chafee Social Science Center, University of Rhode Island
| | - Shayna S Bassett
- Department of Psychology, Chafee Social Science Center, University of Rhode Island
| | - Jennifer G Clarke
- Center for Primary Care and Prevention, Memorial Hospital, Brown University
| |
Collapse
|
4
|
Durante JC, Sims J, Jarin J, Gold MA, Messiah SE, Francis JKR. Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence. Adolesc Health Med Ther 2023; 14:97-114. [PMID: 37181329 PMCID: PMC10167958 DOI: 10.2147/ahmt.s374268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.
Collapse
Affiliation(s)
- Julia C Durante
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Children’s Health System of Texas, Dallas, TX, USA
| | - Jessica Sims
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Children’s Health System of Texas, Dallas, TX, USA
| | - Jason Jarin
- Children’s Health System of Texas, Dallas, TX, USA
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Melanie A Gold
- Department of Pediatrics and Department of Population & Family Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Sarah E Messiah
- University of Texas Health Science Center at Houston, School of Public Health, Dallas Campus, Dallas, TX, USA
- Center for Pediatric and Population Health, UTHealth School of Public Health, Dallas, TX, USA
- Department of Pediatrics, McGovern Medical School, Houston, TX, USA
| | - Jenny K R Francis
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Children’s Health System of Texas, Dallas, TX, USA
- Peter O’Donnell School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
5
|
Kottke MJ, Sales JM, Goedken P, Brown JL, Hatfield-Timajchy K, Koumans EH, Hardin JW, Kraft JM, Kourtis AP. 2gether: A Clinic-Based Intervention to Increase Dual Protection from Sexually Transmitted Infections and Pregnancy in Young African American Females. J Womens Health (Larchmt) 2023; 32:29-38. [PMID: 36413049 DOI: 10.1089/jwh.2022.0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: To determine whether the 2gether intervention increases use of a dual protection (DP; concurrent prevention of pregnancy and sexually transmitted infections [STIs]) strategy and decreases pregnancy and STIs among young African American females, who disproportionately experience these outcomes. Materials and Methods: We conducted a randomized clinical trial comparing the 2gether intervention to standard of care (SOC). Participants were self-identified African American females aged 14-19 years who were sexually active with a male partner in the past 6 months. Participants were followed for 12 months; 685 were included in the analytic sample. The primary biologic outcome was time to any incident biologic event (chlamydia, gonorrhea, trichomonas infections, or pregnancy). The primary behavioral outcomes were use of and adherence to a DP strategy. Results: 2gether intervention participants had a decreased hazard of chlamydia, gonorrhea, trichomonas infections, or pregnancy during follow-up, hazard ratio = 0.73 (95% confidence interval [CI] 0.58-0.92), and were more likely to report use of condoms plus contraception, generally, adjusted risk ratio (aRR) = 1.61 (95% CI 1.15-2.26) and condoms plus an implant or intrauterine device (IUD), specifically, aRR = 2.11 (95% CI 1.35-3.29) in the prior 3 months compared with those receiving SOC. 2gether participants were also more likely to report use of condoms plus an implant or IUD at last sex and consistently over the prior 3 months. Conclusions: 2gether was efficacious in increasing use of condoms with contraception and decreasing pregnancy or selected STIs in our participants. Implementation of this intervention in clinical settings serving young people with high rates of pregnancy and STIs may be beneficial. ClinicalTrials.gov, No. NCT02291224 (https://clinicaltrials.gov/ct2/show/NCT02291224?term=2gether&draw=2&rank=5).
Collapse
Affiliation(s)
- Melissa J Kottke
- Department of Gynecology and Obstetrics, Jane Fonda Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica M Sales
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Peggy Goedken
- Department of Gynecology and Obstetrics, Jane Fonda Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer L Brown
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Psychology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kendra Hatfield-Timajchy
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emilia H Koumans
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - James W Hardin
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina, USA
| | - Joan Marie Kraft
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Athena P Kourtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
6
|
Bassett SS, Delaney DJ, Moore AM, Clair-Michaud M, Clarke JG, Stein L. Motivational interviewing to reduce risky sexual behaviors among at-risk male youth: A randomized controlled pilot study. Psychol Serv 2022; 19:167-175. [PMID: 33411550 PMCID: PMC9069535 DOI: 10.1037/ser0000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite male youth taking more sexual risks that lead to unwanted partner pregnancy and/or sexually transmitted infections (STIs), research evaluating interventions for risky sex has focused almost exclusively on adolescent and adult females. With STIs among male youth on the rise, behavioral interventions that target risky sex among male youth are needed. PURPOSE A randomized controlled pilot study was conducted to examine the feasibility and acceptability of two manualized behavioral interventions for sexually active male youth. METHODS Sexually active at-risk male youth (N = 27) were recruited and randomized to receive one session of motivational interviewing (MI) or didactic educational counseling (DEC). Assessment interviews were conducted prior to and 3 months following the intervention session. RESULTS Support for the feasibility and acceptability of delivering behavioral interventions to reduce risky sexual behaviors among at-risk male youth was found. Compared to participants in DEC at follow-up, participants in MI reported having significantly fewer sexual encounters with casual partners, used substances at the time of sex significantly less often with all partners and casual partners, and reported fewer incidents of using substances at the time of sex without a condom with all partners. Conversely, participants who received MI used substances at the time of sex with main partners and used substances at the time of sex without a condom more often with main partners at follow-up compared to participants who received DEC. CONCLUSIONS Results of the pilot study support conducting a larger randomized controlled trial to examine treatment effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Collapse
Affiliation(s)
| | - Daniel J. Delaney
- Department of Psychology, Social Sciences Research Center,
University of Rhode Island, Kingston, RI
| | - Amy M. Moore
- Department of Nutrition and Food Sciences, University of
Rhode Island, Kingston, RI
| | | | - Jennifer G. Clarke
- Center for Alcohol and Addiction Studies, Brown University
School of Public Health, Providence, RI
| | - L.A.R. Stein
- Department of Psychology, Social Sciences Research Center,
University of Rhode Island, Kingston, RI
- The Rhode Island Training School, Cranston, RI
- Center for Alcohol and Addiction Studies, Brown University
School of Public Health, Providence, RI
| |
Collapse
|
7
|
Robinson M, Aventin Á, Hanratty J, Ruane-McAteer E, Tomlinson M, Clarke M, Okonofua F, Lohan M. Nothing so practical as theory: a rapid review of the use of behaviour change theory in family planning interventions involving men and boys. Reprod Health 2021; 18:126. [PMID: 34120630 PMCID: PMC8201745 DOI: 10.1186/s12978-021-01173-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/06/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND There is growing recognition of the need for interventions that effectively involve men and boys to promote family planning behaviours. Evidence suggests that the most effective behavioural interventions in this field are founded on theoretical principles of behaviour change and gender equality. However, there are few evidence syntheses on how theoretical approaches are applied in this context that might guide best practice in intervention development. This review addresses this gap by examining the application and reporting of theories of behaviour change used by family planning interventions involving men and boys. METHODS We adopted a systematic rapid review approach, scoping findings of a previously reported evidence and gap map of intervention reviews (covering 2007-2018) and supplementing this with searches of academic databases and grey literature for reviews and additional studies published between 2007 and 2020. Studies were eligible for inclusion if their title, abstract or keywords referred to a psychosocial or behavioural intervention targeting family planning behaviours, involved males in delivery, and detailed their use of an intervention theory of change. RESULTS From 941 non-duplicate records identified, 63 were eligible for inclusion. Most records referenced interventions taking place in low- and middle-income countries (65%). There was a range of intervention theories of change reported, typically targeting individual-level behaviours and sometimes comprising several behaviour change theories and strategies. The most commonly identified theories were Social Cognitive Theory, Social Learning Theory, the Theory of Planned Behaviour, and the Information-Motivation-Behaviour Skills (IMB) Model. A minority of records explicitly detailed gender-informed elements within their theory of change. CONCLUSION Our findings highlight the range of prevailing theories of change used for family planning interventions involving men and boys, and the considerable variability in their reporting. Programmers and policy makers would be best served by unified reporting and testing of intervention theories of change. There remains a need for consistent reporting of these to better understand how complex interventions that seek to involve men and boys in family planning may lead to behaviour change.
Collapse
Affiliation(s)
- Martin Robinson
- School of Nursing and Midwifery and Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Áine Aventin
- School of Nursing and Midwifery and Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Jennifer Hanratty
- School of Nursing and Midwifery and Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK
| | | | - Mark Tomlinson
- School of Nursing and Midwifery and Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK
- Institute for Life Course Health Research, Stellenbosch University, Stellenbosch, South Africa
| | - Mike Clarke
- School of Nursing and Midwifery and Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Friday Okonofua
- Women's Health Action Research Centre, Benin City, Edo State, Nigeria
| | - Maria Lohan
- School of Nursing and Midwifery and Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK
| |
Collapse
|
8
|
Stephenson J, Bailey JV, Blandford A, Brima N, Copas A, D'Souza P, Gubijev A, Hunter R, Shawe J, Rait G, Oliver S. An interactive website to aid young women's choice of contraception: feasibility and efficacy RCT. Health Technol Assess 2020; 24:1-44. [PMID: 33164729 DOI: 10.3310/hta24560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Effective use of contraception can reduce numbers of unintended pregnancies, but misunderstandings and concerns about contraception abound. Increasingly, women seek health-care information online. OBJECTIVES To develop an interactive website to aid informed choice of contraceptive method, including long-acting reversible contraception (Phase I), and test its effectiveness in a parallel, single-blind randomised trial (Phase II). Approval came from London - Camden & King's Cross Research Ethics Committee (reference 17/LO/0112). SETTING AND PARTICIPANTS For both phases, women aged 15-30 years were recruited from general practice, sexual health services, maternity services, community pharmacies and an abortion service. DESIGN In Phase I, we conducted three systematic literature reviews, a review of YouTube (YouTube, LLC, San Bruno, CA, USA) videos about contraception, and focus groups and interviews with young women to explore barriers to and concerns and misperceptions about contraception. We then iteratively co-designed an interactive website, Contraception Choices [URL: www.contraceptionchoices.org (accessed June 2020)], with young women and a software company. In Phase II, we evaluated the website through a randomised trial that began as a feasibility trial. Early demand for Contraception Choices stimulated a design change from a feasibility to an efficacy trial, with follow-up for clinical outcomes at 3 and 6 months. A randomisation list was incorporated into the trial software program to allocate participants to the intervention (website) or control group (standard care). INTERVENTION Contraception Choices is a co-designed, evidence-based, interactive website to aid informed choice of contraception. It provides information about different methods, addresses common concerns and offers tailored contraceptive options in response to individual preferences. MAIN OUTCOME MEASURES Qualitative - participant views and experience of the intervention, assessed through qualitative interviews. Quantitative primary outcomes - follow-up rate at 6 months in the initial feasibility trial, using a long-acting reversible contraception method, and satisfaction with contraceptive method at 6 months in the efficacy trial. RESULTS A total of 927 women were randomised online to the website (n = 464) or control group (n = 463), of whom 739 (80%) provided follow-up data at 6 months [786 women (85%) provided data at 3 and/or 6 months that were included in the analysis of primary outcomes]. There was little difference between groups in the proportion using long-acting reversible contraception at 6 months [30.4% intervention vs. 31.0% control, adjusted odds ratio after imputation 0.87 (95% confidence interval 0.60 to 1.27)] or in satisfaction with contraceptive method [proportion being 'satisfied' or 'very satisfied', 82.6% intervention vs. 82.1% control, adjusted odds ratio 0.93 (95% confidence interval 0.69 to 1.25)]. Qualitative evaluation indicated highly positive views about the website and increased knowledge of contraceptive methods that could dispel misperceptions. Women appreciated having information tailored to their specific needs and felt better prepared before consultations. LIMITATIONS We did not include intermediate measures, such as knowledge of contraceptive methods, intention to change method or confidence in discussing contraception with a health-care professional, which may have indicated other benefits of using the website. In future, the website should be studied in different settings (e.g. schools and in routine practice) to see whether or not it improves the quality or efficiency of contraceptive consultations. CONCLUSIONS Our systematic review indicated wide-ranging influences on women's use of contraception globally. The website, Contraception Choices, was very popular with young women and contraception service providers. It was not associated with statistically significant differences in use of long-acting reversible contraception or satisfaction with contraceptive method at 6 months. TRIAL REGISTRATION Current Controlled Trials ISRCTN13247829. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 56. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Judith Stephenson
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Julia V Bailey
- Department of Primary Care and Population Health, University College London, Royal Free Hospital, London, UK
| | - Ann Blandford
- UCL Interaction Centre (UCLIC), University College London, London, UK
| | - Nataliya Brima
- Institute for Global Health, University College London, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Preethy D'Souza
- Department of Social Science, UCL Institute of Education, University College London, London, UK
| | - Anasztazia Gubijev
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | | | - Jill Shawe
- Institute of Health and Community, University of Plymouth, Plymouth, UK
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Department of Primary Care and Population Health, University College London, Royal Free Hospital, London, UK
| | - Sandy Oliver
- Department of Social Science, UCL Institute of Education, University College London, London, UK.,Africa Centre for Evidence, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| |
Collapse
|
9
|
Ampt FH, L'Engle K, Lim MSC, Plourde KF, Mangone E, Mukanya CM, Gichangi P, Manguro G, Hellard M, Stoové M, Chersich MF, Jaoko W, Agius PA, Temmerman M, Wangari W, Luchters S. A Mobile Phone-Based Sexual and Reproductive Health Intervention for Female Sex Workers in Kenya: Development and Qualitative Study. JMIR Mhealth Uhealth 2020; 8:e15096. [PMID: 32469326 PMCID: PMC7293053 DOI: 10.2196/15096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/24/2019] [Accepted: 02/03/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Female sex workers (FSWs) have high rates of both unintended pregnancy and HIV, but few health promotion interventions address their contraceptive needs or other sexual and reproductive health and rights (SRHR) concerns. A broader approach integrates contraceptive promotion with HIV and sexually transmitted infection (STI) prevention and management, alcohol awareness, gender-based violence and rights, and health care utilization. The Women's Health Intervention using SMS for Preventing Pregnancy (WHISPER) mobile phone intervention uses a participatory development approach and behavior change theory to address these high-priority concerns of FSWs in Mombasa, Kenya. OBJECTIVE This paper aimed to (1) describe the process of development of the WHISPER intervention, its theoretical framework, key content domains and strategies and (2) explore workshop participants' responses to the proposed intervention, particularly with regard to message content, behavior change constructs, and feasibility and acceptability. METHODS The research team worked closely with FSWs in two phases of intervention development. First, we drafted content for three different types of messages based on a review of the literature and behavior change theories. Second, we piloted the intervention by conducting six workshops with 42 FSWs to test and refine message content and 12 interviews to assess the technical performance of the intervention. Workshop data were thematically analyzed using a mixed deductive and inductive approach. RESULTS The intervention framework specified six SRHR domains that were viewed as highly relevant by FSWs. Reactions to intervention content revealed that social cognitive strategies to improve knowledge, outcome expectations, skills, and self-efficacy resonated well with workshop participants. Participants found the content empowering, and most said they would share the messages with others. The refined intervention was a 12-month SMS program consisting of informational and motivational messages, role model stories portraying behavior change among FSWs, and on-demand contraceptive information. CONCLUSIONS Our results highlight the need for health promotion interventions that incorporate broader components of SRHR, not only HIV prevention. Using a theory-based, participatory approach, we developed a digital health intervention that reflects the complex reality of FSWs' lives and provides a feasible, acceptable approach for addressing SRHR concerns and needs. FSWs may benefit from health promotion interventions that provide relevant, actionable, and engaging content to support behavior change.
Collapse
Affiliation(s)
- Frances H Ampt
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kelly L'Engle
- University of San Francisco, San Francisco, CA, United States
| | - Megan S C Lim
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Emily Mangone
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Peter Gichangi
- Technical University of Mombasa, Mombasa, Kenya.,Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,International Centre for Reproductive Health, Mombasa, Kenya
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia.,Department of Infectious Diseases, The Alfred Hospital, Melbourne, Australia
| | - Mark Stoové
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew F Chersich
- Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paul A Agius
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marleen Temmerman
- Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,International Centre for Reproductive Health, Mombasa, Kenya.,Aga Khan University, Nairobi, Kenya
| | - Winnie Wangari
- International Centre for Reproductive Health, Mombasa, Kenya
| | - Stanley Luchters
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Aga Khan University, Nairobi, Kenya
| |
Collapse
|
10
|
Martín CA, Rivera DE, Hekler EB, Riley WT, Buman MP, Adams MA, Magann AB. Development of a Control-Oriented Model of Social Cognitive Theory for Optimized mHealth Behavioral Interventions. IEEE TRANSACTIONS ON CONTROL SYSTEMS TECHNOLOGY : A PUBLICATION OF THE IEEE CONTROL SYSTEMS SOCIETY 2020; 28:331-346. [PMID: 33746479 PMCID: PMC7977327 DOI: 10.1109/tcst.2018.2873538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Mobile health (mHealth) technologies are contributing to the increasing relevance of control engineering principles in understanding and improving health behaviors, such as physical activity. Social Cognitive Theory (SCT), one of the most influential theories of health behavior, has been used as the conceptual basis for behavioral interventions for smoking cessation, weight management, and other health-related outcomes. This paper presents a control-oriented dynamical systems model of SCT based on fluid analogies that can be used in system identification and control design problems relevant to the design and analysis of intensively adaptive interventions. Following model development, a series of simulation scenarios illustrating the basic workings of the model are presented. The model's usefulness is demonstrated in the solution of two important practical problems: 1) semiphysical model estimation from data gathered in a physical activity intervention (the MILES study) and 2) as a means for discerning the range of "ambitious but doable" daily step goals in a closed-loop behavioral intervention aimed at sedentary adults. The model is the basis for ongoing experimental validation efforts, and should encourage additional research in applying control engineering technologies to the social and behavioral sciences.
Collapse
Affiliation(s)
- César A Martín
- ESPOL Polytechnic University, Escuela Superior Politécnica del Litoral, ESPOL, Facultad de Ingeniería en Electricidad y Computacion, Campus Gustavo Galindo Km. 30.5 Vía Perimetral, P.O. Box 09-01-5863, Guayaquil, Ecuador
| | - Daniel E Rivera
- Control Systems Engineering Laboratory (CSEL), School for Engineering of Matter, Transport, and Energy, Arizona State University, Tempe, AZ, USA
| | - Eric B Hekler
- Center for Wireless and Population Health Systems and the Department of Family Medicine and Public Health, University of California at San Diego, CA, USA
| | - William T Riley
- Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, MD, USA
| | - Matthew P Buman
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, AZ, USA
| | - Marc A Adams
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, AZ, USA
| | - Alicia B Magann
- Control Systems Engineering Laboratory (CSEL), School for Engineering of Matter, Transport, and Energy, Arizona State University, Tempe, AZ, USA
| |
Collapse
|
11
|
Diez E, Lopez MJ, Perez G, Garcia-Subirats I, Nebot L, Carreras R, Villalbi JR. Impact of a community contraceptive counselling intervention on adolescent fertility rates: a quasi-experimental study. BMC Public Health 2020; 20:26. [PMID: 31914967 PMCID: PMC6950873 DOI: 10.1186/s12889-019-8122-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 12/23/2019] [Indexed: 11/26/2022] Open
Abstract
Background From 2000 to 2008, in urban areas in Spain, adolescent fertility and abortion rates underwent unprecedented increases, consecutive to intensive immigration from developing countries. To address unmet needs for contraception information and services, a community-based, gender-sensitive and culturally adapted brief counselling intervention (SIRIAN program) was launched in some deprived neighbourhoods with a high proportion of immigrants in Barcelona. Once a randomized controlled trial demonstrated its effectiveness in increasing the use of contraceptives, we aim to examine its population impact on adolescent fertility rates. Methods Quasi-experimental study with comparison group, using population data from 2005 to 2016. Five neighbourhoods in the lowest tercile of Disposable Household Income were intervened in 2011–13. The comparison group included the three neighbourhoods which were in the same municipal district and in the lowest Disposable Household Income tercile, and displayed the highest adolescent fertility rates. Generalized linear models were fitted to assess absolute adolescent fertility rates and adjusted by immigrant population between pre-intervention (2005–10) and post-intervention periods (2011–16); Difference in Differences and relative pre-post changes analysis were performed. Results In 2005–10 the intervention group adolescent fertility rate was 27.90 (per 1000 women 15–19) and 21.84 in the comparison group. In 2011–16 intervention areas experienced great declines (adolescent fertility rate change: − 12.30 (− 12.45 to − 12.21); p < 0.001), while comparison neighbourhoods remained unchanged (adolescent fertility rate change: 1.91 (− 2.25 to 6.07); p = 0.368). A reduction of − 10.97 points (− 13.91 to − 8.03); p < 0.001) is associated to the intervention. Conclusion Adolescent fertility rate significantly declined in the intervention group but remained stable in the comparison group. This quasi-experimental study provide evidence that, in a country with universal health coverage, a community counselling intervention that increases access to contraception, knowledge and sexual health care in hard-to-reach segments of the population can contribute to substantially reduce adolescent fertility rates. Reducing adolescent fertility rates could become a feasible goal in cities with similar conditions.
Collapse
Affiliation(s)
- Elia Diez
- Agència de Salut Pública de Barcelona, Pl Lesseps 1, 08023, Barcelona, Spain. .,Universitat Autònoma de Barcelona. Campus de la UAB, Pl Cívica s/n., 08193, Bellaterra, Spain. .,CIBER de Epidemiología y Salud Pública (CIBERESP), Centro de Investigación Biomédica en Red. Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, 28029, Madrid, Spain. .,Institut d'Investigació Biomèdica Sant Pau, C/ Sant Antoni Maria Claret 167, 08025, Barcelona, Spain.
| | - Maria J Lopez
- Agència de Salut Pública de Barcelona, Pl Lesseps 1, 08023, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Centro de Investigación Biomédica en Red. Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, 28029, Madrid, Spain.,Institut d'Investigació Biomèdica Sant Pau, C/ Sant Antoni Maria Claret 167, 08025, Barcelona, Spain.,Universitat Pompeu Fabra, Plaça de la Mercè 10, 08002, Barcelona, Spain
| | - Gloria Perez
- Agència de Salut Pública de Barcelona, Pl Lesseps 1, 08023, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Centro de Investigación Biomédica en Red. Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, 28029, Madrid, Spain.,Institut d'Investigació Biomèdica Sant Pau, C/ Sant Antoni Maria Claret 167, 08025, Barcelona, Spain.,Universitat Pompeu Fabra, Plaça de la Mercè 10, 08002, Barcelona, Spain
| | | | - Laia Nebot
- CEPS Salut. C/ Doctor Santponç¸, 60, 08030, Barcelona, Spain
| | - Ramon Carreras
- Universitat Autònoma de Barcelona. Campus de la UAB, Pl Cívica s/n., 08193, Bellaterra, Spain.,Hospital del Mar, Pg Marítim 25, 08003, Barcelona, Spain
| | - Joan R Villalbi
- Agència de Salut Pública de Barcelona, Pl Lesseps 1, 08023, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Centro de Investigación Biomédica en Red. Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, 28029, Madrid, Spain.,Institut d'Investigació Biomèdica Sant Pau, C/ Sant Antoni Maria Claret 167, 08025, Barcelona, Spain.,Universitat Pompeu Fabra, Plaça de la Mercè 10, 08002, Barcelona, Spain
| |
Collapse
|
12
|
Kilander H, Brynhildsen J, Alehagen S, Fagerkrantz A, Thor J. Collaboratively seeking to improve contraceptive counselling at the time of an abortion: a case study of quality improvement efforts in Sweden. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:190-199. [PMID: 31289100 DOI: 10.1136/bmjsrh-2018-200299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/15/2019] [Accepted: 05/16/2019] [Indexed: 05/21/2023]
Abstract
BACKGROUND Many women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on motivational and person-centred counselling, as well as on use of long-acting reversible contraception (LARC). This study aims to describe and evaluate a Quality Improvement Collaborative (QIC) designed to enhance contraceptive services, with regard to changes in healthcare professionals' (HCPs') counselling in clinical practice, and in women's subsequent choice of, and access to, contraception. METHODS Three multiprofessional teams working in abortion services from three hospitals in Sweden, and two women contributing with user experience, participated in a QIC during the period March-November 2017. Using a case study design, we collected and analysed both quantitative and qualitative data. RESULTS Teams agreed on QIC goals, including that ≥50% of women would start LARC within 30 days post-abortion, and tested multiple evidence-based changes, aided by the two women's feedback. During the QIC, participating HCPs reported that they gained new knowledge and developed skills in contraceptive counselling at the time of an abortion. The teams welcomed the development of a performance feedback system regarding women's post-abortion contraception. While the majority of women counselled during the QIC chose LARC, only 20%-40% received it within 30 days post-abortion. CONCLUSION The QIC, incorporating user feedback, helped HCPs to develop capability in providing contraceptive services at the time of an abortion. Timely access to LARC remains a challenge in the present setting.
Collapse
Affiliation(s)
- Helena Kilander
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Obstetrics and Gynaecology, Region Jönköping County, Eksjö, Sweden
| | - Jan Brynhildsen
- Obstetrics and Gynecology, Clinical and Experimental Medicine, Linköping, Sweden
| | - Siw Alehagen
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Amanda Fagerkrantz
- Department of Obstetrics and Gyneacology, Norrköping, Region Ostergotland, Linköping, Sweden
| | - Johan Thor
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden
| |
Collapse
|
13
|
O'Sullivan LF, Majerovich JA, Wuest J. From Promoting Healthy Sexual Functioning to Managing Biomedical Sexual Dysfunction: Health Professional Views of Youth Sexual Health. SAGE Open Nurs 2019; 5:2377960819832676. [PMID: 33415225 PMCID: PMC7774441 DOI: 10.1177/2377960819832676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/15/2019] [Accepted: 01/25/2019] [Indexed: 01/23/2023] Open
Abstract
A body of work emerging in the last few years has expanded the focus of youth
sexual health to include problems in sexual functioning. Recent surveys show
that rates of youth sexual functioning problems are similar to those of adults.
Physicians' lack of awareness about problems of sexual functioning has been
identified as a major obstacle in treatment. Yet little is known about
health-care provider (HCP) perspectives on youth sexual functioning. We
conducted a descriptive qualitative study with HCPs to learn about their
perceptions of adolescent sexual problems and HCP roles in managing these issues
including sexual functioning. Nineteen HCPs: Family physicians, nurse
practitioners, and public health nurses working primarily with youth in
universities, schools, or sexual health clinics were recruited to draw on their
expert knowledge and experience. All completed in-depth individual interviews.
Data were analyzed using directed qualitative content analysis. Our findings
illuminate inconsistent views. Some HCPs, particularly those in youth-focused
services, adopt a holistic role in promoting healthy sexual functioning, and
others, commonly those in general practice, attend only to biomedical issues
related to sexual dysfunction. All HCPs in our study were challenged by a
paucity of sexual health preparation in their formal education. HCP interest in
youth sexual health affected their efforts to acquire new information and
training and, along with the structure of their practice setting, influenced
whether they framed their role in youth sexual health holistically within a
context of social determination or constrained their role to a medical model.
These findings draw attention to the need for new approaches for strengthening
knowledge, training, and resources to foster HCP promotion of healthy sexual
functioning and prevention of lifelong sexual health problems.
Collapse
Affiliation(s)
- Lucia F O'Sullivan
- Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, Canada
| | | | - Judith Wuest
- Faculty of Nursing, University of New Brunswick, Fredericton, New Brunswick, Canada
| |
Collapse
|
14
|
Development of an intervention delivered by mobile phone aimed at decreasing unintended pregnancy among young people in three lower middle income countries. BMC Public Health 2018; 18:576. [PMID: 29716571 PMCID: PMC5930955 DOI: 10.1186/s12889-018-5477-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 04/18/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Unintended pregnancies can result in poorer health outcomes for women, children and families. Young people in low and middle income countries are at particular risk of unintended pregnancies and could benefit from innovative contraceptive interventions. There is growing evidence that interventions delivered by mobile phone can be effective in improving a range of health behaviours. This paper describes the development of a contraceptive behavioural intervention delivered by mobile phone for young people in Tajikistan, Bolivia and Palestine, where unmet need for contraception is high among this group. METHODS Guided by Intervention Mapping, the following steps contributed to the development of the interventions: (1) needs assessment; (2) specifying behavioural change to result from the intervention; (3) selecting behaviour change methods to include in the intervention; (4) producing and refining the intervention content. RESULTS The results of the needs assessment produced similar interventions across the countries. The interventions consist of short daily messages delivered over 4 months (delivered by text messaging in Palestine and mobile phone application instant messages in Bolivia and Tajikistan). The messages provide information about contraception, target attitudes that are barriers to contraceptive uptake and support young people in feeling that they can influence their reproductive health. The interventions each contain the same ten behaviour change methods, adapted for delivery by mobile phone. CONCLUSIONS The development resulted in a well-specified, theory-based intervention, tailored to each country. It is feasible to develop an intervention delivered by mobile phone for young people in resource-limited settings.
Collapse
|
15
|
Asensio A, Nebot L, Estruga L, Perez G, Diez È. [Contraception in the Roma population living in two low-income neighborhoods of Barcelona (Spain)]. GACETA SANITARIA 2018; 33:119-126. [PMID: 29478730 DOI: 10.1016/j.gaceta.2017.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the knowledge and use of contraceptive methods and health services in the Roma population (Kale/Spanish Gitanos) of two low-income neighbourhoods of Barcelona (2011-2015). METHOD Mixed. Community setting. 1) Descriptive cross-sectional study. We interviewed with a questionnaire a sample of residents of childbearing age. We compared the knowledge and use of contraception and services by ethnic self-identification and sex with adjusted logistic regression models to obtain adjusted odds ratio (ORa) and 95% confidence interval (95%CI). 2) Qualitative descriptive study with ethnographic method. We interviewed 10 Roma residents and three health professionals to explore aspects of contraception, family and roles. We performed a narrative analysis of discourse from the recorded texts. RESULTS 834 people participated, with an 11.8% self-identified Roma population. With regard to the non-Roma population, more Roma women used tubal ligation (ORa: 3.0; 95%CI: 1.3-7)] and implant (ORa:4.9; 95%CI: 3.1-72), and had better knowledge of IUD (ORa: 2,4; 95%CI: 1,4-4,1), tubal obstruction (ORa: 3,3; 95%CI: 1,1-9,9) and injectables (ORa: 2,4; 95%CI: 1.3-4.4). Roma men used withdrawal more frequently (ORa: 3.6; 95%CI: 1.3-10), a practice confirmed in the qualitative study. Both communities used emergency contraception and health services. In the Roma population, contraception and reproduction are in the hands of women. As abortion is culturally penalized in the Roma population, women use it, but they face it alone. CONCLUSIONS Gender emerged as a cross-cutting determinant in all issues explored. In the Roma population reproductive control and contraception remain the responsibility of women. Once the family is complete, Roma women use long-term contraception. Both populations use health services.
Collapse
Affiliation(s)
- Alba Asensio
- Agència de Salut Pública de Barcelona, Barcelona, España
| | - Laia Nebot
- CEPS Salut (Associació per la Prevenció i la Promoció de la Salut), Barcelona, España
| | - Lluïsa Estruga
- Agència de Salut Pública de Barcelona, Barcelona, España
| | - Glòria Perez
- Agència de Salut Pública de Barcelona, Barcelona, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Institut d'Investigació Biomèdica Sant Pau, Barcelona, España; Departamento de Pediatría, Obstetricia y Ginecología, Medicina Preventiva y Salud Pública, Universitat Autònoma de Barcelona, Barcelona, España
| | - Èlia Diez
- Agència de Salut Pública de Barcelona, Barcelona, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Institut d'Investigació Biomèdica Sant Pau, Barcelona, España; Departamento de Pediatría, Obstetricia y Ginecología, Medicina Preventiva y Salud Pública, Universitat Autònoma de Barcelona, Barcelona, España; Departamento de Ciencias Experimentales y de la Salud, Universitat Pompeu Fabra, Barcelona, España.
| |
Collapse
|