1
|
Aizire J, Yende-Zuma N, Hanley S, Nematadzira T, Nyati MM, Dadabhai S, Chinula L, Nakaye C, Fowler MG, Taha T. Unintended pregnancy and contraception use among African women living with HIV: Baseline analysis of the multi-country US PEPFAR PROMOTE cohort. PLoS One 2024; 19:e0290285. [PMID: 38466748 PMCID: PMC10927155 DOI: 10.1371/journal.pone.0290285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 08/04/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND About 90% of unintended pregnancies are attributed to non-use of effective contraception-tubal ligation, or reversible effective contraception (REC) including injectables, oral pills, intra-uterine contraceptive device (IUCD), and implant. We assessed the prevalence of unintended pregnancy and factors associated with using RECs, and Long-Acting-Reversible-Contraceptives (LARCs)-implants and IUCDs, among women living with HIV (WLHIV) receiving antiretroviral therapy (ART). METHODS We conducted cross-sectional analyses of the US-PEPFAR PROMOTE study WLHIV on ART at enrollment. Separate outcome (REC and LARC) modified-Poisson regression models were used to estimate prevalence risk ratio (PRR) and corresponding 95% confidence interval (CI). RESULTS Of 1,987 enrolled WLHIV, 990 (49.8%) reported their last/current pregnancy was unintended; 1,027/1,254 (81.9%) non-pregnant women with a potential to become pregnant reported current use of effective contraception including 215/1,254 (17.1%) LARC users. Compared to Zimbabwe, REC rates were similar in South Africa, aPRR = 0.97 (95% CI: 0.90-1.04), p = 0.355, lower in Malawi, aPRR = 0.84 (95% CI: 0.78-0.91), p<0.001, and Uganda, 0.82 (95% CI: 0.73-0.91), p<0.001. Additionally, REC use was independently associated with education attained, primary versus higher education, aPRR = 1.10 (95% CI: 1.02-1.18), p = 0.013; marriage/stable union, aPRR = 1.10 (95% CI: 1.01-1.21), p = 0.039; no desire for another child, PRR = 1.10 (95% CI: 1.02-1.16), p = 0.016; infrequent sex (none in the last 3 months), aPRR = 1.24 (95% CI: 1.15-1.33), p<0001; and controlled HIV load (≤ 1000 copies/ml), PRR = 1.10 (95% CI: 1.02-1.19), p = 0.014. LARC use was independently associated with country (Zimbabwe ref: South Africa, PRR = 0.39 (95% CI: 0.26-0.57), p<0.001; Uganda, PRR = 0.65 (95% CI: 0.42-1.01), p = 0.054; and Malawi, aPRR = 0.87 (95% CI: 0.64-1.19), p = 0.386; HIV load (≤ 1000 copies/ml copies/ml), aPRR=1.73 (95% CI: 1.26-2.37), p<0.001; and formal/self-employment, aPRR = 1.37 (95% CI: 1.02-1.91), p = 0.027. CONCLUSIONS Unintended pregnancy was common while use of effective contraception methods particularly LARCs was low among these African WLHIV. HIV viral load, education, sexual-activity, fertility desires, and economic independence are pertinent individual-level factors integral to the multi-level barriers to utilization of effective contraception among African WLHIV. National programs should prioritize strategies for effective integration of HIV and reproductive health care in the respective African countries.
Collapse
Affiliation(s)
- Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- South Africa Medical Research Council (SAMRC)-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Durban, South Africa
| | - Teacler Nematadzira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Mandisa M. Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Lameck Chinula
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- UNC-CH Department of Obstetrics and Gynecology, Chapel Hill, NC, United States of America
| | - Catherine Nakaye
- Makerere University-Johns Hopkins University (MUJHU) Research Collaboration, Kampala, Uganda
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Taha Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | |
Collapse
|
2
|
Cha H. Past, present, and future dimensions of socioeconomic status and sexual self-efficacy of young women during the transition into adulthood. Soc Sci Med 2022; 306:115128. [PMID: 35716552 DOI: 10.1016/j.socscimed.2022.115128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
Socioeconomic disadvantages can undermine a person's ability to control their sexual lives (sexual self-efficacy) during the transition to adulthood. Most scholarship focuses on proximate circumstances, specifically how sexual self-efficacy is a result of current socioeconomic status. Yet, this sexual agency is embedded within much longer behavioral and psychological trajectories shaped by socioeconomic contexts. Therefore, I identify a novel explanation for sexual self-efficacy by connecting it to past, present, and anticipatory future conceptualizations of young adults' socioeconomic circumstances. Drawing from 2.5 years of quarterly data from the Relationship Dynamics and Social Life Study, I found significant associations between more advantaged past, present, and anticipatory future socioeconomic circumstances and greater sexual self-efficacy during the transition to adulthood. Stage-specific dimensions of socioeconomic status (SES) followed two life course patterns (pathways and accumulation). In addition, prospective SES was found to be a more powerful predictor than childhood and current SES. As such, I encourage researchers to conceptualize socioeconomic status in life course terms to illuminate the underlying causes and consequences of varying young adulthoods.
Collapse
Affiliation(s)
- Hyungmin Cha
- Department of Sociology, University of Texas at Austin, USA; Population Research Center, University of Texas at Austin, USA; Center on Aging and Population Sciences, University of Texas at Austin, USA.
| |
Collapse
|
3
|
Guzzo KB, Hayford SR. Adolescent reproductive attitudes and knowledge effects on early adult unintended and nonmarital fertility across gender. ADVANCES IN LIFE COURSE RESEARCH 2021; 50:100430. [PMID: 34992512 PMCID: PMC8726112 DOI: 10.1016/j.alcr.2021.100430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Theory and evidence suggest strong short-term effects of attitudes toward, and knowledge about, reproduction on women's fertility. Adolescent attitudes and knowledge may also have longer-term implications about the contexts women perceive as appropriate for childbearing and their capacity to manage their preferences. Although previous research on men's fertility is limited, theory would suggest the links between adolescent attitudes and knowledge and subsequent fertility would also exist for men (though perhaps in different ways given the gendered meanings of sex, contraception, and reproduction). We analyze the relationship between reproductive attitudes and knowledge in adolescence and unintended and nonmarital first and second births in early adulthood, using the National Longitudinal Study of Adolescent to Adult Health (N = 9,431). Adolescent reproductive attitudes, especially life course consequences of early childbearing, predict the intendedness and marital status of first and second births. Adolescent reproductive knowledge is more often linked to the context of second births than first births. These associations vary by gender, but the overall results suggest that fertility schemas developed during adolescence predict behavior into early adulthood.
Collapse
Affiliation(s)
- Karen Benjamin Guzzo
- Department of Sociology, Bowling Green State University, Bowling Green, OH, 43403-0222, United States.
| | - Sarah R Hayford
- Department of Sociology, The Ohio State University, 1885 Neil Avenue Mall, Columbus, OH, 43210, United States.
| |
Collapse
|
4
|
Developing a model for reducing maternal mortality in South Africa. FRONTIERS OF NURSING 2021. [DOI: 10.2478/fon-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective
High maternal mortality ratios (MMRs) remain a concern in many parts of the world, especially in developing countries like South Africa. Different models have been developed, tried, and tested worldwide, in the hope that they will reduce maternal mortality, but without much success.
Methods
A qualitative approach was used to conveniently select a sample of 10 women attending an antenatal clinic in a rural area, in one of the districts of KwaZulu-Natal (KZN) Province. Data were collected by means of interviews with the women. Data were analyzed employing Burnard's content analysis approach.
Results
Four themes emerged: (1) age at first pregnancy; (2) birth intervals, risks in pregnancy and hospitalization; (3) the use of contraception; and (4) HIV status. All themes that emerged revealed inattention to reproductive health (RH) needs, resulting in poor RH outcomes as an area of concern.
Conclusions
Greater emphasis needs to be placed on meeting the sexual and reproductive health (SRH) needs of South African women, if maternal mortality rates are to be reduced. An alternative model for reducing maternal mortality in South Africa is proposed.
Collapse
|
5
|
The social context of retrospective-prospective changes in pregnancy desire during the transition to adulthood: The role of fathers and intimate relationships. DEMOGRAPHIC RESEARCH 2021. [DOI: 10.4054/demres.2021.44.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
6
|
Guzzo KB, Hayford SR. Pathways to Parenthood in Social and Family Context: Decade in Review, 2020. JOURNAL OF MARRIAGE AND THE FAMILY 2020; 82:117-144. [PMID: 34012172 PMCID: PMC8130890 DOI: 10.1111/jomf.12618] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/29/2019] [Indexed: 05/12/2023]
Abstract
OBJECTIVE This article reviews research from the past decade on patterns, trends, and differentials in the pathway to parenthood. BACKGROUND Whether, and under what circumstances, people become parents has implications for individual identity, family relationships, the well-being of adults and children, and population growth and age structure. Understanding the factors that influence pathways to parenthood is central to the study of families and can inform policies aimed at changing childbearing behaviors. METHOD This review summarizes recent trends in fertility as well as research on the predictors and correlates of childbearing, with a focus on the United States and on research most relevant to family scholars. We document fertility differentials and prevailing explanations for variation across sub-groups and discuss alternative pathways to parenthood, such as adoption. The article suggests avenues for future research, outlines emerging theoretical developments, and concludes with a discussion of fertility policy. RESULTS U.S. fertility has declined in recent years; whether fertility rates will increase is unclear. Elements of the broader social context such as the Great Recession and increasing economic inequality have impacted pathways to parenthood, and there is growing divergence in behaviors across social class. Scholars of childbearing have developed theories to better understand how childbearing is shaped by life course processes and social context. CONCLUSION Future research on the pathways to parenthood should continue to study group differentials, refine measurement and theories, and better integrate men and couples. Childbearing research is relevant for social policy, but ideological factors impact the application of research to policy.
Collapse
Affiliation(s)
- Karen Benjamin Guzzo
- Department of Sociology, Bowling Green State University, Bowling Green, OH 43403-0222
| | - Sarah R Hayford
- Department of Sociology, The Ohio State University 1885 Neil Avenue Mall Columbus, OH, 43210
| |
Collapse
|
7
|
Guzzo KB, Hayford SR, Lang VW, Wu HS, Barber J, Kusunoki Y. Dimensions of Reproductive Attitudes and Knowledge Related to Unintended Childbearing Among U.S. Adolescents and Young Adults. Demography 2019; 56:201-228. [PMID: 30523559 DOI: 10.1007/s13524-018-0747-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Measures of attitudes and knowledge predict reproductive behavior, such as unintended fertility among adolescents and young adults. However, there is little consensus as to the underlying dimensions these measures represent, how to compare findings across surveys using different measures, or how to interpret the concepts captured by existing measures. To guide future research on reproductive behavior, we propose an organizing framework for existing measures. We suggest that two overarching multidimensional concepts-reproductive attitudes and reproductive knowledge-can be applied to understand existing research using various measures. We adapt psychometric analytic techniques to analyze two data sets: the National Longitudinal Survey of Adolescent to Adult Health (Add Health) and the Relationship Dynamics and Social Life study (RDSL). Although the specific survey measures and sample composition of the two data sets are different, the dimensionality of the concepts and the content of the items used to measure their latent factors are remarkably consistent across the two data sets, and the factors are predictive of subsequent contraceptive behavior. However, some survey items do not seem strongly related to any dimension of either construct, and some dimensions of the two concepts appear to be poorly measured with existing survey questions. Nonetheless, we argue that the concepts of reproductive attitudes and reproductive knowledge are useful for categorizing and analyzing social psychological measures related to unintended fertility. The results can be used to guide secondary data analyses to predict reproductive behavior, compare results across data sets, and structure future data collection efforts.
Collapse
Affiliation(s)
- Karen Benjamin Guzzo
- Department of Sociology, Bowling Green State University, Bowling Green, OH, 43403-0222, USA.
| | - Sarah R Hayford
- Department of Sociology, Ohio State University, 238 Townshend Hall, 1885 Neil Avenue Mall, Columbus, OH, 43210, USA
| | - Vanessa Wanner Lang
- Department of Sociology, Bowling Green State University, Bowling Green, OH, 43403-0222, USA
| | - Hsueh-Sheng Wu
- Center for Family and Demographic Research, Bowling Green State University, Bowling Green, OH, 43403-0222, USA
| | - Jennifer Barber
- Department of Sociology, University of Michigan, 500 S. State Street, Ann Arbor, MI, 48109, USA
| | - Yasamin Kusunoki
- Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, 400 N. Ingalls Street, Ann Arbor, MI, 48109, USA
| |
Collapse
|
8
|
Kost K, Zolna M. Challenging unintended pregnancy as an indicator of reproductive autonomy: a response. Contraception 2019; 100:5-9. [PMID: 31059700 DOI: 10.1016/j.contraception.2019.04.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Kathryn Kost
- Guttmacher Institute, 125 Maiden Lane, New York, NY 10038.
| | - Mia Zolna
- Guttmacher Institute, 125 Maiden Lane, New York, NY 10038
| |
Collapse
|
9
|
Guzzo KB, Hayford SR, Lang VW. Adolescent Fertility Attitudes and Childbearing in Early Adulthood. POPULATION RESEARCH AND POLICY REVIEW 2019; 38:125-152. [PMID: 31543558 PMCID: PMC6754103 DOI: 10.1007/s11113-018-9499-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 10/13/2018] [Indexed: 10/28/2022]
Abstract
Teens' attitudes about adolescent childbearing predict childbearing in the short term. If these attitudes reflect persistent goals and values, they may also be linked to later outcomes. To test long-term linkages, we analyze the association of adolescent fertility attitudes with actual and prospective fertility in adulthood using Waves I (1994-95) and IV (2007-08) of the National Longitudinal Study of Adolescent to Adult Health and focusing on men (N = 4,275) and women (N=4,418) without a teen birth. For women, we find that more negative teen attitudes predict lower hazards of a first birth up to around age 30 but that teens' attitudes are unrelated to planned childlessness among those who have not yet had children. Men's adolescent attitudes are unrelated to actual fertility or prospective intentions. For both men and women, more advantaged individuals are less likely to have had a child by around age 30; socioeconomic advantage is also related to postponement of childbearing rather than planned childlessness, though more so for women than men. We interpret the findings as evidence that, for girls, teens' attitudes toward adolescent childbearing capture an internalization of social schema about childbearing, childrearing, and sequencing with other life outcomes but do not reflect overall preferences about having children. More work is needed to understand the psychosocial factors that influence men's fertility.
Collapse
Affiliation(s)
- Karen Benjamin Guzzo
- Department of Sociology Bowling Green State University Bowling Green, OH 43403-0222 419-372-3312,
| | - Sarah R Hayford
- Department of Sociology The Ohio State University 1885 Neil Avenue Mall Columbus OH, 43210 614-292-9538,
| | - Vanessa Wanner Lang
- Department of Sociology Bowling Green State University Bowling Green, OH 43403-0222,
| |
Collapse
|
10
|
Rocca CH, Ralph LJ, Wilson M, Gould H, Foster DG. Psychometric Evaluation of an Instrument to Measure Prospective Pregnancy Preferences: The Desire to Avoid Pregnancy Scale. Med Care 2019; 57:152-158. [PMID: 30550399 PMCID: PMC6331264 DOI: 10.1097/mlr.0000000000001048] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Existing approaches to measuring women's pregnancy intentions suffer important limitations, including retrospective assessment, overly simple categories, and a presumption that all women plan pregnancies. No psychometrically valid scales exist to prospectively measure the ranges of women's pregnancy preferences. MATERIALS AND METHODS Using a rigorous construct modeling approach, we developed a scale to measure desire to avoid pregnancy. We developed 60 draft items from existing research, assessed comprehension through 25 cognitive interviews, and administered items in surveys with 594 nonpregnant women in 7 primary and reproductive health care facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used item response theory to reduce the item set and assess the scale's reliability, internal structure validity, and external validity. Items were included based on fit to a random effects multinomial logistic regression model (partial credit item response model), correspondence of item difficulty with participants' pregnancy preference levels, and consistency of each item's response options with overall scale scores. RESULTS The 14 final items covered 3 conceptual domains: cognitive preferences, affective feelings, and practical consequences. Items fit the unidimensional model, with a separation reliability of 0.90 (Cronbach α: 0.95). The scale met established criteria for internal validity, including correspondence between each item's response categories and overall scale scores. We found no important differential item functioning by participant characteristics. CONCLUSIONS A robust measure is available to prospectively measure desire to avoid pregnancy. The measure can aid in identifying women who could benefit from contraceptive care and research on less desired pregnancy.
Collapse
Affiliation(s)
- Corinne H. Rocca
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, School of Medicine, San Francisco
| | - Lauren J. Ralph
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, School of Medicine, San Francisco
| | - Mark Wilson
- University of California, Graduate School of Education, Berkeley, CA
| | - Heather Gould
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, School of Medicine, San Francisco
| | - Diana G. Foster
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, School of Medicine, San Francisco
| |
Collapse
|
11
|
Rice WS, Turan B, Stringer KL, Helova A, White K, Cockrill K, Turan JM. Norms and stigma regarding pregnancy decisions during an unintended pregnancy: Development and predictors of scales among young women in the U.S. South. PLoS One 2017; 12:e0174210. [PMID: 28328960 PMCID: PMC5362217 DOI: 10.1371/journal.pone.0174210] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 03/06/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Norms and stigma regarding pregnancy decisions (parenting, adoption, and abortion) are salient to maternal well-being, particularly for groups disproportionately affected by unintended pregnancy. However, there are few validated measures of individual-level perceptions of norms and stigma around pregnancy decisions. Additionally, little is known about variation in the content of norms regarding pregnancy decisions, and in stigma related to violations of these norms, across socio-demographic groups. METHODS To create measures of perceived norms and stigma around pregnancy decisions, we developed and pre-tested 97 survey items using a mixed methods approach. The resulting survey was administered to 642 young adult women recruited from health department clinics and a public university campus in Birmingham, Alabama. Principal components factor analyses, reliability analyses, independent t-tests, and correlation analyses were conducted to establish the reliability and validity of scales. Additionally, multiple linear regression was used to identify demographic predictors of higher scale scores. RESULTS Factor analyses revealed four subscales for each pregnancy decision: conditional acceptability, anticipated reactions, stereotypes/misperceptions, and attitudes. The total scales and their subscales demonstrated good internal reliability (alpha coefficients 0.72-0.94). The mean scores for each scale were significantly associated with each other, with related measures, and differed by sociodemographic characteristics. Specifically, in adjusted analyses, women in the university setting and White women expressed more negative attitudes and stigma around parenting. Minority women endorsed more negative norms and stigma around adoption. Finally, women from the health department, White women, and religious women expressed more negative norms and stigma around abortion. CONCLUSION Findings suggest that our multidimensional measures have good psychometric properties in our sample of young women in the U.S. South, and highlight the importance of conceptualizing and measuring norms and stigmas around all pregnancy decisions. These scales may be of use in research on pregnancy decision-making and evaluation of stigma-reduction interventions.
Collapse
Affiliation(s)
- Whitney S. Rice
- Department of Psychology, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Bulent Turan
- Department of Psychology, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Kristi L. Stringer
- Department of Medical Sociology, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Anna Helova
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Kari White
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Kate Cockrill
- Sea Change Program, Tides Foundation, Oakland, CA, United States of America
| | - Janet M. Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| |
Collapse
|