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November 24, 2009
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Health and Wellbeing Click on a researcher's name to display only his or her recent research projects.
The existence of a relationship between education and health is well established. Less well known is that the importance of education to health varies both across the individual life course and across birth cohorts. In previous research, Scott Lynch found that education's effect on health grows across age at the individual level and is becoming increasingly important to health at the societal level. Over the last year, Lynch completed and published a paper investigating the role that income plays in these changing individual-level and societal-level relationships. He found that, at the same time the overall effect of education on health is increasing, a growing proportion of this effect operates through income. Additionally, the increasingly important role income plays in explaining the education-health relationship is due to a strengthening of the associations both between education and income and between income and health. At the individual level, he found that income plays an increasingly important role in linking education and health until just after midlife, when the effect of both education and income declines. These results suggest that a more complex approach to examining life course patterns of schooling and health is warranted. Currently, Lynch is investigating whether the measurement of education influences our estimates of the changing effect of education on health. Research often arbitrarily chooses between a years-of-schooling and a diploma/degree approach to measuring education. Yet, the choice of measure may be important, especially if education's role in society is changing over time. So far, Lynch has found that the association between diploma/degree attainment and health is strengthening across time, while the association between years of schooling and health is not. This result is consistent with the finding that income is playing an increasingly important role in explaining the link between education and health and the hypothesis that credentialism is occurring--that diplomas are becoming increasingly important in granting access to higher-paying jobs with better benefits, both of which may influence health.
By examining social gradients in health measures for Hispanics and whites in the U.S., Noreen Goldman and colleagues identified an unusual pattern among Hispanics-- relatively weak education differentials for a number of health outcomes and health behaviors. An extension of this research revealed that much of the mortality advantage of Hispanics stemmed from better than expected mortality among lower SES Hispanics. These studies led to the development of a collaborative project by Noreen Goldman, Anne Pebley (University of California-Los Angeles), and Rebeca Wong (University of Texas) to investigate the extent to which these SES gradients are unique to Hispanic groups and to identify the mechanisms that underlie these patterns. This project involves examining SES differentials in health in Mexico and the potential role of acculturation and assimilation in producing these atypical health gradients in the United States.
Several studies related to this project were recently completed or are underway. Goldman, Duncan Thomas (Duke University), Graciela Teruel (Ibero-American University, Mexico) and Luis Rubalcava (CIDE, Mexico) analyzed data from the 2002 and 2005 waves of the Mexican Family Life Survey (MxFLS) to examine whether there is any evidence to support the "healthy migrant hypothesis"--i.e., whether immigrants from Mexico to the U.S. during the inter-survey period are positively selected by education and health status. The results, published in the American Journal of Public Health, suggest very modest health-related selection.
Rachel Kimbro (Rice University), graduate student Sharon Bzostek, Goldman, and Germán Rodríguez examined education differentials in a broad range of health measures and across diverse racial and ethnic groups based on the NHIS. In a paper in Health Affairs, they demonstrate that education is a more powerful determinant of health for some groups than others, and that the education gradients in health for foreign-born groups are generally more modest than those for the corresponding native-born populations.
Two postdoctoral fellows--Alison Buttenheim and Margot Jackson--are collaborating on the Latino health project. Alison Buttenheim estimated SES gradients in obesity and smoking from Mexican data (ENSA). The results underscore the complexity of the socioeconomic determinants of health related behaviors in Mexico, with the magnitude and direction of the associations varying by sex, urban/rural location, and nature of the SES indicator (education vs. wealth). In a second paper in progress, they incorporate a measure of regional outmigration from the Mexican census to test hypotheses about gradients among Mexican-origin adults in the United States. Margot Jackson has been using data on foreign-born and native residents from the Los Angeles Family and Neighborhood Survey to examine how the economic and cognitive returns to education depend not only on the level of schooling, but on where the schooling was obtained.
Noreen Goldman, Maxine Weinstein (Georgetown University), and Dana Glei (University of California- Berkeley) are continuing to collaborate with colleagues at the Bureau of Health Promotion, Department of Health in Taiwan, on the Social Environment and Biomarkers of Aging Study (SEBAS). This data collection effort, supported by the National Institute on Aging, was designed to provide insights into the role of physiological processes in the complex relationships among stressful experience, the social environment, and physical and mental health. The first wave of the survey, fielded in 2000, includes home-based interviews, collection of blood and urine samples, and physicians' health exams from about 1,000 middle-aged and elderly respondents. Respondents are a random sub-sample from an ongoing national survey that has collected periodic interviews between 1989 and 2003 in Taiwan. SEBAS II, which was fielded between August 2006 and January 2007, has obtained a second set of measurements for biomarkers collected in 2000 as well as several new physiological measures, including (1) inflammatory markers, such as C-reactive protein and fibrinogen; (2) health assessments in the home--blood pressure, grip strength, lung function, timed walks, and chair stands; and (3) additional questions in the household interview on pain, perceived stress, stressful and traumatic events, and sleep.
During the past year, Goldman, Weinstein and Glei have been preparing data from SEBAS II for public use. A summary paper of the Taiwan project to date was published in the National Academy of Sciences volume, Biosocial Surveys. In addition, numerous projects based on SEBAS I have been ongoing. For example, Glei, Goldman and Weinstein explored the extent to which chronic stressors predicted physiological dysregulation in the cardiovascular, immune, and neuroendocrine systems and the role of individual and environmental characteristics in mediating that relationship. In a paper in Psychosomatic Medicine, they concluded that, although the relationship between life challenges and physiological dysregulation was generally weak, the combination of low social position, weak social networks, and poor coping ability was associated with greater physiological consequences. In a recently published paper, Goldman and colleagues used survival data from Taiwan to demonstrate that an array of biomedical measurements that are not typically measured in clinical exams (measures of immune and neuroendocrine function) are at least as predictive as clinical measures (e.g., blood pressure, cholesterol, glucose levels) of the risks of dying in a three-year period. In an ongoing update of this analysis, they demonstrate that a set of disease progression markers and non-clinical measures each provide more discriminatory power in predicting six-year mortality than standard cardiovascular and metabolic risk factors. An analysis of sex differences in mortality suggests that the majority of excess male mortality results from the fact that Taiwanese men are more likely to smoke than women; several markers of disease progression and inflammation explain a modest amount of the sex difference in mortality.
Goldman and postdoctoral fellow Amy Collins examined whether findings from previous studies demonstrating that subjective measures of relative social position are significant predictors of health are biased. Their results, published in Social Science and Medicine, underscore that the associations are substantially attenuated when estimated from longitudinal data with controls for health status at baseline. Together with Germán Rodríguez, Collins and Goldman analyzed the relationship between measures of positive wellbeing and subsequent disability. Their findings demonstrate that life satisfaction and perceptions of future happiness are associated with the development of fewer mobility limitations during follow-up, but only for those participants who had no mobility limitations at baseline. The results suggest a protective relationship between psychological wellbeing and physical decline in later life.
A major research initiative of Elizabeth Mitchell Armstrong is a study of the evolution of fetal personhood and its impact on the practice and ethics of obstetrics. Advances in medical technology have reconfigured our cultural understandings of pregnancy, giving rise to a new cultural idea, that of fetal personhood--the notion that the fetus is a person, distinct from the pregnant woman. Armstrong's research examines how that idea has shaped the way pregnant women, obstetricians and the public at large think about pregnancy, pregnant women and fetuses. Armstrong's collaboration with Dan Carpenter (Harvard University) and Marie Hojnacki (Pennsylvania State University) is an investigation of agenda setting around disease. This project seeks to understand how and why some diseases get more attention in the public arena than other diseases. A paper based on this project won the Eliot Freidson Award from the Medical Sociology section of the American Sociological Association in 2007. Armstrong is also a co-investigator on a proposed multi-site study that will collect qualitative and quantitative data to understand how women make decisions about childbirth, particularly in light of recent policy and media attention to the issue of elective cesarean delivery. Armstrong has also begun working on a new study of lay and professional attitudes towards immunization, as well as continuing to work with an interdisciplinary research group on ideas about risk in obstetrics and gynecology. The group published a paper on the risks, values, and decision making in pregnancy in Obstetrics and Gynecology, the leading clinical journal for ob/gyns in the United States.
In an ongoing project with Adriana Lleras-Muney and David Cutler (Harvard University), preliminary results suggest that income and budget constraints explain about 30 percent of the differences in health behaviors across education groups. Surprisingly, only a small part of the differences by education can be explained by differential knowledge of specific health risks (such as the risks associated with smoking). Most strikingly, a substantial part of the gradient seems to be due to differences in cognition or decision-making abilities, and how information about health is perceived and implemented. A new project with Christina Paxson and Cecilia Rouse (Princeton University) looks at health effects arising from postsecondary education. They are collecting data to evaluate the health impact of the "Opening Doors" education intervention, which randomly offers financial, mentoring, and curriculum services to community college entrants from disadvantaged backgrounds. Although this project could greatly improve our understanding of the effects of education on health in developed countries today, the preliminary results are disappointing because the program appears to have been unsuccessful at raising educational attainment, making it impossible to study the subsequent effects of increased education on health. Lleras-Muney intends to continue working in this area and hopefully attempt to estimate causal effects of education on health from other randomized education interventions.
Lleras-Muney has begun studying the economic consequences of poor health and the enormous increase in life expectancy worldwide over the past century. A common argument made by economists is that increases in life expectancy affect the incentives to invest in education and health (such behaviors are frequently modeled as a form of savings). This theoretical prediction is one reason why many argue that disease elimination is a powerful strategy toward reducing poverty and increasing GDP in developing countries, in Africa, particularly. The magnitude of these effects is not well understood, however. To estimate the effect of life expectancy on educational attainment, Seema Jayachandran (Stanford University) and Lleras-Muney examine maternal mortality declines that took place in Sri Lanka between 1946 and 1953. Maternal mortality was a major killer of prime-age women, and its elimination resulted in large increases in the life expectancy of women relative to men in a very short period of time. Using variation across districts, over time and by gender, they find that the 80 percent reduction in maternal mortality risk increased female life expectancy by 1.7 year (a 4.5 percent increase in prime-age years), and increased female literacy by 7.2 percent. Lower maternal mortality risk also increased the birth rate.
Michelle DeKlyen collaborated with psychologist Virginia Kwan (Princeton University) in an examination of the drinking behavior and attitudes of Princeton University students. Preliminary results suggest that students who report higher social anxiety, depression, and narcissism are more likely to drink in response to peer pressure. The amount students say they drink is related to how much they think other students drink; this may be particularly true of students who score high on narcissism.
Douglas Massey serves as Principal Investigator on a new study funded by NICHD, on a subcontract from Northwestern University, on social influences on early adult stress biomarkers. Social contexts are critical determinants of human development and health, but we know very little about the processes or pathways through which they influence our physical development, health, and wellbeing. This study seeks to determine the extent to which multiple subjective and physiological measures of stress reflect overlapping vs. distinct markers of strain on the individual. This will be done by analyzing the interrelations among self-report measures of cognitive/emotional stress and measures of cardiovascular, metabolic, endocrine, immune, and inflammatory activity gathered simultaneously in Wave IV of the Add Health study. Massey's work will focus on how measures of socioeconomic status, neighborhood factors, and interpersonal relationships in childhood/adolescence and over the transition to adulthood influence stress in early adulthood, using models that attempt to control for selection into these social environments. The rationale for this work was laid out in an article on segregation and stratification published in The DuBois Review.
Alison Buttenheim, Harold Alderman (the World Bank), and Jed Friedman (the World Bank) are evaluating a World Food Programme school feeding initiative in Lao PDR. The project included a baseline survey of 4,500 households with school aged children in 2005, prior to the roll-out of four randomized school feeding interventions in four districts of northern Lao PDR. Baseline data reveal high rates of stunting and wasting among the Lao children and low levels of school enrollment. The team will return to the field in fall 2008 for the follow-up study and then analyze the impact of the different interventions on children's health and educational outcomes.
Using longitudinal data from 14 urban slum communities in Dinajpur, Bangladesh, Alison Buttenheim examined the effect of improved sanitation on child health to assess the relative importance of household vs. neighborhood characteristics and of adult latrine usage vs. safe disposal of children's feces. Results suggest that increases in improved latrine use among neighboring households with young children (proxying the safe disposal of children's feces) are associated with significant increases in weight-for-height. No effects are observed for increases in improved latrine usage among neighboring households with no young children (proxying adult latrine usage) nor for latrine usage changes within the child's own household. Buttenheim concludes that sanitation improvements offer important externalities, and that sanitation programs must encourage the safe disposal of children's feces in order to realize maximum health gains.
Alison Buttenheim and Elizabeth Frankenberg (Duke University) investigated the impact of a major expansion in access to midwifery services on use of prenatal care and delivery assistance for women of reproductive age in Indonesia. Between 1991 and 1998, Indonesia trained some 50,000 midwives, placing them in relatively poor communities that were relatively distant from health centers. Regardless of a woman's educational level, additions of village midwives to communities are associated with significant increases in receipt of iron tablets and in choices about care during delivery that reflect a movement away from reliance on traditional birth attendants. For women with relatively low levels of education, village midwives have the additional benefits of increasing use of any prenatal care, and of use of prenatal care during the first trimester. In a separate study also using the Indonesia Family Life Survey, Buttenheim is evaluating the relationship between contraceptive use and participation in microfinance programs, a phenomenon that has not been widely studied outside of Bangladesh.
Burton Singer's research has two primary foci: (1) identification of social, biological, and environmental risks associated with vector-borne diseases in the tropics and implications for the design and implementation of tropical disease control programs, and (2) integration of psychosocial and biological evidence to characterize pathways to alternative states of health. The latter focus has emphasized studies of the biological substrates of psychological wellbeing and of the interplay between cumulative adverse and positive experiences over the life course. The first focus has included assessments of the interrelationships between ecological transformation, economic development, and malaria on the Amazon frontier in Brazil. It has also included studies of urban malaria in Africa. A second central feature has been historical analyses of the bases for successful malaria control programs from 1900 to the present and implications for current health policy in the tropics. Work on tropical health issues is centered around a study of urban malaria in Dar es Salaam, Tanzania, linked to the implementation of a new malaria control program for the city. Complementary to the urban studies are rural investigations in western Cote d'Ivoire focused on malaria, schistosomiasis, and a range of geohelminths. A novel aspect of this work is the introduction of NMR spectroscopy on urine and serum samples to carry out diagnosis of a broad spectrum of parasitic infections on the basis of metabolic profiles. Publications characterizing the metabolic profiles of infection with schistosomiasis (S. mansoni and S. japonicum), African Trypanosomiasis (T. brucei brucei), and malaria (P.berghi) in animal models have appeared over the past several years.
Complementary to the biological and epidemiological studies in the tropics has been a series of policy analyses focused on health impact assessment and mitigation strategies for large scale development programs. Analyses of health impact assessments for the Chad-Cameroon Petroleum Development and Pipeline Project and Nam Theun 2 Hydroelectric Project in Laos have been carried out in collaboration with Juerg Utzinger (Swiss Tropical Institute) and Gary Krieger (Newfields, Inc., Denver). Singer has also carried out an in-depth policy analysis of the health consequences of the Madeira River Hydropower Project in Brazil in collaboration with Marcia Castro (Harvard University). A series of analyses of the health impact assessment and mitigation requirements currently developing as legislation for the state of Alaska-- linked to mining, oil, and gas projects--is planned in collaboration with Gary Krieger.
Regarding the biological substrates of life histories and wellbeing, Singer and Carol Ryff (University of Wisconsin) have a national survey (MIDUS II) that went into the field in July 2003 that focuses on characterizing complex pathways to health and illness. This study also includes extensive biomarker assessments that will be utilized in their program aimed at refining operationalizations of the concept of allostatic load. Genetic studies of discordant and concordant twin pairs will be conducted with a focus on personality characteristics such as neuroticism. This large NIH-funded project will run thru 2008. Singer and Ryff have also recently initiated a companion study to MIDUS, based in Japan. This will facilitate international comparative analyses of biomarker and genetic profiles linked to psychosocial phenotypes.
James Trussell and Kelly Cleland continue their collaborative work with the Association of Reproductive Health Professionals (ARHP) on increasing public awareness of and access to emergency contraception. ARHP and the Office of Population Research sponsor the Emergency Contraception Hotline (1-888-NOT-2-LATE) and the Emergency Contraception Website (not-2-late.com). The Hotline provides detailed information about emergency contraception, as well as the phone numbers of five nearby clinicians who will provide emergency contraceptives in the United States. The Website contains more detailed information and the complete listing of providers. The Hotline is available in English and in Spanish. The website is available in English, Spanish, French, and Arabic. Since it was launched on February 14, 1996, the Hotline has received more than 700,000 calls. The Website has received more than five million visitors since it was launched in October 1994; there are currently about 125,000 visitors per month. The Website was completely redesigned and re-launched in September 2006.
With colleagues from the University of Rochester, Lisa Wynn (Macquarie University), Kelly Cleland, and James Trussell conducted a study of 200 women in New York State seeking ECP prescriptions through the internet. Eight in ten Internet users have sought health information online, and web-based medical resources are growing in number. Yet little is known about women who seek ECPs from the Internet. Using a mixed methods approach, with surveys and qualitative interviews conducted by telephone, this study collected descriptive data on women seeking ECPs via the Internet, identified barriers to ECP access, and assessed attitudes towards advance provision and nonprescription ECPs. Participants were predominately white, college-educated, and urban residents. Most women sought ECPs through the Internet without first seeking prescriptions from local providers, anticipating structural and attitudinal barriers to obtaining ECPs from local providers. While women supported advance prescription of ECPs, there was less enthusiasm for nonprescription ECPs due to concerns that others (but not themselves) would engage in risky sexual behavior. Yet even in this group of women seeking drug prescriptions through unconventional means, many women still stated that they valued the consultation with a health professional and would still prefer to speak with a clinician even if nonprescription ECPs were available. This study showed that there is a need to address beliefs that increased ECP availability promotes risky sexual behavior, as current evidence refutes this concern.
In a paper prepared for an IUSSP workshop on ethics and reproductive health and later published in Studies in Family Planning, Lisa Wynn, James Trussell, Angel Foster (Ibis Reproductive Health), and Joanna Erdman (University of Toronto Law School) comparatively examine the debates over non-prescription access to emergency contraceptive pills in the United States and Canada. In April 2005, Health Canada reclassified the emergency contraceptive pill (ECP) Plan B as a non-prescription drug. Upon reclassification, provincial pharmacy regulators restricted the sale of Plan B to behind-the-counter status, thereby requiring pharmacist assessment and counseling at the point of sale. A coalition of national organizations in Canada is petitioning to have the status of ECPs moved off-schedule, i.e. sold without pharmacist intervention. These groups object to the way that some pharmacists require women seeking ECPs to provide information about their sexual history in order to receive the product. This research project compares arguments employed by proponents of expanded ECP access in Canada and the United States to challenge the prescription status of the medication. In Canada, the dominant argument asserted women's rights to equitable and effective access to health care services. In the United States, proponents of expanded ECP access asserted the drug's safety and ability to reduce public health problems. This research project uses critical discourse analysis to deconstruct the key texts and position statements in favor of expanded ECP access in both countries and reveal the implicit underlying assumptions about sexuality, the role of the state and medical authorities in the sexual lives of men and women, and the rights and abilities of individual women to make informed decisions regarding their sexuality and reproductive health. A harm reduction model predominated in the health arguments marshaled in support of expanding ECP access. In this view, sex leads to various problems, from the transmission of sexually transmitted infections to unintended pregnancy, pregnancy-related morbidity, and abortion. Expanding access to ECPs reactively contains some of these public health problems. A competing framework arguing in favor of expanded EC access was also evident, particularly in the Canadian context; this model asserted women's right to healthy, satisfying, non-procreative sex and the right to make informed choices about their contraceptive needs from among all safe and effective options and free from the intervention of the state and medical authorities. This research project reflects on the success of these two lines of argumentation in both influencing and challenging regulatory policy as well as in shaping societal discourse on reproductive health and sexuality.
Using data from a prospective population-based cohort in France (the Cocon survey, 2001-2004), Caroline Moreau, James Trussell, and Nathalie Bajos (National Institute of Health and Medical Research, France) examined the impact of ECP use on women's regular contraceptive use patterns in the French context of direct pharmacy access to ECPs. Their results show that easy availability of ECPs does not result in the abandonment of regular contraceptive use. However, they also found that use of ECPs does not necessarily result as a bridge to use more effective contraception; while 30 percent of those using a non-highly effective contraceptive or no method at the time of ECP use did switch to a highly effective method, 22 percent of those using a highly effective method at the time of ECP use switched to a less effective or no method.
In a paper published in Obstetrics & Gynecology, James Trussell, Elizabeth Raymond (Family Health International), and Chelsea Polis (Harvard School of Public Health) systematically reviewed data on effects of increased access to emergency contraceptive pills (ECPs) on unintended pregnancy rates and use of the pills. They included studies that compared the effect of different levels of access to emergency contraceptive pills on pregnancy rates, use of the pills, and other outcomes. Of the 717 articles identified, they selected 23 for review. The studies included randomized trials, cohort studies, and evaluations of community interventions. The quality of these studies varied. In all but one study, increased access to emergency contraceptive pills was associated with greater use. However, no study found an impact on pregnancy or abortion rates. They concluded that increased access to emergency contraceptive pills enhances use but has not been shown to reduce unintended pregnancy rates, primarily because ECPs are not used often enough. Specifically, even when women received ECPs at no cost in advance for later use should the need arise, they did not use ECPs in the vast majority of cycles in which pregnancy occurred, primarily because they did not think they were at risk.
James Trussell participated in a hormonal contraceptives trial methodology consensus conference held in September 2005 in Philadelphia. The result was a pair of papers published in Contraception. The first paper provided a description of methodologies applied in the U.S. Food and Drug Administration (FDA) medical officer's review of clinical trial data as contained in the Summary Basis of Approvals of New Drug Applications, results of the review and general conclusions. The authors concluded that data collection methods and analysis of self-reported episodes of bleeding and spotting in combined hormonal contraceptive trials have been highly variable with respect both to definitions and to analytical methods. No standards exist to regulate data collection techniques, methods of reporting, or analysis of bleeding and spotting events during clinical trials of combined hormonal contraceptives. For the purposes of regulatory review of hormonal contraceptives, data regarding the incidence of bleeding and spotting events are not included in either of the traditional categories of efficacy and safety. This lack of standardization has led to publication of confusing and sometimes misleading information about cycle control profiles among combined hormonal contraceptives. The second paper provided recommendations regarding best practices in trial design, data collection, and analysis regarding bleeding data in combined hormone contraception trials. The FDA convened its advisory committee of Reproductive Health Drugs in January 2007 to consider issues involved in clinical trials of combined hormonal contraceptives; Trussell was a member of that committee, which unanimously recommended that the FDA adopt these recommendations.
In a paper published in Contraception, James Trussell estimated the cost of unintended pregnancy in the United States. Despite the many contraceptive options available in the United States, nearly half (49 percent) of the 6.4 million pregnancies each year are unintended; these represent a significant cost to the health care system. The total number of unintended pregnancies and their outcomes were obtained from the literature. Direct medical costs were estimated for each unintended pregnancy outcome. The direct medical costs of unintended pregnancies were $5 billion in 2002. Direct medical cost savings due to contraceptive use were $19 billion. Unintended pregnancies are a costly problem in the United States. Contraceptive use can reduce direct and indirect costs, so payers may realize cost savings by providing coverage of contraceptive products.
In a paper published in Obstetrics & Gynecology, Caroline Moreau, James Trussell, and colleagues in France examined oral contraceptive (OC) tolerance. In recent years, healthcare providers have increasingly favored the prescription of the lowest estrogen dose formulations combined with third-generation progestins, based on theoretical improvements in safety and tolerance. However, no clear evidence supports these choices. This study examines the frequencies of reported symptoms by OC composition among French women. A population-based cohort of 2,863 women studied between 2000 and 2004 was used to compare the frequency of reported symptoms (weight gain, nausea, breast tenderness, lower frequency of menstrual periods, breakthrough bleeding, painful and heavy periods, swollen legs) by type of OCs (classified by estrogen dosage, progestin component, and sequence of administration). Results show little variation in the frequency of symptoms by type of OCs, with the exception of progestin-only pills being associated with higher frequencies of breakthrough bleeding and lower frequencies of menstrual periods. They found no decrease in the reporting of symptoms with the reduction in estrogen dosage, nor with the use of third- compared with second-generation OCs. Likewise, they found little variation by sequence of administration of OCs (monophasic versus triphasic). In the absence of sufficient evidence-based data to support the existence of differences in the tolerance profile of low dose combined OCs, future well-designed randomized trials are needed to guide providers in their choice of OCs. However, research should also assess the effectiveness of counselling on the tolerance of OCs, an intervention that may prove to be more rewarding than basing the choice of OCs on their theoretical properties.
Contraceptive discontinuation contributes significantly to the high rates of unintended pregnancies in the United States. Caroline Moreau, Kelly Cleland, and James Trussell examined contraceptive discontinuation throughout women's lives, focusing specifically on discontinuation due to dissatisfaction with the method. The study population, drawn from the 2002 National Survey of Family Growth, consisted of 6,724 women (15-44 years of age) who had ever used a reversible contraceptive method. They first estimated the proportion of women who discontinued their contraceptive due to dissatisfaction and examined the social and demographic characteristics associated with method discontinuation. They then calculated method-specific discontinuation rates due to dissatisfaction and analyzed the reasons for dissatisfaction given by women who stopped using Norplant, Depo-Provera, oral contraceptives, or condoms. Overall, 46 percent of women discontinued at least one method because they were unsatisfied with it. The likelihood of contraceptive discontinuation due to dissatisfaction depended on women's age, number of partners, parity, and whether they reported a history of unintended pregnancy. Women with the highest level of education and income were also more likely to discontinue their contraceptive due to dissatisfaction. Dissatisfaction-related discontinuation rates varied widely by method: the diaphragm and cervical cap showed the highest rates of discontinuation (52 percent), followed by long-acting hormonal methods, discontinued by 42 percent of users. Oral contraceptives were associated with a 29 percent dissatisfaction related discontinuation rate while condoms had the lowest rate of discontinuation due to dissatisfaction (12 percent). They conclude that a broader understanding of women's concerns and experiences using contraception could help healthcare providers redesign counseling strategies to improve contraceptive continuation.
Using data from a population-based cohort on contraception and abortion in France (Cocon survey), Caroline Moreau, James Trussell, Germán Rodríguez and Jean Bouyer (National Institute of Health and Medical Research, France) estimated method-specific contraceptive failure rates among women in France. They computed their estimates using shared frailty hazards models. They found an overall first year failure rate of 2.9 percent. The IUD had the lowest first year failure rate (1.1 percent), followed by the pill (2.4 percent), the male condom (3.3 percent), fertility awareness methods (7.4 percent), withdrawal (10.1 percent), and spermicides (19.8 percent). The lower contraceptive failure rates among French women compared to those reported for U.S. women suggests differences in contraceptive practices that need to be further explored.
In 2002, Kaiser Permanente health plan in California changed its contraceptive benefits to cover 100 percent of the costs of the most effective forms of contraception (intrauterine contraceptives, injectables, and implants) and for emergency contraceptive pills for all members. The benefit change was advocated by physician leaders across the system as an effort to promote more effective contraceptive use and thereby reduce unintended pregnancies. With colleagues from Kaiser Permanente, James Trussell conducted a retrospective observational study to describe the mix of reversible contraceptives procured before and after the benefit change. They then estimated couple-years of protection to examine whether the contraceptive mix changed to more effective reversible methods. After the benefit change, couple-years of protection increased 28 percent (from 2001-02 to 2003-04) while the caseload of females aged 15-44 fell by one percent. Couple-years of protection for intrauterine contraceptives and injectables rose 137 percent and 32 percent, respectively, while couple-years of protection for the pill, patch, and ring rose only 16 percent. The estimated average annual contraceptive failure rate among women using hormonal contraceptives and intrauterine contraceptives declined from 7.0 percent to 6.4 percent. Use of the levonorgestrel emergency contraceptive pill rose 88 percent. The investigators concluded that removal of the cost of contraception may result in increased utilization of more effective methods and emergency contraceptive pills.
James Trussell and colleagues from the Guttmacher Institute provided updated estimates of contraceptive discontinuation, contraceptive failure, and resumption of contraceptive use for the most commonly used reversible methods in the United States. Estimates were obtained using the 2002 National Survey of Family Growth and the 2001 Abortion Patient Survey to correct for underreporting of abortion in the NSFG. Altogether, 12.4 percent of all episodes of contraceptive use ended with a failure within 12 months after initiation of use. Injectable and oral contraceptives remain the most effective reversible methods used by women in the United States, with probabilities of failure during the first 12 months of use of 7 percent and 9 percent, respectively. The probabilities of failure for withdrawal (18 percent) and the condom (17 percent) are similar. Reliance on fertility-awareness-based methods results in the highest probability of failure (25 percent). There was no clear improvement in contraceptive effectiveness between 1995 and 2002. Altogether, 47 percent of all reversible methods used were discontinued for method-related reasons by the end of 12 months. However, they found that only 20.9 percent of reversible method use is discontinued in the first year if they eliminate change of method as a reason for discontinuation. The male condom was the method most likely to be discontinued (57.1 percent). By comparison, similar levels of method-related reasons for discontinuation in the first year of use were found for withdrawal (54.2 percent) and fertility-awareness-based methods (53.2 percent). Lower levels of discontinuation for method-related reasons were found for the pill (32.7 percent) and for Depo-Provera (44.0 percent). By the end of the first year, 80.3 percent of periods of non-use following discontinuation of use of a contraceptive method had ended with resumption of use of some type of contraceptive. A very high proportion of resumption occurs in the first month that a woman is exposed to risk of unintended pregnancy after discontinuation. Overall, 71.5 percent of non-use intervals had already ended in resumption of use in less than one month.
The UK Medical Eligibility Criteria (UK MEC) were adapted from the WHO Medical Eligibility Criteria to reflect evidenced-based practice in the United Kingdom. One significant change concerns combined hormonal contraceptive (CHC) use and body mass index (BMI). In the UK MEC, use of CHC by women with a BMI of 35-39 has been rated UK MEC 3, and for women with a BMI ≥40, use of CHC has been rated UK MEC 4. This change was prompted by concerns about the effect of CHC use on the risk of venous thromboembolism (VTE). James Trussell, Kate Guthrie (Sexual and Reproductive Healthcare Partnership, Hull and East Yorkshire), and Bimla Schwarz (University of Pittsburgh) reviewed the evidence for that change and examined the consistency of this recommendation with recommendations with respect to age and smoking. They examined five large recent studies of the effect of combined oral contraceptives (COCs) and BMI on VTE. They found that all evidence was expressed as relative risks. When they instead estimate absolute or attributable risks, they conclude that the UK MEC recommendations with respect to CHU use and obesity are inconsistent with those for age and smoking, that use of CHCs among women with a BMI of 35-39 is generally safe and should be changed from a UK MEC 3 to a UK MEC 2, and that there are no data on the safety of use of CHCs among women with a BMI ≥40.
James Trussell was responsible for the chapters on choosing a contraceptive (effectiveness, safety, and personal considerations), emergency contraception, postpartum contraception and lactation, and contraceptive efficacy for the nineteenth edition of Contraceptive Technology, published in late 2007. The Food and Drug Administration has mandated that his summary table of pregnancy rates during typical use and during perfect use of available contraceptive options (Table 27-1) be included in the labeling for all contraceptives marketed in the United States.
Charles Westoff, with funding from the Hewlett Foundation, completed an analysis of trends in sexual activity in sub- Saharan Africa, pursuing the interesting finding that sexual activity seems to be declining in ten countries in southern and eastern Africa but not in West Africa. The report appeared in the Journal of Biososical Science. The likelihood is that the difference is associated with the higher rates of HIV/AIDS in southern and eastern Africa. Westoff had explored changes in sexual activity in Africa based on a comparison of data for 1998 and 2003 in Kenya. The overall analysis was prompted by the appearance of a stall in contraceptive prevalence over the five-year period. However, when contraceptive prevalence was measured for sexually active women (rather than for all women), there was no evidence of any stall--the proportion using contraception increased significantly, as had been expected. It turns out that there has been a decline in recent sexual activity. Detailed analyses indicate that recent sex (in the preceding four weeks) had declined by eight percent for all women--a decline that was evident at all ages and marital statuses. Other evidence showed an increase in the median age at first sexual intercourse in Kenya from 16.7 in 1998 to 17.8 by 2003. Kenya is one of the sub-Saharan African countries with a significant prevalence of HIV-AIDS, estimated from blood test data in the survey to be 9.7 percent in 2003 for women 15-49. These apparent changes in Kenya prompted Westoff to look at other African countries with high levels of HIVAIDS that had conducted two or more recent surveys. These countries included Eritrea 1995-2002, Namibia 1992-2000, Rwanda 1992-2000, Tanzania 1999-2004, Uganda 1995-2001, and Zambia 1996-2001. Recent sexual activity was seen to decline in all six of these countries (ranging from 6-21 percent) as well as in Kenya. This was only a quick superficial observation, but it was sufficiently suggestive and potentially important in public health terms to persuade Westoff to develop a grant proposal to examine these trends in much greater detail.
Based on an update for 57 developing countries, Charles Westoff has shown that unmet need for family planning has declined recently in most of these countries except in sub-Saharan Africa, where little change is evident in 15 of 23 countries with available trend data. In the least developed of these latter countries, there are significant proportions of married women who have never used a method and who report that they do not intend to use any.
With Tomas Frejka, Westoff also found that one reason for the higher fertility rate in the U.S. compared with Europe is the greater religiousness of Americans. In an analysis involving 34 European countries and the U.S., European women are observed to be less religious by any measure than American women. In both parts of the world, more religious women have higher fertility. The research tries to estimate how much European fertility would rise if they were as religious as American women. A small increase would be expected for Europe as a whole with a much higher increase for Western Europeans. They also determined that Muslim women in Europe have higher fertility than non-Muslim women, but the rates are converging over time. The greater religiousness and differences in the status of women also play a role.
Westoff's current main research efforts have been directed toward developing a method of estimating abortion rates for different countries. The method is based on the very high correlation with the use of modern methods of contraception in the more developed countries, and it includes the total fertility rate as well in the less developed countries.
Angus Deaton has conducted research that documents how heights have changed over time in numerous countries, and explores the associations between average adult heights of birth cohorts on the one hand and, on the other, income and disease in the year of birth. Deaton and Carlos Bozzoli and Climent Quintana-Domeque (Princeton University) use self-reported height data from the European Community Household Panel (ECHP), which provides nationally representative surveys for Austria, Belgium, Denmark, Finland, Greece, Ireland, Italy, Portugal, Spain, and Sweden, together with self-reported heights from the National Health Interview Survey (NHIS) in the United States, and measured heights from the Health Survey of England (HSE). For all these countries, heights increased between those born in 1950 and those born in 1980. But all show a pattern of first increasing and then holding constant. This process was completed very early in the "most advanced" countries of Scandinavia, where there has been little or no increase in average heights since 1950, whereas in Portugal, Greece, Spain, and Italy, height increased throughout the period, with little sign of recent slowing.
In other research, Deaton examines the relationship between infant mortality and height. Deaton shows that patterns of income, height, and infant mortality across the world are very different from those in the rich countries, perhaps because of the greater importance of genetics at the population level, or perhaps because of nutritional factors that are not well understood, such as "niche" diets that support good health in spite of poverty. Deaton has also conducted research on sexual dimorphism--differences in the heights of adult men and women--in India, a country with a long history of discrimination against women. Since men and women face the same epidemiological environment, differences in their heights should convey differences in nutrition and/or health care in childhood.
Angus Deaton also used evidence from a Gallup world poll to investigate income, aging, health, and wellbeing around the world. During 2006, the Gallup Organization collected World Poll data using an identical questionnaire from national samples of adults from 132 countries. Deaton presents an analysis of the data on life-satisfaction (happiness) and health satisfaction and their relationships with national income, age, and life-expectancy. Average happiness is strongly related to per capita national income, with each doubling of income associated with a near one point increase in life satisfaction on a scale from 0 to 10. Unlike previous findings, the effect holds across the range of international incomes; if anything, it is slightly stronger among rich countries. Conditional on national income, recent economic growth makes people unhappier, improvements in life-expectancy make them happier, but life-expectancy itself has little effect. Age has an internationally inconsistent relationship with happiness. National income moderates the effects of aging on self-reported health, and the decline in health satisfaction and rise in disability with age are much stronger in poor countries than in rich countries. In line with earlier findings, people in much of Eastern Europe and in the countries of the former Soviet Union are particularly unhappy and particularly dissatisfied with their health, and older people in those countries are much less satisfied with their lives and their health than are younger people. HIV prevalence in Africa has little effect on Africans' life or health satisfaction; the fraction of Kenyans who are satisfied with their personal health is the same as the fraction of Britons and higher than the fraction of Americans. The United States ranks 81st out of 115 countries in the fraction of people who have confidence in their healthcare system and has a lower score than countries such as India, Iran, Malawi, or Sierra Leone. While the strong relationship between life-satisfaction and income gives some credence to the measures, the lack of such correlations for health shows that happiness (or self-reported health) measures cannot be regarded as useful summary indicators of human welfare in international comparisons.
Joanna Kempner is completing a book manuscript on headaches called Not Tonight: Headache and the Politics of Legitimacy. Headache is infused with cultural meanings, mostly dismissive. "Not tonight, honey" is, of course, the classic cliché about headache, signaling women's desire to avoid sex with their partners. Yet headaches, especially migraine, are a significant problem for millions of people. According to the World Health Organization, migraine is the 19th most disabling disorder in the world and the 12th most significant cause of disability for women. Examining headache historically, medically, and culturally, Not Tonight looks at how a disorder disrupts so many lives yet still has trouble establishing legitimacy. Kempner traces the current crisis in legitimacy to deep-seated cultural beliefs about pain, gender, and the distinction between mind and body. Not Tonight shows how stakeholders in medicine--providers, patients, the pharmaceutical industry, and patient advocacy groups--create alliances to shape how people think about headache. Even their most robust efforts have spawned uneven results, reinforcing some of the very stereotypes they attempt to overturn. This analysis casts new light on how cultural beliefs about gender and pain influence not only whose suffering we legitimate, but which remedies are marketed, how medicine is practiced, and what knowledge about headache is and is not produced.
Kempner also has an ongoing project, investigating the formation and maintenance of "forbidden knowledge," that looks at the suppression of science. This is an understudied but increasingly important area of study, as global debates address whether and how to place limits on potentially dangerous knowledge from fetal tissue research to genetically modified organisms. While these big debates present a visible and readily analyzed system of constraints that guide what scientists choose not to do, Kempner's research shows that most constraints on science are less visible--scientists choose what not to study based on ideological and/or disciplinary predilections, real or perceived threats from outside corporate interest and political groups, and a perceived moral sense that scientists have an obligation to report the truth.
As Joanna Kempner is discovering in another project, "The Politics of Sex Research," political culture and public controversies are a strong force shaping the kinds of health studies that researchers are willing to conduct. Her data, collected from sexuality and HIV researchers, demonstrates how HIV researchers have self-censored in response to a political climate perceived to be hostile to their research. Self censorship is widespread, and many have reportedly left the field or academia altogether. As data analysis proceeds, Kempner is building a theoretical framework to explain how researchers' tenuous, but important, relationships with the federal government shape what is and is not studied.
Anne Case is collaborating with researchers at the University of Cape Town on many health, education, and development research projects. She is also conducting research on the costs associated with illness and death at the Africa Centre for Health and Population Studies, a demographic surveillance site in KwaZulu-Natal. With Christina Paxson, she continues to investigate the impact of poor childhood health and circumstance on opportunities and outcomes for individuals over the life course in both developed and developing countries.
In a noteworthy 1993 Studies in Family Planning manuscript, Ruth Dixon-Mueller highlighted the absence of attention to women's sexuality in reproductive health research and programming. Many years later, despite the increased availability of research on sexuality in general due to the HIV/AIDS epidemic, we still know comparatively little about how women's desire for pleasure affects their reproductive health behaviors. We increasingly recognize how women's sexual autonomy is limited by gender inequality, yet our understandings of how women's pleasure-seeking, like men's, may influence their sexual risk behaviors remain extremely limited. Jenny Higgins and Jennifer Hirsch (Columbia University) review some of the field's "pleasure deficits," including condom and contraceptive research and programming. They also review the few studies and programs that do associate risk reduction practices with women's sexual functioning and desires. In the conclusion to their article in International Family Planning Perspectives on the pleasure deficit, revisiting the "sexuality connection" in reproductive health, they provide suggestions on how to better attend to individual, cultural, and structural influences on sexuality and pleasure seeking in future research. In another article, published in Atlantis, Higgins outlines the pleasure deficit in public health research on family planning and applies feminist theorizations of heterosex to a study contraceptive use and sexual pleasure. She considers the limitations and potentials of theorizing heterosex variously as agential, transgressive, and/or constrained for public health research.
Higgins and Hirsch continued their research on pleasure and power, incorporating sexuality, agency, and inequality into research on contraceptive use and unintended pregnancy. We know surprisingly little about how contraception affects sexual enjoyment and functioning (and vice versa), particularly for women. What do people seek from sex, and how do these sexual experiences shape contraceptive use? Higgins and Hirsch draw on qualitative data to make three points. First, pleasure varies--both women and men reported multiple forms of enjoyment, of which physical pleasure was only one. Second, pleasure matters, in that clear links existed between the forms of pleasure respondents sought and their contraceptive practices. Third, pleasure intersects with power and social inequality, so that both gender and social class shaped sexual preferences and contraceptive use patterns. These findings call for a reframing of behavioral models explaining why people use (or don't use) contraception. Their article in the American Journal of Public Health concludes with implications for research and programming.
Jenny Higgins, Jennifer Hirsch (Columbia University), and James Trussell, in their work on pleasure, prophylaxis, and procreation, produced a qualitative analysis of intermittent contraceptive use and unintended pregnancy. Although pregnancy ambivalence is consistently associated with poorer contraceptive use, little is known about the sexual, social, and emotional dynamics at work in pregnancy ambivalence. The study analyzes qualitative data from in-depth sexual and reproductive history interviews with 36 women and men. Participants were asked about the relational and emotional circumstances surrounding each pregnancy, as well as their thoughts about conceiving a baby with both current and previous partners. Half of respondents had experienced at least one unintended pregnancy. Respondents described three categories of pleasure related to pregnancy ambivalence: active eroticization of risk, in which pregnancy fantasies heightened the charge of the sexual encounter; passive romanticization of pregnancy, in which people neither actively sought nor prevented conception; and an escapist pleasure in imagining that a pregnancy would sweep one away from hardship. All three categories were associated with misuse or nonuse of coitus-dependent methods. For some individuals, the perceived emotional and sexual benefits of conception may outweigh the goal of averting conception, even when a child is not wholly intended. Future behavioral studies should collect more nuanced data on pregnancy-related pleasures. We need to devise clearer clinical guidelines for assessing ambivalence and for linking ambivalent clients with longer-acting methods that are not coitus-dependent.
Jenny Higgins and Irene Browne (Emory University) examined perceptions of sexual needs and sexual control, and how "doing" class and gender influences sexual risk-taking. The poor are disproportionately affected by unintended pregnancy and STIs. However, we know relatively little about the sexual processes behind these disparities. Despite studies of gender enactment's influence on sexual behaviors, few analyses examine the sexual "doing" of social class. Higgins and Browne conducted sexual history interviews with 36 women and men, half middle class and half poor and working class. Most respondents reported that men have greater sexual appetites than women, but the middle class were more likely to cite social influences, while the poor and working class respondents primarily ascribed biological origins. The social construction of sexual controllability among the middle class contributed to perceptions that sex was a containable force. Poor and working class women described men's sexual needs as physiologically irrepressible, which shaped sexual refusal. Their findings move beyond SES as a risk factor and explore two examples of how gender and social class mediate people's sexual selves and health.
Jeanne Altmann's research deals with life history approaches to behavioral ecology and with non-experimental research design. Most of her empirical work has been carried out on the baboons of Amboseli National Park, Kenya, for which longitudinal studies have been conducted since 1971. She and her collaborators emphasize an integrated, holistic approach by carrying out concurrent studies of behavior, ecology, demography, genetics, and physiology at the level of individuals, social groups, and populations. Their current research centers on the magnitude and sources of variability in primate life histories, parental care, and behavioral ontogeny. For baboons, they are analyzing sources of variability within groups and examining patterns in their stability among groups and populations and across time. In one series of studies, they are interested in the extent to which various life-history and developmental parameters are food-limited. In others, they are examining empirically and theoretically the effects of social structure within groups on demographic processes within and among groups and across generations. Recently, Altmann and her collaborators have been conducting studies that relate endocrine and genetic data to demographic and behavioral information for the same individuals in the Amboseli baboon population.
Alan Krueger has expanded his work with Daniel Kahneman (Princeton University) and others on measuring wellbeing and time use. They have recently completed a major survey that extends the American Time Use Survey. The new survey is called the Princeton Affect and Time Survey, and it is based on a population sample of 6,000 households. They expect that major results will flow from this work in the upcoming year, and it will form the basis for an NBER conference and volume that Krueger is organizing on National Time Accounting. He is hoping that National Time Accounting will eventually prove as useful as the National Income and Product Accounts.
In a paper published in the July 9, 2009 issue of the New England Journal of Medicine, Mary Fjerstad (Planned Parenthood Federation of America [PPFA]),James Trussell, Irving Sivin (Population Council) Steve Lichtenberg (Northwestern) and Vanessa Cullins (PPFA) sought to determine the rates of serious infection following medical abortion and also to evaluate the association between different infection-reduction measures and changes in the rates of serious infection. From 2001 to March 2006 Planned Parenthood health centers throughout the United States provided medical abortion principally by a regimen of oral mifepristone followed 24 to 48 hours later by vaginal misoprostol. In response to concerns about serious infections, in early 2006 Planned Parenthood changed the route of misoprostol administration to buccal and required either routine antibiotic coverage or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine antibiotic coverage for all medical abortions. Rates of serious infection dropped significantly after the joint change to 1) buccal misoprostol replacing vaginal misoprostol and 2) either sexually transmitted infection (STI) testing or routine antibiotic coverage as part of the medical abortion regimen (73% decline from 93/100,000 to 25/100,000 , absolute reduction 67/100,000 [ 95% CI 44-94], p < 0.001). The subsequent change to routine antibiotic coverage led to a further significant reduction in the rate of serious infection (76% decline from 25/100,000 to 6/100,000, absolute reduction 19/100,000 [ 95% CI 2-34], p=0.03). Together, medical abortion with buccal misoprostol combined with routine antibiotic coverage brought the serious infection rate down by 93%, from 93 to 7 per 100,000 (absolute reduction 86/100,000 (95% CI 64-112, p < 0.001). Source: OPR Annual Reports.
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