Z Stein

Columbia University, New York City, NY, United States

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Publications (183)1298.91 Total impact

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    ABSTRACT: Relatively few interventions have tested the efficacy of female condom promotion either alone or in combination with other barrier methods. We evaluated the efficacy of a two-session (enhanced) cognitive-behavioral intervention (EI) (n = 147) against a one-session control (minimal) educational intervention (MI) (n = 149) to promote female condom (FC) use among female students aged 18-28 at a South African university. We assessed change from baseline to 2.5 and 5 months in number of vaginal intercourse occasions unprotected by male or female condoms in EI versus MI using generalized linear models with a log link function and GEE. Both groups reported significant reductions in number of unprotected vaginal intercourse occasions from baseline to each follow-up, with no significant difference between the two-session and single-session intervention. Introduction of a brief group-based MI FC promotion intervention with FC access holds promise for delivery in clinics and other community venues.
    AIDS and Behavior 08/2014; · 3.49 Impact Factor
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    Sexual Health 03/2013; · 1.65 Impact Factor
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    ABSTRACT: In preparation for a school-based intervention in KwaZulu-Natal, South Africa, a cross-sectional survey of potential HIV risk factors in youth aged 14-17 (n=983) was conducted. Boys were significantly more likely than girls to report lifetime sexual activity (37.7% v. 13.8%, P<0.01). Among boys and girls, 46.1% reported condom use at last sex. Discussion of condom use with a partner was the strongest predictor of condom use (boys, odds ratio (OR)=7.39; girls, OR=5.58, P<0.0001). Age was independently associated with sexual activity for boys (OR=1.49, P<0.0001) and girls (OR=1.74, P=0.02). For boys, perceptions of male peer behaviour were associated with both ever having participated in sexual activity (OR=1.48, P<0.01) and condom use at last sex (OR=1.79, P<0.01). Girls who equated condom use with having numerous partners were more likely to use them. Among boys, results challenged some expected gender beliefs: support for girls' initiative in relationship formation and refusal of sex were significant predictors of sexual activity. Among girls, higher pregnancy risk perception (OR=1.32, P=0.02) and knowledge (OR=4.85, P=0.055) were associated with sexual activity. Creating more gender equitable norms can reduce HIV risk behaviours. HIV prevention interventions should build on existing gender equitable beliefs, and work to promote others, including sexual communication and negotiation skills, and modelling of positive peer norms.
    Sexual Health 05/2012; 9(2):178-86. · 1.65 Impact Factor
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    ABSTRACT: Women comprise one-half of people infected with the human immunodeficiency virus in the world, and about 70% of them live in sub-Saharan Africa. Advancing, untreated HIV disease in women has resulted in substantial declines in fertility rates, life expectancy and infant mortality rates, and an increased burden of tuberculosis. Three decades into the pandemic, our knowledge of HIV acquisition in women remains sparse, as are options of what women can use to reduce their risk of acquiring HIV. Here, we describe the role of pre-HIV responses to venereal diseases and then discuss unwanted pregnancies, early perceptions of the HIV epidemic in setting prevention priorities, and the history of microbicide development. Opportunities to reduce HIV risk in women through sexual reproductive health services are highlighted. Women are key to turning the tide of the HIV pandemic. Microbicides provide an opportunity to ensure survival of women while addressing the power disparities that underpin women's vulnerability to HIV.
    Best practice & research. Clinical obstetrics & gynaecology 02/2012; 26(4):487-93. · 1.87 Impact Factor
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    ABSTRACT: We surveyed 111 male clients of an HIV/AIDS service organization in New York City in 2008 and 2009. Seventeen percent had used the female condom for anal intercourse; of these, 89.3% had used the female condom with male partners, 21.4% with female partners, and 10.7% with both. Users of the female condom for vaginal intercourse were more likely to use it for anal intercourse (odds ratio = 12.7; 95% confidence interval = 2.5, 64.9; P = .002). The safety and efficacy of the female condom for anal intercourse are unknown and should be evaluated.
    American Journal of Public Health 12/2011; 101(12):2241-4. · 3.93 Impact Factor
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    ABSTRACT: Objectives  To assess the uptake of HIV testing among preschool children with HIV-positive mothers in a peri-urban population-based study in KwaZulu-Natal, South Africa, an area of high HIV prevalence. Methods  All children 4-6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty-seven HIV-infected mothers were interviewed to identify barriers to testing their children. Results  One thousand five hundred and eighty-three children (88% of eligible children) and their caregivers participated. Of the biological mothers, 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother, only 41% had been tested for HIV (23% tested positive). Subsequently, 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV-infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. Conclusions  In this community with high HIV prevalence, HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV, particularly those of infected mothers, is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children, especially for those who missed PMTCT opportunities in infancy.
    Tropical Medicine & International Health 08/2011; 16(12):1490-4. · 2.94 Impact Factor
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    ABSTRACT: Religious and secular institutions advocate strategies that represent all points on the continuum to reduce the spread of HIV/AIDS. Drawing on an extensive literature review of studies conducted in sub-Saharan Africa, we focus on those secular institutions that support all effective methods of reducing HIV/AIDS transmission and those conservative religious institutions that support a limited set of prevention methods. We conclude by identifying topics for dialogue between these viewpoints that should facilitate cooperation by expanding the generally acceptable HIV/AIDS prevention methods, especially the use of condoms.
    Global Public Health 08/2011; 6 Suppl 2:S192-209. · 0.92 Impact Factor
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    Louise Kuhn, Ida Susser, Zena Stein
    The Lancet 07/2011; 378(9787):285-7. · 39.21 Impact Factor
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    ABSTRACT: Young men in South Africa can play a critical role in preventing new human immunodeficiency virus (HIV) infections, yet are seldom targeted for HIV prevention. While reported condom use at last sex has increased considerably among young people, consistent condom use remains a challenge. In this study, 74 male higher education students gave their perspectives on male and female condoms in 10 focus group discussions. All believed that condoms should be used when wanting to prevent conception and protect against HIV, although many indicated that consistent condom use was seldom attained, if at all. Three possible situations for not using condoms were noted: (i) when sex happens in the heat of the moment and condoms are unavailable, (ii) when sexual partnerships have matured and (iii) when female partners implicitly accept unprotected sex. Men viewed it as their responsibility to have male condoms available, but attitudes about whose decision it was to initiate condom use were mixed. Almost all sexually active men had male condom experience; however, very few had used female condoms. Prevention initiatives should challenge traditional gendered norms that underpin poor condom uptake and continued use and build on the apparent shifts in these norms that are allowing women greater sexual agency.
    Health Education Research 06/2011; 26(5):859-71. · 1.66 Impact Factor
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    ABSTRACT: As the focal science for public health, epidemiology has been a large tent supporting diverse activities. The hospital epidemiologist, the cancer trialist, the researcher studying teenage dating violence, and the theorist elaborating epidemic curves all work on different topics using disparate methods, but all of them could and should be comfortable under that one tent. Epidemiology certainly has seen its share of internecine squabbles. These quarrels have generic causes that include noble attempts to differentiate new work directions, to shake up priorities or to motivate constituencies toward new conceptualizations. Some rifts grow from the sincere attempt by some to correct what they see as past mistakes in research direction or problem framing, which may spur defense of long-standing efforts in which considerable time and effort has been invested. A fractious crowd is sometimes encouraged to patch things over and get along, but it is not entirely clear that such an approach is necessary or right when it comes to disagreements among scientists. According to one school of thought, to which we subscribe, the more active the dialogue and criticism between scientists, the more vibrant the field. Nevertheless, no matter how much one believes in the merits of reasoned debate, one must lament the energy expended on disagreements that stem from nothing other than miscommunication of ideas. At one time or another we have all seen reasonable people talk past each other because they use the same terms with different definitions attached, or because they do not stand willingly in their opposite’s shoes to view the other side of the discussion with intellectual empathy. We support reasoned debate, but we wish to avoid the unproductive debate that characterizes conversations that slide past each other without meaningful discourse. One specific debate, the one that prompts this comment, has focused on the role of social class in disease. It has simmered for years while its participants have unproductively talked past one another. The debate has ranged wide, but we focus on three of the actors who could have done better, and whom we now wish to hold to account. We are happy to name names: we refer to ourselves. The origin of the miscommunication was a statement in the 1986 text of one of us:
    European Journal of Epidemiology 06/2011; 26(6):431-2. · 5.12 Impact Factor
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    ABSTRACT: Health care providers can play a key role in influencing clients to initiate and maintain use of the female condom, an underused method for HIV/STI and pregnancy prevention. In 2001-2002, based on semistructured interviews with 78 health care providers from four types of settings in New York City, we found that most providers had seen the female condom, but they had not used it and did not propose the method to clients. They lacked details about the method-when to insert it, where it can be obtained, and its cost. Gender of provider, provider level of training, and setting appeared to influence their attitudes. Unless and until provider training on the female condom is greatly improved, broader acceptance of this significant public health contribution to preventing HIV/AIDS and unwanted pregnancy will not be achieved.
    AIDS education and prevention: official publication of the International Society for AIDS Education 02/2011; 23(1):65-77. · 1.51 Impact Factor
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    ABSTRACT: High rates of unintended pregnancies and sexually transmitted infection (STI), including HIV, highlight the importance of promoting dual protection (DP) - i.e., methods that offer concurrent protection against unintended pregnancies and STI - during contraceptive counseling. Using a Phase II quasi-experimental design, this study compared an individualized, clinic-based, nurse-delivered intervention designed to increase DP against standard of care among 101 HIV negative women accessing contraceptive services in medically under-served areas of New York City. Participants were evaluated at baseline, post-counseling, and six months later. Findings indicated that the intervention has possible benefit. At six-month follow-up, there was greater perceived susceptibility to STI and fewer condom-unprotected vaginal sex occasions in the intervention arm. Women in the intervention also had five times the odds of reporting female condom use. Results suggest that this intervention has the potential for a larger population impact and should be more rigorously evaluated in a Phase III trial.
    AIDS Care 01/2011; 23(4):467-75. · 1.60 Impact Factor
  • International Journal of Epidemiology 12/2010; 39(6):1417-25. · 6.98 Impact Factor
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    ABSTRACT: As life expectancy for HIV-infected persons improves, studies in sub-Saharan Africa show that a considerable proportion of HIV-positive women and men desire to have children. Integrating sexual and reproductive health care into HIV services has until now emphasized the right of women to make informed choices about their reproductive lives and the right of self-determination to reproduce, but this is often equated with avoidance of pregnancy. Here, we explore guidance and attention to safer conception for HIV-infected women and men. We find this right lacking. Current sexual and reproductive health guidelines are not proactive in supporting HIV-positive people desiring children, and are particularly silent about the fertility needs of HIV-infected men and uninfected men in discordant partnerships. Public health policymakers and providers need to engage the HIV-infected and uninfected to determine both the demand for and how best to address the need for safer conception services.
    Journal of Public Health Policy 12/2009; 30(4):367-78. · 1.48 Impact Factor
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    ABSTRACT: Despite limited safety data and the absence of efficacy data, several studies have reported that the female condom is being used for anal sex by men who have sex with men. We describe providers' awareness of female condom use during anal sex among their clients and their experiences in counseling clients. We conducted semi-structured interviews with 78 health-care providers recruited from various health-care delivery systems in New York City: a family planning agency, a sexually transmitted infection agency, a hospital-based obstetrics and gynecology clinic, and two community-based AIDS service organizations. While two-thirds of providers reported that they were uncertain as to whether the female condom could or should be used for anal intercourse, nearly one-third believed that anything is better than nothing to prevent HIV/sexually transmitted infections during anal sex. Few providers had actually talked with clients about anal use of the female condom, and clients themselves had seldom mentioned nor asked for information about such use. Our findings highlight providers' uncertainty about anal use of the female condom. Lacking guidelines regarding the safety and efficacy of female condom use during anal sex, health-care providers are left to make their own well-intentioned recommendations (or not) to potential users. The dearth of information on female condom use during anal sex could encourage individuals to use the female condom for anal sex, which may increase HIV transmission risk or represent a missed opportunity for protecting non-condom users. There is a need for a series of harm-reduction, acceptability, and efficacy studies and, in the interim, for the development of a carefully qualified safety set of guidelines regarding anal use of the female condom for health-care providers.
    AIDS Care 09/2009; 21(9):1185-94. · 1.60 Impact Factor
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    Zena Stein, Louise Kuhn
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    ABSTRACT: New studies of breastfeeding have discovered or confirmed the benefits to mother and child. They reinforce an emphasis on exclusive breastfeeding - no other food or fluids - during the first 6 months. Studies include findings from across the world, in well-resourced and poorly resourced settings. They also emphasize longer duration of breastfeeding, into the second year of life, and gradual rather than abrupt weaning. For HIV-infected mothers, the dangers of non-exclusive feeding in the first half year of life have been well documented in recent publications. Other studies open up the possibilities for antiretroviral treatment to accompany breastfeeding, whether given to the mother, or child, or both. To be effective, implementation of any recommendations must consider individual, family, and community resources.
    Journal of Public Health Policy 09/2009; 30(3):300-10. · 1.48 Impact Factor
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    ABSTRACT: Legal barriers to conducting public health research on methods of protection for anal intercourse were lifted in the United States in 2003 when the US Supreme Court invalidated all state antisodomy laws. Although research funding has been available for the development of rectal microbicides, the female condom, which has already been approved for vaginal use, has not been evaluated for anal use. Although there is no evidence that the female condom is safe for anal intercourse, it has already been taken up for off-label use by some men who have sex with men. This demonstrates the urgent need for more protection options for anal intercourse and, more immediately, the need to evaluate the safety and efficacy of the female condom for anal intercourse.
    American Journal of Public Health 05/2009; 99(6):985-7. · 3.93 Impact Factor
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    ABSTRACT: In post-Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for women's ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively 'privileged' group, there is little information on gender norms that might shape responses to HIV-prevention programmes. To elicit gender norms regarding women's and men's roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi-structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV- and pregnancy-prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of women's rights in the post-Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co-existence of traditional constructions of gender that operate to constrain women's freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote women's protection against unintended pregnancy and HIV/STIs.
    Culture Health & Sexuality 03/2009; 11(2):139-57. · 1.55 Impact Factor
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    ABSTRACT: The distribution of enuresis was found to vary with social class and family setting. A model of enuretic survivors illustrates that general factors connected with social class seem most relevant to children of an age to enter school, family deviance to pre-pubertal schoolchildren, and discontinuous family relationships to pubescent children.Trends in these data have been examined for congruence with hypotheses formulated from these findings, before seeking a larger body of material in which probability tests can be made.Structural and cultural factors differentiated between the families of five-year-old enuretic children and their controls. Enuretic families had made fewer extraneous marriages than the families of controls, they had less often established residential independence at marriage, and the mother had gone out to work in the child's early years somewhat more often.The elements common to deviant families differentiated between the families of ten-year-old enuretic children and their controls. The families of ten-year-old enuretic children were more often in poverty, and their mothers more often handicapped or burdened.Continence was somewhat delayed in children exposed at an early age to a wide range of social interaction and less exclusive relations with their mothers; was furthur delayed in children whose mothers were personally or socially handicapped in the maternal role; and was apparently most delayed in those who suffered total disruption of maternal relations.RÉSUMÉLes families des enfants énurétiquesOn a trouvé que la distribution de l'énurésie variait avec la classe sociale et les conditions familliales. Un modèle de survivants énurétiques démontre que les facteurs généraux en connection avec la classe sociale semblent plus applicables aux enfants en âge d'entrer à l'école, les déviations familliales aux écoliers avant la puberté, et l'interruption de rapports familliaux aux enfants pubères.On a examiné si les tendances révélées dans ces données sont conformes aux théories formulées d'après trois résultats avant de rechercher une plus grande masse de matériel où Ton pourra pratiquer des calculs de probabilité.Des facteurs de structure et de culture différenciaient les families des enfants énurétiques de cinq ans de celles de leurs contrôles. Les families d'énurétiques avaient contracté moins de seconde mariages que les families des contrôles, elles avaient moins souvent établi des résidences indépendantes au moment du mariage, et la mère était partie travailler pendant les premières années de l'enfant un peu plus souvent.Les éléments communs aux families désunies différenciaient les families des enfants énurétiques de 10 ans de celles de leurs contrôles. Les families des enfants énurétiques de 10 ans étaient plus souvent pauvres, et leurs mères étaient plus souvent handicappées ou surmenées.La continence était en quelque sorte retardée chez les enfants exposés pendant leur jeune âge â une large série d'interéactions sociales et à des relations moins exclusives avec leur mêre; elle était encore plus retardée chez les enfants dont les mêres étaient handicapées personnellement ou socialement dans leur rôle maternel; et les délais les plus importants apparemment survenaient chez ceux qui souffraient d'une interruption totale des relations maternelles.ZUSAMMENFASSUNGFamilienverhältnisse enuretischer KinderEs wurde festgestellt dass das Auftreten von Enuresis aufgrund sozialer Klasse und Familienumgebung variiert. Eine Aufstellung von Enuretikern zeigt dass allgemeine, mit der sozialen Stellung verbundene Faktoren den stärksten Einfluss auf Kinder im Vorschulalter, Familien-Abweichungen auf Kinder im prepubertären Schulalter und unter-brochene Familienverhältnisse auf pubertäre Kinder haben.Die aus disen Daten ersichtlichen Tendenzen sind auf Kongruenz mit aus drei Befunden formulierten Hypothesen untersucht worden, bevor man darangeht, einen grössen Korpus von Material zusammenzutragen, in dem Wahrscheinlichkeits-Tests ausgeführt werden können.Struktur- und Kulturfaktoren differenzierten sich zwischen den Familien mit fünfjährigen enuretischen Kindern und ihren Vergleichsfamilien. Enuretische Familien hatten weniger ‘auswärtige’ Ehen geschlossen, hatten bei der Eheschliessung nicht so oft eigene Wohnungen bezogen, und während der frühen Jahre des Kindes war die Mutter etwas häufiger zu auswärtiger Verdienstarbeit gegangen.Die den abweichenden Familien gemeinsamen Elemente unterschieden sich zwischen den Familien zehnjähriger enuretischer Kinder und ihren Vergleicheobjekten. Die Familien zehnjähriger enuretischer Kinder litten öfter an Armut, und ihre Mütter waren öfter behindert oder überbelastet.Diese Befunden werden erörtert im Hinblick darauf, wie sie auf die Beziehungen enuretischer Kinder mit ihren Familien und im besonderen mit ihren Müttern einwirken.RESUMENFamilias de niños enureticosSe halló que la distribución de la enuresis varía según la clase social y la situación familiar. Un estudio de niños no curados muestra que factores generates asociados con la clase social son los más pertinentes para los niños que comienzan la escuela, que la desviación familiar es más pertinente en la prepubertad, y que relaciones familiares interrumpidas son muy importantes para los niños que han llegado a la pubertad.Se han examinado tendencias en estos datos para hallar si acuerdan con unas hipótetis deducidas de tres experiencias, antes de buscar una materia más grande para hacer pruebas de probabilidad.Las familias de los niños enuréticos de 5 años, y las familias de niños no enuréticos de la misma edad, se diferenciaban por su estructura y cultura. Los padres de los niños enuréticos se habían casado menos veces afuera, el matrimonio al casarse tenía menos veces una morada suya, y la madre había trabajado más veces durante los primeros años de vida del niño.Las familias de los niños enuréticos de 10 años y las de los niños de control se diferenciaban en todo lo que contribuye a la desviación familiar. Las familias de los niños enuréticos eran más veces pobres, y sus madres tenían más veces incapacidades o un exceso de trabajo.Continencia estaba algo retardada en niños expuestos muy jóvenes a relaciones sociales extensas, y a relaciones menos exclusivas con sus madres; estaba más retardada en niños cuyas madres tenían inhabilidades personales o sociales para el papel de madre, y muy retardada en niños que sufrieron un rompimiento total de relaciones con sus madres.
    Developmental Medicine & Child Neurology 11/2008; 7(6):658 - 676. · 2.68 Impact Factor
  • Zena A Stein, Mervyn W Susser
    Journal of Public Health Policy 07/2008; 29(2):187-91. · 1.48 Impact Factor

Publication Stats

3k Citations
1,298.91 Total Impact Points


  • 1967–2012
    • Columbia University
      • • Department of Epidemiology
      • • Department of Psychiatry
      • • Gertrude H. Sergievsky Center
      • • College of Physicians and Surgeons
      New York City, NY, United States
  • 2011
    • RTI International
      Durham, North Carolina, United States
  • 1977–2011
    • New York State Psychiatric Institute
      New York City, New York, United States
  • 1960–2008
    • The University of Manchester
      Manchester, England, United Kingdom
  • 2007
    • University of Campinas
      Conceição de Campinas, São Paulo, Brazil
  • 2003
    • Philadelphia University
      Philadelphia, Pennsylvania, United States
  • 2000
    • New York Academy of Medicine
      New York City, New York, United States
    • City University of New York - Hunter College
      • Department of Anthropology
      Manhattan, NY, United States
  • 1999
    • South African Medical Research Council
      Kaapstad, Western Cape, South Africa
  • 1998
    • University of Washington Seattle
      • Division of Medical Genetics
      Seattle, WA, United States
  • 1995
    • University of KwaZulu-Natal
      • Department of Paediatrics and Child Health
      Durban, KwaZulu-Natal, South Africa
  • 1992–1995
    • University of California, Berkeley
      • School of Public Health
      Berkeley, MO, United States
  • 1975
    • New York City Department of Health and Mental Hygiene
      New York, United States
  • 1972
    • Institute of Food Research
      Norwich, England, United Kingdom