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Andrzej Kulczycki
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ABSTRACT: Latin America is undergoing profound social, economic, political, demographic, and epidemiologic change. Reproductive health indicators have generally improved over the past two decades, but most pregnancies are still unintended and more than 4 million are terminated annually. Clandestine abortions necessitated by restrictive legal and social structures cause more than 1,000 deaths and 500,000 hospitalizations per year, primarily among poor and marginalized women. Abortions are becoming safer and less frequent, however, as a consequence of increased modern contraceptive use, misoprostol adoption, emergency contraception availability, and postabortion care provision, notwithstanding many impediments to these changes. Advocacy and conflict over abortion have grown. The contested policy shifts include Mexico City's 2007 legalization of first-trimester abortion. Drawing on numerous sources of evidence, this article provides a regional analysis of the rapidly changing practice and context of abortion in Latin America, and examines emerging issues, legal and policy developments, and contrasting country situations.
Studies in Family Planning 09/2011; 42(3):199-220. · 1.28 Impact Factor
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ABSTRACT: Use of the intrauterine device (IUD) in the United States has recently increased. New evidence for women with employer-sponsored health insurance permits analysis of variation and trends in such use.
A retrospective analysis of annual IUD insertion rates between 2002 and 2008 was conducted by evaluating claims from the MarketScan® Commercial Research Databases for US women insured by plans that covered IUD insertions. Estimates were weighted to be nationally representative.
IUD insertion rates increased from 1.6/1000 women of reproductive age to 9.8/1000 over 2002-2008 and varied substantially by state. Insertion rates of the levonorgestrel-releasing intrauterine system (LNG-IUS) increased from 0.4/1000 to 7.7/1000, whereas the insertion rates of copper T380A IUD (copper IUD) increased from 0.6/1000 to 1.5/1000. IUD insertions, which are most common among women aged 25-34 years, increased at roughly the same rate across all age groups.
The sixfold increase in IUD insertion rates between 2002 and 2008 was accompanied by an increase in the share IUD use with the LNG-IUS from 40% to 85%. Substantial geographic and age variations existed.
Contraception 07/2011; 85(2):155-9. · 2.72 Impact Factor
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ABSTRACT: It has not been well established whether common indices of male condom failure are valid predictors of biologically meaningful exposure during condom use.
To address this gap, the authors compared self-reported condom malfunctions (i.e., breakage and slippage) and incorrect condom practices to 2 following objective measures of failure: prostate-specific antigen (PSA) detected in vaginal swabs collected after condom use and structural integrity of used condoms. The study, conducted in 2000-2001, evaluated 635 male condoms used by 77 women attending an outpatient, reproductive-health clinic in Birmingham, AL.
Women reported breakage or slippage for 7.9% of condoms; 3.5% of postcoital swabs had moderate or high levels of PSA; and laboratory testing of used condoms revealed breaks (1.1%) and leaks (2.0%). Self-reported breakage and slippage was associated with moderate/high PSA concentrations in postcoital swabs only when the malfunctions were not accompanied by reports of corrective actions to reduce exposure (adjusted odds ratio [aOR], 6.9; 95% confidence interval [CI], 1.8-26.2). Defects observed in postcoital laboratory testing were related to PSA detection (aOR, 8.0; 95% CI, 1.5-42.6). Incorrect practices defined on the condom label were frequent, but not all types were associated with semen exposure. Furthermore, other practices not currently label-defined were associated with semen exposure: touching the tip of the penis with his hands (aOR, 6.2; 95% CI, 2.3-17.0) or with her hands (aOR, 2.8; 95% CI, 1.1-72) before donning the condom.
Used correctly, male condoms afforded good protection based on objective measures of failure.
Sexually transmitted diseases 01/2011; 38(7):580-6. · 2.58 Impact Factor
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ABSTRACT: The diaphragm is receiving renewed attention not only for its dual method potential but also because of improved design. To facilitate method re-introduction, we examined what providers think about this female-controlled barrier contraceptive.
A questionnaire administered to 450 women's health nurse practitioners (NPs) asked about their practice experience and issues concerning diaphragm use. Latent class analysis (LCA) was used to identify different groups of providers, based on patterns of perceptions regarding various potential obstacles to diaphragm use. Provider profiles were further described in terms of individual and practice characteristics.
The survey achieved a 47% response rate (n = 214). Respondents saw, on average, 31 family planning patients/week; 87% had fitted a diaphragm, although only 40% had done so in the previous year. Three groups holding significantly different perceptions of obstacles to diaphragm prescription were identified. Group 1 (13% of respondents), with more practice experience in delivering women's healthcare and fitting diaphragms, considered all obstacles relatively inconsequential. Group 2 (40%) had comparatively minor concerns, whereas Group 3 (47%) perceived all issues as major obstacles. All groups stressed the diaphragm's limited promotion, and for 87% of the respondents, concerns about effectiveness and nonfamiliarity with the method also assumed more salience.
Emerging statistical modeling approaches that go beyond standard aggregate analyses helped identify three groups of women's health nurse practitioners. By considering their diverse perceptions of potential obstacles to diaphragm use, strategies aimed at changing provider behaviors may be developed to reverse declining prescribing rates and retain the diaphragm as a viable reproductive healthcare option for women.
Journal of Women s Health 07/2010; 19(7):1355-61. · 1.57 Impact Factor
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ABSTRACT: Women have used the contraceptive diaphragm for decades. Although use has recently declined, the diaphragm may find a new role in STI/HIV and dual-prevention programmes when microbicides become available. We developed a questionnaire to examine seven provider issues identified as possible barriers to diaphragm use among advanced practice nurses (APNs) specialising in women's health. The perceived degree to which each issue represented a barrier was examined. Non-parametric correlations were calculated between diaphragm fitting history, demographic and practice characteristics, and the response ratings for each issue.
Responses were analysed for 204 APNs who averaged 15 years' experience in women's health care; 87% had fitted a diaphragm at least once, but 40% had not prescribed one in the past year. The degree to which each issue was perceived as a barrier varied. Based on respondents' ratings of a 'more than moderate barrier,' diaphragm non-promotion by women's health providers, effectiveness doubts, unfamiliarity and lack of access to educational materials were more often perceived as impeding diaphragm use. Other results indicated that APNs with recent diaphragm fitting history perceived five of the seven issues to be less of a barrier: non-promotion by women's health providers, lack of access to educational materials and to a fitting set, unfamiliarity, and inadequate reimbursement.
Formulation of successful strategies to reintroduce the diaphragm will depend on better identification and understanding of provider-perceived barriers. This paper offers new insights about such barriers and guidance for the development of strategies for diaphragm reintroduction.
Journal of Family Planning and Reproductive Health Care 04/2010; 36(2):79-82. · 1.64 Impact Factor
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ABSTRACT: The diaphragm, once the most commonly used female contraceptive method, is being re-evaluated for prevention against some sexually transmitted infections (STIs), including HIV. However, provider views about this prescription-based method are poorly understood. Using expert panels, this study aimed to identify facilitative strategies to increase diaphragm use. The nominal group technique (NGT) was employed using a novel web-based interface to systematically elicit and prioritise responses to a specific question about what can be done to encourage providers to recommend diaphragm use. Two NGT sessions were convened with 15 geographically dispersed panelists who had extensive knowledge and experience with the diaphragm. Participants were identified using purposeful and snowball sampling.
Panel 1 identified 22 strategies for encouraging providers to recommend diaphragm use, with seven perceived as relatively more important (67% of the total available votes). Panel 2 identified 31 strategies, nine of which accounted for 77% of the votes. Both sessions highlighted that to make the diaphragm a more plausible option, educational materials and tools are needed to better inform providers and patients about the method and its specific advantages.
The enhanced, Internet-based NGT offers the family planning and reproductive health care field a powerful and inexpensive tool for systematically collecting and analysing expert opinion. Results are being used to develop a questionnaire to further examine strategies that may help promote diaphragm use and to refine ideas for intervention design. This will facilitate method reintroduction, if the diaphragm is proven effective against STIs/HIV, especially when used with a microbicide.
Journal of Family Planning and Reproductive Health Care 11/2008; 34(4):227-31. · 1.64 Impact Factor
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Andrzej Kulczycki
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ABSTRACT: In Turkey, contraceptive use has become more widespread, but little is known about the concurrence of spousal reports or the relative influence of communication, decision making and power differentials on method use.
Data from the 1998 Turkish Demographic and Health Survey (DHS) for 1,546 married couples were tested for concurrence between spousal reports on fertility and family planning variables. Multivariate regression analyses based on wives', husbands' and joint reports of current contraceptive use were used to assess the association between such use and various background, communication and interspousal variables.
Spousal reports on most fertility and contraceptive use measures demonstrated moderate to high concordance, whereas reports of approval of family planning showed only fair concordance. After adjusting for background factors, models based on wives' and husbands' reports showed that current contraceptive use was positively associated with the number of methods known (odds ratios, 1.2 and 1.1, respectively) and perception of spousal approval (3.3 and 2.0, respectively), and in the husbands' model, with approval of either spouse or both (3.8-5.8). In the combined model, contraceptive use was positively associated with both partners approving of family planning (2.4), and negatively associated with both partners wanting more than three children and with only wives wanting three or fewer (0.4 and 0.6, respectively).
Discrepancies between spousal reports were less significant in Turkey than in most developing countries with DHS data, but the differences were not inconsequential to explaining how spousal attitudes and preferences influence contraceptive use. No evidence was found associating interspousal power differentials with method use. Further research is needed to improve the testing and modeling of such dyadic processes.
International Perspectives on Sexual and Reproductive Health 10/2008; 34(3):127-37. · 1.43 Impact Factor
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ABSTRACT: Little is known about intimate partner violence in the Middle East and North Africa. This review synthesizes and critically evaluates the literature. Of 59 studies found, only 21 reported data on the prevalence of such violence or on beliefs regarding its justification, covering just 9 countries. Spousal abuse is pervasive and widely accepted. Victims are of all ages and are more likely to be rural and less educated. National data from Egypt and Jordan indicate almost 9 in 10 ever-married women accept at least one reason for wife beating. Change is possible but will require increased research, coalition building, and intervention efforts.
Violence Against Women 02/2008; 14(1):53-70. · 1.33 Impact Factor
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Andrzej Kulczycki
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ABSTRACT: The 1994 International Conference on Population and Development held in Cairo recognized the centrality of reproductive health to human rights and development. Progress on the Cairo agenda has slowed for numerous reasons, however. The United States, once an enthusiastic promoter of this agenda and still the world's leading reproductive health donor, has revised its reproductive health policies radically since the 2000 presidential election of George W. Bush. This study examines how policies have been reconfigured in five key reproductive health areas, sparking controversy both in the United States and internationally. These categories are the content of sex education, access to emergency contraception and to abortion services, condom effectiveness, and HIV/AIDS prevention. The analysis presented here elucidates how ideological considerations have superseded public health and ethical concerns and reflects on health and ethical consequences.
Studies in Family Planning 01/2008; 38(4):333-51. · 1.28 Impact Factor
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ABSTRACT: In this 2000-2001 study, the authors compared the effectiveness of the male latex condom and the female polyurethane condom by assessing frequency and types of mechanical failure and by evaluating semen exposure during use. Eligible women from Birmingham, Alabama, were randomly assigned to begin the study with 10 male condoms and then switch to 10 female condoms (n = 55), or vice versa (n = 53), and were trained to use both types. Data collection included questionnaires for each condom use and measurement of prostate-specific antigen in specimens of vaginal fluid taken before and after intercourse. Participants returned 700 male condoms and 678 female condoms, and they reported mechanical problems for 9% and 34%, respectively. Moderate-high postcoital prostate-specific antigen levels (> or = 22 ng/ml) were detected in 3.5% of male condom uses and 4.5% of female condom uses (difference = 1%, 95% confidence interval: -1.6, 3.7). Moderate-high prostate-specific antigen values (> or = 22 ng/ml) were more frequent with mechanical problems (male condom, 9.6%; female condom, 9.4%) but less frequent with other problems (3.0% and 0.9%) or correct use with no problems (2.7% and 2.5%). This study indicates that although mechanical problems are more common with the female condom than with the male condom, these devices may involve a similar risk of semen exposure. Objectively assessed semen exposure is associated with self-reported mechanical problems.
American Journal of Epidemiology 08/2007; 166(1):88-96. · 5.22 Impact Factor
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ABSTRACT: To compare self-reported condom use problems and objectively determined semen exposure in 2 populations.
Two randomized crossover trials in the United States and Brazil compared the failure rates of the female condom (FC) and male condom (MC). Participants used both condom types, completed condom-specific questionnaires to report problems, and collected precoital and postcoital samples of vaginal fluid. Prostate-specific antigen (PSA) was detected by immunoassay.
Problems with condom use were reported less frequently in the Brazilian study (rate difference: FC = 24%, P <0.0001, MC = 5%, P = 0.003). By contrast, the PSA detection rates were similar for both the FC and the MC (rate difference: FC = 2%, MC = 1%, not significant). These results suggest that the PSA detection rate was similar in the 2 study groups and that self-reported problems may be a less reliable measure of condom failure.
Use of biomarkers of condom failure like PSA may help to strengthen the validity of studies promoting behavior change for the prevention of sexually transmitted diseases.
Sex Transm Dis 08/2007; 34(8):557-62. · 2.87 Impact Factor
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ABSTRACT: Our goal was to examine relationships among access to a medical home, special-health-care-needs status, and child and family characteristics in one Southern state. We hypothesized that access to a medical home is influenced by several family and child sociodemographic characteristics, including special-health-care status.
We used data from the 2003 National Survey of Children's Health. The study sample comprised all Alabama resident children. The main dependent variable was a medical home; the primary independent variable classified children according to children-with-special-health-care-needs status. We controlled for child age, gender, race, family structure, health status, insurance coverage, household education, and poverty. We first explored means or proportions for the study variables and then estimated multivariate logistic regression models.
Children with special health care needs were significantly more likely than children without special health care needs to have a personal doctor or nurse, to have a preventive health care visit in the previous 12 months, and to have good communication with their provider. Children with special health care needs were also more likely to experience problems accessing specialty care, equipment, or services. Being uninsured, living at or near the federal poverty level, in a household where no one completed high school, being black, having less than excellent or good health, and living in a nontraditional family structure were characteristics associated with being less likely to have a medical home. In general, children-with-special-health-care-needs status was not related to having a medical home, but dependency on prescription medicine was.
Assuring that all children, irrespective of family income, have access to and are enrolled in health insurance plans will move us closer to the national goal of having a medical home for all children, especially those with a special health care need, by 2010.
PEDIATRICS 03/2007; 119 Suppl 1:S107-13. · 4.47 Impact Factor
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Andrzej Kulczycki
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ABSTRACT: Prevalence rates for condom use are low across the Middle East despite limited alternate contraceptive options and growing awareness of sexually transmitted diseases (STDs) and HIV/AIDS. Virtually no research exists to explain this situation and to guide policy development or effective interventions. An analysis of 25 focus-group discussions with married women and men, interviews with service providers, and a survey of 589 women of childbearing age in a rural district of southern Lebanon reveal that a broad and complex set of sociocultural factors influence condom use. In the study area, 7 percent of married women currently use condoms, 24 percent reported ever use, and inconsistent use is common. Condoms are preferred primarily for their lack of physiological side effects. Five factors were found to impede method adoption and sustained use. These include various encumbering beliefs, reduced sexual pleasure, adverse experiences, gender-related fears and tensions, and a residual social stigma attached to condoms. Several strategies are suggested to increase and improve condom use. These issues will assume greater importance as fertility declines further in the region, demand for contraception continues to increase, and STDs and HIV/AIDS become more deeply rooted, as has occurred in other parts of the world.
Studies in Family Planning 01/2005; 35(4):246-60. · 1.28 Impact Factor
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Andrzej Kulczycki
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ABSTRACT: This paper seeks to understand why Turkey has one of the highest rates of withdrawal (coitus interruptus) use in the world. Despite a pronounced fertility decline, a marked increase in contraceptive prevalence, and expansion of family planning activities, in 1998 one in four Turkish couples relied on withdrawal, and this fraction has remained stable since 1983. In contrast to previous research that has focused on women's reports, here we use the husbands' module of the 1998 Turkish Demographic and Health Survey to examine user characteristics and attitudes, as well as the determinants of withdrawal use among a representative sample of 1950 currently married men in Turkey. Multivariate methods are employed to estimate these effects and the likelihood of using withdrawal rather than other methods. Among other findings, less egalitarian-minded husbands were more likely to select withdrawal over other contraceptive methods, but measures of male authority had only partial predictive power after controlling for other variables. Although withdrawal use typically reflects husbands' preferences, it is widely practiced as it satisfies user requirements and simplifies women's lives. The results of this study are discussed in a broader historical and cultural context and used to provide insight into how Turkey's family planning and reproductive health programs might be improved. In contrast to neighboring countries, there is little sign of withdrawal being displaced in Turkey anytime soon by modern methods.
Social Science [?] Medicine 10/2004; 59(5):1019-33. · 2.70 Impact Factor
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ABSTRACT: Although studies have assessed the acceptability of male and female condoms, comparative trial data are lacking.
A sample of 108 women in stable relationships recruited from an urban, reproductive health clinic were randomly assigned to use 10 male or female condoms, followed by use of 10 of the other type. A nurse provided instruction in correct method use. Demographic information was collected in a baseline questionnaire; acceptability data were collected in follow-up and exit questionnaires and coital logs. Nonparametric and chi-square statistics were used to analyze measures of the methods' relative acceptability. Bowker's test of symmetry was adapted to test the null hypothesis of no difference in acceptability between condom types.
Participants used 678 female and 700 male condoms. Although neither method scored high on user satisfaction measures, the 63 women completing the study protocol preferred the male condom to the female condom for ease of application or insertion, ease of removal, general fit, feel of the condom during intercourse and ease of penetration. Participants reported that their partner also favored the male condom, although women generally appeared to like this method more than their partner did. In a direct comparison between the methods at the end of the study, women generally judged male condoms superior on specified preference criteria.
Across a range of criteria, the female condom was less acceptable than the male condom to most women and their partners. Although both types had low acceptability, they are needed and valid methods of pregnancy and disease prevention. That neither rated high on user satisfaction measures underscores the need for more barrier methods that women and men can use.
Perspectives on Sexual and Reproductive Health 36(3):114-9. · 1.41 Impact Factor
