Publications by authors named "Lisa M Calhoun"

29 Publications

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A vignette-based approach to understanding social norms around family planning in three Nigerian cities.

Glob Public Health 2021 May 25:1-13. Epub 2021 May 25.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Understanding the mechanisms through which social norms shape contraceptive use can help prevent unintended pregnancies in low-income countries. The Nigerian Urban Reproductive Health Initiative (NURHI) aimed to increase contraceptive uptake through advocacy, service delivery, and demand generation. Using data from focus group discussions, we examined whether social norms around family planning (FP), and specifically use of modern contraception (MC), varied among women and girls of reproductive age exposed to varying levels of the programme in three Nigerian cities. Injunctive social norms were generally unfavourable of unmarried adolescent girls' use of MC, though participants often shared exceptions for certain types of adolescents whose use of MC would be acceptable. There was greater acceptability for MC use by women who wanted to space or limit pregnancies. Participants reported that norms around FP and MC use have become more accepting in their communities over time. Normative differences between cities were identified. Participants' perceptions of religious leaders' support for FP use may have contributed to positively influencing social norms.
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http://dx.doi.org/10.1080/17441692.2021.1928261DOI Listing
May 2021

Her, his, and their fertility desires and contraceptive behaviours: A focus on young couples in six countries.

Glob Public Health 2021 May 3:1-17. Epub 2021 May 3.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Most studies examining contraceptive use among women focus on their own fertility desires and family planning attitudes and do not incorporate the desires and attitudes of their partner. Using Demographic and Health Survey data from young couples (wife is aged 15-24) from six countries, we use descriptive and multivariate analyses to examine the association between couple-level fertility desires and current contraceptive use and women's future intention to use contraception. Results demonstrate that young couples want to have children immediately or may want to delay having children for two or more years; very few do not want (more) children. Discordant fertility desires were found in all countries. Compared to couples where both partners want a child soon, young couples that want to delay childbearing or where the husband wants a child, and the wife wants to delay or avoid childbearing are significantly more likely to use contraception. Similar results are found for women's intention to use contraception. When discordant fertility desires are associated with the outcomes, the young wife's fertility desire matters more than her husband's. Among young couples, promoting communication and positive social norms for delaying a first or second birth can lead to positive health outcomes for mothers and babies.
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http://dx.doi.org/10.1080/17441692.2021.1922732DOI Listing
May 2021

The association of empowerment measures with maternal, child and family planning outcomes in Plateau State Nigeria by urban-rural residence.

BMC Pregnancy Childbirth 2021 Feb 27;21(1):170. Epub 2021 Feb 27.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Nigeria is experiencing a high level of urbanization and urban poverty. Within Nigeria maternal and child health and family planning outcomes may differ by residence (capital city, urban/non-capital city and rural) as well as by measures of women's empowerment and wealth. This paper presents a detailed analysis of maternal and child health and family planning outcomes in Plateau State, Nigeria.

Methods: Data came from the 2017 Nigerian Urban Reproductive Health Initiative Sustainability Study. Multivariable logistic regression was used to study the associations between the key independent variables of residence, women's empowerment and wealth with having a skilled birth attendant at childbirth and childhood preventative visits. The women's empowerment variables included perceptions about household decision-making, financial decision-making, views on wife beating and having a prohibition, defined as a restriction on specific activities imposed by a woman's husband. Multinomial regression was used to study the association of the same factors with the family planning outcome which had three categories - no use, traditional method use and modern method use. Regressions were also run separately for urban and rural populations.

Results: Women in the capital city of Jos were significantly more likely to have a skilled birth attendant at childbirth, take a child to a preventative visit and use family planning than women in rural areas of Plateau State. Three of the four measures of empowerment (household decision-making, financial decision-making and having a prohibition) were significantly associated with the family planning outcome, while having a prohibition was negatively associated with having a skilled birth attendant at childbirth. In rural areas, women involved in financial decisions were significantly less likely to use a modern method compared to a traditional method. Wealth was a significant factor for all outcomes.

Discussion: State-level analyses can provide valuable information to inform programs and policies at a local level. Efforts to improve use of maternal and child health and family planning services in Plateau state, Nigeria, should consider women's empowerment, residence and poverty. Community education on the effectiveness of modern versus traditional methods and potential side effects of specific modern methods, may help women make informed decisions about contraception.
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http://dx.doi.org/10.1186/s12884-021-03659-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916291PMC
February 2021

Influences on contraceptive method choice among adolescent women across urban centers in Nigeria: a qualitative study.

Contracept Reprod Med 2021 Feb 16;6(1). Epub 2021 Feb 16.

Carolina Population Center, University of North Carolina-Chapel Hill, Chapel Hill, USA.

Background: Despite calls to increase contraceptive use among adolescents and youth, large gaps still exist, creating an unmet need for family planning. Past research has focused on barriers to seeking a method. There is less understanding of the types of methods young women want and who and what influences these decisions. This study examines what method characteristics young Nigerian women prioritize when choosing a method to inform future family planning programming.

Methods: In 2018, eight focus group discussions (FGD) were conducted in the Nigerian cities of Ilorin and Jos with 83 young women ages 15-24. Participants were identified by community contacts and separated into groups by religion and marital status. The discussion guide utilized a vignette structure to understand the participants' perceptions on contraceptive behavior and attitudes and misconceptions surrounding different types of methods. The FGDs were undertaken and analyzed by collaborative teams from the University of Ibadan and the University of North Carolina-Chapel Hill. A thematic analysis of the transcripts was performed using Atlas.ti, including two rounds of coding, and multiple reviews by the research team.

Results: The method characteristics associated with young women's contraceptive decisions include: side effects, reliability, length of coverage, privacy, cost, and accessibility. Side effects, reliability, and privacy were described as negatively linked to short-acting methods whereas easy accessibility and low cost were positive characteristics of these methods. Long-acting methods were generally viewed as positive. Participants' focus on side effects commonly resulted from concerns about the impact on future fertility. The characteristics prioritized by individuals change throughout their adolescence and as their marital status changes. Providers, peers, parents, and partners were all found to have an influence over method choice in different ways. The role of these influencers also changes over the adolescent years.

Conclusion: This study demonstrates that programs should prioritize expanding method choice to increase the number of available options to ensure all young women can access a method that fits their desired method characteristics. Programming should ensure that medically accurate information is widely distributed to harness providers, peers, parents and partners as a resource for information about specific methods.
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http://dx.doi.org/10.1186/s40834-020-00146-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888078PMC
February 2021

Government stakeholders' perspectives on the family planning environment in three Nigerian cities: qualitative findings from the Nigerian Urban Reproductive Health Initiative (NURHI) Sustainability Study.

Glob Health Action 2020 12;13(1):1847821

Carolina Population Center, The University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.

: The Nigerian government has made numerous commitments to expanding access to family planning services for its population yet has faced many challenges in implementing these commitments. Foreign donors provide support for expanding access to family planning in key populations. : This study examines the family planning environment after donor funding has ended, including how government stakeholders perceive family planning services and their role in providing them post donor funding. : The NURHI Sustainability Study used qualitative data to evaluate the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI), which focused on increasing the use of modern contraceptive methods, particularly among the urban poor. This study presents results from in-depth interviews with 16 key government stakeholders, selected using purposive sampling methods, in three cities: Ilorin (where NURHI Phase 1 programming discontinued in 2015), Kaduna (where programming continued under NURHI Phase 2), and Jos (a comparison city). A thematic analysis was employed to identify key themes related to government stakeholders' perspectives on the family planning environment and sustainability of NURHI programming. : Respondents from all three cities highlighted local political leaders' positive perceptions about family planning. All respondents were open to continued foreign donor support for family planning services while respondents in Kaduna and Jos emphasized the need for governments to lead efforts among all family planning actors. Stakeholders highlighted the benefits of a dedicated and implemented family planning budget line and encouraged continued state financial support. Respondents in Kaduna and Ilorin praised the positive influence of NURHI programming while those from Ilorin reflected on the need for future programs to gradually close-out their efforts to support sustainability. : As donors look to transition to government ownership of family planning efforts, it is important for family planning programs to understand and incorporate government stakeholders' perspectives into their sustainability planning efforts.
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http://dx.doi.org/10.1080/16549716.2020.1847821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717862PMC
December 2020

Influences on seeking a contraceptive method among adolescent women in three cities in Nigeria.

Reprod Health 2020 Oct 28;17(1):167. Epub 2020 Oct 28.

Institute of Child Health, University of Ibadan, College of Medicine, Ibadan, Nigeria.

Background: Despite international support for increasing access to contraceptives among adolescents, gaps in use still exist worldwide. Past research has identified barriers to use across all levels of the socioecological model including restrictive policies, a lack of youth friendly services, and knowledge gaps. This study was conducted to further identify influences on contraceptive use among adolescent girls in Nigeria in hopes of guiding future policies and programs.

Methods: In 2018, 12 focus group discussions (FGD) were conducted in three cities in Nigeria with young women ages 15-24 with the objective of determining what and who influence adolescents' contraceptive seeking behaviors. A vignette structure was used to identify perceptions on injunctive and descriptive community norms that influence adolescent contraceptive behaviors. The FGDs were conducted by members of the University of Ibadan Centre for Population and Reproductive Health (CPRH) and analyzed by a researcher at the University of North Carolina-Chapel Hill's Carolina Population Center using a thematic analysis approach.

Results: Participants identified community level resistance to sex and contraceptive use among unmarried adolescents though also acknowledged that these adolescent behaviors are still occurring despite established norms. Concerns about side effects and the preservation of fertility were frequently attached to contraceptive use and pointed to as a reason for community resistance to contraceptive use among this population. Participants saw peers, parents and partners as influencers on a girl's decision to seek a method, though each were believed to play a different role in that decision.

Conclusion: The findings show that that despite barriers created by established injunctive norms, young women with a supportive social network can access contraceptive methods despite these barriers. By harnessing the influence of peers, partners and parents, the Nigerian family planning efforts can strive to improve the health and well-being of young people.
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http://dx.doi.org/10.1186/s12978-020-01019-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594415PMC
October 2020

The Examination of Diffusion Effects on Modern Contraceptive Use in Nigeria.

Demography 2020 06;57(3):873-898

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-3305, USA.

This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.
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http://dx.doi.org/10.1007/s13524-020-00884-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329794PMC
June 2020

On the sustainability of a family planning program in Nigeria when funding ends.

PLoS One 2019 26;14(9):e0222790. Epub 2019 Sep 26.

Data Research and Mapping Corporation, Abuja, Nigeria.

Few studies have examined the sustainability of family planning program outcomes in the post-program period. This article presents the results of a natural experiment where the Nigerian Urban Reproductive Health Initiative Phase I programming ended in early 2015 and Phase II activities continued in a subset of cities. Using data collected in 2015 and 2017, we compare contraceptive ideation and modern family planning use in two cities: Ilorin where program activities concluded in 2015 and Kaduna where program activities continued. The results demonstrate that exposure to program activities decreased in Ilorin but for those individuals reporting continuing exposure, the effect size of exposure on modern family planning use remained the same and was not significantly different from Kaduna. Modern family planning use continued to increase in both cites but at a lower rate than during Phase I. The results are useful for designing family planning programs that sustain beyond the life of the program.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222790PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6762171PMC
April 2020

Assessing the sustainability of the Nigerian urban reproductive health initiative facility-level programming: longitudinal analysis of service quality.

BMC Health Serv Res 2019 Aug 9;19(1):559. Epub 2019 Aug 9.

Department of Economics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: To date, there is little information on the sustainability of family planning (FP) service quality after completion of a donor-funded program. This paper examines the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI) program on quality of FP services in two cities: Ilorin, where the program ended in March 2015 and Kaduna where the program continued.

Methods: Data come from three time periods: 2011, before program implementation; 2014, near Phase 1 completion; and 2017, two-years post Phase 1. In 2011, we undertook a facility audit and provider surveys in all public sector facilities in each city as well as all private facilities mentioned as the source for FP or maternal, newborn, and child health services in a 2010 women's household survey. In 2014 and 2017, we returned to the same facilities to undertake the facility audit and provider surveys. Quality is measured from principal component analyses of 30 items from the facility audit and provider surveys. Service use outcomes are measured as the ratio of FP clients (total and new) to the number of reproductive health staff members. Multivariate random effect models are estimated to examine changes in the outcomes over time, between NURHI and non-NURHI facilities and by city.

Results: We demonstrate that NURHI facilities had better quality and higher service use than non-NURHI facilities. Further, while quality of services was higher in Ilorin in 2011, by 2014 and three years later (2017), the quality was better in Kaduna where the program continued. In addition, while no difference was found in service utilization between Ilorin and Kaduna in 2014, by 2017, Kaduna had significantly more new FP users than Ilorin.

Conclusions: In Ilorin, quality of services did not continue its strong upward trend after the program ended. Programs need to consider long-term strategies that support continuation of program components post program implementation. This may include ensuring continued training of providers and addressing equipment and commodity stock-outs through system changes rather than specific facility-level changes. The findings from this study can be used to inform future programs seeking to improve quality of FP services in a sustainable manner.
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http://dx.doi.org/10.1186/s12913-019-4388-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688378PMC
August 2019

Association of men's exposure to family planning programming and reported discussion with partner and family planning use: The case of urban Senegal.

PLoS One 2018 25;13(9):e0204049. Epub 2018 Sep 25.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.

Background: Family planning programs increasingly aim to encourage men to be involved in women's reproductive health decision-making as well as support men to be active agents of change for their own and the couple's reproductive health needs. This study contributes to this area of work by examining men's exposure to family planning (FP) program activities in urban Senegal and determining whether exposure is associated with reported FP use and discussion of family planning with female partners.

Methods: This study uses data from two cross-sectional surveys of men in four urban sites of Senegal (Dakar, Pikine, Guédiawaye, Mbao). In 2011 and 2015, men ages 15-59 in a random sample of households from study clusters were approached and asked to participate in a survey about their fertility and family planning experiences. These data were used to determine the association between exposure to the Initiative Sénégalaise de Santé Urbaine (in English: Senegal Urban Reproductive Health Initiative) family planning program interventions with men's reported modern family planning use and their reported discussion of FP with their partners. Since data come from the same study clusters at each time period, fixed effects methods at the cluster level allowed us to control for possible program targeting by geographic area.

Results: Multivariate models demonstrate that religious leaders speaking favorably about family planning, seeing FP messages on the television, hearing FP messages on the radio, and exposure to community outreach activities with a FP focus (e.g., house to house and community religious dialogues) are associated with reported modern family planning use and discussion of family planning with partners among men in the four urban sites of Senegal.

Conclusions: This study demonstrates that it is possible to reach men with FP program activities in urban Senegal and that these activities are positively associated with reported FP behaviors.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204049PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6155530PMC
March 2019

Reaching Urban Female Adolescents at Key Points of Sexual and Reproductive Health Transitions: Evidence from a Longitudinal Study from Kenya.

Afr J Reprod Health 2018 Mar;22(1):47-59

Department of Economics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Urban areas include large numbers of adolescents (ages 15-19) and young adults (ages 20-24) who may have unmet sexual and reproductive health (SRH) needs. Worldwide, adolescents contribute 11% of births, many of which are in low and middle-income countries. This study uses recently collected longitudinal data from urban Kenyan women to examine the association between targeted intervention activities and adolescents' SRH transitions. The focus was on a female adolescent (15-19) sample and their transition to first sex and first pregnancy/birth. Multinomial logistic regression methods were used to examine whether exposure to program activities was associated with delays in transitions. Overall, a high percentage of adolescents were exposed to television activities with family planning messages. About a third were exposed to community events, program posters, or the Shujaaz comic book that included themes related to relationships and positive health outcomes using recognizable characters. Multivariate analyses found that exposure to the Shujaaz comic book was associated with remaining sexually inexperienced and never pregnant at end line. Future programs for urban adolescents should implement interventions that test novel media strategies, like the Shujaaz comic book, that may be more interesting for young people. Innovative strategies are needed to reach female adolescents in urban settings.
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http://dx.doi.org/10.29063/ajrh2018/v22i1.5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6639007PMC
March 2018

Sex composition and its impact on future childbearing: a longitudinal study from urban Uttar Pradesh.

Reprod Health 2018 Feb 27;15(1):35. Epub 2018 Feb 27.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.

Background: The sex composition of existing children has been shown to influence childbearing decision-making and behaviors of women and couples. One aspect of this influence is the preference for sons. In India, where son preference is deeply entrenched, research has normally focused on rural areas using cross-sectional data. However, urban areas in India are rapidly changing, with profound implications for childbearing patterns. Yet, evidence on the effect of the sex composition of current children on subsequent childbearing intentions and behavior in urban areas is scant. In this study, we analyze the impact of sex composition of children on subsequent (1) parity progression, (2) contraceptive use, and (3) desire for another child.

Methods: We analyze prospective data from women over a four year period in urban Uttar Pradesh using discrete-time event history logistic regression models to analyze parity progression from the first to second parity, second to third parity, and third to fourth parity. We also use logistic regression models to analyze contraceptive use and desire for another child.

Results: Relative to women with no daughters, women with no sons had significantly higher odds of progressing to the next birth (parity 1 - aOR: 1.31; CI: 1.04-1.66; parity 2 - aOR: 4.65; CI: 3.11-6.93; parity 3 - aOR:3.45; CI: 1.83-6.52), as well as reduced odds of using contraception (parity 2 - aOR:.58; CI: .44-.76; parity 3 - aOR: .58; CI: .35-.98). Relative to women with two or more sons, women with two or more daughters had significantly higher odds of wanting to have another child (parity 1 - aOR: 1.33; CI: 1.06-1.67; parity 2 - aOR: 3.96; CI: 2.45-6.41; parity 3-4.89; CI: 2.22-10.77).

Conclusions: Our study demonstrates the pervasiveness of son preference in urban areas of Uttar Pradesh. We discuss these findings for future programmatic strategies to mitigate son preference in urban settings.
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http://dx.doi.org/10.1186/s12978-018-0482-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5830318PMC
February 2018

Women's contraceptive discontinuation and switching behavior in urban Senegal, 2010-2015.

BMC Womens Health 2018 02 5;18(1):35. Epub 2018 Feb 5.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.

Background: With the focus of global and national family planning initiatives on reaching "additional user" targets, it is increasingly important for programs to assess contraceptive method discontinuation and switching. This analysis calculated the discontinuation rate and method-specific discontinuation rates, examined reasons given for contraceptive discontinuation, and assessed characteristics associated with subsequent contraceptive switching and abandonment among women living in urban areas of Senegal.

Methods: Data came from the Measurement, Learning & Evaluation project's 2015 survey of 6927 women of reproductive age living in six urban sites (Dakar, Pikine, Guédiawaye, Mbao, Kaolack and Mbour). Information on contraceptive use and discontinuation for the five years preceding the survey were recorded in a monthly calendar. Single decrement life tables were used to calculate discontinuation rates. Descriptive analyses were used to assess reasons for discontinuation and method switching after discontinuation. A multinomial logistic regression was used to estimate the likelihood of being a non-user in-need of contraception, a non-user not in-need of contraception, or a method switcher in the month after discontinuation, by sociodemographic and other characteristics.

Results: The 12-month discontinuation rate for all methods was 34.7%. Implants had the lowest one-year discontinuation rates (6.3%) followed by the intrauterine device (IUD) (18.4%) while higher rates were seen for daily pills (38%), injectables (32.7%), and condoms (62.9%). The most common reasons for discontinuation were reduced need (45.6%), method problems (30.1%), and becoming pregnant while using (10.0%). Only 17% of discontinuations were followed by use of another method; most often daily pills (5.2%) or injectables (4.2%). In the multivariate analysis, women with any formal education (primary, secondary or higher) were more than 50% more likely to switch methods than remain in need of contraception after discontinuation than women with no education or Koranic-only education (RRR = 1.59, p-value = 0.004; RRR = 1.55, p-value = 0.031). The likelihood of switching compared to being "in need" was also significantly higher for women who were married and who discontinued traditional methods.

Conclusions: To support increased contraceptive method use, women with no education and unmarried women are priorities for counseling and information about side effects and method switching at the time of method adoption.
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http://dx.doi.org/10.1186/s12905-018-0529-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5800088PMC
February 2018

Impact of the Urban Reproductive Health Initiative on family planning uptake at facilities in Kenya, Nigeria, and Senegal.

BMC Womens Health 2018 01 5;18(1). Epub 2018 Jan 5.

Department of Maternal and Child Health, Gillings School of Global Public Health, and Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: The 2012 London Summit on Family Planning set ambitious goals to enable 120 million more women and adolescent girls to use modern contraceptives by 2020. The Urban Reproductive Health Initiative (URHI) was a Bill & Melinda Gates Foundation funded program designed to help contribute to these goals in urban areas in India, Kenya, Nigeria, and Senegal. URHI implemented a range of country-specific demand and supply side interventions, with supply interventions generally focused on improved service quality, provider training, outreach to patients, and commodity stock management. This study uses data collected by the Measurement, Learning & Evaluation (MLE) Project to examine the effectiveness of these supply-side interventions by considering URHI's influence on the number of family planning clients at health facilities over a four-year period in Kenya, Nigeria, and Senegal.

Methods: The analysis used facility audits and provider surveys. Principal-components analysis was used to create country-specific program exposure variables for health facilities. Fixed-effects regression was used to determine whether family planning uptake increased at facilities with higher exposure. Outcomes of interest were the number of new family planning acceptors and the total number of family planning clients per reproductive health care provider in the last year.

Results: Higher program component scores were associated with an increase in new family planning acceptors per provider in Kenya (β = 18, 95% CI = 7-29), Nigeria (β = 14, 95% CI = 8-20), and Senegal (β = 7, 95% CI = 3-12). Higher scores were also associated with more family planning clients per provider in Kenya (β = 31, 95% CI = 7-56) and Nigeria (β = 26, 95% CI = 15-38), but not in Senegal.

Conclusions: Supply-side interventions have increased the number of new family planning acceptors at facilities in urban Nigeria, Kenya, and Senegal and the overall number of clients in urban Nigeria and Kenya. While tailoring to the local environment, programs seeking to increase family planning use should include components to improve availability and quality of family planning services, which are part of a rights-based approach to family planning programming.
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http://dx.doi.org/10.1186/s12905-017-0504-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756340PMC
January 2018

The Effect of the Removal of User Fees for Delivery at Public Health Facilities on Institutional Delivery in Urban Kenya.

Matern Child Health J 2018 03;22(3):409-418

Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.

Objectives In 2013, Kenya removed delivery fees at public health facilities in an effort to promote equity in access to health services and address high maternal mortality. This study determines the effect of the policy to remove user fees on institutional delivery in a population-based sample of women from urban Kenya. Methods Longitudinal data were collected from a representative sample of 8500 women from five cities in Kenya in 2010 with a follow-up interview in 2014 (response rate 58.9%). Respondents were asked about their most recent birth since 2008 at baseline and 2012 at endline, including the delivery location. Multinomial logistic regression is used, controlling for the temporal time trend and background characteristics, to determine if births which occurred after the national policy change were more likely to occur at a public facility than at home or a private facility. Results Multivariate findings show that women were significantly more likely to deliver at a public facility as compared to a private facility after the policy. Among the poor, the results show that poor women were significantly more likely to deliver in a public facility compared to home or a private facility after policy change. Conclusions for Practice These findings show Kenya's progress towards achieving universal access to delivery services and meeting its national development targets. The removal of delivery fees in the public sector is leading to increased use of facilities for delivery among the urban poor; this is an important first step in reducing maternal death.
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http://dx.doi.org/10.1007/s10995-017-2408-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845052PMC
March 2018

Longitudinal Evaluation of the Tupange Urban Family Planning Program in Kenya.

Int Perspect Sex Reprod Health 2017 06 1;43(2):75-87. Epub 2017 Jun 1.

Context: Levels of fertility and contraceptive use have long fluctuated in Kenya. The multicomponent Tupange program, part of the Urban Reproductive Health Initiative, was initiated in 2011 to increase use of modern family planning methods.

Methods: Women aged 15-49 in the five Kenyan cities where Tupange was implemented were interviewed in 2010 and reinterviewed in 2014 to obtain information on their contraceptive use and exposure to components of the Tupange program. Fixed-effects models were estimated to identify associations between program exposure and use of modern family planning methods. Analyses were performed to determine the relative cost-effectiveness of program components.

Results: During the four-year follow-up period, the proportion of women using modern contraceptives increased from 45% to 52%, and the proportion of users who were using long-acting or permanent methods rose from 6% to 19%. The fixed-effects model indicated that modern method use was associated with having heard Tupange-related local radio programming and marginally associated with having discussed family planning with a community health worker (CHW); among women who were unmarried or did not give birth during the study period, modern method use was associated with living near program facilities. Local radio programming was the most cost-effective program component, followed by proximity to Tupange facilities and discussions with CHWs.

Conclusions: Urban reproductive health programs seeking to increase use of modern family planning methods in Kenya and other Sub-Saharan African settings should consider multicomponent approaches that include CHW activities, local radio programming and improvements to the supply environment.
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http://dx.doi.org/10.1363/43e4117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5897119PMC
June 2017

Counseling during Maternal and Infant Health Visits and Postpartum Contraceptive use in Uttar Pradesh, India.

Int Perspect Sex Reprod Health 2016 12;42(4):167-178

International Center for Research on Women, New Delhi, India.

Context: Postpartum family planning is a compelling concern of global significance due to its salience to unplanned pregnancies, and to maternal and infant health in developing countries. Yet, women face the highest level of unmet need for contraception in the year following a birth. A cost-effective way to inform women about their risk of becoming pregnant after the birth of a child is to integrate family planning counseling and services with maternal and infant health services.

Methods: We use recently collected survey data from 2733 women from six cities in Uttar Pradesh, India who had a recent birth (since 2011) to examine the role of exposure to family planning information at maternal and infant health visits on (1) any contraceptive use in the postpartum period, and (2) choice of modern method in the postpartum period. We use discrete-time event history multinomial logit models to examine the duration to contraceptive use, and choice of modern method, in the 12 months following the last birth since 2011.

Results: We find that receiving counseling in an institution at the time of delivery has the strongest influence on women's subsequent uptake of modern contraception (female sterilization and IUD). Being visited by a CHW in the extended postpartum period was also strongly associated with subsequent uptake of modern contraception (IUD, condom and hormonal contraception).

Conclusion: Providing postpartum family planning counseling at key junctures during maternal health visits has the potential to increase uptake of modern contraceptive method in urban Uttar Pradesh.
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http://dx.doi.org/10.1363/42e2816DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477656PMC
December 2016

Examination of youth sexual and reproductive health transitions in Nigeria and Kenya using longitudinal data.

BMC Public Health 2017 01 31;17(1):142. Epub 2017 Jan 31.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: The adolescent (ages 15-19) and young adult (ages 20-24) years are a crucial time as many sexual and reproductive health (SRH) transitions take place in these years. The study of youth SRH transitions in sub-Saharan Africa is limited due to a paucity of longitudinal data needed to examine the timing and circumstances of these transitions.

Methods: This paper uses recently collected longitudinal data from select urban areas in Kenya and Nigeria that include a large youth sample at baseline (2010/2011) and endline (2014). We control for unobserved heterogeneity in our modelling approach to correct for selectivity issues that are often ignored in similar types of analyses.

Results: We demonstrate that the transition patterns (i.e., sexual initiation, first marriage, and first pregnancy/birth) differ within and across the urban areas and countries studied. Urban Kenyan youth have more premarital sex and pregnancy than youth from the Nigerian cities. Further analyses demonstrate that more educated and wealthier youth transition later than their less educated and poorer counterparts.

Conclusions: The findings from this study can be used to inform programs seeking to serve young people based on their varying reproductive health needs in different contexts over the adolescent and young adult years.
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http://dx.doi.org/10.1186/s12889-017-4039-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5282773PMC
January 2017

Impact evaluation of the Urban Health Initiative in urban Uttar Pradesh, India.

Contraception 2016 06 3;93(6):519-25. Epub 2016 Mar 3.

Carolina Population Center at the University of North Carolina at Chapel Hill.

Objectives: The Urban Health Initiative (UHI) was initiated in 2009 with the goal of increasing family planning (FP) use among the poor in urban areas of Uttar Pradesh, India. The Measurement, Learning & Evaluation project (MLE) was tasked with rigorous impact evaluation of the UHI. This paper presents the impact evaluation findings of the UHI program.

Study Design: The MLE design includes a longitudinal sample of women and health facilities with baseline (2010) and endline (2014) data collection in six cities in Uttar Pradesh, India. At baseline, samples representative of women in each city were selected with oversampling of the poor. Eighty-four percent of women interviewed at baseline were reinterviewed 4 years later at endline. The longitudinal data support a within/fixed-effects approach to identification of program impact on changes in modern FP use.

Results: Impact evaluation results show significant effects of exposure to both demand and supply side program activities. In particular, women exposed to brochures (marginal effect: 6.96, p<.001), billboards/posters/wall hangings (marginal effect: 2.09, p<.05), and FP on the television (marginal effect: 2.46, p<.001) were significantly more likely to be using a modern method at endline. In addition, we found borderline significance for being exposed to a community health worker (marginal effect: 1.66, p<.10) and living close to an improved public and private supply environment where UHI undertook activities (marginal effects and p values: 2.48, p<.05 and 1.56, p<.10, respectively).

Conclusions: UHI program activities were designed to complement the Government of India's strategies aimed at ensuring access to and provision of FP to urban poor populations. The effective demand- and supply-side strategies of the UHI program are therefore likely to be sustainable and scalable to other urban areas in India.

Implications Statement: Findings from this study are important for designing sustainable and scalable FP strategies for urban India where increases in FP use will be relevant for meeting international FP targets.
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http://dx.doi.org/10.1016/j.contraception.2016.02.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863519PMC
June 2016

Integration of family planning with maternal health services: an opportunity to increase postpartum modern contraceptive use in urban Uttar Pradesh, India.

J Fam Plann Reprod Health Care 2016 Apr 30;42(2):107-15. Epub 2015 Nov 30.

Group Director, Social and Economic Development Group, International Center for Research on Women, New Delhi, India.

Background: Maternal health (MH) services provide an invaluable opportunity to inform and educate women about family planning (FP). It is expected that this would enable women to choose an appropriate method and initiate contraception early in the postpartum period. In this study we examined interactions with health providers for MH services, and the effect of FP information provision during these interactions on the postpartum use of modern contraceptive methods.

Methods: This study used midline data collected from 990 women who had delivered a live birth between January 2010 and the date of the midline survey in 2012. These women were asked a series of questions about their last delivery, including interactions with health providers during pregnancy, delivery and the postpartum period, if they received FP information during these interactions, and their contraceptive use during the postpartum period.

Results: The study found that FP information provision as part of antenatal care in the third trimester, delivery and the postpartum period have a positive association with postpartum modern contraceptive use in urban Uttar Pradesh. However, health providers often miss these opportunities. Despite a high proportion of women coming into contact with health providers when utilising MH services, only a small proportion received FP information during these interactions.

Conclusions: Integration of FP with MH services can increase postpartum modern contraceptive use. With the launch of the National Urban Health Mission, there now exists appropriate policy and programmatic environments for integration of FP and MH services in urban settings in India. However, this will require a concentrated effort both to enhance the capacity of health providers and encourage supportive supervision.
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http://dx.doi.org/10.1136/jfprhc-2015-101271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853573PMC
April 2016

Interpersonal communication as an agent of normative influence: a mixed method study among the urban poor in India.

Reprod Health 2015 Aug 12;12:71. Epub 2015 Aug 12.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Although social norms are thought to play an important role in couples' reproductive decisions, only limited theoretical or empirical guidance exists on how the underlying process works. Using the theory of normative social behavior (TNSB), through a mixed-method design, we investigated the role played by injunctive norms and interpersonal discussion in the relationship between descriptive norms and use of modern contraceptive methods among the urban poor in India.

Methods: Data from a household survey (N = 11,811) were used to test the underlying theoretical propositions, and focus group interviews among men and women were then conducted to obtain more in-depth knowledge about decision-making processes related to modern contraceptive use.

Results: Spousal influence and interpersonal communication emerged as key factors in decision-making, waning in the later years of marriage, and they also moderated the influence of descriptive norms on behaviors. Norms around contraceptive use, which varied by parity, are rapidly changing with the country's urbanization and increased access to health information.

Conclusion: Open interpersonal discussion, community norms, and perspectives are integral in enabling women and couples to use modern family planning to meet their current fertility desires and warrant sensitivity in the design of family planning policy and programs.
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http://dx.doi.org/10.1186/s12978-015-0061-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533786PMC
August 2015

Understanding patterns of temporary method use among urban women from Uttar Pradesh, India.

BMC Public Health 2014 Sep 29;14:1018. Epub 2014 Sep 29.

Carolina Population Center, University of North Carolina, Chapel Hill, USA.

Background: Almost one in five contraceptive users in India uses a temporary method. It is important to understand user profiles and method use patterns for optimal program targeting.This analysis examines differences in demographic characteristics, discontinuation and use patterns of temporary method users among a representative sample of urban women from four cities in Uttar Pradesh, India.

Methods: Individual data from a panel of women aged 15-49 were collected in 2010 in Agra, Aligarh, Allahabad, and Gorakhpur and follow-up data from the same women were collected in 2012. A contraceptive calendar was used to collect month-by-month data on contraceptive use, non-use, discontinuation, reason for discontinuation, and pregnancy and birth, covering the approximately two-year period between the baseline and midterm surveys. The analysis sample is 4,023 non-sterilized women in union at baseline. A descriptive comparison is made of socio-demographic characteristics, fertility desires, discontinuation, method switching, and pregnancy outcomes. Reasons for discontinuation are assessed by the order of discontinuation.

Results: There were a number of socio-demographic differences between users of temporary methods during the calendar period; by education, wealth, and caste. Notably, women who used only condoms during this time had the most education, were the least likely to be poor, and the least likely to be from a scheduled caste or tribe as compared to users of other temporary methods. Compared to the full sample of women, users of temporary methods during this period were less likely to reside in slum areas. The group of multiple method users was small in comparison to the groups of women using a single method throughout the calendar period. This indicates that there was little method switching between condoms, traditional methods, and other forms of modern methods reported in the calendar.

Conclusions: The calendar may not be well-suited to measure coital-dependent contraceptive use (e.g., condoms and traditional methods), as "continuous" monthly use may be overstated. A coital episode-specific data collection tool may produce more accurate records of contraceptive use in such contexts. Research findings also lead to useful programmatic recommendations for addressing unmet need and unintended pregnancies in urban Uttar Pradesh and beyond.
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http://dx.doi.org/10.1186/1471-2458-14-1018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4190301PMC
September 2014

Men's attitudes on gender equality and their contraceptive use in Uttar Pradesh India.

Reprod Health 2014 Jun 4;11:41. Epub 2014 Jun 4.

International Center for Research on Women (ICRW), New Delhi, India.

Background: Men play crucial role in contraceptive decision-making, particularly in highly gender-stratified populations. Past research examined men's attitudes toward fertility and contraception and the association with actual contraceptive practices. More research is needed on whether men's attitudes on gender equality are associated with contraceptive behaviors; this is the objective of this study.

Methods: This study uses baseline data of the Measurement, Learning, and Evaluation (MLE) Project for the Urban Health Initiative in Uttar Pradesh, India. Data were collected from a representative sample of 6,431 currently married men in four cities of the state. Outcomes are current use of contraception and contraceptive method choice. Key independent variables are three gender measures: men's attitudes toward gender equality, gender sensitive decision making, and restrictions on wife's mobility. Multivariate analyses are used to identify the association between the gender measures and contraceptive use.

Results: Most men have high or moderate levels of gender sensitive decision-making, have low to moderate levels of restrictions on wife's mobility, and have moderate to high levels of gender equitable attitudes in all four cities. Gender sensitive decision making and equitable attitudes show significant positive association and restrictions on wife's mobility showed significant negative relationship with current contraceptive use.

Conclusion: The study demonstrates that contraceptive programs need to engage men and address gender equitable attitudes; this can be done through peer outreach (interpersonal communication) or via mass media. Engaging men to be more gender equal may have an influence beyond contraceptive use in contexts where men play a crucial role in household decision-making.
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http://dx.doi.org/10.1186/1742-4755-11-41DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051668PMC
June 2014

Provider imposed restrictions to clients' access to family planning in urban Uttar Pradesh, India: a mixed methods study.

BMC Health Serv Res 2013 Dec 23;13:532. Epub 2013 Dec 23.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.

Background: Medical barriers refer to unnecessary policies or procedures imposed by health care providers that are not necessarily medically advised; these restrictions impede clients' access to family planning (FP). This mixed methods study investigates provider imposed barriers to provision of FP using recent quantitative and qualitative data from urban Uttar Pradesh, India.

Methods: Baseline quantitative data were collected in six cities in Uttar Pradesh, India from service delivery points (SDP), using facility audits, exit interviews, and provider surveys; for this study, the focus is on the provider surveys. More than 250 providers were surveyed in each city. Providers were asked about the FP methods they provide, and if they restrict clients' access to each method based on age, parity, partner consent, or marital status. For the qualitative research, we conducted one-on-one interviews with 21 service providers in four of the six cities in Uttar Pradesh. Each interview lasted approximately 45 minutes.

Results: The quantitative findings show that providers restrict clients' access to spacing and long-acting and permanent methods of FP based on age, parity, partner consent and marital status. Qualitative findings reinforce that providers, at times, make judgments about their clients' education, FP needs and ability to understand FP options thereby imposing unnecessary barriers to FP methods.

Conclusions: Provider restrictions on FP methods are common in these urban Uttar Pradesh sites. This means that women who are young, unmarried, have few or no children, do not have the support of their partner, or are less educated may not be able to access or use FP or their preferred method. These findings highlight the need for in-service training for staff, with a focus on reviewing current guidelines and eligibility criteria for provision of methods.
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http://dx.doi.org/10.1186/1472-6963-13-532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879325PMC
December 2013

Determinants and coverage of vaccination in children in western Kenya from a 2003 cross-sectional survey.

Am J Trop Med Hyg 2014 Feb 16;90(2):234-41. Epub 2013 Dec 16.

University of Michigan School of Public Health, Ann Arbor, Michigan; Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention Research and Public Health Collaboration, Centre for Global Health Research, Kisumu, Kenya.

This study assesses full and timely vaccination coverage and factors associated with full vaccination in children ages 12-23 months in Gem, Nyanza Province, Kenya in 2003. A simple random sample of 1,769 households was selected, and guardians were invited to bring children under 5 years of age to participate in a survey. Full vaccination coverage was 31.1% among 244 children. Only 2.2% received all vaccinations in the target month for each vaccination. In multivariate logistic regression, children of mothers of higher parity (odds ratio [OR] = 0.27, 95% confidence interval [95% CI] = 0.13-0.65, P ≤ 0.01), children of mothers with lower maternal education (OR = 0.35, 95% CI = 0.13-0.97, P ≤ 0.05), or children in households with the spouse absent versus present (OR = 0.40, 95% CI = 0.17-0.91, P ≤ 0.05) were less likely to be fully vaccinated. These data serve as a baseline from which changes in vaccination coverage will be measured as interventions to improve vaccination timeliness are introduced.
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http://dx.doi.org/10.4269/ajtmh.13-0127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919223PMC
February 2014

The effect of family sex composition on fertility desires and family planning behaviors in urban Uttar Pradesh, India.

Reprod Health 2013 Sep 11;10:48. Epub 2013 Sep 11.

Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: A cultural preference for sons has been well documented in India, resulting in skewed sex ratios, especially exhibited in northwest India. Previous research has shown that family sex composition is associated with family planning (FP) use and couples' desire for more children. This study examines family sex composition and fertility and FP behaviors in urban Uttar Pradesh, India; little work has examined these issues in urban settings where family sizes are smaller and FP use is common.

Methods: Data for this analysis comes from a 2010 representative survey of married, non-pregnant fecund women aged 15-49 from six cities in Uttar Pradesh, India. Multivariate analyses are used to examine the association between family sex composition and fertility desires and FP use.

Results: The multivariate results indicate that family sex composition is associated with fertility desires and FP use. Women without living children and without at least one child of each sex are significantly less likely to want no more children and women with both sons and daughters but more sons are significantly more likely to want no more children as compared to women that have both sons and daughters but more daughters. Women with no living children and women with daughters but no sons are less likely to be modern FP users than nonusers whereas women with both sons and daughters but more sons are more likely to be modern FP users than nonusers as compared to women with both sons and daughters but more daughters.

Conclusions: These findings confirm that family sex composition affects fertility behavior and also reveals that preference for sons persists in urban Uttar Pradesh. These results underscore the importance of programs and policies that work to enhance the value of girl children.
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http://dx.doi.org/10.1186/1742-4755-10-48DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3848571PMC
September 2013

Measurement of unmet need for family planning: longitudinal analysis of the impact of fertility desires on subsequent childbearing behaviors among urban women from Uttar Pradesh, India.

Contraception 2013 Oct 26;88(4):553-60. Epub 2013 Apr 26.

Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA; Measurement, Learning, & Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, NC, USA. Electronic address:

Background: The measure of unmet need relies on women's reported fertility desires; previous research has demonstrated that fertility desires may be fluid and not firm.

Study Design: Our study uses recently collected longitudinal data from four cities in Uttar Pradesh, India, to examine whether women's fertility desires and family planning (FP) use at baseline predict pregnancy/birth experience in the 2-year follow-up period.

Results: Multivariate models demonstrate that women who were using any method of FP and reported an intention to stop childbearing were the least likely to experience a pregnancy/birth in the 2-year follow-up period. The stated desire to delay childbearing, whether or not the woman was using FP, did not distinguish pregnancy/birth experience. Ninety-two percent of pregnancies/births over the follow-up period were considered "wanted then" suggesting post-hoc rationalization of the pregnancy/birth even among those women who reported a desire to stop childbearing 2 years earlier.

Conclusions: More nuanced assessments of fertility intentions may be needed to adequately gauge latent FP needs. Non-users of FP may be ambivalent about future childbearing and the timing of future births; these women may not have an unmet need for FP as typically defined.
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http://dx.doi.org/10.1016/j.contraception.2013.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835184PMC
October 2013

Combined sewage overflows (CSO) are major urban breeding sites for Culex quinquefasciatus in Atlanta, Georgia.

Am J Trop Med Hyg 2007 Sep;77(3):478-84

Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

A longitudinal study of mosquito ecology in Tanyard Creek, an urban stream in Atlanta, GA, that receives combined storm and waste water effluent from the Atlanta combined sewage overflow system, was undertaken in 2006. Culex quinquefasciatus was the dominant species found, but Culex restuans was also abundant during the spring with limited numbers of Culex nigripalpis and Anopheles punctipennis also collected. Significant differences in mosquito densities were found with greater densities associated with side pools of water and stagnant water. Mosquito numbers are regulated largely by flooding of the stream by effluent discharges exceeding 15 kgal/min. These floods are associated with significant immediate reductions, but not complete elimination, of mosquitoes from Tanyard Creek. Mosquito numbers rebound within 5-10 days after such floods and rapidly reach high densities.
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September 2007

Genetic diversity and population structure of Escherichia coli isolated from freshwater beaches.

Environ Microbiol 2007 Sep;9(9):2274-88

Microbial Evolution Laboratory, National Food Safety and Toxicology Center, Michigan State University, East Lansing, MI 48824, USA.

Escherichia coli is an important member of the gastrointestinal tract of humans and warm-blooded animals (primary habitat). In the external environment outside the host (secondary habitat), it is often considered to be only a transient member of the microbiota found in water and soil, although recent evidence suggests that some strains can persist in temperate soils and freshwater beaches. Here we quantified the population genetic structure of E. coli from a longitudinal collection of environmental strains isolated from six freshwater beaches along Lake Huron and the St. Clair River in Michigan. Multilocus enzyme electrophoresis (MLEE) and multilocus sequence typing (MLST) revealed extensive genetic diversity among 185 E. coli isolates with an average of 40 alleles per locus. Despite evidence for extensive recombination generating new alleles and genotypic diversity, several genotypes marked by distinct MLEE and MLST profiles were repeatedly recovered from separate sites at different times. A PCR-based phylogrouping technique showed that the persistent, naturalized E. coli belonged to the B1 group. These results support the hypothesis that persistent genotypes have an adaptive advantage in the secondary habitat outside the host.
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http://dx.doi.org/10.1111/j.1462-2920.2007.01341.xDOI Listing
September 2007