Office of Population Research, Princeton University

Health and Wellbeing

Chang Y. Chung • Kelly Cleland • Noreen Goldman • Dawn Koffman • Germán Rodríguez • Matthew Salganik • James Trussell • Sarinnapha Vasunilashorn • Charles F. Westoff

Rebecca Casciano worked with Hilary Levey Friedman (Harvard University) on a project examining the correlates of pediatric sports injuries, with a particular emphasis on whether there is a relative age effect for sports injuries. The project draws on a large-N probability sample of patients seen in the Division of Sports Medicine at the Children's Hospital of Boston between 2000 and 2009. In light of evidence that children born closer to the cutoff months for participation in youth sports leagues have an advantage (in the form of size and coordination) over their "younger" peers, they investigate whether this advantage translates into differences in sports injuries across birth months. In a separate paper, they examine the correlates of overuse and traumatic sports injuries and use decomposition methods to explain large sex differences in overuse injuries.

Noreen Goldman has been working with Anne Pebley (UCLA) to understand SES gradients in health-related measures among Hispanic groups. In collaboration with Goldman, Pebley, and Rebeca Wong (University of Texas), former postdoctoral fellow Alison Buttenheim (University of Pennsylvania) estimated SES gradients in obesity and smoking in Mexico. The findings, which are published in Global Public Health, underscore that the socioeconomic determinants of smoking and obesity in Mexico are complex, with the magnitude and direction of the associations varying by sex, urban/rural location, and nature of the SES indicator (education vs. wealth).

In an effort to determine whether weak education differentials in health among Mexican Americans arise from “imported gradients,” a paper in Social Science and Medicine by former postdoctoral fellow Alison Buttenheim (University of Pennsylvania) in collaboration with Noreen Goldman, Anne Pebley (UCLA), Rebeca Wong (University of Texas) and Chang Chung, compares education gradients in smoking and obesity between recently-arrived Mexican immigrants in the U.S. and those for high-migration areas in Mexico. Using L.A.FANS data, Buttenheim, Goldman and Pebley have determined the extent of underestimation of obesity prevalence among adolescents and the evolution of patterns of obesity among Mexican immigrant and native adolescents.

Additional research based on L.A. FANS by Noreen Goldman and Anne Pebley (UCLA), in collaboration with Mathew Creighton (Universitat Pompeu Fabra), explores the role of social and linguistic acculturation in accounting for patterns of obesity as well as dietary and physical activity behaviors, by immigrant generation and duration of immigration among Mexicans in the US. In a recent paper in Social Science and Medicine, Goldman, Creighton, Graciela Teruel (Universidad Iberoamericana, Mexico) and Luis Rubalcava (CAMBS/Centro de Investigación de Docencia Económicas, Mexico) demonstrate a link between the presence of migration networks to the U.S. and the development of adolescent obesity among Mexicans.

Noreen Goldman, Maxine Weinstein (Georgetown University), and Dana Glei (Georgetown University) are continuing to collaborate with colleagues at the Bureau of Health Promotion, Department of Health in Taiwan on the Social Environment and Biomarkers of Aging Study (SEBAS). This data collection effort, supported by the National Institute on Aging, was designed to enhance understanding of the role of physiological processes in the complex relationships among life challenge, the social environment, and physical and mental health. The first wave of the survey, fielded in 2000, includes home-based interviews, collection of blood and urine samples, and physicians’ health exams, from about 1,000 middle-aged and elderly respondents. Respondents are a random sub-sample from an ongoing national survey (Taiwan Longitudinal Survey of Aging, or TLSA) that has collected periodic interviews between 1989 and 2011 in Taiwan. SEBAS II, which was fielded between August, 2006 and January, 2007 obtained a second set of measurements for biomarkers collected in 2000 as well as several new physiological measures, including (1) inflammatory markers, such as C-reactive protein and fibrinogen; (2) health assessments in the home – blood pressure, grip strength, lung function, timed walks, and chair stands; and (3) additional questions in the household interview on pain, perceived stress, stressful and traumatic events, and sleep. In the fall of 2011, the Taiwan Longitudinal Study of Aging (TLSA) will collect additional data for SEBAS respondents, including health measurements and cognitive performance, evaluated in the respondent’s home. Numerous projects based on the SEBAS data have been undertaken or completed during 2010. These papers examine determinants of a range of health-related outcomes, including depressive symptoms, sleep behavior, physiological dysfunction (such as inflammation), physical performance, and survival. Most of the recent papers take advantage of the newly available data in SEBAS II. Numerous other recent papers exploit the longitudinal feature of SEBAS by estimating change between the two waves

In a paper published in Depression and Anxiety that examines a polymorphism related to serotonin transport (5-HTTLPR), Noreen Goldman and SEBAS colleagues identify an allele in the Taiwanese population that has rarely been identified in other groups and explore the association among alleles of 5HTTLPR, sex, stressful experience and depressive symptoms.

In a paper in Journal of Aging and Health, former student Kim Smith (Mathematical Policy Research) and Noreen Goldman examine responses from two new SEBAS questions – interviewer- and physician-assessed health of the respondent – and find that these external evaluators take into account some aspects of health that receive little weight in respondents’ own ratings.

In a paper in Journals of Gerontology, former postdoctoral fellow Jen Cornman (Jennifer C. Cornman Consulting, Granville, OH), in collaboration with Noreen Goldman, Germán Rodríguez and other SEBAS colleagues, use objective performance measurements to determine whether socioeconomic and demographic differences in reported mobility difficulty are attributable to differential perceptions of health that result in the differential use of response categories. Another analysis uses recently collected to explore the association between physiological dysregulation and both relaxation practices and physical exercise.

In a paper in Annals of Epidemiology, former student Jenn Dowd (Hunter College), Noreen Goldman and Maxine Weinstein (Georgetown University), use SEBAS data to examine associations between biomarkers of inflammation and self-reported sleep characteristics in an effort to assess the direction of causality. In a paper in Research on Aging, Goldman and colleagues use physiological data from the two waves of SEBAS to estimate age-related changes in biomarkers of chronic disease

As part of a large project using pooled data from 2 cycles of the National Survey of Family Growth, Kelli Stidham Hall, Caroline Moreau, and James Trussell are examining trends in reproductive health service use and formal and informal sex communication from 2002 to 2008 among adolescent and young adult women in the United States. The multipronged project aims to: 1) describe reproductive health service use and identify correlates of and disparities in service use, 2) describe informal (parental) and formal (school, church, community) sex communication and identify correlates of having received sex communication, 3) identify changes in reproductive health service use and in sex communication from 2002 to 2008, 4) explore relationships between receipt of sex communication and reproductive health service use. Preliminary findings suggest that the majority of young women have received informal (75%) and formal (92%) education, most commonly on abstinence (60%) but also on sexually transmitted infections (53%) and contraception (58%). Informal communication, particularly on abstinence (4%, p=0.03), increased from 2002 to 2008 (overall 7%, p=0.001) but not formal communication (p=0.63). Reproductive health service use in the previous year was reported by over half of adolescents and young adults (55%), yet it decreased over time (15% from 2002 to 2008, p<0.001). Both sex communication and service use varied by sociodemographic factors including age, education, race/ethnicity and reproductive histories. This preliminary data is under review for presentation at upcoming 2011 annual conferences for the North American Forum for Family Planning, the American Public Health Association, the Nurse Practitioner’s in Women’s Health Association, and the University of Chicago Reproductive Justice and Health Care Reform Conference. This project will contribute a series of publications for peer-reviewed reproductive public health journals.

In collaboration with colleagues at the University of Michigan Population Studies Center, Kelli Stidham Hall, Caroline Moreau and James Trussell are examining the impact of attitudinal, psychosocial and health-related factors on patterns of contraceptive use and unintended pregnancy among adolescents. Using novel, dynamic, time series approach from a longitudinal study funded by the National Institutes of Health, NICHD (P.I. Jennifer Barber), the investigators are analyzing associations among changing pregnancy intentions and attitudes, depression, stress, general health, body mass index and other psychosocial context factors and changing coital and non-coital specific contraceptive use and unintended pregnancy. The project uses weekly self-reported data collected via multimodal (internet and telephone journals) format over the 2.5 year study from young women ages 18-19 years recruited from one Michigan county. The investigators aim to build upon their previous research concerning factors associated with contraceptive misuse and unintended pregnancy and address limitations in previous methods of measurement. The results will produce essential new insights into the processes surrounding contraceptive misuse leading to unintended pregnancy as a high priority public health and policy concern.

In a systematic review published in the Journal of Women’s Health, Kelli Stidham Hall and her colleagues from Columbia University Schools of Public Health, Medicine and Nursing (Carolyn Westhoff , Katherine O’Connell White, and Nancy Reame) sought to evaluate the literature on measurement approaches for studying the use of oral contraception. Their aim was to help clarify unaddressed inconsistencies in OC behavior findings possibly related to limitations in existing methodological approaches. The team used established databases to identify relevant published research from January 1965 to December 2009. The authors found that terminology used to describe OC use, which included “continuation,” “compliance,” and “adherence,” differed across studies and was rarely defined. The majority of studies reviewed (n=27/38; 71%) relied solely upon self-report measures of OC use. Only two reports described survey or interview questions, and reliability and validity data were seldom described. More rigorous measurement methods such as pill counts (electronic or manual), serum and urinary biomarkers, and pharmacy records were infrequently employed. Nineteen studies simultaneously used more than one method, but only three studies compared direct and indirect methods. The authors concluded that lack of a consistent, well-defined measurement of OC use limits our understanding of contraceptive misuse and related negative outcomes. Recommendations for future research included clarifying terminology, developing standardized measures, incorporating multi-method approaches with innovative methods, and publishing details of measurement methods.

In collaboration with her colleagues from Columbia University Schools of Public Health, Medicine and Nursing (Carolyn Westhoff, Paula Castano, and Patricia Stone), Kelli Stidham Hall, studied measurement approaches for oral contraceptive knowledge. The study, published in the journal Patient Education and Counseling sought to evaluate the findings and methodological limitations of research in which OC knowledge has been measured in order to facilitate understanding of relationships between OC knowledge and contraceptive behavior. Primary research articles from January 1965 to January 2009 were identified and audited for study characteristics, purpose for measuring OC knowledge, key findings and measurement properties including administration method, knowledge domains, reliability, validity, health literacy and cultural sensitivity. Twenty-one studies were included: 18 cohort studies, including one psychometric evaluation, and three randomized trials. Results on OC knowledge outcomes were variable. Measures were largely self-administered survey (n = 15) and lacked assessment of all OC knowledge domains. Information on measures’ characteristics, reliability, validity, health literacy and cultural sensitivity was limited. The authors concluded that existing OC knowledge measures lack critical psychometric elements, leading to inconsistent and unreliable findings. Poor OC knowledge measurement precludes identifying counseling needs and developing interventions for contraceptive behavior change. The authors recommended the following: measurement information in publications, psychometric evaluations, formal reliability/validity techniques, and attention to all OC knowledge domains, health literacy and cultural sensitivity.

Derived from her National Institutes of Health-funded dissertation research at Columbia University and in collaboration with her colleagues and mentors from Columbia Schools of Public Health, Nursing and Medicine (Carolyn Westhoff, Nancy Reame, Vaughn Rickert, Katharine O’Connell White), Kelli Stidham Hall studied the impact of adverse psychological conditions, perceived side effects and discontinuation of oral contraception (OC) among minority adolescent and young adult family planning patients. Specifically, the study prospectively examined associations among depressed mood (Center for Epidemiologic Studies-Depression Screen), perceived stress (Perceived Stress Scale-10), and ED symptoms (Eating Disorder Screen for Primary Care) and OC mood and weight changes and discontinuation among family planning patients participating in an OC continuation intervention trial. Data from interview-administered questionnaires (baseline and 6-month) with 354 adolescents and young adults (ages 13-24 years) were analyzed with multiple logistic regression. Rates of depressed mood, stress, ED symptoms, mood and weight changes were high and over half the sample had discontinued OCs by 6 months. Baseline adverse psychological conditions and perceived weight changes at 6 months increased the risk of OC discontinuation. Ultimately, the findings suggest improved understanding of contributing factors to poor contraceptive behavior can promote positive family planning outcomes. Study findings were presented at the 2010 Annual Conference for the Association of Reproductive Health Professionals, the 2010 Annual Conference for the North American Society for Pediatric and Adolescent Gynecology and the 2011 Annual Conference of the Society for Adolescent Medicine and Health. A series of publications are in progress to disseminate this research in the journals, Contraception, Journal of Adolescent Health, and the Journal of Pediatric and Adolescent Gynecology.

As part of a larger randomized trial to evaluate daily educational text message reminders to promote oral contraceptive (OC) continuation and knowledge in adolescents conducted at Columbia University Department of Obstetrics and Gynecology, Division of Family Planning, Kelli Stidham Hall, and her colleagues at Columbia University, Paula Castano, MD, MPH, Carolyn Westhoff, MD, MSc, conducted an OC knowledge project. The project sought to 1) design, implement, test and evaluate a comprehensive OC contraceptive knowledge instrument to measure the six dimensions of OC knowledge: mechanism of action, effectiveness, use, side effects, risks, and benefits, 2) analyze data collected with the instrument to describe OC knowledge among OC initiators and users, 3) evaluate the impact of the intervention on OC knowledge at 6 months and 4) examine associations between OC knowledge and OC continuation at 6 months, among the 659 adolescents ages 13-25 years who presented to an urban family planning clinic for OCs. Participants were randomized to receive routine clinical care alone or routine care plus six months of daily text message reminders with educational content adapted from standard handouts. Using the 41-item knowledge questionnaire, OC knowledge was assessed at baseline and knowledge and OC continuation was assessed at six months among the participants. In brief, OC knowledge was low among young OC-using women and disparities existed across sociodemographic groups. The text message intervention improved OC knowledge more so than routine care alone. Finally, OC knowledge was associated with OC continuation even while controlling for key confounders. These preliminary findings have been presented at the 2010 Annual Conference of the North American Society for Pediatric and Adolescent Gynecology, the 2011 Annual Conference of the Society for Adolescent Medicine, and are under review for the 2011 Annual Conference for the North American Forum on Family Planning. A series of manuscript publications are in progress.

Genevieve Pham-Kanter and Noreen Goldman worked on a project examining the effect of children on the mortality of parents. Focusing on PR China and Taiwan--two settings in which institutional and cultural norms are such that sons play a primary role in the material and financial support of parents--they find that, surprisingly, there is little evidence that sons are protective. Instead, they report that sons are largely neutral (relative to daughters) with respect to parental mortality, and that in Taiwan, daughters may have been more beneficial than sons in reducing older age mortality in recent years.

In “Assessing Respondent-Driven Sampling” published in the Proceedings of the National Academy of Sciences (PNAS), Matthew Salganik and Sharad Goel (Microeconomics and Social Systems, Yahoo! Research) examined Respondent Driven sampling (RDS). RDS is a network-based technique for estimating traits in hard-to-reach populations, for example, the prevalence of HIV among drug injectors. In recent years RDS has been used in more than 120 studies in more than 20 countries and by leading public health organizations, including the Centers for Disease Control and Prevention in the United States. Despite the widespread use and growing popularity of RDS, there has been little empirical validation of the methodology. Salganik and Goel investigated the performance of RDS by simulating sampling from 85 known, network populations. Across a variety of traits they found that RDS is substantially less accurate than generally acknowledged and that reported RDS confidence intervals are misleadingly narrow. Moreover, because the simulations model a scenario in which the theoretical RDS sampling assumptions hold exactly, it is unlikely that RDS performs any better in practice than in these simulations. Notably the poor performance of RDS is driven not by the bias but by the high variance of estimates, a possibility that had been largely overlooked in the RDS literature. Given the consistency of the results across networks and the generous sampling conditions, they concluded that RDS as currently practiced may not be suitable for key aspects of public health surveillance where it is now extensively applied.

James Trussell and Kelly Cleland continue their collaborative work with the Association of Reproductive Health Professionals (ARHP) on increasing public awareness of and access to emergency contraception. ARHP and the Office of Population Research sponsor the Emergency Contraception Website (not-2-late.com). The Website contains detailed information about emergency contraception including the brand names of pills that can be used for emergency contraception in every country, and a database of providers of emergency contraception in the U.S. The website is available in English, Spanish, French, and Arabic. The Website has received more than 11.6 million visitors since it was launched in October 1994; there are currently about 200,000 visitors per month. The Website was completely redesigned and relaunched in September, 2006.

In a paper published in Culture, Health and Sexuality, Lisa Wynn (Macquarie University), Angel Foster (Ibis Reproductive Health) and James Trussell analyzed 1,134 emails sent to the Emergency Contraception Website over a one-year period. The words and metaphors that people use to describe sexuality and reproductive health reflect experiences with peers, sexual partners, health service providers and public health campaigns. Through an examination of the terminology used by people to describe contraceptive methods, sexual intercourse and other sexual acts, the authors analyze what those terms signify within their textual context. They find that the kinds of risk concerns used in assessing sexual activity – whether evaluating pregnancy risk, disease transmission risk or moral risk – influence the definitions people give to terms that are multiply defined or whose definitions are culturally contested. This finding emerged clearly in the meanings given to terms for ‘sex’ and ‘unprotected sex’, which varied widely. They conclude with a discussion of the implications of this finding for research, clinical care and health education activities.

The safety of emergency contraceptive pills (ECPs) has been extensively studied and confirmed, yet some concerns remain about whether the use of ECPs increases the risk of ectopic pregnancy when treatment fails. To answer this question, Kelly Cleland, James Trussell, Elizabeth Raymond (Family Health International), Linan Cheng (Shanghai Institute of Planned Parenthood Research), and Zhu Haoping (Minhang Central hospital, Shanghai Jiaotong University) used data from 135 studies which included a defined population of women treated one time with ECPs (either mifepristone or levonorgestrel), and in which the number and location of pregnancies were ascertained. In the studies of mifepristone, 3 out of 494 (0.6%) pregnancies were ectopic; in the levonorgestrel studies, 3 out of 282 (1.1%) were ectopic. The rate of ectopic pregnancy when ECP treatment fails does not exceed the rate observed in the general population (between 0.8% and 2.0% of all reported pregnancies). Because ECPs are effective in lowering the risk of pregnancy, their use should reduce the chance that an act of intercourse will result in ectopic pregnancy. This review was published in Obstetrics & Gynecology in June 2010.

In a paper in Contraception, Mary Fjerstad (Ipas), James Trussell, Irving Sivin (Population Council) Steve Lichtenberg (Northwestern University) and Vanessa Cullins (Planned Parenthood Federation of America) examined the severity of infection before and after the adoption of new infection control measures. In response to concerns about serious infections following medical abortion, in early 2006 Planned Parenthood changed the route of misoprostol administration from vaginal to buccal and required either routine antibiotic coverage or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine antibiotic coverage for all medical abortions. They previously reported a pronounced drop in the rate of serious infection following the adoption of these new infection control measures. Their objective here is to assess whether the degree of severity of the serious infections differed in the three infection-control groups (vaginal misoprostol and no antibiotics, buccal misoprostol and screen-and-treat, buccal misoprostol and routine antibiotics) or, equivalently, to assess whether the declines in rates of serious infections after the adoption of new infection control measures differed across degree of severity categories. Of particular importance is whether the new infection control measures selectively reduced the least severe serious infections but did not diminish the rate of the most severe infections. They performed a retrospective analysis assessing the degree of severity of infections before infection controls were implemented and after each of the two new measures was adopted: buccal administration of antibiotics with either screen-and-treat or routine antibiotic coverage. They ranked the severity of infection from 1 (when treatment occurred in an emergency department) to 4 (when death occurred). We compared the distribution of the severity of serious infections in the three infection control groups (none, buccal misoprostol and screen-and-treat, buccal misoprostol and routine antibiotics), or, equivalently, assessed whether the declines in rates of serious infections after the adoption of new infection control measures differed across degree of severity categories using the Jonckheere-Terpstra test for a doubly ordered 4×3 table. The distribution of infection by severity was the same for all three infection control groups. Likewise, when the two new infection control groups―buccal misoprostol plus either screen-and-treat or routine antibiotics―were combined, the distribution of infection by severity was the same before and after the new measures were implemented. They conclude that the pronounced decline in the rate of serious infections occurred in each category of severity.

In a paper in Human Fertility, Steve Killick (The Hull York Medical School), Christine Leary (Hull Royal Infirmary), James Trussell, and Katherine A. Guthrie (Sexual and Reproductive Healthcare Partnership, Hull and East Yorkshire) examined whether motile spermatozoa are released with pre-ejaculatory fluid and whether this fluid therefore poses a risk for unintended pregnancy. Pre-ejaculatory fluid is released from the male urethra in amounts of up to 4ml during sexual arousal, prior to ejaculation. It is said to originate from Cowper’s glands and the Glands of Littre, which open at different sites along the length of the urethra. These glands secrete an alkaline fluid containing numerous enzymes and mucus but no sperm. Despite this lack of sperm, current advice is that any fluid emanating from the penis prior to ejaculation could be contaminated with sperm and therefore should be regarded as potentially fertile and capable of resulting in an unwanted pregnancy. Indeed, the NHS Choices website states that “Millions of sperm are also found in the liquid produced by the penis as soon as it is erect (hard). This means that a man doesn't have to ejaculate for pregnancy to occur.” Identical statements are found on many other websites. Guidelines therefore recommend condom use from the very first moment of sexual contact and limit the opportunity for foreplay, hence reducing the popularity of condom use. The source for the claim that pre-ejaculatory fluid contains sperm is entirely unclear. Masters and Johnson stated in Human Sexual Response that there were “large numbers of active spermatozoa in the pre-ejaculatory secretion.” However, they were unable to produce data to substantiate that claim. In fact, to date, no study has found motile sperm in the pre-ejaculate. Forty samples of pre-ejaculatory fluid were examined from 27 volunteer men. Samples were obtained by masturbation and by touching the end of the penis with a petri dish prior to ejaculation. Eleven of the 27 subjects (41%) produced pre-ejaculatory samples that contained spermatozoa and in 10 of these cases (37%) a reasonable proportion of the sperm were motile. The volunteers produced on up to 5 separate occasions and sperm were found in either all or none of their pre-ejaculatory samples. The authors conclude condoms should continue to be used from the first moment of genital contact and that it may be that some men are able to practice coitus interruptus more successfully than others, as they are less likely to leak spermatozoa in their pre-ejaculatory fluid.

In a paper published in Sexual Health, Jenny Higgins (Columbia University), James Trussell, Kenneth Davidson (University of Wisconsin, Eau Claire) and Nelwyn Moore (University of Texas, San Marcos) analyzed data from a cross-sectional sexuality survey of university students from two college campuses, one Midwestern and one Southern (N=1504). Out of 16 possible sexual combinations of four sexual activities (masturbation, oral sex, vaginal sex, and anal sex), only four categories contained more than 5% of respondents: masturbation, oral, and vaginal sex only (37%); oral and vaginal sex only (20%); all four activities (14%); and none of these activities (8%). One in five respondents (20%) had ever engaged in anal sex. Although women were significantly less likely than men to have ever masturbated, those who had started at relatively young ages had masturbated frequently in the past year. Findings also illustrated challenges to young people’s sexual health, including lack of contraceptive use, lack of verbal sexual consent, and alcohol use proximal to sex. Anal sex is increasingly normative among young people, and safer sex efforts should encourage condom use during vaginal and anal sex. However, very few college students appear to be substituting oral or anal sex for vaginal sex. The investigators conclude that masturbation, which is very common among young adults (although less so among young women), should be encouraged as an essential aspect of sexual wellbeing. Finally, condom promotion alone will fail unless young people are helped to develop sexual communication skills and sexual fluency.

Jenny Higgins (Columbia University), James Trussell, Kenneth Davidson (University of Wisconsin, Eau Claire) and Nelwyn Moore (University of Texas, San Marcos) analyzed data from a cross-sectional sexuality survey university students from four college campuses to examine (1) verbal versus implied consent and (2) physiological and psychological satisfaction at first heterosexual intercourse. The paper on consent appeared in the American Journal of Health Education and the paper sexual satisfaction appeared in the Journal of Sex Research. Among those with consensual first intercourse experiences (N=1,883), half (49%) provided nonverbal consent. Black men were the most likely to provide nonverbal consent (61%), followed by white men (55%), black women (51%), and white women (43%). Respondents who used condoms at first intercourse were more likely to provide verbal consent, suggesting that condoms may prompt sexual discussions—or that sexual discussions may prompt condom use. On the other hand, even when controlling for covariates, those who provided nonverbal consent were less likely to have used contraception (significantly so for women). Therefore, they conclude that enhanced sexual communication skills are greatly needed and that public health practitioners should investigate type of consent in future research and programming, with sensitivity to gender and racial influences. Both black and white women were significantly less likely than black and white men to experience considerable or extreme satisfaction at first vaginal intercourse, particularly physiological satisfaction. Among all four gender-race groups, being in a committed relationship with one’s sexual partner greatly increased psychological satisfaction, particularly among women. Experiencing less guilt at first sexual intercourse was also strongly associated with psychological satisfaction for women. Findings highlight strong gender asymmetry in affective sexual experience and suggest that developing sexual relationships with partners they care for and trust will foster satisfaction among young people at first vaginal intercourse.

Despite the widespread use of highly effective contraception in France, the incidence of abortion is among the highest in Western Europe. Using a large national sample of women undergoing an abortion, Caroline Moreau, Jean Bouyer (INSERM), Nathalie Bajos (INSERM), and James Trussell examined contraceptive patterns of use before and after an abortion. The study population consisted of a representative sample of 7,541 women undergoing an abortion in mainland France in 2007 and 2,742 women undergoing an abortion in the French overseas territories of La Reunion in the Indian Ocean and Guadeloupe in the Caribbean. They studied women’s use of contraception before and after the abortion and investigated the factors associated with the prescription of a very effective method after the procedure. A third of women were not using contraception in the month they conceived, this proportion varying from 40% in Guadeloupe to 33% and 32% in mainland France and La Reunion. A third of women reported the same contraceptive situation before and after the abortion, 55% switched to methods that were more effective. As a result, a majority of women (75% in Guadeloupe,77% in mainland France and 86% in La Reunion) were prescribed very effective methods of contraception after the procedure (although only 36% received a prescription for long acting methods), while 13% (in La Reunion) to 24% (in Guadeloupe) reported not receiving a prescription for contraception after the abortion. Thus regional disparities in pre-abortion use of contraception remained after the procedure, suggesting the inability of the French abortion health care system to reduce pre-existing contraceptive disparities across regions. This work was published in 2010 in Contraception and the European Journal of Contraception and Reproductive Health.

Building upon previous work on contraceptive failure rates and discontinuation, Caroline Moreau and James Trussell plan to refine their comparative analysis of method-specific failure rates using new data from France in order to address the methodological differences identified in the first comparative study with the U.S. In particular, the harmonization of the definitions of contraceptive failures and the use of national data on contraceptive use among women seeking an abortion will narrow the methodological divergences between studies and therefore allow for a closer assessment of user failure variation by country. Exploring why and how contraceptive use yields different outcomes in terms of user failures by country will provide new insights on on ways to reduce the wide gap between typical use and perfect use failure rates for method requiring daily adherence. The broad scope of both the French and U.S. national surveys on sexual and reproductive health will also allow extending their comparative approach to other research topics, including men’s experience of unintended pregnancies and their role in the contraceptive decision making process. A combined analysis of women and men’s responses will allow for a better understanding of the role of men in the control over fertility and the importance of gender roles in this process.

In a paper published in Atherosclerosis, Sarinnapha Vasunilashorn, Dana Glei (Georgetown University), Chia-Ying Lan (Department of Health in Taiwan), Ron Brookmeyer (UCLA), Maxine Weinstein (Georgetown University), and Noreen Goldman examined the relationship between apolipoprotein E (ApoE), biomarkers, and mortality. Polymorphisms of the apolipoprotein E gene (ApoE) have been associated with health and longevity. Numerous studies have linked ApoE to health outcomes including cardiovascular disease and mortality, but far fewer studies have examined the relationship of ApoE to other biological markers of health. This study investigated the relationship between ApoE and mortality, as well as ApoE and a set of biomarkers related to cardiovascular and immune function, in a population-based sample of Taiwanese adults ages 54+. ApoE ε2 carriers were less likely to have at-risk levels of high-density lipoprotein and total cholesterol than non-carriers (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.25-0.83 and OR 0.45, 95% CI 0.29-0.71, respectively). ApoE ε4 carriers were less likely to have elevated levels of C-reactive protein (CRP) than non-carriers (OR 0.62, 95% CI 0.39-0.96). ApoE genotype was not, however, associated with mortality after 8-years of follow-up. Their findings confirm the association between ApoE ε2 and cholesterol levels, suggesting a potential protective effect of ApoE ε2 on blood lipids. They also contribute to reports on the relationship between ApoE ε4 carrier status and lower CRP levels.

In an ongoing research project, Charles Westoff with Dawn Koffman and Caroline Moreau are studying the implications of exposure to television and radio both for reproductive behavior and to knowledge and behavior associated with HIV-AIDS. In the reproductive area in which 48 countries in the DHS program are studied, there are very strong associations of contraceptive behavior especially with the frequency of watching television. These associations extend beyond connections with education, wealth, urban residence and other covariates and apply both to men (mainly in sub-Saharan Africa) as well as to women. The relationships extend to the desired number of children as well as to recent fertility. The work on HIV-AIDS is just beginning.

A recently published monograph in the DHS Analytical Studies, “Birth Spacing and Limiting Connections” by Charles Westoff and Dawn Koffman attempts to answer the question of whether the use of contraception for birth spacing leads to its later use for birth limitation. This is an important question for family planning and population policy since the inducements to use contraception are typically advertised in the context of the health of mothers and children rather than to the social and economic advantages of smaller families. The DHS surveys are not ideal to answer the main question since they are cross-sectional rather than the longitudinal which would be the ideal design. We developed an algorithm to estimate the proportion of current limiters who had formerly been spacers. Altogether, 34 of the 51 countries studied show at least half of current limits with earlier spacing experience. The main conclusion is that spacing leads to limiting but we cannot document its effect on the number of children desired.

Charles Westoff, with Florina Serbanescu and Paul Stupp (both in the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA), described two different analytical approaches to the measurement of the decline in abortion in the country of Georgia in a 2010 International Perspectives article, “Contraception Matters: Two Approaches to Analyzing Evidence of the Abortion Decline in Georgia”. The two different methodologies yield essentially the same results, that the nonuse of any method was the main determinant of the high unintended pregnancy rate and that the increase in modern contraceptive use was the main explanation for the decline in the abortion rate in Georgia.

A paper by Charles Westoff on estimating abortion rates that was originally presented at an IUSSP seminar in Paris in 2007, and subsequently published by DHS, has been included in a new publication by the Guttmacher Institute and the IUSSP: “Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review”. In this volume, Westoff summarized his original contribution, which was the development of an abortion prediction formula based on the proportion of married women using modern contraception in combination with the total fertility rate.

An analysis published in a 2008 edition of Demographic Research (Puur, et al.) reported that, in eight European countries, men with egalitarian gender attitudes both desired and had more children than men with more traditional gender attitudes. These unexpected findings led Charles Westoff and Jenny Higgins (Columbia University) to explore a similar research question with a different dataset-the European/World Value Surveys. But they found, without exception, a negative association between men’s egalitarian attitudes and fertility, not only in the selected eight European countries but also in a considerable number of other developed countries. In their response article, “Relationships between men’s gender attitudes and fertility,” Westoff and Higgins share these findings and explore possible reasons for and implications of why their analysis differed from the original article by Purr, et al.

People Administration Faculty Staff Students Jobs Research Projects Seminars Working Papers and Publications Dissertations Training Prospective Students Programs Courses Course Schedule Workshops Resources Data Archive Library Pop Index NIH Public Access Policy Mail OPR Mail	Health and Wellbeing Chang Y. Chung • Kelly Cleland • Noreen Goldman • Dawn Koffman • Germán Rodríguez • Matthew Salganik • James Trussell • Sarinnapha Vasunilashorn • Charles F. Westoff Rebecca Casciano worked with Hilary Levey Friedman (Harvard University) on a project examining the correlates of pediatric sports injuries, with a particular emphasis on whether there is a relative age effect for sports injuries. The project draws on a large-N probability sample of patients seen in the Division of Sports Medicine at the Children's Hospital of Boston between 2000 and 2009. In light of evidence that children born closer to the cutoff months for participation in youth sports leagues have an advantage (in the form of size and coordination) over their "younger" peers, they investigate whether this advantage translates into differences in sports injuries across birth months. In a separate paper, they examine the correlates of overuse and traumatic sports injuries and use decomposition methods to explain large sex differences in overuse injuries. Noreen Goldman has been working with Anne Pebley (UCLA) to understand SES gradients in health-related measures among Hispanic groups. In collaboration with Goldman, Pebley, and Rebeca Wong (University of Texas), former postdoctoral fellow Alison Buttenheim (University of Pennsylvania) estimated SES gradients in obesity and smoking in Mexico. The findings, which are published in Global Public Health, underscore that the socioeconomic determinants of smoking and obesity in Mexico are complex, with the magnitude and direction of the associations varying by sex, urban/rural location, and nature of the SES indicator (education vs. wealth). In an effort to determine whether weak education differentials in health among Mexican Americans arise from “imported gradients,” a paper in Social Science and Medicine by former postdoctoral fellow Alison Buttenheim (University of Pennsylvania) in collaboration with Noreen Goldman, Anne Pebley (UCLA), Rebeca Wong (University of Texas) and Chang Chung, compares education gradients in smoking and obesity between recently-arrived Mexican immigrants in the U.S. and those for high-migration areas in Mexico. Using L.A.FANS data, Buttenheim, Goldman and Pebley have determined the extent of underestimation of obesity prevalence among adolescents and the evolution of patterns of obesity among Mexican immigrant and native adolescents. Additional research based on L.A. FANS by Noreen Goldman and Anne Pebley (UCLA), in collaboration with Mathew Creighton (Universitat Pompeu Fabra), explores the role of social and linguistic acculturation in accounting for patterns of obesity as well as dietary and physical activity behaviors, by immigrant generation and duration of immigration among Mexicans in the US. In a recent paper in Social Science and Medicine, Goldman, Creighton, Graciela Teruel (Universidad Iberoamericana, Mexico) and Luis Rubalcava (CAMBS/Centro de Investigación de Docencia Económicas, Mexico) demonstrate a link between the presence of migration networks to the U.S. and the development of adolescent obesity among Mexicans. Noreen Goldman, Maxine Weinstein (Georgetown University), and Dana Glei (Georgetown University) are continuing to collaborate with colleagues at the Bureau of Health Promotion, Department of Health in Taiwan on the Social Environment and Biomarkers of Aging Study (SEBAS). This data collection effort, supported by the National Institute on Aging, was designed to enhance understanding of the role of physiological processes in the complex relationships among life challenge, the social environment, and physical and mental health. The first wave of the survey, fielded in 2000, includes home-based interviews, collection of blood and urine samples, and physicians’ health exams, from about 1,000 middle-aged and elderly respondents. Respondents are a random sub-sample from an ongoing national survey (Taiwan Longitudinal Survey of Aging, or TLSA) that has collected periodic interviews between 1989 and 2011 in Taiwan. SEBAS II, which was fielded between August, 2006 and January, 2007 obtained a second set of measurements for biomarkers collected in 2000 as well as several new physiological measures, including (1) inflammatory markers, such as C-reactive protein and fibrinogen; (2) health assessments in the home – blood pressure, grip strength, lung function, timed walks, and chair stands; and (3) additional questions in the household interview on pain, perceived stress, stressful and traumatic events, and sleep. In the fall of 2011, the Taiwan Longitudinal Study of Aging (TLSA) will collect additional data for SEBAS respondents, including health measurements and cognitive performance, evaluated in the respondent’s home. Numerous projects based on the SEBAS data have been undertaken or completed during 2010. These papers examine determinants of a range of health-related outcomes, including depressive symptoms, sleep behavior, physiological dysfunction (such as inflammation), physical performance, and survival. Most of the recent papers take advantage of the newly available data in SEBAS II. Numerous other recent papers exploit the longitudinal feature of SEBAS by estimating change between the two waves In a paper published in Depression and Anxiety that examines a polymorphism related to serotonin transport (5-HTTLPR), Noreen Goldman and SEBAS colleagues identify an allele in the Taiwanese population that has rarely been identified in other groups and explore the association among alleles of 5HTTLPR, sex, stressful experience and depressive symptoms. In a paper in Journal of Aging and Health, former student Kim Smith (Mathematical Policy Research) and Noreen Goldman examine responses from two new SEBAS questions – interviewer- and physician-assessed health of the respondent – and find that these external evaluators take into account some aspects of health that receive little weight in respondents’ own ratings. In a paper in Journals of Gerontology, former postdoctoral fellow Jen Cornman (Jennifer C. Cornman Consulting, Granville, OH), in collaboration with Noreen Goldman, Germán Rodríguez and other SEBAS colleagues, use objective performance measurements to determine whether socioeconomic and demographic differences in reported mobility difficulty are attributable to differential perceptions of health that result in the differential use of response categories. Another analysis uses recently collected to explore the association between physiological dysregulation and both relaxation practices and physical exercise. In a paper in Annals of Epidemiology, former student Jenn Dowd (Hunter College), Noreen Goldman and Maxine Weinstein (Georgetown University), use SEBAS data to examine associations between biomarkers of inflammation and self-reported sleep characteristics in an effort to assess the direction of causality. In a paper in Research on Aging, Goldman and colleagues use physiological data from the two waves of SEBAS to estimate age-related changes in biomarkers of chronic disease As part of a large project using pooled data from 2 cycles of the National Survey of Family Growth, Kelli Stidham Hall, Caroline Moreau, and James Trussell are examining trends in reproductive health service use and formal and informal sex communication from 2002 to 2008 among adolescent and young adult women in the United States. The multipronged project aims to: 1) describe reproductive health service use and identify correlates of and disparities in service use, 2) describe informal (parental) and formal (school, church, community) sex communication and identify correlates of having received sex communication, 3) identify changes in reproductive health service use and in sex communication from 2002 to 2008, 4) explore relationships between receipt of sex communication and reproductive health service use. Preliminary findings suggest that the majority of young women have received informal (75%) and formal (92%) education, most commonly on abstinence (60%) but also on sexually transmitted infections (53%) and contraception (58%). Informal communication, particularly on abstinence (4%, p=0.03), increased from 2002 to 2008 (overall 7%, p=0.001) but not formal communication (p=0.63). Reproductive health service use in the previous year was reported by over half of adolescents and young adults (55%), yet it decreased over time (15% from 2002 to 2008, p<0.001). Both sex communication and service use varied by sociodemographic factors including age, education, race/ethnicity and reproductive histories. This preliminary data is under review for presentation at upcoming 2011 annual conferences for the North American Forum for Family Planning, the American Public Health Association, the Nurse Practitioner’s in Women’s Health Association, and the University of Chicago Reproductive Justice and Health Care Reform Conference. This project will contribute a series of publications for peer-reviewed reproductive public health journals. In collaboration with colleagues at the University of Michigan Population Studies Center, Kelli Stidham Hall, Caroline Moreau and James Trussell are examining the impact of attitudinal, psychosocial and health-related factors on patterns of contraceptive use and unintended pregnancy among adolescents. Using novel, dynamic, time series approach from a longitudinal study funded by the National Institutes of Health, NICHD (P.I. Jennifer Barber), the investigators are analyzing associations among changing pregnancy intentions and attitudes, depression, stress, general health, body mass index and other psychosocial context factors and changing coital and non-coital specific contraceptive use and unintended pregnancy. The project uses weekly self-reported data collected via multimodal (internet and telephone journals) format over the 2.5 year study from young women ages 18-19 years recruited from one Michigan county. The investigators aim to build upon their previous research concerning factors associated with contraceptive misuse and unintended pregnancy and address limitations in previous methods of measurement. The results will produce essential new insights into the processes surrounding contraceptive misuse leading to unintended pregnancy as a high priority public health and policy concern. In a systematic review published in the Journal of Women’s Health, Kelli Stidham Hall and her colleagues from Columbia University Schools of Public Health, Medicine and Nursing (Carolyn Westhoff , Katherine O’Connell White, and Nancy Reame) sought to evaluate the literature on measurement approaches for studying the use of oral contraception. Their aim was to help clarify unaddressed inconsistencies in OC behavior findings possibly related to limitations in existing methodological approaches. The team used established databases to identify relevant published research from January 1965 to December 2009. The authors found that terminology used to describe OC use, which included “continuation,” “compliance,” and “adherence,” differed across studies and was rarely defined. The majority of studies reviewed (n=27/38; 71%) relied solely upon self-report measures of OC use. Only two reports described survey or interview questions, and reliability and validity data were seldom described. More rigorous measurement methods such as pill counts (electronic or manual), serum and urinary biomarkers, and pharmacy records were infrequently employed. Nineteen studies simultaneously used more than one method, but only three studies compared direct and indirect methods. The authors concluded that lack of a consistent, well-defined measurement of OC use limits our understanding of contraceptive misuse and related negative outcomes. Recommendations for future research included clarifying terminology, developing standardized measures, incorporating multi-method approaches with innovative methods, and publishing details of measurement methods. In collaboration with her colleagues from Columbia University Schools of Public Health, Medicine and Nursing (Carolyn Westhoff, Paula Castano, and Patricia Stone), Kelli Stidham Hall, studied measurement approaches for oral contraceptive knowledge. The study, published in the journal Patient Education and Counseling sought to evaluate the findings and methodological limitations of research in which OC knowledge has been measured in order to facilitate understanding of relationships between OC knowledge and contraceptive behavior. Primary research articles from January 1965 to January 2009 were identified and audited for study characteristics, purpose for measuring OC knowledge, key findings and measurement properties including administration method, knowledge domains, reliability, validity, health literacy and cultural sensitivity. Twenty-one studies were included: 18 cohort studies, including one psychometric evaluation, and three randomized trials. Results on OC knowledge outcomes were variable. Measures were largely self-administered survey (n = 15) and lacked assessment of all OC knowledge domains. Information on measures’ characteristics, reliability, validity, health literacy and cultural sensitivity was limited. The authors concluded that existing OC knowledge measures lack critical psychometric elements, leading to inconsistent and unreliable findings. Poor OC knowledge measurement precludes identifying counseling needs and developing interventions for contraceptive behavior change. The authors recommended the following: measurement information in publications, psychometric evaluations, formal reliability/validity techniques, and attention to all OC knowledge domains, health literacy and cultural sensitivity. Derived from her National Institutes of Health-funded dissertation research at Columbia University and in collaboration with her colleagues and mentors from Columbia Schools of Public Health, Nursing and Medicine (Carolyn Westhoff, Nancy Reame, Vaughn Rickert, Katharine O’Connell White), Kelli Stidham Hall studied the impact of adverse psychological conditions, perceived side effects and discontinuation of oral contraception (OC) among minority adolescent and young adult family planning patients. Specifically, the study prospectively examined associations among depressed mood (Center for Epidemiologic Studies-Depression Screen), perceived stress (Perceived Stress Scale-10), and ED symptoms (Eating Disorder Screen for Primary Care) and OC mood and weight changes and discontinuation among family planning patients participating in an OC continuation intervention trial. Data from interview-administered questionnaires (baseline and 6-month) with 354 adolescents and young adults (ages 13-24 years) were analyzed with multiple logistic regression. Rates of depressed mood, stress, ED symptoms, mood and weight changes were high and over half the sample had discontinued OCs by 6 months. Baseline adverse psychological conditions and perceived weight changes at 6 months increased the risk of OC discontinuation. Ultimately, the findings suggest improved understanding of contributing factors to poor contraceptive behavior can promote positive family planning outcomes. Study findings were presented at the 2010 Annual Conference for the Association of Reproductive Health Professionals, the 2010 Annual Conference for the North American Society for Pediatric and Adolescent Gynecology and the 2011 Annual Conference of the Society for Adolescent Medicine and Health. A series of publications are in progress to disseminate this research in the journals, Contraception, Journal of Adolescent Health, and the Journal of Pediatric and Adolescent Gynecology. As part of a larger randomized trial to evaluate daily educational text message reminders to promote oral contraceptive (OC) continuation and knowledge in adolescents conducted at Columbia University Department of Obstetrics and Gynecology, Division of Family Planning, Kelli Stidham Hall, and her colleagues at Columbia University, Paula Castano, MD, MPH, Carolyn Westhoff, MD, MSc, conducted an OC knowledge project. The project sought to 1) design, implement, test and evaluate a comprehensive OC contraceptive knowledge instrument to measure the six dimensions of OC knowledge: mechanism of action, effectiveness, use, side effects, risks, and benefits, 2) analyze data collected with the instrument to describe OC knowledge among OC initiators and users, 3) evaluate the impact of the intervention on OC knowledge at 6 months and 4) examine associations between OC knowledge and OC continuation at 6 months, among the 659 adolescents ages 13-25 years who presented to an urban family planning clinic for OCs. Participants were randomized to receive routine clinical care alone or routine care plus six months of daily text message reminders with educational content adapted from standard handouts. Using the 41-item knowledge questionnaire, OC knowledge was assessed at baseline and knowledge and OC continuation was assessed at six months among the participants. In brief, OC knowledge was low among young OC-using women and disparities existed across sociodemographic groups. The text message intervention improved OC knowledge more so than routine care alone. Finally, OC knowledge was associated with OC continuation even while controlling for key confounders. These preliminary findings have been presented at the 2010 Annual Conference of the North American Society for Pediatric and Adolescent Gynecology, the 2011 Annual Conference of the Society for Adolescent Medicine, and are under review for the 2011 Annual Conference for the North American Forum on Family Planning. A series of manuscript publications are in progress. Genevieve Pham-Kanter and Noreen Goldman worked on a project examining the effect of children on the mortality of parents. Focusing on PR China and Taiwan--two settings in which institutional and cultural norms are such that sons play a primary role in the material and financial support of parents--they find that, surprisingly, there is little evidence that sons are protective. Instead, they report that sons are largely neutral (relative to daughters) with respect to parental mortality, and that in Taiwan, daughters may have been more beneficial than sons in reducing older age mortality in recent years. In “Assessing Respondent-Driven Sampling” published in the Proceedings of the National Academy of Sciences (PNAS), Matthew Salganik and Sharad Goel (Microeconomics and Social Systems, Yahoo! Research) examined Respondent Driven sampling (RDS). RDS is a network-based technique for estimating traits in hard-to-reach populations, for example, the prevalence of HIV among drug injectors. In recent years RDS has been used in more than 120 studies in more than 20 countries and by leading public health organizations, including the Centers for Disease Control and Prevention in the United States. Despite the widespread use and growing popularity of RDS, there has been little empirical validation of the methodology. Salganik and Goel investigated the performance of RDS by simulating sampling from 85 known, network populations. Across a variety of traits they found that RDS is substantially less accurate than generally acknowledged and that reported RDS confidence intervals are misleadingly narrow. Moreover, because the simulations model a scenario in which the theoretical RDS sampling assumptions hold exactly, it is unlikely that RDS performs any better in practice than in these simulations. Notably the poor performance of RDS is driven not by the bias but by the high variance of estimates, a possibility that had been largely overlooked in the RDS literature. Given the consistency of the results across networks and the generous sampling conditions, they concluded that RDS as currently practiced may not be suitable for key aspects of public health surveillance where it is now extensively applied. James Trussell and Kelly Cleland continue their collaborative work with the Association of Reproductive Health Professionals (ARHP) on increasing public awareness of and access to emergency contraception. ARHP and the Office of Population Research sponsor the Emergency Contraception Website (not-2-late.com). The Website contains detailed information about emergency contraception including the brand names of pills that can be used for emergency contraception in every country, and a database of providers of emergency contraception in the U.S. The website is available in English, Spanish, French, and Arabic. The Website has received more than 11.6 million visitors since it was launched in October 1994; there are currently about 200,000 visitors per month. The Website was completely redesigned and relaunched in September, 2006. In a paper published in Culture, Health and Sexuality, Lisa Wynn (Macquarie University), Angel Foster (Ibis Reproductive Health) and James Trussell analyzed 1,134 emails sent to the Emergency Contraception Website over a one-year period. The words and metaphors that people use to describe sexuality and reproductive health reflect experiences with peers, sexual partners, health service providers and public health campaigns. Through an examination of the terminology used by people to describe contraceptive methods, sexual intercourse and other sexual acts, the authors analyze what those terms signify within their textual context. They find that the kinds of risk concerns used in assessing sexual activity – whether evaluating pregnancy risk, disease transmission risk or moral risk – influence the definitions people give to terms that are multiply defined or whose definitions are culturally contested. This finding emerged clearly in the meanings given to terms for ‘sex’ and ‘unprotected sex’, which varied widely. They conclude with a discussion of the implications of this finding for research, clinical care and health education activities. The safety of emergency contraceptive pills (ECPs) has been extensively studied and confirmed, yet some concerns remain about whether the use of ECPs increases the risk of ectopic pregnancy when treatment fails. To answer this question, Kelly Cleland, James Trussell, Elizabeth Raymond (Family Health International), Linan Cheng (Shanghai Institute of Planned Parenthood Research), and Zhu Haoping (Minhang Central hospital, Shanghai Jiaotong University) used data from 135 studies which included a defined population of women treated one time with ECPs (either mifepristone or levonorgestrel), and in which the number and location of pregnancies were ascertained. In the studies of mifepristone, 3 out of 494 (0.6%) pregnancies were ectopic; in the levonorgestrel studies, 3 out of 282 (1.1%) were ectopic. The rate of ectopic pregnancy when ECP treatment fails does not exceed the rate observed in the general population (between 0.8% and 2.0% of all reported pregnancies). Because ECPs are effective in lowering the risk of pregnancy, their use should reduce the chance that an act of intercourse will result in ectopic pregnancy. This review was published in Obstetrics & Gynecology in June 2010. In a paper in Contraception, Mary Fjerstad (Ipas), James Trussell, Irving Sivin (Population Council) Steve Lichtenberg (Northwestern University) and Vanessa Cullins (Planned Parenthood Federation of America) examined the severity of infection before and after the adoption of new infection control measures. In response to concerns about serious infections following medical abortion, in early 2006 Planned Parenthood changed the route of misoprostol administration from vaginal to buccal and required either routine antibiotic coverage or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine antibiotic coverage for all medical abortions. They previously reported a pronounced drop in the rate of serious infection following the adoption of these new infection control measures. Their objective here is to assess whether the degree of severity of the serious infections differed in the three infection-control groups (vaginal misoprostol and no antibiotics, buccal misoprostol and screen-and-treat, buccal misoprostol and routine antibiotics) or, equivalently, to assess whether the declines in rates of serious infections after the adoption of new infection control measures differed across degree of severity categories. Of particular importance is whether the new infection control measures selectively reduced the least severe serious infections but did not diminish the rate of the most severe infections. They performed a retrospective analysis assessing the degree of severity of infections before infection controls were implemented and after each of the two new measures was adopted: buccal administration of antibiotics with either screen-and-treat or routine antibiotic coverage. They ranked the severity of infection from 1 (when treatment occurred in an emergency department) to 4 (when death occurred). We compared the distribution of the severity of serious infections in the three infection control groups (none, buccal misoprostol and screen-and-treat, buccal misoprostol and routine antibiotics), or, equivalently, assessed whether the declines in rates of serious infections after the adoption of new infection control measures differed across degree of severity categories using the Jonckheere-Terpstra test for a doubly ordered 4×3 table. The distribution of infection by severity was the same for all three infection control groups. Likewise, when the two new infection control groups―buccal misoprostol plus either screen-and-treat or routine antibiotics―were combined, the distribution of infection by severity was the same before and after the new measures were implemented. They conclude that the pronounced decline in the rate of serious infections occurred in each category of severity. In a paper in Human Fertility, Steve Killick (The Hull York Medical School), Christine Leary (Hull Royal Infirmary), James Trussell, and Katherine A. Guthrie (Sexual and Reproductive Healthcare Partnership, Hull and East Yorkshire) examined whether motile spermatozoa are released with pre-ejaculatory fluid and whether this fluid therefore poses a risk for unintended pregnancy. Pre-ejaculatory fluid is released from the male urethra in amounts of up to 4ml during sexual arousal, prior to ejaculation. It is said to originate from Cowper’s glands and the Glands of Littre, which open at different sites along the length of the urethra. These glands secrete an alkaline fluid containing numerous enzymes and mucus but no sperm. Despite this lack of sperm, current advice is that any fluid emanating from the penis prior to ejaculation could be contaminated with sperm and therefore should be regarded as potentially fertile and capable of resulting in an unwanted pregnancy. Indeed, the NHS Choices website states that “Millions of sperm are also found in the liquid produced by the penis as soon as it is erect (hard). This means that a man doesn't have to ejaculate for pregnancy to occur.” Identical statements are found on many other websites. Guidelines therefore recommend condom use from the very first moment of sexual contact and limit the opportunity for foreplay, hence reducing the popularity of condom use. The source for the claim that pre-ejaculatory fluid contains sperm is entirely unclear. Masters and Johnson stated in Human Sexual Response that there were “large numbers of active spermatozoa in the pre-ejaculatory secretion.” However, they were unable to produce data to substantiate that claim. In fact, to date, no study has found motile sperm in the pre-ejaculate. Forty samples of pre-ejaculatory fluid were examined from 27 volunteer men. Samples were obtained by masturbation and by touching the end of the penis with a petri dish prior to ejaculation. Eleven of the 27 subjects (41%) produced pre-ejaculatory samples that contained spermatozoa and in 10 of these cases (37%) a reasonable proportion of the sperm were motile. The volunteers produced on up to 5 separate occasions and sperm were found in either all or none of their pre-ejaculatory samples. The authors conclude condoms should continue to be used from the first moment of genital contact and that it may be that some men are able to practice coitus interruptus more successfully than others, as they are less likely to leak spermatozoa in their pre-ejaculatory fluid. In a paper published in Sexual Health, Jenny Higgins (Columbia University), James Trussell, Kenneth Davidson (University of Wisconsin, Eau Claire) and Nelwyn Moore (University of Texas, San Marcos) analyzed data from a cross-sectional sexuality survey of university students from two college campuses, one Midwestern and one Southern (N=1504). Out of 16 possible sexual combinations of four sexual activities (masturbation, oral sex, vaginal sex, and anal sex), only four categories contained more than 5% of respondents: masturbation, oral, and vaginal sex only (37%); oral and vaginal sex only (20%); all four activities (14%); and none of these activities (8%). One in five respondents (20%) had ever engaged in anal sex. Although women were significantly less likely than men to have ever masturbated, those who had started at relatively young ages had masturbated frequently in the past year. Findings also illustrated challenges to young people’s sexual health, including lack of contraceptive use, lack of verbal sexual consent, and alcohol use proximal to sex. Anal sex is increasingly normative among young people, and safer sex efforts should encourage condom use during vaginal and anal sex. However, very few college students appear to be substituting oral or anal sex for vaginal sex. The investigators conclude that masturbation, which is very common among young adults (although less so among young women), should be encouraged as an essential aspect of sexual wellbeing. Finally, condom promotion alone will fail unless young people are helped to develop sexual communication skills and sexual fluency. Jenny Higgins (Columbia University), James Trussell, Kenneth Davidson (University of Wisconsin, Eau Claire) and Nelwyn Moore (University of Texas, San Marcos) analyzed data from a cross-sectional sexuality survey university students from four college campuses to examine (1) verbal versus implied consent and (2) physiological and psychological satisfaction at first heterosexual intercourse. The paper on consent appeared in the American Journal of Health Education and the paper sexual satisfaction appeared in the Journal of Sex Research. Among those with consensual first intercourse experiences (N=1,883), half (49%) provided nonverbal consent. Black men were the most likely to provide nonverbal consent (61%), followed by white men (55%), black women (51%), and white women (43%). Respondents who used condoms at first intercourse were more likely to provide verbal consent, suggesting that condoms may prompt sexual discussions—or that sexual discussions may prompt condom use. On the other hand, even when controlling for covariates, those who provided nonverbal consent were less likely to have used contraception (significantly so for women). Therefore, they conclude that enhanced sexual communication skills are greatly needed and that public health practitioners should investigate type of consent in future research and programming, with sensitivity to gender and racial influences. Both black and white women were significantly less likely than black and white men to experience considerable or extreme satisfaction at first vaginal intercourse, particularly physiological satisfaction. Among all four gender-race groups, being in a committed relationship with one’s sexual partner greatly increased psychological satisfaction, particularly among women. Experiencing less guilt at first sexual intercourse was also strongly associated with psychological satisfaction for women. Findings highlight strong gender asymmetry in affective sexual experience and suggest that developing sexual relationships with partners they care for and trust will foster satisfaction among young people at first vaginal intercourse. Despite the widespread use of highly effective contraception in France, the incidence of abortion is among the highest in Western Europe. Using a large national sample of women undergoing an abortion, Caroline Moreau, Jean Bouyer (INSERM), Nathalie Bajos (INSERM), and James Trussell examined contraceptive patterns of use before and after an abortion. The study population consisted of a representative sample of 7,541 women undergoing an abortion in mainland France in 2007 and 2,742 women undergoing an abortion in the French overseas territories of La Reunion in the Indian Ocean and Guadeloupe in the Caribbean. They studied women’s use of contraception before and after the abortion and investigated the factors associated with the prescription of a very effective method after the procedure. A third of women were not using contraception in the month they conceived, this proportion varying from 40% in Guadeloupe to 33% and 32% in mainland France and La Reunion. A third of women reported the same contraceptive situation before and after the abortion, 55% switched to methods that were more effective. As a result, a majority of women (75% in Guadeloupe,77% in mainland France and 86% in La Reunion) were prescribed very effective methods of contraception after the procedure (although only 36% received a prescription for long acting methods), while 13% (in La Reunion) to 24% (in Guadeloupe) reported not receiving a prescription for contraception after the abortion. Thus regional disparities in pre-abortion use of contraception remained after the procedure, suggesting the inability of the French abortion health care system to reduce pre-existing contraceptive disparities across regions. This work was published in 2010 in Contraception and the European Journal of Contraception and Reproductive Health. Building upon previous work on contraceptive failure rates and discontinuation, Caroline Moreau and James Trussell plan to refine their comparative analysis of method-specific failure rates using new data from France in order to address the methodological differences identified in the first comparative study with the U.S. In particular, the harmonization of the definitions of contraceptive failures and the use of national data on contraceptive use among women seeking an abortion will narrow the methodological divergences between studies and therefore allow for a closer assessment of user failure variation by country. Exploring why and how contraceptive use yields different outcomes in terms of user failures by country will provide new insights on on ways to reduce the wide gap between typical use and perfect use failure rates for method requiring daily adherence. The broad scope of both the French and U.S. national surveys on sexual and reproductive health will also allow extending their comparative approach to other research topics, including men’s experience of unintended pregnancies and their role in the contraceptive decision making process. A combined analysis of women and men’s responses will allow for a better understanding of the role of men in the control over fertility and the importance of gender roles in this process. In a paper published in Atherosclerosis, Sarinnapha Vasunilashorn, Dana Glei (Georgetown University), Chia-Ying Lan (Department of Health in Taiwan), Ron Brookmeyer (UCLA), Maxine Weinstein (Georgetown University), and Noreen Goldman examined the relationship between apolipoprotein E (ApoE), biomarkers, and mortality. Polymorphisms of the apolipoprotein E gene (ApoE) have been associated with health and longevity. Numerous studies have linked ApoE to health outcomes including cardiovascular disease and mortality, but far fewer studies have examined the relationship of ApoE to other biological markers of health. This study investigated the relationship between ApoE and mortality, as well as ApoE and a set of biomarkers related to cardiovascular and immune function, in a population-based sample of Taiwanese adults ages 54+. ApoE ε2 carriers were less likely to have at-risk levels of high-density lipoprotein and total cholesterol than non-carriers (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.25-0.83 and OR 0.45, 95% CI 0.29-0.71, respectively). ApoE ε4 carriers were less likely to have elevated levels of C-reactive protein (CRP) than non-carriers (OR 0.62, 95% CI 0.39-0.96). ApoE genotype was not, however, associated with mortality after 8-years of follow-up. Their findings confirm the association between ApoE ε2 and cholesterol levels, suggesting a potential protective effect of ApoE ε2 on blood lipids. They also contribute to reports on the relationship between ApoE ε4 carrier status and lower CRP levels. In an ongoing research project, Charles Westoff with Dawn Koffman and Caroline Moreau are studying the implications of exposure to television and radio both for reproductive behavior and to knowledge and behavior associated with HIV-AIDS. In the reproductive area in which 48 countries in the DHS program are studied, there are very strong associations of contraceptive behavior especially with the frequency of watching television. These associations extend beyond connections with education, wealth, urban residence and other covariates and apply both to men (mainly in sub-Saharan Africa) as well as to women. The relationships extend to the desired number of children as well as to recent fertility. The work on HIV-AIDS is just beginning. A recently published monograph in the DHS Analytical Studies, “Birth Spacing and Limiting Connections” by Charles Westoff and Dawn Koffman attempts to answer the question of whether the use of contraception for birth spacing leads to its later use for birth limitation. This is an important question for family planning and population policy since the inducements to use contraception are typically advertised in the context of the health of mothers and children rather than to the social and economic advantages of smaller families. The DHS surveys are not ideal to answer the main question since they are cross-sectional rather than the longitudinal which would be the ideal design. We developed an algorithm to estimate the proportion of current limiters who had formerly been spacers. Altogether, 34 of the 51 countries studied show at least half of current limits with earlier spacing experience. The main conclusion is that spacing leads to limiting but we cannot document its effect on the number of children desired. Charles Westoff, with Florina Serbanescu and Paul Stupp (both in the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA), described two different analytical approaches to the measurement of the decline in abortion in the country of Georgia in a 2010 International Perspectives article, “Contraception Matters: Two Approaches to Analyzing Evidence of the Abortion Decline in Georgia”. The two different methodologies yield essentially the same results, that the nonuse of any method was the main determinant of the high unintended pregnancy rate and that the increase in modern contraceptive use was the main explanation for the decline in the abortion rate in Georgia. A paper by Charles Westoff on estimating abortion rates that was originally presented at an IUSSP seminar in Paris in 2007, and subsequently published by DHS, has been included in a new publication by the Guttmacher Institute and the IUSSP: “Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review”. In this volume, Westoff summarized his original contribution, which was the development of an abortion prediction formula based on the proportion of married women using modern contraception in combination with the total fertility rate. An analysis published in a 2008 edition of Demographic Research (Puur, et al.) reported that, in eight European countries, men with egalitarian gender attitudes both desired and had more children than men with more traditional gender attitudes. These unexpected findings led Charles Westoff and Jenny Higgins (Columbia University) to explore a similar research question with a different dataset-the European/World Value Surveys. But they found, without exception, a negative association between men’s egalitarian attitudes and fertility, not only in the selected eight European countries but also in a considerable number of other developed countries. In their response article, “Relationships between men’s gender attitudes and fertility,” Westoff and Higgins share these findings and explore possible reasons for and implications of why their analysis differed from the original article by Purr, et al.	Projects by Theme You may browse the research projects by topic, just select one of the signature themes below and click on 'View' Projects by Person Information about recent research projects may also be found by selecting a researcher and clicking on 'View'. Annual Report The material in this section is also available in printer-friendly pdf format as part of OPR's Annual Report for 2011 (file size is ~3 MB). Reports for previous years available in PDF format: 2010, 2009, 2008, 2007, 2006, and 2005.
	Office of Population Research, Princeton University, Wallace Hall, Princeton NJ 08544 Phone: (609) 258-4870 • Fax: (609) 258-1039 • Email: webmaster

People

Research

Training

Resources

Mail

Health and Wellbeing

Projects by Theme

Projects by Person

Annual Report