Papers by Conrad Otterness
Sexual and Reproductive Health Matters, 2019
In March 2011, the Myanmar Government transitioned to a nominally civilian parliamentary governme... more In March 2011, the Myanmar Government transitioned to a nominally civilian parliamentary government, resulting in dramatic increases in international investments and tenuous peace in some regions. In March 2015, Community Partners International, the Women's Refugee Commission, and four communitybased organisations (CBOs) assessed community-based sexual and reproductive health (SRH) services in eastern Myanmar amidst the changing political contexts in Myanmar and Thailand. The team conducted 12 focus group discussions among women of reproductive age (18-49 years) with children under five and interviewed 12 health workers in Kayin State, Myanmar. In Mae Sot and Chiang Mai, Thailand, the team interviewed 20 representatives of CBOs serving the border regions. Findings are presented through the socioecological lens to explore gender-based violence (GBV) specifically, to examine continued and emerging issues in the context of the political transition. Cited GBV includes ongoing sexual violence/rape by the military and in the community, trafficking, intimate partner violence, and early marriage. Despite the political transition, women continue to be at risk for military sexual violence, are caught in the burgeoning economic push-pull drivers, and experience ongoing restrictive gender norms, with limited access to SRH services. There is much fluidity, along with many connections and interactions among the contributing variables at all levels of the socioecological model; based on a multisectoral response, continued support for innovative, community-based SRH services that include medical and psychosocial care are imperative for ethnic minority women to gain more agency to freely exercise their SR rights.
Original research article Bridge over troubled waters: considerations in transitioning emergency contraceptive users to hormonal methods
RESEARCH ARTICLE Health and Human Rights in Eastern Myanmar after the Political Transition: A Population-Based Assessment Using Multistaged Household Cluster Sampling
Background Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Q... more Background Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative reports suggest that exposure to violence and displacement has declined while international assistance for health services has increased. An assessment of the impact of these changes on the health and human rights situation has not been published. Methods and Findings Five community-based organizations conducted household surveys using two-stage cluster sampling in five states in eastern Myanmar from July 2013-September 2013. Data was col-lected from 6, 178 households on demographics, mortality, health outcomes, water and sanitation, food security and nutrition, malaria, and human rights violations (HRV). Among children aged 6-59 months screened, the prevalence of global acute malnutrition (repre-senting moderate or severe malnutrition) was 11.3 % (8.0 – 14.7). A total of 250 deaths oc-
Introduction Emergency contraceptive pills (ECPs) were developed and marketed with the emergency ... more Introduction Emergency contraceptive pills (ECPs) were developed and marketed with the emergency aspect firmly in mind, but research and anecdotal evidence indicate that some women use them as a form of regular contraception, spurring efforts in the reproductive health community to explore the development of a coitally-dependent oral contraceptive pill. Methods We asked women of reproductive age in Nairobi, Kenya and Lagos, Nigeria how likely they would be to use a hypothetical pericoital pill and why. Results Bivariate logistic regressions indicated that women aged 18-35 years, with secondary education or higher, and who had ever used condoms or short-acting methods, were more likely to say that they would use this hypothetical pill. Women who had ever used a family planning method or ECPs were also more likely to say they would use this pill. The likely adopters reported that they would use the pericoital method if it prevented pregnancy with little or no health problems and was convenient and easy to use. Conclusion The findings suggest that should a safe and effective pericoital hormonal pill become available then a significant number of women would adopt this method.
Studies in Family Planning, 2012
Arriving late for scheduled contraceptive reinjections is common in many countries and contribute... more Arriving late for scheduled contraceptive reinjections is common in many countries and contributes to discontinuation when providers are unsure how to manage such clients. A clinic-randomized cohort and cross-sectional study with more than 5,000 clients using injectable contraceptives was conducted in the Eastern Cape province of South Africa to test the effectiveness of a provider job aid for managing late-returning clients and promoting continued use of the method. A marginally significant difference in reinjection rates between intervention and control groups was found for those up to two weeks late, and reanalysis excluding one clinic that experienced stockout issues revealed a significant difference. The difference in reinjection rates for those 2-12 weeks late was also found to be significant. The onereinjection cycle continuation rate for the intervention group was higher than that for the control group, but the difference was not statistically significant. Appropriate management of late-returning clients is critical, and this study illustrates that reinjection rates can be significantly increased with a low-resource provider job aid.
Conflict and Health, Apr 27, 2019
BackgroundMyanmar transitioned to a nominally civilian government in March 2011. It is unclear ho... more BackgroundMyanmar transitioned to a nominally civilian government in March 2011. It is unclear how, if at all, this political change has impacted migration at the household level.MethodsWe present household-level in- and out-migration data gathered during the Eastern Burma Retrospective Mortality Survey (EBRMS) conducted in 2013. Household level in-and out-migration information within the previous year was gathered via a cross-sectional, retrospective, multi-stage population-based cluster randomized survey conducted in eastern Myanmar. Univariate, bivariate and regression analyses were conducted.ResultsWe conducted a cross-sectional survey of 6620 households across Eastern Myanmar between July and September of 2013. Out-migration outstripped in-migration more than 6:1 overall during the year prior to the survey – for international migration this ratio was 29:1. Most in-migrants had moved to their present location in the study area from other areas in Myanmar (87%). Only 11.3% (27 individuals) had returned from another country (Thailand). Those who migrated out of eastern Myanmar during the previous year were more likely to be male (55.2%), and three times more likely to be between the ages of 15–25 (49.5%) than non-migrants. The primary reason cited for a return to the household was family (26.3%) followed by work (23.2%). The primary reason cited for migrating out of the household was for education (46.4%) followed by work (40.2%). Respondents from households that reported out-migration in the past year were more likely to screen positive for depressive symptoms than households with no migration (PR 1.85; 95% CI 1.16, 2.97). Women in households with in-migration were more likely to be malnourished and had a higher unmet need for contraception. Forced labor, one subset of human rights violations experienced by this population, was reported by more in-migrant (8%) than out-migrant households (2.2%), though this finding did not reach statistical significance.ConclusionsThese analyses suggest that opportunities for employment and education are the primary drivers of migration out of the household, despite an overall improvement in stability and decrease in prevalence of human rights violations found by EBRMS 2013. Additionally, migration into and out of households in eastern Myanmar is associated with changes in health outcomes.
Contraceptive Injections in Rural Drug Shops in Uganda
Background: Small private drug shops are ubiquitous in many African countries, and, at the commun... more Background: Small private drug shops are ubiquitous in many African countries, and, at the community level, are often the first stop for rural dwellers seeking health care. They are also controversial: drug shop operators are notorious in some countries for selling controlled, counterfeit or tainted drugs, and for providing health services for which they are not qualified. In Uganda, most rural drug shops illegally sell and inject Depo Provera. Methodology: In August 2007, we visited 139 drug shops in three rural districts of Uganda and interviewed the operators, collecting data on provider qualifications, injection practices, and contraceptive knowledge and attitudes. Subsequently, we trained many of the drug shop operators as community-based distributors of Depo Provera, and then re-interviewed the operators in subsequent months to evaluate the impact of training on safe provision of injectable contraception. Results: Baseline data showed that nearly 90% of drug shops both sold an...
East African medical journal, 2010
To test whether a single take home dose of infant nevirapine increased infant uptake without decr... more To test whether a single take home dose of infant nevirapine increased infant uptake without decreasing institutional deliveries. Cluster randomised post-test only study with control group. Ten hospitals in urban areas of Coast, Rift Valley, and Western provinces, Kenya. Pregnant women with HIV, 18 years and older, and at least 32 weeks gestation recruited during antenatal care and followed up at home approximately one week after delivery. In the intervention group, women were given a single infant's dose of nevirapine to take home prior to delivery. In the control group, no changes were made to the standard of care. Mothers' reports of infant uptake of nevirapine and place of delivery. Uptake of the infant's nevirapine dose was high, 94% in the intervention group and 88% in the control group (p=0.096). Among women who delivered at home, uptake was higher significantly among infants whose mothers got the take home dose compared to women who did not get the dose (93% vs. ...
Alzheimer's disease in South Carolina, 1994
Journal of the South Carolina Medical Association (1975), 1995
Protocols, 1996
Background-Progestin-only contraceptives (POCs) are appropriate for many women who cannot or shou... more Background-Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users. Objectives-The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight. Search methods-Through May 2013, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. The 2010 search also included EMBASE. For the initial review, we contacted investigators to identify other trials. Selection criteria-All comparative studies were eligible that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight. Data collection and analysis-Two authors extracted the data. We computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated. Main results-We found 16 studies; one examined progestin-only pills, one studied the levonorgestrel-releasing intrauterine system (LNG-IUS), four examined an implant, and 10 focused on depot medroxyprogesterone acetate (DMPA). Outcomes examined were changes in body weight only (14 studies), changes in both body weight and body composition (1 study), and Contact person: Laureen M Lopez, Clinical Sciences, FHI 360,
The …, 1997
The effects of a physical activity intervention on strength, balance, motor coordination, and mob... more The effects of a physical activity intervention on strength, balance, motor coordination, and mobility were tested in a quasi-experiment at rural congregate nutrition sites. Twice-weekly sessions of low intensity movements were conducted for one year. Logistic regression results showed significant differences between intervention (n = 61) and comparison (n = 49) groups on several performance-based measures. Intervention subjects perceived significantly greater improvements in physical functioning over the previous year than did comparison subjects. A qualitative evaluation revealed perceived program benefits of pain reduction, increased flexibility, muscle strengthening, increased walking speed, and improved mental outlook.
Behavioral interventions for improving condom use for dual protection
Protocols, 1996
ABSTRACT Unprotected sex is a major risk factor for disease, disability, and mortality in many ar... more ABSTRACT Unprotected sex is a major risk factor for disease, disability, and mortality in many areas of the world due to the prevalence and incidence of sexually transmitted infections (STI) including HIV. The male condom is one of the oldest contraceptive methods and the earliest method for preventing the spread of HIV. When used correctly and consistently, condoms can provide dual protection, i.e., against both pregnancy and HIV/STI. We examined comparative studies of behavioral interventions for improving condom use. We were interested in identifying interventions associated with effective condom use as measured with biological assessments, which can provide objective evidence of protection. Through September 2013, we searched computerized databases for comparative studies of behavioral interventions for improving condom use: MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, OpenGrey, COPAC, ClinicalTrials.gov, and ICTRP. We wrote to investigators for missing data. Studies could be either randomized or nonrandomized. They examined a behavioral intervention for improving condom use. The comparison could be another behavioral intervention, usual care, or no intervention. The experimental intervention had an educational or counseling component to encourage or improve condom use. It addressed preventing pregnancy as well as the transmission of HIV/STI. The focus could be on male or female condoms and targeted to individuals, couples, or communities. Potential participants included heterosexual women and heterosexual men.Studies had to provide data from test results or records on a biological outcome: pregnancy, HIV/STI, or presence of semen as assessed with a biological marker, e.g., prostate-specific antigen. We did not include self-reported data on protected or unprotected sex, due to the limitations of recall and social desirability bias. Outcomes were measured at least three months after the behavioral intervention started. Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures. Seven studies met our eligibility criteria. All were randomized controlled trials; six assigned clusters and one randomized individuals. Sample sizes for the cluster-randomized trials ranged from 2157 to 15,614; the number of clusters ranged from 18 to 70. Four trials took place in African countries, two in the USA, and one in England. Three were based mainly in schools, two were in community settings, one took place during military training, and one was clinic-based.Five studies provided data on pregnancy, either from pregnancy tests or national records of abortions and live births. Four trials assessed the incidence or prevalence of HIV and HSV-2. Three trials examined other STI. The trials showed or reported no significant difference between study groups for pregnancy or HIV, but favorable effects were evident for some STI. Two showed a lower incidence of HSV-2 for the behavioral-intervention group compared to the usual-care group, with reported adjusted rate ratios (ARR) of 0.65 (95% CI 0.43 to 0.97) and 0.67 (95% CI 0.47 to 0.97), while HIV did not differ significantly. One also reported lower syphilis incidence and gonorrhea prevalence for the behavioral intervention plus STI management compared to the usual-care group. The reported ARR were 0.58 (95% CI 0.35 to 0.96) and 0.28 (95% CI 0.11 to 0.70), respectively. Another study reported a negative effect on gonorrhea for young women in the intervention group versus the control group (ARR 1.93; 95% CI 1.01 to 3.71). The difference occurred among those with only one year of the intervention. We found few studies and little clinical evidence of effectiveness for interventions promoting condom use for dual protection. We did not find favorable results for pregnancy or HIV, and only found some for other STI. The overall quality of evidence was moderate to low; losses to follow up were high. Effective interventions for improving condom use are needed to prevent pregnancy and HIV/STI transmission. Interventions should be feasible for resource-limited settings and tested using valid and reliable outcome measures.
Women’s ability to self-screen for contraindications to combined oral contraceptive pills in Tanzanian drug shops
International Journal of Gynecology & Obstetrics, 2013
To estimate the accuracy of self-screening for contraindications to combined oral contraceptive p... more To estimate the accuracy of self-screening for contraindications to combined oral contraceptive pills (COCs) and to estimate the proportion of women with contraindications to hormonal methods among those using drug shops in Tanzania. Trained nurses interviewed 1651 women aged 18-39 years who self-screened for contraindications to COCs with the help of a poster at drug shops in Tanzania. Nurse assessment of the women served as the gold standard for comparison with self-assessment. Blood pressure was also measured onsite. Nurses reported that 437 (26.5%) women were not eligible to use COCs, compared with 485 (29.4%) according to self-report. Overall, 133 (8.1%) women who said that they were eligible were deemed ineligible by nurses. The rate of ineligibility was artificially high owing to participant and nurse assessments that were incorrectly based on adverse effects of pill use and cultural reasons, and because of the sampling procedure, which intercepted women regardless of their reasons for visiting the drug shop. Adjusted rates of ineligibility were 8.6% and 12.7%, respectively, according to nurse and participant assessment. Both nurses and women underestimated the prevalence of hypertension in the present group. Self-screening among women in rural and peri-urban Tanzania with regard to contraindications to COC use was comparable to assessment by trained nurses.
How big is the commercial sector for FP in Indonesia?
Increases in the size of the private sector are sometimes interpreted as lowering dependency on d... more Increases in the size of the private sector are sometimes interpreted as lowering dependency on donors. However, the private sector includes both commercial and non-commercial providers. An increase in the non-commercial sector signals a growth in dependency if client payments are low and donors cover most costs. This presentation will determine the percentage of women that get contraception from the commercial sector as compared with those classified private sector users. A key assumption is that a commercial provider will not provide a service for which price is below direct costs. Information on contraceptive use, source, wealth and prices paid for services was obtained from the 2002/3 DHS for Indonesia. Information on costs was obtained from the Reproductive Health Needs Assessment model supplemented by salary data. Our estimates indicate that the commercial sector for implants and injectables is considerable smaller than is the private sector. For sterilization the commercial s...
Health and Human Rights in Eastern Myanmar after the Political Transition: A Population-Based Assessment Using Multistaged Household Cluster Sampling
PLOS ONE, 2015
Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative ... more Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative reports suggest that exposure to violence and displacement has declined while international assistance for health services has increased. An assessment of the impact of these changes on the health and human rights situation has not been published. Five community-based organizations conducted household surveys using two-stage cluster sampling in five states in eastern Myanmar from July 2013-September 2013. Data was collected from 6, 178 households on demographics, mortality, health outcomes, water and sanitation, food security and nutrition, malaria, and human rights violations (HRV). Among children aged 6-59 months screened, the prevalence of global acute malnutrition (representing moderate or severe malnutrition) was 11.3% (8.0-14.7). A total of 250 deaths occurred during the year prior to the survey. Infant deaths accounted for 64 of these (IMR 94.2; 95% CI 66.5-133.5) and there were 94 child deaths (U5MR 141.9; 95% CI 94.8-189.0). 10.7% of households (95% CI 7.0-14.5) experienced at least one HRV in the past year, while four percent reported 2 or more HRVs. Household exposure to one or more HRVs was associated with moderate-severe malnutrition among children (14.9 vs. 6.8%; prevalence ratio 2.2, 95% CI 1.2-4.2). Household exposure to HRVs was associated with self-reported fair or poor health status among respondents (PR 1.3; 95% CI 1.1-1.5). This large survey of health and human rights demonstrates that two years after political transition, vulnerable populations of eastern Myanmar are less likely to experience human rights violations compared to previous surveys. However, access to health services remains constrained, and risk of disease and death remains higher than the country as a whole. Efforts to address these poor health indicators should prioritize support for populations that remain outside the scope of most formal government and donor programs.
One versus multiple packs for women starting oral contraceptive pills: a comparison of two distribution regimens
Contraception, 2009
Despite World Health Organization and International Planned Parenthood Federation recommendations... more Despite World Health Organization and International Planned Parenthood Federation recommendations to provide multiple pill cycles to new users, many programs in developing countries still give only one pill cycle to new acceptors. To compare provision of a single versus multiple packs of pills, new pill users in 20 matched public sector clinics in Jamaica were assigned to one of two pill regimens in which they received either one (then subsequently three) or four pill cycles at method initiation. The primary outcome was the proportion of women who used pills beyond 4 months. Among 655 women, those receiving one cycle of pills at initiation, followed by counseling and a three-pack resupply, were no more likely to be using pills after 4 months than women who received four packs at initiation (odds ratio=1.33; 95% confidence interval=0.88-2.0). In both pill regimen groups, returning late to the clinic for resupply was a problem. However, more women in the 1+3-pack regimen group returned late to study clinics to obtain their fifth cycle of pills than their counterparts in the 4-pack regimen group (53% vs. 28%). Our findings support the recommendation that pill users should be given more than one cycle to start, because an extra visit for resupply contributes to clinic and provider costs. Moreover, providing more pill cycles at initiation would decrease the likelihood that women experience a gap in pill use between cycles.
International Family Planning Perspectives, 2007
CONTEXT: Research examining hormonal injectable contraceptive continuation has focused on clients... more CONTEXT: Research examining hormonal injectable contraceptive continuation has focused on clients' intentional discontinuation. Little attention, however, has been paid to unintentional discontinuation due to providers' management of clients who would like to continue use but arrive late for their scheduled reinjections.
Contraception, 2012
Background: As emergency contraceptive pills (ECPs) become increasingly available through pharmac... more Background: As emergency contraceptive pills (ECPs) become increasingly available through pharmacies, concerns about potential overuse of this product have emerged. In response, bridging women from ECPs to ongoing contraception was advanced as a solution.
Impact of a Provider Job Aid Intervention on Injectable Contraceptive Continuation in South Africa
Studies in Family Planning, 2012
Arriving late for scheduled contraceptive reinjections is common in many countries and contribute... more Arriving late for scheduled contraceptive reinjections is common in many countries and contributes to discontinuation when providers are unsure how to manage such clients. A clinic-randomized cohort and cross-sectional study with more than 5,000 clients using injectable contraceptives was conducted in the Eastern Cape province of South Africa to test the effectiveness of a provider job aid for managing late-returning clients and promoting continued use of the method. A marginally significant difference in reinjection rates between intervention and control groups was found for those up to two weeks late, and reanalysis excluding one clinic that experienced stockout issues revealed a significant difference. The difference in reinjection rates for those 2-12 weeks late was also found to be significant. The one-reinjection cycle continuation rate for the intervention group was higher than that for the control group, but the difference was not statistically significant. Appropriate management of late-returning clients is critical, and this study illustrates that reinjection rates can be significantly increased with a low-resource provider job aid.
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Papers by Conrad Otterness