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Early marriage and childbearing put young women and their babies at risk of poor health and well-being. This study uses two rounds of longitudinal data from young women ages 15-19 in 2015-2016 and followed in 2018-2019 to determine factors associated with contraceptive use before a first pregnancy among young, married women in Bihar and Uttar Pradesh, India. Discrete time hazard models were used to analyze time to first use starting from the month of marriage. Overall, use of contraception prior to a first pregnancy was low in this sample (between 12 to 20% used before a first pregnancy). Young women who reported that someone discussed the importance of delaying a first birth at the time of marriage were significantly more likely to have used a method of family planning (FP) before a first pregnancy than those who did not receive this information. Further, women who discussed FP with their husband before a first pregnancy were more likely to use contraception. Finally, among recently married young women, those who experienced pressure to have a child were less likely to use before a first pregnancy. As young women recognize the advantages of delaying a first birth and adopt FP to meet their needs, social norms around early childbearing will slowly adjust and early use to delay a first pregnancy will become more normative.

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Understanding what factors influence postpartum contraceptive use among young people (ages 15-24 years) is important since this group often has closely spaced and unintended births. Using secondary data gathered for an evaluation of a Bill & Melinda Gates Foundation funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria, we determine the direct and indirect effects of community beliefs and attitudes on adolescent and youth postpartum contraceptive method choice. Our statistical methods control for the endogenous timing of the initiation of sexual activity and the timing and number of births to each respondent by simultaneous estimation of equations for these choices with the choice of postpartum contraceptive method. We find that community beliefs and attitudes have important effects on our primary outcome of postpartum contraceptive use and we quantify the size of both direct and indirect effects on postpartum contraceptive method choice using simulations. The findings from this study can be used to inform programs seeking to increase young women's postpartum contraceptive use for healthy spacing and timing of births.

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Few studies to date have determined the effect of provider bias based on age, parity, and marital status on women's method and facility choice. Using data from women using modern methods in six cities of Senegal and a facility survey that included a facility audit and provider interviews, we undertake conditional logit analyses to determine whether women's choice of a family planning facility is associated with provider bias at the facility, controlling for other facility characteristics (e.g., size, sector, and number of methods available). We find that women bypass facilities where there is greater provider bias to attain their current family planning method. Women also bypass facilities of lower quality. This is the first study to demonstrate the effects of provider bias on women's contraceptive seeking behaviors and suggests the importance of training providers to reduce age and parity bias that affect access to a full range of methods and facilities for all women.

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This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.

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BACKGROUND: Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use. METHODS: Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods. RESULTS: Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon. CONCLUSIONS: These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.

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BACKGROUND: Following the 2014 sugary drinks tax implementation in Mexico, promising reduction in the volume of purchases of taxed beverages were observed overall and at different store-types. However, the tax's effects on purchasing patterns of calories and sugar remain unclear. METHODS: Using longitudinal data from Mexican households (n = 7038), we examined changes in volume, calories and total sugar of packaged beverages purchased from 2012 to 2016 overall and by store-type. We used fixed effects models to estimate means for volume, calories, and sugar of households. To address the potential selectivity from households shopping at different stores, we calculated inverse probability weights to model the purchases changes over time by store-type. RESULTS: For taxed beverages, the volume of purchases declined by - 49 ml and -30 ml in the first year and second year post tax (2014 and 2015, respectively), while purchases leveled off in the third year of the tax (2016). Calories and sugar from taxed beverage purchases decreased over time, with the majority of the declines occurring in the first two years post-tax implementation. The volume of untaxed beverage purchases increased, whereas changes in calories and total sugar of untaxed beverages were minimal. Store level purchases of taxed beverages significantly decreased in the first two years post taxation (2014 and to 2015) only in supermarkets and traditional stores. The steepest declines in purchases of taxed beverages in 2014 were observed at supermarkets (- 40 ml or - 45%). The volume of purchases of untaxed beverages increased over time in almost all store-types, while calories and sugar minimally decreased over time. CONCLUSION: Although the Mexican tax on SSBs has lowered the purchases of sugary drinks 3 years after the tax implementation, the tax should be strengthened and store-specific interventions should be implemented to further reduce SSBs purchases in the Mexican population.

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Few studies have examined the sustainability of family planning program outcomes in the post-program period. This article presents the results of a natural experiment where the Nigerian Urban Reproductive Health Initiative Phase I programming ended in early 2015 and Phase II activities continued in a subset of cities. Using data collected in 2015 and 2017, we compare contraceptive ideation and modern family planning use in two cities: Ilorin where program activities concluded in 2015 and Kaduna where program activities continued. The results demonstrate that exposure to program activities decreased in Ilorin but for those individuals reporting continuing exposure, the effect size of exposure on modern family planning use remained the same and was not significantly different from Kaduna. Modern family planning use continued to increase in both cites but at a lower rate than during Phase I. The results are useful for designing family planning programs that sustain beyond the life of the program.

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BACKGROUND: To date, there is little information on the sustainability of family planning (FP) service quality after completion of a donor-funded program. This paper examines the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI) program on quality of FP services in two cities: Ilorin, where the program ended in March 2015 and Kaduna where the program continued. METHODS: Data come from three time periods: 2011, before program implementation; 2014, near Phase 1 completion; and 2017, two-years post Phase 1. In 2011, we undertook a facility audit and provider surveys in all public sector facilities in each city as well as all private facilities mentioned as the source for FP or maternal, newborn, and child health services in a 2010 women's household survey. In 2014 and 2017, we returned to the same facilities to undertake the facility audit and provider surveys. Quality is measured from principal component analyses of 30 items from the facility audit and provider surveys. Service use outcomes are measured as the ratio of FP clients (total and new) to the number of reproductive health staff members. Multivariate random effect models are estimated to examine changes in the outcomes over time, between NURHI and non-NURHI facilities and by city. RESULTS: We demonstrate that NURHI facilities had better quality and higher service use than non-NURHI facilities. Further, while quality of services was higher in Ilorin in 2011, by 2014 and three years later (2017), the quality was better in Kaduna where the program continued. In addition, while no difference was found in service utilization between Ilorin and Kaduna in 2014, by 2017, Kaduna had significantly more new FP users than Ilorin. CONCLUSIONS: In Ilorin, quality of services did not continue its strong upward trend after the program ended. Programs need to consider long-term strategies that support continuation of program components post program implementation. This may include ensuring continued training of providers and addressing equipment and commodity stock-outs through system changes rather than specific facility-level changes. The findings from this study can be used to inform future programs seeking to improve quality of FP services in a sustainable manner.

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We use individual-level health facility choice data from urban Senegal to estimate consumer preferences for facility characteristics related to maternal health services. We find that consumers consider a large number of quality related facility characteristics, as well as travel costs, when making their health facility choice. In contrast to the typical assumption in the literature, our findings indicate that individuals frequently bypass the facility nearest their home. In light of this, we show that the mismeasured data used commonly in the literature produces biased preference estimates; most notably, the literature likely overestimates consumer distaste for travel.

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Social inequalities in health and human capital are core concerns of sociologists, but little research examines the developmental stage when such inequalities are likely to emerge-the transition to adulthood. With new data and innovative statistical methods we conceptually develop, and empirically operationalize, pathways of physical health and human capital accumulation from adolescence into young adulthood, using an autoregressive cross-lagged structural equation model. Results reveal that pathways of health and human capital accumulate at differential rates across the transition to adulthood; evidence of cross-lagged effects lend support for both social causation and health selection hypotheses. We then apply this model to assess the presence of social inequality in metabolic syndrome-the leading risk factor of cardiovascular disease in the U.S. Findings document social stratification of cardiovascular health that is robust to both observed and unobserved social and health selection mechanisms. We speculate that this social stratification will only increase as this cohort ages.

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BACKGROUND: Family planning programs increasingly aim to encourage men to be involved in women's reproductive health decision-making as well as support men to be active agents of change for their own and the couple's reproductive health needs. This study contributes to this area of work by examining men's exposure to family planning (FP) program activities in urban Senegal and determining whether exposure is associated with reported FP use and discussion of family planning with female partners. METHODS: This study uses data from two cross-sectional surveys of men in four urban sites of Senegal (Dakar, Pikine, Guédiawaye, Mbao). In 2011 and 2015, men ages 15-59 in a random sample of households from study clusters were approached and asked to participate in a survey about their fertility and family planning experiences. These data were used to determine the association between exposure to the Initiative Sénégalaise de Santé Urbaine (in English: Senegal Urban Reproductive Health Initiative) family planning program interventions with men's reported modern family planning use and their reported discussion of FP with their partners. Since data come from the same study clusters at each time period, fixed effects methods at the cluster level allowed us to control for possible program targeting by geographic area. RESULTS: Multivariate models demonstrate that religious leaders speaking favorably about family planning, seeing FP messages on the television, hearing FP messages on the radio, and exposure to community outreach activities with a FP focus (e.g., house to house and community religious dialogues) are associated with reported modern family planning use and discussion of family planning with partners among men in the four urban sites of Senegal. CONCLUSIONS: This study demonstrates that it is possible to reach men with FP program activities in urban Senegal and that these activities are positively associated with reported FP behaviors.

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

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Research in developing countries is rarely focused on examining how supply side factors affect family planning decisions due to a lack of facility-level data. When these data exist, analyses tend to focus on rural environments. In this paper, we study the effects that health facility access and quality have on contraceptive use and desired number of children for women in urban Senegal. Unlike related studies focusing on rural environments, we find no evidence that greater access to health facilities and pharmacies increases contraceptive use among urban women. However, we do find that contraceptive use among urban women is higher with greater facility quality. For example, we find that increasing the proportion of pharmacies employing multiple pharmacists from 0% to 50% would increase contraceptive use by 6.0 percentage points, and increasing the proportion of facilities with family planning guidelines/protocols from 50% to 100% would increase use by 2.1 percentage points.

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BACKGROUND: The relationship between food environment exposures and diet behaviours is unclear, possibly because the majority of studies ignore potential residual confounding. METHODS: We used 20 years (1985-1986, 1992-1993 2005-2006) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study across four US cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California) and instrumental variables (IV) regression to obtain causal estimates of longitudinal associations between the percentage of neighbourhood food outlets (per total food outlets within 1 km network distance of respondent residence) and an a priori diet quality score, with higher scores indicating higher diet quality. To assess the presence and magnitude of bias related to residual confounding, we compared results from causal models (IV regression) to non-causal models, including ordinary least squares regression, which does not account for residual confounding at all and fixed-effects regression, which only controls for time-invariant unmeasured characteristics. RESULTS: The mean diet quality score across follow-up was 63.4 (SD=12.7). A 10% increase in fast food restaurants (relative to full-service restaurants) was associated with a lower diet quality score over time using IV regression (ß=-1.01, 95% CI -1.99 to -0.04); estimates were attenuated using non-causal models. The percentage of neighbourhood convenience and grocery stores (relative to supermarkets) was not associated with diet quality in any model, but estimates from non-causal models were similarly attenuated compared with causal models. CONCLUSION: Ignoring residual confounding may generate biased estimated effects of neighbourhood food outlets on diet outcomes and may have contributed to weak findings in the food environment literature.

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BACKGROUND: It is unknown whether efforts to reduce hypertension burden in countries with very high prevalence, would be more effective if directed at hypertension diagnosis vs. treatment. Most analyses do not address bias and correlation across the sequence from elevated blood pressure (BP) to hypertension diagnosis and treatment, leading to potentially misleading findings. METHODS: Using data spanning 18 years of the China Health and Nutrition Survey (n = 18,926; ages 18-75 years), we used an innovative 3-step, integrated system of equations to predict the sequence from: (i) elevated BP (systolic/diastolic BP ≥ 140/90 mm Hg) to (ii) diagnosed hypertension conditional on elevated BP, and to (iii) treatment (medication use) conditional on diagnosis, accounting for measured and unmeasured individual- and community-level confounders at each of the 3 steps. We compared results to separate traditional logistic regression models without control for unmeasured confounding. RESULTS: Using our 3-step model, elevated BP increased from 12.6% and 8.5% (1991) to 36.8% and 29% (2009) in men and women, respectively, but diagnosis remained under 50%. We found widening disparities in hypertension diagnosis (higher hypertension at lower vs. higher education (difference of 2% in 1991 that widened to 5% in 2009)) and narrowing disparities in education (difference of 6% in 1991 to 4% in 2009) and insurance status (difference of 7% in 1991 to 2% in 2009) for treatment. CONCLUSIONS: Our 3-step model improved model fit over traditionally used models. Our findings highlight serious barriers to hypertension diagnosis in Chinese adults, particularly among men and individuals of low attained education.

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Background: Findings in the observational retail food environment and obesity literature are inconsistent, potentially due to a lack of adjustment for residual confounding. Methods: Using data from the CARDIA study (n = 12 174 person-observations; 6 examinations; 1985-2011) across four US cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA), we used instrumental-variables (IV) regression to obtain causal estimates of the longitudinal associations between the percentage of neighbourhood food stores or restaurants (per total food outlets within 1 km network distance of respondent residence) with body mass index (BMI), adjusting for individual-level socio-demographics, health behaviours, city, year, total food outlets and market-level prices. To determine the presence and extent of bias, we compared the magnitude and direction of results with ordinary least squares (OLS) and random effects (RE) regression, which do not control for residual confounding, and with fixed effects (FE) regression, which does not control for time-varying residual confounding. Results: Relative to neighbourhood supermarkets (which tend to be larger and have healthier options than grocery stores), a higher percentage of grocery stores [mean = 53.4%; standard deviation (SD) = 31.8%] was positively associated with BMI [ß = 0.05; 95% confidence interval (CI) = 0.01, 0.10] using IV regression. However, associations were negligible or null using OLS (ß = -0.001; 95% CI = -0.01, 0.01), RE (ß = -0.003; 95% CI = -0.01, 0.0001) and FE (ß = -0.003; 95% CI = -0.01, 0.0002) regression. Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model. Conclusions: Longitudinal associations between neighbourhood food outlets and BMI were greater in magnitude using a causal model, suggesting that weak findings in the literature may be due to residual confounding.

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BACKGROUND: Little is known about how diet-related and activity-related amenities relate to residential location behaviour. Understanding these relationships is essential for addressing residential self-selection bias. METHODS: Using 25 years (6 examinations) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study (n=11 013 observations) and linked neighbourhood-level data from the 4 CARDIA baseline cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California, USA), we characterised participants' neighbourhoods as having low, average or high road connectivity and amenities using non-hierarchical cluster analysis. We then used repeated measures multinomial logistic regression with random effects to examine the associations between individual-level sociodemographics and neighbourhood-level characteristics with residential neighbourhood types over the 25-year period, and whether these associations differed by individual-level income. RESULTS: Being female was positively associated with living in neighbourhoods with low (vs high) road connectivity and activity-related and diet-related amenities among high-income individuals only. At all income levels, a higher percentage of neighbourhood white population and neighbourhood population <18 years were associated with living in neighbourhoods with low (vs high) connectivity and amenities. Individual-level race; age; and educational attainment, neighbourhood socioeconomic status and housing prices did not influence residential location behaviour related to neighbourhood connectivity and amenities at any income level. CONCLUSIONS: Neighbourhood-level factors appeared to play a comparatively greater role in shaping residential location behaviour than individual-level sociodemographics. Our study is an important step in understanding how residential locational behaviour relates to amenities and physical activity opportunities, and may help mitigate residential self-selection bias in built environment studies.

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INTRODUCTION: Understanding what influences where food outlets locate is important for mitigating disparities in access to healthy food outlets. However, few studies have examined how neighborhood characteristics influence the neighborhood food environment over time, and whether these relationships differ by neighborhood-level income. METHODS: Neighborhood-level data from four U.S. cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA) from 1986, 1993, 1996, 2001, 2006, and 2011 were used with two-step econometric models to estimate longitudinal associations between neighborhood-level characteristics (z-scores) and the log-transformed count/km2 (density) of food outlets within real estate-derived neighborhoods. Associations were examined with lagged neighborhood-level sociodemographics and lagged density of food outlets, with interaction terms for neighborhood-level income. Data were analyzed in 2016. RESULTS: Neighborhood-level income at earlier years was negatively associated with the current density of convenience stores (ß= -0.27, 95% CI= -0.16, -0.38, p<0.001). The percentage of neighborhood white population was negatively associated with fast food restaurant density in low-income neighborhoods (10th percentile of income: ß= -0.17, 95% CI= -0.34, -0.002, p=0.05), and the density of smaller grocery stores across all income levels (ß= -0.27, 95% CI= -0.45, -0.09, p=0.003). There was a lack of policy-relevant associations between the pre-existing food environment and the current density of food outlet types, including supermarkets. CONCLUSIONS: Socioeconomically disadvantaged and minority populations may attract "unhealthy" food outlets over time. To support equal access to healthy food outlets, the availability of "less healthy" food outlets types may be relatively more important than the potential lack of supermarkets or full-service restaurants.

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We used full-system-estimation instrumental-variables simultaneous equations modeling (IV-SEM) to examine physical activity relative to body mass index (BMI; weight (kg)/height (m)(2)) using 25 years of data (1985/1986 to 2010/2011) from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (n = 5,115; ages 18-30 years at enrollment). Neighborhood environment and sociodemographic instruments were used to characterize physical activity, fast-food consumption, smoking, alcohol consumption, marriage, and childbearing (women) and to predict BMI using semiparametric full-information maximum likelihood estimation to control for unobserved time-invariant and time-varying residual confounding and differential measurement error through model-derived discrete random effects. Comparing robust-variance ordinary least squares, random-effects regression, fixed-effects regression, single-equation-estimation IV-SEM, and full-system-estimation IV-SEM, estimates from random- and fixed-effects models and the full-system-estimation IV-SEM were unexpectedly similar, despite the lack of control for residual confounding with the random-effects estimator. Ordinary least squares tended to overstate the significance of health behaviors in BMI, while results from single-equation-estimation IV-SEM were notably different, revealing the impact of weak instruments in standard instrumental-variable methods. Our robust findings for fixed effects (which does not require instruments but has a high cost in lost degrees of freedom) and full-system-estimation IV-SEM (vs. standard IV-SEM) demonstrate potential for a full-system-estimation IV-SEM method even with weak instruments.

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OBJECTIVES: The Urban Health Initiative (UHI) was initiated in 2009 with the goal of increasing family planning (FP) use among the poor in urban areas of Uttar Pradesh, India. The Measurement, Learning & Evaluation project (MLE) was tasked with rigorous impact evaluation of the UHI. This paper presents the impact evaluation findings of the UHI program. STUDY DESIGN: The MLE design includes a longitudinal sample of women and health facilities with baseline (2010) and endline (2014) data collection in six cities in Uttar Pradesh, India. At baseline, samples representative of women in each city were selected with oversampling of the poor. Eighty-four percent of women interviewed at baseline were reinterviewed 4 years later at endline. The longitudinal data support a within/fixed-effects approach to identification of program impact on changes in modern FP use. RESULTS: Impact evaluation results show significant effects of exposure to both demand and supply side program activities. In particular, women exposed to brochures (marginal effect: 6.96, p<.001), billboards/posters/wall hangings (marginal effect: 2.09, p<.05), and FP on the television (marginal effect: 2.46, p<.001) were significantly more likely to be using a modern method at endline. In addition, we found borderline significance for being exposed to a community health worker (marginal effect: 1.66, p<.10) and living close to an improved public and private supply environment where UHI undertook activities (marginal effects and p values: 2.48, p<.05 and 1.56, p<.10, respectively). CONCLUSIONS: UHI program activities were designed to complement the Government of India's strategies aimed at ensuring access to and provision of FP to urban poor populations. The effective demand- and supply-side strategies of the UHI program are therefore likely to be sustainable and scalable to other urban areas in India. IMPLICATIONS STATEMENT: Findings from this study are important for designing sustainable and scalable FP strategies for urban India where increases in FP use will be relevant for meeting international FP targets.

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