Birth "outside of guidance"-An exploration of a Birth Choices Clinic in the United Kingdom

BACKGROUND

Decision-making around birthplace is complex and multifactorial. The role of clinicians is to provide unbiased, evidence-based information to support women and birthing people to make decisions based on what matters to them. Some decisions may fall outside of clinical guidance and recommendations. Birth Choices Clinics can provide an opportunity for extended discussion and personalized birthplace planning. This study aimed to explore the rationale behind choosing birthplace "outside of guidance" and examine the outcomes for women who attended a Birth Choices Clinic.

METHODS

The study was descriptive using data extracted from clinical documentation and consultation. The data included demographic information, maternal characteristics, reason for choosing a midwifery-led birth setting, birthplace preference, and outcome.

RESULTS

Eighty-two women used the Birth Choices Clinic between April 2022 and February 2023 in one large maternity unit in the UK. Reasons for choosing birth in a midwifery-led setting included having access to a birthing pool, to reduce the chance of obstetric interventions and pragmatic reasons. Sixty-five percent of women experienced a spontaneous vaginal birth, 10% experienced an assisted vaginal birth, and 23% experienced a cesarean birth. Of the 33 women who ultimately commenced labor care in a midwifery-led setting, 76% (n = 25/33) birthed in this setting without complications. Transfer rates in labor were similar to those in a "low-risk" pregnant population.

DISCUSSION

Birth choice clinics may facilitate an understanding of material risk and support individualizing birth planning. There is evidence that women changed their planned birthplace, possibly in recognition of a move along the risk spectrum.

Being able to be myself: Understanding autonomy and autonomy-support from the perspectives of autistic adults with intellectual disabilities

LAY ABSTRACT

Autistic young adults with intellectual disabilities want to be autonomous but are less autonomous than other people. However, they can be autonomous with appropriate support. We wanted to learn how we can support autistic adults with intellectual disabilities to be more autonomous. We designed our study with help from five autistic community partners to make sure the research was relevant to autistic people and would improve their lives. We talked with eight autistic young adults with intellectual disabilities about autonomy. We defined "talk" as verbal language, as well as non-verbal cues such as body language, facial expressions, vocalizations, and laughter. We did art projects and played games while we talked. We met in small groups over multiple sessions. Our participants told us that being autonomous meant being able to be themselves. They told us three main ways to support their autonomy: (1) having choice and control, (2) being able to communicate in their own way, and (3) being in a safe environment. Families, support staff, and caregivers can use this information to help autistic young adults with intellectual disabilities to be autonomous.

Optogenetic Inhibition of Rat Anterior Cingulate Cortex Impairs the Ability to Initiate and Stay on Task

Our prior research has identified neural correlates of cognitive control in the anterior cingulate cortex (ACC), leading us to hypothesize that the ACC is necessary for increasing attention as rats flexibly learn new contingencies during a complex reward-guided decision-making task. Here, we tested this hypothesis by using optogenetics to transiently inhibit the ACC, while rats of either sex performed the same two-choice task. ACC inhibition had a profound impact on behavior that extended beyond deficits in attention during learning when expected outcomes were uncertain. We found that ACC inactivation slowed and reduced the number of trials rats initiated and impaired both their accuracy and their ability to complete sessions. Furthermore, drift-diffusion model analysis suggested that free-choice performance and evidence accumulation (i.e., reduced drift rates) were degraded during initial learning-leading to weaker associations that were more easily overridden in later trial blocks (i.e., stronger bias). Together, these results suggest that in addition to attention-related functions, the ACC contributes to the ability to initiate trials and generally stay on task.

Contraceptive uptake and compliance after structured contraceptive counseling - secondary outcomes of the LOWE trial

INTRODUCTION

Highly effective long-acting reversible contraceptive (LARC) methods reduce unintended pregnancy rates; however, these methods are underutilized. The LOWE trial intervention provided structured contraceptive counseling resulting in increased uptake of LARC. This longitudinal follow up of the LOWE study assessed the long-term impact of the intervention by investigating the contraceptive use at 12 months with a focus on continued use of LARC.

MATERIAL AND METHODS

In the cluster randomized LOWE trial, abortion, youth, and maternal health clinics were randomized to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of an educational video on contraceptive methods, key questions asked by the health care provider, a tiered effectiveness chart and a box of contraceptive models. Women ≥ age 18, who were sexually active or planned to be in the upcoming 6 months, could participate in the study. We assessed self-reported contraceptive use at three, six and 12 months. Contraceptive choice and switches were analyzed with descriptive statistics. Contraceptive use at 12 months and continued use of LARC were analyzed using mixed logistic regressions, with clinic included as a random effect. Analysis with imputed values were performed for missing data to test the robustness of results.

RESULTS

Overall, at 12 months, women in the intervention group were more likely to be using a LARC method (aOR 1.90, 95% CI: 1.31-2.76) and less likely to be using a short-acting reversible contraceptive (SARC) method (aOR 0.66, 95% CI: 0.46-0.93) compared to the control group. Women counseled at abortion (aOR 2.97, 95% CI: 1.36-6.75) and youth clinics (aOR 1.81, 95% CI: 1.08-3.03) were more likely to be using a LARC method, while no significant difference was seen in maternal health clinics (aOR 1.84, 95% CI: 0.96-3.66). Among women initiating LARC, continuation rates at 12 months did not differ between study groups (63.9% vs. 63.7%). The most common reasons for contraceptive discontinuation were wish for pregnancy, followed by irregular bleeding, and mood changes.

CONCLUSIONS

The LOWE trial intervention resulted in increased LARC use also at 12 months. Strategies on how to sustain LARC use needs to be further investigated.

Noise annoys-But personal choice can attenuate noise effects on cardiac response reflecting effort

Since personal choice fosters commitment and shields action execution against potentially conflicting influences, two laboratory experiments with university students (N = 228) tested whether engaging in action by personal choice versus external assignment of task characteristics moderates the effect of irrelevant acoustic noise on cardiovascular responses reflecting effort. Participants who could personally choose the stimulus color of moderately difficult cognitive tasks were expected to be shielded against the irrelevant noise. By contrast, when the stimulus color was externally assigned, we predicted receptivity for the irrelevant noise to be high. As expected, in both experiments, participants in the assigned color condition showed stronger cardiac pre-ejection period reactivity during task performance when exposed to noise than when working in silence. On the contrary, participants who could choose the stimulus color were shielded against the noise effect on effort. These findings conceptually replicate and extend research on the action shielding effect by personal choice and hold practical implications for occupational health.

The generalization-across-dimensions model applied to conditional temporal discrimination

Can simple choice conditional-discrimination choice be accounted for by recent quantitative models of combined stimulus and reinforcer control? In Experiment 1, two sets of five blackout durations, one using shorter intervals and one using longer intervals, conditionally signaled which subsequent choice response might provide food. In seven conditions, the distribution of blackout durations across the sets was varied. An updated version of the generalization-across-dimensions model nicely described the way that choice changed across durations. In Experiment 2, just two blackout durations acted as the conditional stimuli and the durations were varied over 10 conditions. The parameters of the model obtained in Experiment 1 failed adequately to predict choice in Experiment 2, but the model again fitted the data nicely. The failure to predict the Experiment 2 data from the Experiment 1 parameters occurred because in Experiment 1 differential control by reinforcer locations progressively decreased with blackout durations, whereas in Experiment 2 this control remained constant. These experiments extend the ability of the model to describe data from procedures based on concurrent schedules in which reinforcer ratios reverse at fixed times to those from conditional-discrimination procedures. Further research is needed to understand why control by reinforcer location differed between the two experiments.

Learning to Choose: Behavioral Dynamics Underlying the Initial Acquisition of Decision-Making

Current theories of decision-making propose that decisions arise through competition between choice options. Computational models of the decision process estimate how quickly information about choice options is integrated and how much information is needed to trigger a choice. Experiments using this approach typically report data from well-trained participants. As such, we do not know how the decision process evolves as a decision-making task is learned for the first time. To address this gap, we used a behavioral design separating learning the value of choice options from learning to make choices. We trained male rats to respond to single visual stimuli with different reward values. Then, we trained them to make choices between pairs of stimuli. Initially, the rats responded more slowly when presented with choices. However, as they gained experience in making choices, this slowing reduced. Response slowing on choice trials persisted throughout the testing period. We found that it was specifically associated with increased exponential variability when the rats chose the higher value stimulus. Additionally, our analysis using drift diffusion modeling revealed that the rats required less information to make choices over time. These reductions in the decision threshold occurred after just a single session of choice learning. These findings provide new insights into the learning process of decision-making tasks. They suggest that the value of choice options and the ability to make choices are learned separately and that experience plays a crucial role in improving decision-making performance.

Long-Term Effectiveness of a Multi-Strategy Choice Architecture Intervention in Increasing Healthy Food Choices of High-School Students From Online Canteens (Click & Crunch High Schools): Cluster Randomized Controlled Trial

BACKGROUND

School canteens are a recommended setting to influence adolescent nutrition due to their scope to improve student food choices. Online lunch ordering systems ("online canteens") are increasingly used and represent attractive infrastructure to implement choice architecture interventions that nudge users toward healthier food choices. A recent cluster randomized controlled trial demonstrated the short-term effectiveness (2-month follow-up) of a choice architecture intervention to increase the healthiness of foods purchased by high school students from online canteens. However, there is little evidence regarding the long-term effectiveness of choice architecture interventions targeting adolescent food purchases, particularly those delivered online.

OBJECTIVE

This study aimed to determine the long-term effectiveness of a multi-strategy choice architecture intervention embedded within online canteen infrastructure in high schools at a 15-month follow-up.

METHODS

A cluster randomized controlled trial was undertaken with 1331 students (from 9 high schools) in New South Wales, Australia. Schools were randomized to receive the automated choice architecture intervention (including menu labeling, positioning, feedback, and prompting strategies) or the control (standard online ordering). The foods purchased were classified according to the New South Wales Healthy Canteen strategy as either "everyday," "occasional," or "should not be sold." Primary outcomes were the average proportion of "everyday," "occasional," and "should not be sold" items purchased per student. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases. Outcomes were assessed using routine data collected by the online canteen.

RESULTS

From baseline to 15-month follow-up, on average, students in the intervention group ordered significantly more "everyday" items (+11.5%, 95% CI 7.3% to 15.6%; P<.001), and significantly fewer "occasional" (-5.4%, 95% CI -9.4% to -1.5%; P=.007) and "should not be sold" items (-6%, 95% CI -9.1% to -2.9%; P<.001), relative to controls. There were no between-group differences over time in the mean energy, saturated fat, sugar, or sodium content of lunch orders.

CONCLUSIONS

Given their longer-term effectiveness, choice architecture interventions delivered via online canteens may represent a promising option for policy makers to support healthy eating among high school students.

TRIAL REGISTRATION

Australian Clinical Trials ACTRN12620001338954, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380546 ; Open Science Framework osf.io/h8zfr, https://osf.io/h8zfr/.

Toward a further understanding of assent

Arranging assent opportunities is an increasingly common strategy for involving clients in therapeutic decisions within behavior analysis. Recent behavior-analytic articles have helped create a basic behavioral definition and conceptualization of assent, but much more guidance is needed for practitioners and researchers interested in embedding assent into their practices. The purpose of this article is to advance the conceptualization and understanding of assent and assent practices by refining previous definitions and conceptualizations of assent and providing six essential considerations for embedding assent into practice. The six considerations consist of determining the applicability and feasibility of assent, assessing assent-related skills, arranging assent procedures and teaching assent-related skills, arranging fair choices, selecting opportunities to assess assent, and informally assessing assent. Following the discussion of the considerations for assent practices, we issue a call for specific topics of research on assent.

Relative preference for distinct reinforcers maintaining destructive behavior

The literature offers few recommendations for sequencing exposure to treatment conditions with individuals with multiply maintained destructive behavior. Identifying relative preference for the functional reinforcers maintaining destructive behavior may be one means of guiding that decision. The present study presents a preliminary attempt at developing a robust relative preference and reinforcer assessment for individuals with multiply maintained destructive behavior. Guided and free-choice trials were implemented in which participants chose between two multiple-schedule arrangements, each of which programmed signaled periods of isolated reinforcer availability and unavailability. Consistent participant choice and responding during free-choice trials was then used to thin the corresponding schedule of reinforcement. The results demonstrated a strong preference for one of the two functional reinforcers for all four participants, yet preferences differed across participants and were not well predicted by responding in prior analyses.

Resurgence Following Higher or Lower Quality Alternative Reinforcement

Resurgence is a temporary increase in a previously suppressed target behavior following a worsening in reinforcement conditions. Previous studies have examined how higher rates or magnitudes of alternative reinforcement affect suppression of the target behavior and subsequent resurgence. However, there has been no investigation of the effects of higher versus lower qualities of alternative reinforcement on resurgence. Using a three-phase resurgence preparation with rats, the present experiments examined the effects of an alternative reinforcer that was of higher (Experiment 1) or lower (Experiment 2) quality than the reinforcer that had previously maintained the target behavior. The results of both experiments showed greater reductions in target behavior with a higher quality alternative reinforcer and larger increases in target responding when a higher quality alternative reinforcer was removed. Along with prior findings with higher rates and magnitudes of alternative reinforcement, these findings suggest that variations in reinforcer dimensions that increase the efficacy of alternative reinforcement also tend to increase resurgence when alternative reinforcement is removed. The results are discussed in terms of the resurgence as choice in context model and in terms of potential clinical implications.

A review of the concurrent-chains arrangement to assess intervention choice: 2018-2023

The purpose of this review is to summarize recent literature on the use of concurrent-chains arrangements in the assessment of preference for interventions (or intervention components) in the applied literature. The types of interventions and participants are described briefly, and procedural variations, ethical considerations, and recommendations for future research are discussed.

A Reexamination of the Relationship between Training Practices and Welfare in the Management of Ambassador Animals

There is an ethical need to document and develop best practices for meeting ambassador animals' welfare needs within the context of meeting zoo and aquarium program objectives. This is because ambassador animals experience direct and frequent contact with humans. This paper rigorously synthesizes behavioral research and theory, contemporary practices, and personal experiences to offer key concepts that can be applied to meet ambassador animal welfare needs. These key concepts include addressing an animal's recognition of choice and control, the use of the most positive and least intrusive effective interventions when training animals to participate in programming, and an overall reduction in aversive strategy use. Our model for increasing ambassador animal welfare focuses on seven main areas of concern, including the following: choosing the most suitable animal for the program; choosing the human with the right skills and knowledge for the program; using the most positive, least intrusive, effective training methods; developing a strong trusting relationship between trainer and animal; developing a comprehensive enrichment program; the need for institutional support; and creating opportunities for animals to practice species-appropriate behaviors. Our model will provide guidelines for improved ambassador animal welfare that can be refined with future research.

Effects of different Ficus feeding experiences on host preference of Perina nuda larvae (Lepidoptera: Lymantriidae)

Perina nuda (Lepidoptera: Lymantriidae) is a serious pest of banyan trees (Ficus spp.), which is distributed in South China, but little is known about the host preference on the different banyan tree species. To address this gap, we conducted experiments to investigate larval feeding preferences, assessing the impact of feeding experience in both choice and no-choice conditions. Fifth and sixth instars were exposed to 4 banyan species, and food intake, feeding area, and relative ingestion index were measured. Our findings reveal that Ficus concinna was the preferred host of fifth instars in choice tests, while sixth instars exhibited a preference for this host in no-choice tests. In contrast, fifth instars did not display a significant preference for any of the 4 species in no-choice tests. However, sixth instars fed on F. microcarpa, F. altissima, and F. concinna continued to exhibit a preference for the original host. These observations indicate that larval feeding preference changes with instar, and feeding experience contributes to a preference for the original host. Consequently, the feeding preference of P. nuda larvae is influenced by multiple factors, including instar and previous feeding experience. These findings enhance our understanding of P. nuda's ecological interactions and its potential impact on various banyan tree species.

Medication-Free Treatment in Mental Health Care How Does It Differ from Traditional Treatment?

Background

Norwegian authorities have implemented treatment units devoted to medication-free mental health treatment nationwide to improve people's freedom of choice. This article examines how medication-free treatment differs from treatment as usual across central dimensions.

Methods

The design was mixed methods including questionnaire data on patients from a medication-free unit and two comparison units (n 59 + 124), as well as interviews with patients (n 5) and staff (n 8) in the medication-free unit.

Results

Medication-free treatment involved less reliance on medications and more extensive psychosocial treatment that involved a culture of openness, expression of feelings, and focus on individual responsibility and intensive work. The overall extent of patient influence for medication-free treatment compared with standard treatment was not substantially different to standard treatment but varied on different themes. Patients in medication-free treatment had greater freedom to reduce or not use medication. Medication-free treatment was experienced as more demanding. For patients, this could be connected to a stronger sense of purpose and was experienced as helpful but could also be experienced as a type of pressure and lack of understanding. Patients in medication-free treatment reported greater satisfaction with the treatment, which may be linked to a richer psychosocial treatment package that focuses on patient participation and freedom from pressure to use medication.

Conclusion

The findings provide insights into how a medication-free treatment service might work and demonstrate its worth as a viable alternative for people who are not comfortable with the current medication focus of mental health care. Patients react differently to increased demands and clinicians should be reflexive of the dimensions of individualism-relationism in medication-free treatment services. This knowledge can be used to further develop and improve both medication-free treatment and standard treatment regarding shared decision-making.

Trial Registration

This study was registered with ClinicalTrials.gov (Identifier NCT03499080) on 17 April 2018.

Joint encoding of stimulus and decision in monkey primary visual cortex

We investigated whether neurons in monkey primary visual cortex (V1) exhibit mixed selectivity for sensory input and behavioral choice. Parallel multisite spiking activity was recorded from area V1 of awake monkeys performing a delayed match-to-sample task. The monkeys had to make a forced choice decision of whether the test stimulus matched the preceding sample stimulus. The population responses evoked by the test stimulus contained information about both the identity of the stimulus and with some delay but before the onset of the motor response the forthcoming choice. The results of subspace identification analysis indicate that stimulus-specific and decision-related information coexists in separate subspaces of the high-dimensional population activity, and latency considerations suggest that the decision-related information is conveyed by top-down projections.

A hippocampo-cortical pathway detects changes in the validity of an action as a predictor of reward

Much research has been dedicated to understanding the psychological and neural bases of goal-directed action, yet the relationship between context and goal-directed action is not well understood. Here, we used excitotoxic lesions, chemogenetics, and circuit-specific manipulations to demonstrate the role of the ventral hippocampus (vHPC) in contextual learning that supports sensitivity to action-outcome contingencies, a hallmark of goal-directed action. We found that chemogenetic inhibition of the ventral, but not dorsal, hippocampus attenuated sensitivity to instrumental contingency degradation. We then tested the hypothesis that this deficit was due to an inability to discern the relative validity of the action compared with the context as a predictor of reward. Using latent inhibition and Pavlovian context conditioning, we confirm that degradation of action-outcome contingencies relies on intact context-outcome learning and show that this learning is dependent on vHPC. Finally, we show that chemogenetic inhibition of vHPC terminals in the medial prefrontal cortex also impairs both instrumental contingency degradation and context-outcome learning. These results implicate a hippocampo-cortical pathway in adapting to changes in instrumental contingencies and indicate that the psychological basis of this deficit is an inability to learn the predictive value of the context. Our findings contribute to a broader understanding of the neural bases of goal-directed action and its contextual regulation.

Choice Enhances Placebo Hypoalgesia More in Weaker Placebo Contexts: A Partial Reinforcement Study

Providing individuals with choice over treatment has been found to enhance placebo hypoalgesia. However, this choice effect is not always present. The current study tested whether the strength of the placebo context influenced the effect of choice on placebo hypoalgesia. Using an established electrocutaneous pain paradigm, the choice effect was compared when placebo hypoalgesia was induced by Continuous Reinforcement (CRF) (strong placebo context) versus partial reinforcement (PRF) (weak placebo context). Healthy volunteers (N = 133) were randomized to receive either choice over treatment administration or no choice and then to placebo conditioning under either CRF (placebo always followed by surreptitious pain reduction during training) or PRF (placebo only followed by surreptitious pain reduction on half of the training trials). At the test, placebo hypoalgesia was greater and more resistant to extinction overall for those with choice. Importantly, however, the choice effect in enhancing the magnitude of placebo hypoalgesia was stronger after PRF than CRF. These results indicate that choice may have greater placebo-enhancing power in weaker placebo contexts. Therefore, choice may be a cheap and effective tool for improving clinical outcomes by facilitating placebo hypoalgesia when the existing treatment context is insufficient to produce placebo hypoalgesia itself. PERSPECTIVE: This study demonstrates that the enhancing effect of choice on placebo hypoalgesia is greater in a weaker placebo context. As such, offering choice could be an ethical way to effectively improve pain outcomes when placebo effects cannot be readily produced by the treatment context.

The multiple-stimulus-without-replacement preference assessment tool and its predictive validity

This study demonstrates the use of two web-based programs, one to identify video preferences and the other to assess their reinforcing effects. We used the Multiple-Stimulus-Without-Replacement Preference Assessment Tool (MSWO PAT) to identify the video preference hierarchies of seven participants, ages 4-11 years old. We then used a customized reinforcer assessment program that arranged a concurrent-chains preparation with programmed conjugate schedules of reinforcement. Button presses emitted by participants modulated the quality (volume and opacity) of selected videos on a moment-to-moment basis, allowing us to identify the reinforcing effects of the videos in little time. The results showed that the preference assessment had predictive value for five of seven participants. We discuss the MSWO PAT, parameters that may affect the identification of preferences and the use of conjugate schedules to identify reinforcers.

A view-based decision mechanism for rewards in the primate amygdala

Primates make decisions visually by shifting their view from one object to the next, comparing values between objects, and choosing the best reward, even before acting. Here, we show that when monkeys make value-guided choices, amygdala neurons encode their decisions in an abstract, purely internal representation defined by the monkey's current view but not by specific object or reward properties. Across amygdala subdivisions, recorded activity patterns evolved gradually from an object-specific value code to a transient, object-independent code in which currently viewed and last-viewed objects competed to reflect the emerging view-based choice. Using neural-network modeling, we identified a sequence of computations by which amygdala neurons implemented view-based decision making and eventually recovered the chosen object's identity when the monkeys acted on their choice. These findings reveal a neural mechanism in the amygdala that derives object choices from abstract, view-based computations, suggesting an efficient solution for decision problems with many objects.

Effects of naltrexone on amphetamine choice in rhesus monkeys and rats

Clinical amphetamine use is constrained by high abuse potential, and amphetamine use disorder is a persistent clinical problem with no approved medications for its treatment. The opioid antagonist naltrexone has been reported to reduce some abuse-related effects of amphetamine. This study used an amphetamine-versus-food choice procedure in rhesus monkeys and rats to test the hypothesis that naltrexone might serve as either (a) a maintenance medication for amphetamine use disorder treatment or (b) an "abuse-deterrent" adjunct to clinical amphetamine formulations. Male rhesus monkeys and male and female rats were trained to choose between increasing unit doses of intravenous amphetamine and an alternative food reinforcer during daily behavioral sessions. Experiment 1 evaluated effectiveness of continuous naltrexone maintenance to reduce amphetamine-versus-food choice in both monkeys and rats. Experiment 2 combined naltrexone with amphetamine in fixed-proportion amphetamine + naltrexone mixtures to evaluate the effectiveness of naltrexone in both species to reduce mixture choice relative to amphetamine-alone choice. Amphetamine maintained a dose-dependent increase in amphetamine choice in both monkeys and rats. Naltrexone maintenance did not significantly decrease amphetamine choice in either species. Addition of naltrexone to amphetamine reduced amphetamine choices per session in monkeys, but behavior was not reallocated to food choice, and in rats, the addition of naltrexone only decreased food choice without significantly affecting amphetamine choice. These results argue against the use of naltrexone as either (a) a maintenance medication for treatment of amphetamine use disorder or (b) an "abuse-deterrent" adjunct to amphetamine for clinical applications. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Adherence, safety, and choice of the monthly dapivirine vaginal ring or oral emtricitabine plus tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis among African adolescent girls and young women: a randomised, open-label, crossover trial

BACKGROUND

Half of new HIV acquisitions in Africa occur in adolescent girls and young women. Pre-exposure prophylaxis (PrEP) with oral tenofovir disoproxil fumarate plus emtricitabine or the monthly dapivirine vaginal ring is efficacious but has lower adherence and effectiveness among adolescent girls and young women. We aimed to assess product adherence, safety, and choice of oral PrEP compared with the dapivirine ring among African adolescent girls and young women.

METHODS

MTN-034/REACH was a randomised, open-label, phase 2a crossover trial among HIV-seronegative, non-pregnant adolescent girls and young women aged 16-21 years at four clinical research sites in South Africa, Uganda, and Zimbabwe. Participants were randomly assigned (1:1) to either the dapivirine ring or daily oral PrEP (200 mg of emtricitabine and 300 mg of tenofovir disoproxil fumarate) for 6 months, then switched to the other product option for 6 months, followed by a third 6-month period in which participants were given a choice of oral PrEP, the dapivirine ring, or neither. Fixed block randomisation was used, stratified by site. The primary adherence endpoint was use of each product during the randomised periods, with high use defined as tenofovir-diphosphate concentrations greater than or equal to 700 fmol/punch (associated with taking an average of four or more tablets per week in the previous month) and greater than or equal to 4 mg dapivirine released from the returned ring (continuous use for 28 days in the previous month) based on residual drug concentrations. The primary safety endpoint was grade 2 or higher adverse events during each randomised period of 24 weeks of ring and oral PrEP. This trial is registered at ClinicalTrials.gov, NCT03593655.

FINDINGS

From Feb 6, 2019 to Sept 9, 2021, 396 adolescent girls and young women were screened, 247 of whom were enrolled and randomly assigned (6 months of the ring followed by 6 months of oral PrEP n=124; 6 months of oral PrEP followed by 6 months of the ring n=123). Median age was 18 years (IQR 17-19). 54 grade 2 or higher product-related adverse events were reported during oral PrEP and five during dapivirine ring use, with no product-related serious adverse events. High adherence was observed in 753 (57%) of the 1316 oral PrEP visits and 806 (57%) of the 1407 dapivirine ring visits. Four women acquired HIV during follow-up.

INTERPRETATION

Adherence was moderately high and similar between oral PrEP and the dapivirine ring with favourable safety and tolerability. Oral PrEP and the dapivirine ring are effective, safe, and well tolerated HIV prevention options for adolescent girls and young women who would benefit from a choice of PrEP formulations to meet their needs and preferences.

FUNDING

National Institutes of Health.

The difficult process of autonomous choice: using I-poems to understand experiences of abortion-seekers in The Netherlands

While key barriers to abortion care accessibility have been established, little is known about the experiences of people having abortions in the Netherlands. Stories of individual abortion-seekers can help counteract stereotyping, diminish abortion stigma, and improve accessibility. This study's research question is: What experiences do abortion-seekers in the Netherlands have with abortion care and what new insights can the I-poem method of analysis provide? This qualitative feminist study used transcripts of semi-structured, in-depth interviews with abortion-seekers from previous research to create I-poems. Using a grounded theory method, the I-poems were coded deductively to validate previous findings, and inductively to generate new insights. The I-poems revealed that although abortion-seekers felt autonomous, their decision-making was complicated by doubt concerning their partner's views and/or suitability as a parent, feelings of shame, and a lack of support. The abortion-seekers were often slowed by obstacles in policy and care; waiting caused feelings of fear and panic and routine pre-abortion ultrasounds led to anxiety. They often did not know what to expect from their body or the abortion procedure. I-poems show how autonomous choice in abortion care is socially constructed rather than purely individual. Abortion providers must pay special attention to external factors complicating the decision-making process such as partner discordance (even in stable relationships) and anxiety due to waiting times and routine pre-abortion ultrasound. Future action on normalisation of information provided on all aspects of choosing an abortion is necessary to realise informed choice and reduction of abortion stigma.Plain language summary Abortion is a medical procedure that ends a pregnancy. In some countries, people can easily get an abortion. In others, it is illegal or difficult to access. In the Netherlands, abortion is accessible and legal before 24 weeks of pregnancy and can be performed upon request of the abortion seeker. This policy is often seen as liberal, as it allows people to make their own decisions about their bodies. Still, abortion stigma is present in Dutch society. Stigma around abortion refers to negative attitudes and beliefs that society has towards people who have had abortions or are considering having one.Research by Holten et al⁷ looked at how easy it is for abortion seekers in the Netherlands to access abortion services. The study highlighted that people in the Netherlands still face barriers to accessing abortion services. For example: the law and regulations regarding abortions and the fact that people had difficulty in talking about their abortion due to stigma.The abovementioned study gives a broad view on challenges in the accessibility of abortion in the Netherlands, but the individual experiences are not portrayed.The goal of this study is to learn about the personal experiences of abortion-seekers in the Netherlands. It aims to understand what it's like for these people to access abortion services and what we can learn from their individual stories by using a method of analysis called I-poem. I-poems are a type of poem created by the researcher by looking for sentences using the first-person pronoun "I" in interview texts. I poems show the personal experience or point of view of the person interviewed. This type of poem is often used to express emotions or share personal stories or observations.This study used interviews with people who have had abortions to create I-poems. The grounded theory method was used to analyse the I-poems in two ways: confirming what was found in previous studies, and also providing new insights from the data.The study found that the people contemplating having an abortion had a hard time making the decision to have an abortion because they had doubts, were worried about what their partner would think, felt ashamed to talk about it with friends and family, and didn't have enough support. They also faced challenges like having to wait for the abortion because of clinic schedules and laws and getting ultrasounds before the procedure, which made them anxious. It was also found that the people contemplating abortion were unsure of what to expect from the abortion procedure and how their body would react, which made the decision even harder.The study concludes that even when people felt in control of their decision, the decision-making process was still difficult. The decision is not just personal, but is also affected by society, partners, and healthcare policies. The waiting time and the ultrasound before the abortion made the process harder, and abortion seekers were not aware of what to expect from the procedure. More information and education on all aspects of having an abortion should be provided to help people to make better informed decisions and reduce the abortion stigma. Further research on experiences of routine ultrasound before abortion in the Netherlands is needed to improve abortion care.

Putting a price on healthy eating: public perceptions of the need for further food pricing policies in the UK

BACKGROUND

Understand factors that influence food choice and explore public perceptions of the need for government policies to improve diets in the UK, particularly food pricing interventions.

METHODS

A qualitative study design was used with semi-structured interviews. The study was carried out in Greater Manchester, England. In all, 15 participants from a diverse range of backgrounds were recruited.

RESULTS

Food price, lack of time, availability, and food knowledge and culture were key factors that led some study participants towards unhealthy food choices. The UK's individual, willpower-focused approach to tackling obesity was deemed ineffective and many participants supported further government intervention. Product reformulation was supported as a less intrusive and less regressive way of improving diets than taxation. There was also support for increasing cooking classes within schools.

CONCLUSIONS

Whilst the government ambition to half childhood obesity by 2030 is welcome, population level interventions that enable healthier food choices are needed to achieve this goal. Rising global food prices may make reformulation a more practical policy option than further pricing interventions. Mandatory reformulation of convenience meal and snack products and strengthening education in schools may represent a publicly acceptable and effective package of interventions within a comprehensive strategy to tackle obesity.

Women's experiences and views of outpatient and inpatient induction of labor with oral misoprostol: A secondary qualitative study

INTRODUCTION

As labor induction rates continue to increase, so has the interest in performing induction in an outpatient setting for pregnancies defined as low-risk. Twenty women participated in the pilot study of a Randomized Controlled Trial (RCT) comparing inpatient and outpatient labor induction with oral misoprostol. This study aimed to explore women's experiences of outpatient induction of labor and their views on this as an alternative method to inpatient labor induction.

METHODS

Semi-structured interviews were conducted, from November 2021 to January 2022 with eight women randomized to outpatient induction and four women randomized to inpatient induction. Verbatim transcribed interviews were analyzed using Graneheim and Lundman's content analysis.

RESULTS

Three main categories emerged: the required framework around outpatient labor induction, what felt better at home and what felt safer at the hospital. To feel secure at home, women needed sufficient information, close follow-up while at home, and an easy-to-administer induction method. Outpatient labor induction gave women the opportunity of constant support from the partner and increased freedom of movement and self-expression. Some expressed relief over being randomized to inpatient labor induction, because of easy access to health providers, fetal monitoring, and not risking giving birth before arrival to the hospital. Women stressed the importance of being given a choice.

CONCLUSIONS

Outpatient labor induction contributed to a positive birth experience and should be considered as an alternative for women with low-risk pregnancies. Shared decision-making, including the opportunity for women to change their mind, is essential as induction and early labor affects women's whole childbirth experience.