Application of Respondent Driven Sampling to Collect Baseline Data on FSWs and MSM for HIV Risk Reduction Interventions in Two Urban Centres in Papua New Guinea The need to obtain unbiased information among hard -- to-reach and hidden populations for behavioural and biological surveillance , epidemiological studies , and intervention program evaluations has led researchers to search for a suitable sampling method . One method that has been tested among IDU and MSM recently is respondent-driven sampling -LRB- RDS -RRB- . We used RDS to conduct a behavioural survey among FSWs and MSM in two urban centres in Papua New Guinea -LRB- PNG -RRB- . In this paper we present the lessons learned implementing RDS in a developing country setting . We also present comparisons of RDSAT-adjusted versus unadjusted crude estimates of some key socio-demographic indicators as well as comparisons between the estimates from RDS and a hypothetical time -- location sample -LRB- TLS -RRB- . Overall , the use of RDS among the MSM and FSWs in PNG had numerous advantages in terms of collecting a required sample size in a short time period , minimizing costs and maximising security for staff and respondents . Although there were a few problems these were easily remedied and we would recommend RDS for other similar studies in PNG and other developing countries . Introduction Papua New Guinea is currently experiencing a major generalized HIV epidemic driven by high rates of unprotected sex , multiple sexual partners , early age of sexual debut , and high rates of STIs . Sexual violence and aggression is also widespread .1 PNG 's HIV surveillance system has limited capacity , and valid scientific information is needed to guide community prevention efforts .2 Female sex workers -LRB- FSWs -RRB- and men who have sex with men -LRB- MSM -RRB- have been identified as groups at high -- risk for HIV throughout the world . There have been few published studies about FSWs in PNG .3,4 No previous quantitative research has been conducted with MSM in PNG , but qualitative research and unpublished reports indicate that MSM behaviour is prevalent in some areas of the country .5 Moreover , numerous anthropological studies indicate that many tribes in PNG have practised male -- male sexual behaviour in traditional rites and rituals .6 -- 8 The major challenge in studying HIV -- risk behaviours and developing prevention efforts among high risk populations is gathering information from non -- biased samples .9 Members of population groups such as men who have sex with men -LRB- MSM -RRB- , injecting drug users -LRB- IDU -RRB- and female sex workers -LRB- FSWs -RRB- are involved in stigmatized or illegal behaviour , leading individuals to hide their identity and to be reluctant to participate in research studies . No sampling frame exists for these groups , and the fact that creating one may be difficult and very costly makes them hard to sample with traditional probability -- based sampling methods . Respondent driven sampling -LRB- RDS -RRB- is a relatively new adaptation of chain -- referral sampling , where subsequent respondents are recruited by previous respondents through their network of acquaintances .9 -- 11 It has several features that overcome the limitations of other sampling methods that allow it to provide unbiased and representative population -- based estimates . RDS has therefore been recommended as an alternative sampling approach for `` hidden '' populations that do not congregate in identifiable or accessible locations .12 -- 14 Because RDS relies on participants from the target population to recruit subsequent respondents , it has the advantages that it requires less detailed formative research , is less costly , can be completed in a shorter amount of time , and has greater external validity than other methods . This paper presents lessons learned from applying RDS in a study to collect baseline behavioural data for HIV prevention programming among two high risk populations in two urban centres in Papua New Guinea . The research among FSWs in Goroka and Port Moresby and MSM in Port Moresby was linked to the Poro Sapot Project -LRB- PSP -RRB- , which is an HIV prevention initiative of Save the Children in PNG -LRB- SCiPNG -RRB- . The Papua New Guinea Institute of Medical Research -LRB- PNGIMR -RRB- partnered with SCiPNG and Family Health International -LRB- FHI -RRB- to conduct the research . Reasons for Choosing RDS The first phase of the research project was a qualitative evaluation of the two target populations . Qualitative research methods included field observations , focus group discussions , in -- depth interviews , and key informant interviews . In addition , a literature review of research studies on these populations in PNG was carried out . Our formative research showed that there was a relatively large and socially well connected population of MSM in Port Moresby , the capital and largest city of PNG . Although there were a number of commercial and public spaces where MSM met and socialised , none of them catered to a primarily MSM clientele . There were no formal community -- based or social organizations of gay or homosexual men . Due to social stigma and discrimination , the vast majority of MSM kept their sexual orientation hidden from their family , friends and co -- workers . The lack of MSM -- identified sites and the hidden nature of homosexuality in PNG meant that it would be difficult to use time -- location sampling -LRB- TLS -RRB- as the recruitment methodology .13,14 The decision to use RDS for the survey of FSWs came about following formative assessments in both locations . FSWs in PNG were found to be very mobile . Although a few illegal brothels did exist , only a small number of women worked in those locations . Most FSWs frequented formal establishments such as disco bars , hotels , motels , and guest houses in search of potential clients . In most locations FSWs mixed with the general population in a way that would have made it difficult to differentiate sex workers from other females . In addition , security for the research staff and participants was a major concern . MSM informants had complained of physical and verbal abuse due to social stigmatization . The crime rate in Port Moresby was very high and had steadily deteriorated in the time period before the research was conducted . Since most MSM and FSWs went out at night to socialise or meet clients , it would have been difficult to ensure the security of research staff members if they had to contact potential respondents in public areas . RDS provided a safer alternative in this regard because respondents were not actively recruited by study interviewers but were instead referred by their peers to be interviewed at a safe study facility during a convenient time of the day . Research Methods The field work in Port Moresby began in February 2005 and was completed at the beginning of April 2005 . Data collection in Goroka began in April 2005 and was completed in 2 weeks . The interviewers were all FSWs and MSM who received 1 and 1/2 weeks of intensive training prior to the starting of field work . The research teams at each site were comprised of a coupon manager , a research assistant and a group of peer interviewers . In Port Moresby we trained and used six MSM interviewers and four FSWs interviewers . In Goroka we trained and used five FSWs interviewers . The Coupon Management System A coupon management system was developed in Microsoft FoxPro 2.6 and was used to track the relationships between the recruiters and their recruits . The same program was used to record biometric measurements -LRB- circumference of both wrists and length of both forearms -RRB- , which were used to check for and prevent duplication of recruitment . The latter was done through the calculation of the index of differences between the candidate and all of the other biometric measures already entered .15 Recruitment of Seeds and Study Participants The FSWs seeds for the RDS sample were drawn from distinct geographic areas within Port Moresby and Goroka . The areas chosen in each location were the coverage areas that were mapped out and targeted for the intervention programs . Therefore eight seeds were chosen who lived and worked in five different areas of the city of Port Moresby , and six seeds were chosen from six different areas in Goroka . These areas and the number of seeds drawn for Port Moresby and Goroka are shown in Tables 1 and 2 , respectively . Table 1Socio -- demographic characteristics of FSWs in Port Moresby SeedsSample -LRB- n = 8 -RRB- Percent -LRB- n = 245 -RRB- Crude -LRB- % -RRB- RDSAT -- adjusted -LRB- % -RRB- Absol . diff -LRB- % -RRB- Age16 -- 19112.54819.625.05.420 -- 24112.53815.518.63.125 -- 29112.55422.022.70.730 +562.510542.933.59.4 Marital statusEver married675 .018575.566.98.8 Currently married112 .55823.717.26.5 Currently married cohabiting with spouse00 .072.93.91.0 Education levelNo formal education00 .05823.726.67.9 Primary337 .512149.447.51.9 Secondary562 .56124.922.22.7 Other -LRB- eg . vocational -RRB- 00.052.03.21.2 Region of birthHighlands225 .011346.142.73.4 Southern562 .511647.351.23.9 Others112 .5166.55.90.6 Place of residenceTown/Koki area225 .06225.318.46.9 Boroko area112 .510040.823.617.27 -- mile/airport225 .0156.14.61.5 Gordons/Hohola225 .0197.88.81.0 Waigani/Gerehu112 .54618.843.224.4 Others00 .031.21.11.2 Table 2Socio -- demographic characteristics of FSWs in Goroka SeedsSample -LRB- n = 6 -RRB- Percent -LRB- n = 249 -RRB- Crude -LRB- % -RRB- RDSAT -- adjusted -LRB- % -RRB- Absol . diff -LRB- % -RRB- Age16 -- 19116.74518.116.61.520 -- 24116.78032.135.33.225 -- 29116.76224.923.91.030 +350.06224.924.00.9 Marital statusEver married350 .016465.965.80.1 Currently married00 .02710.812.41.6 Currently married cohabiting with spouse00 .000.00.00.0 Education levelNo formal education233 .38734.935.80.9 Primary233 .310843.443.20.2 Secondary233 .35321.322.00.7 Other -LRB- eg . vocational -RRB- 00.020.81.00.2 Region of birthHighlands6100 .023895.696.40.8 Momase00 .083.22.70.5 Others00 .031.20.80.4 Place of residenceSeigu/fish Wara116 .77329.331.21.9 Asariyufa116 .76224.926.31.4 North Goroka116 .73514.111.13.0 Kama116 .7124.82.62.2 Lofi/Faniyufa116 .7239.27.12.1 Waterise116 .73212.915.52.6 Others00 .0124.85.70.9 In some areas of Port Moresby two seeds were chosen : one seed was a younger FSWs while the other was an older one . Formative research had shown that the younger and older FSWs in some locations did not mix socially and therefore could be considered as separate populations . In other areas only one seed was used as in these areas the younger and older FSWs mixed together socially . The eligibility criteria for the selection of FSWs seeds as well as their subsequent recruits were defined as `` a female over the age of 16 who has exchanged sex for money or other goods and services in the last 12 months and is not drunk at the time of the interview . '' For the MSM study in Port Moresby we also attempted to recruit a diverse set of seeds based on self -- identified sexual orientation and region of origin . Seeds were recruited through SCiPNG , which had recently initiated a peer education program with MSM . The peer educators in the project also worked as interviewers for the research . These men tended to recruit MSM seeds from their own social group . As a result , eight of the ten seeds used were self -- identified as homosexual , and seven of the ten were from the southern region , which was the site of the research . As we will report later , the biases inherent within the initial group of MSM seeds were not present in the final sample population , in line with RDS theory . The eligibility criteria for the selection of the MSM seeds as well as their subsequent recruits were defined as `` a man over the age of 16 who has had sex with another man in the last 12 months and is not drunk at the time of the interview . '' In none of the three study groups was it found necessary to add additional seeds during the course of the study . Incentives Seeds and their recruits were offered monetary incentives as well as gift bags containing pamphlets , posters , free condoms and lubricant . Participants in Port Moresby were given 20 PNG Kina -LRB- K20 , equal to U.S. $ 6.00 -RRB- for successfully participating in the study and K10 -LRB- U.S. $ 3.00 -RRB- each for every successfully recruited peer . The FSWs in Goroka were given K10 -LRB- U.S. $ 3.00 -RRB- for participating and K5 -LRB- U.S. $ 1.50 -RRB- for every successful recruitment made . The amount for incentive was less in Goroka because of the lower cost of living there compared to Port Moresby . Interviews and Setting As part of the RDS field work in Port Moresby , the research team rented two private properties situated in secluded locations of the city . The FSWs study in Goroka was also carried out at a private property in a residential part of town . Data was collected by trained interviewers who were MSM and FSWs themselves and was directly supervised by the principal investigators . All interviews took place in private rooms with only the interviewer and subject present . The secure nature of the locations used also allowed the research staff to exclude non -- participants from the sites while recruitment and interviews were taking place . Participants gave witnessed verbal consent to be part of the study . Interviews were conducted using a structured questionnaire . Information obtained included demographics , sexual behaviour , drug and alcohol use , knowledge and use of male and female condoms , knowledge and attitudes towards HIV/AIDS and STI , history and treatment seeking behaviour of STI , experience with stigma and discrimination , and exposure to intervention programs . The MSM interviews included information about their sexual orientation . Additional information was collected that was specifically required for RDS methodology : personal network size , relationships to recruiters , and the number of recruitment refusals encountered . Sample Sizes A total of 245 and 249 FSWs were interviewed in Port Moresby and Goroka , respectively . For the MSM study in Port Moresby , a total of 225 MSM participants were interviewed . A total of 471 and 621 coupons were given out to 157 and 207 FSWs in Port Moresby and Goroka , respectively , while 603 coupons were given out to 201 MSM . Participants in all sites were told in advance that recruitment would stop when the desired sample size was reached . Participants who had lost a coupon were not given any additional ones . Failure to meet the eligibility criteria resulted in 15 females -LRB- four from Goroka -RRB- and 35 males being refused participation in the study . Half of the women who were excluded in Port Moresby were under 16 years of age , while the other half were excluded because they reported that they had never sold sex . The four FSWs that were excluded in Goroka were all under 16 years of age . The bulk of the men that were excluded from the MSM study -LRB- 33 -RRB- did not meet the criteria of having had sex with another man in the previous 12 months , while two others were excluded for trying to repeat the interview . Data Analysis Methods Data was double entered using Microsoft FoxPro 2.6 and analysed using Stata 8.0 -LRB- Stata Corporation , Texas , USA -RRB- , RDS Analysis Tool -LRB- RDSAT , Cornell University , NY , USA -RRB- and EpiInfo 6.04 -LRB- CDC , USA and WHO , Geneva -RRB- . Adjusted analysis was carried out using RDSAT on single categorical variables whereas bivariate and multivariate analysis was done using EpiInfo and Stata . RDSAT adjusts the analysis of population estimates by taking into consideration the links between the recruiters and their recruits as well as their reported personal network sizes .11,12 A detailed description of the methods of calculation is beyond the scope of this paper . Some Key Results Of the 157 and 207 FSWs in Port Moresby and Goroka that were given coupons , 56.7 and 42.0 % , respectively , recruited one or more of their peers into the study . For the MSM study , 57.2 % of the 201 participants that were given coupons recruited one or more peers . Two questions were asked with regards to the number of coupons given out and the number of refusals encountered by each recruiter to determine refusal rates . However , the research assistants did not consistently record the answers to these questions . Nevertheless , the refusal rates appeared to be very low as indicated by the fact that 74.2 and 85.1 % of the FSWs recruiters who successfully recruited other participants in Port Moresby and Goroka returned all three coupons . Of the successful MSM recruiters , 52.2 % of them had all three coupons returned , 35.6 % had two coupons returned and 12.2 % had one coupon returned . Half of the MSM seeds -LRB- five -RRB- did not recruit any peers while three FSWs seeds -LRB- two from Port Moresby -RRB- did not recruit any peer . It took a median of 4 days -LRB- Range = 1 -- 12 -RRB- and 3.5 days -LRB- Range = 1 -- 10 -RRB- for a coupon to be returned by FSWs in Port Moresby and Goroka , respectively . MSM returned the coupon at a median of 3 days -LRB- range = 1 -- 18 -RRB- . For both the FSWs and MSM , however , recruitment occurred at a much faster rate than had been anticipated and recruits presented to the study locations faster than they could be interviewed . It became necessary to slow down recruitment by scheduling interviews each day on a first -- come first -- served basis . Those that could not be interviewed the day they first presented were scheduled for the next day . Eventually the recruiters were told to bring their recruits in on specified dates in order to control the flow of new subjects to the study sites . The fast rate of recruitment for the three subpopulations enabled the sample sizes for FSWs in Port Moresby and Goroka to be reached in 17 and 20 days , respectively , while the sample size for MSM was reached in 22 days . The main sociodemographic characteristics of the seeds and the overall samples for the three studies are presented in Tables 1 , 2 and 3 . Comparisons between the RDSAT -- adjusted and crude analyses are given as well . Table 3Socio -- demographic characteristics of MSM in Port Moresby SeedsSample -LRB- n = 10 -RRB- Percent -LRB- n = 225 -RRB- Crude -LRB- % -RRB- RDSAT -- adjusted -LRB- % -RRB- Absol . diff -LRB- % -RRB- Age16 -- 19220.04921.820.81.020 -- 24110.08136.038.12.125 -- 29660.06026.727.71.030 +110.03515.613.22.4 Education levelNo formal education00 .0125.36.71.4 Primary00 .08738.749.510.8 Secondary660 .06930.740.49.7 Secondary440 .0156.73.13.6 Employment statusUnemployed220 .012054.052.02.0 Employed330 .02913.011.02.0 Self -- employed550 .06931.035.04.0 Students00 .042.02.00.0 Region of birthHighlands220 .03314.723.99.2 Southern -- gulf only110 .011450.754.13.4 Southern -- others660 .04821.310.710.6 New Guinea islands00 .0104.44.80.4 Momase110 .0208.96.32.6 Sexual orientationHeterosexual110 .02912.910.02.9 Gay/homosexual880 .06528.923.05.9 Bisexual110 .013158.267.08.8 Paid by man for sexYes990 .016975.170.74.4 No110 .05624.929.24.3 The results for the FSWs study in Port Moresby show that , while the seeds where roughly comparable to the overall sample , there were still some major differences with regard to educational status and region of birth . For the FSWs study in Goroka , there was less variation between the seeds and final sample -LRB- Table 2 -RRB- , although the seeds tended to be older than overall sample . The most striking differences between the initially selected seeds and the final sample were found for the MSM study in Port Moresby -LRB- Table 3 -RRB- . The final sample was younger , less educated , and more often unemployed . In addition , while the majority of the seeds -LRB- 80 % -RRB- were gay identified , less than a third of the final sample self -- identified as homosexual and the majority of the final sample self -- identified as bisexual . For all three studies -LRB- Tables 1 , 2 and 3 -RRB- , a common pattern in the findings that emerged with regard to comparisons of the characteristics of seeds and final samples , was that the overall sample was of lower socioeconomic status -LRB- especially for the MSM study -RRB- . This suggests that RDS is able to penetrate `` hidden '' populations that are often very different from the initially selected seeds . In terms of the comparisons between the RDSAT -- adjusted and crude analysis in Tables 1 , 2 and 3 , the greatest variations between the two analyses -LRB- as measured by the percent of absolute difference -RRB- were found for FSWs in Port Moresby . This was especially true with regard to place of residence , where up to 24.4 % differences were found for the ones that reside in one part of the city -LRB- Table 1 -RRB- . For FSWs in Goroka , considerably less variation was found with absolute differences ranging from 0 to 3.2 % -LRB- Table 2 -RRB- . For the MSM study , some considerable differences were also seen and absolute differences ranged from 0 to 10.8 % . The results presented in Tables 4 and 5 were an attempt to understand the potential differences in respondent characteristics that would have existed between RDS and TLS , had this latter sampling method been used instead of RDS . The hypothetical TLS group for this analysis included FSWs and MSM respondents who reported that they ` always ' looked for and met their sexual partners in visible locations that would have been likely included in a TLS sampling frame -LRB- i.e. , nightclubs , bars , hotels , guesthouses and identifiable public venues -RRB- . The results shown in Table 4 indicate that the RDS samples for FSWs in both Port Moresby and Goroka were younger and less educated than the hypothetical TLS group . While reported condom use with clients was similar between the RDS and TLS groups , reported condom use with non -- paying partners was substantially lower among the RDS group . On the other hand , forced sex , knowledge , and reported STI symptoms were higher in the TLS group . Analysis of the key program exposure variable , contacted by peer educator , also revealed that program exposure was substantially lower among the RDS sample than hypothetical TLS sample . The analysis of the MSM study population in Port Moresby -LRB- Table 5 -RRB- showed striking differences in almost all variables examined . In comparison to the hypothetical TLS group , the RDS group was older , less educated , more likely to be unemployed , more likely to identify their sexual orientation as heterosexual or bisexual and less likely to use condoms for partnerships examined . This group was also less likely to use lubricant during anal sex and less likely to have been exposed to HIV prevention programming . On the other hand , the hypothetical TLS group was more likely to report forced sex , incidents of discrimination and symptoms of STIs . Table 4RDS versus hypothesized TLS estimates of key indicators for FSWsKey indicatorsPort Moresby -LRB- % -RRB- Goroka -LRB- % -RRB- RDSa -LRB- n = 235 -RRB- TLS -LRB- n = 103 -RRB- RDSa -LRB- n = 227 -RRB- TLS -LRB- n = 165 -RRB- Age16 -- 2443.636.951.949.725 +56.263.147.950.3 Education levelNo formal education26 .621.435.830.1 Primary47 .553.343.244.6 Secondary22 .224.322.024.1 Used condom with client at last sex86 .088.279.077.7 Used condom consistently with clientc62 .661.231.331.3 Used condom with non -- paying partner at last sex48 .375.743.062.0 Used condom consistently with non -- paying partnerc33 .548.716.026.0 Forced to have sexb58 .466.766.570.5 Thinks mosquitos can transmit HIV37 .150.030.736.1 Had vaginal dischargeb43 .253.428.637.4 Had sore in/around vaginab20 .524.312.119.4 Never contacted by peerb educator24 .418.540.939.6 aRDSAT adjustedbIn the last 12 monthscIn the last 4 weeksTable 5RDS versus hypothesized TLS estimates of key indicators for MSM It is important to note that the observed differences between the two groups in Tables 4 and 5 would have been even more pronounced if the comparisons had been made between the mutually exclusive categories -- the hypothetical TLS group and the RDS group restricted to respondents who would likely not have been sampled using TLS . Discussion of the Lessons Learned Sampling procedures should be capable of reaching all members of the population or subpopulation under surveillance in order to produce unbiased estimates of trends in HIV behavioural risks .12 In this respect , RDS was chosen to study the three subpopulations of interest in PNG after carefully considering its advantages and disadvantages for each target group . Many factors prompted us to opt for RDS instead of other sampling methods . For MSM , the main reasons why other sampling methods would not be adequate were that most of them were hidden due to social stigma and that no public venues existed to use as a sampling frame for TLS . For the FSWs , creation of a sampling frame for random sampling or TLS would be difficult and costly given their very high mobility and the illegal nature of sex work in PNG . For all three target groups in both locations , security for both the subjects and the research staff was a major concern . This is an issue specific to PNG , but may also be an important issue in other developing countries with unstable economic and political situations . The ability to conduct interviews in a private and secure location during the daytime and have potential subjects come directly to the study location after being recruited by previous respondents was a major advantage of RDS in this study . In PNG , it would have been difficult to have ensured the safety of the research staff if they had to go out into the field at night time or may have required hiring security guards at considerable expense . RDS has been described by those studying more the difficult sub -- population of illicit drug users as a flexible and robust method that can produce a sample representative of the heterogeneity of the target population .16 We had a similar experience in implementing RDS among FSWs and MSM in a developing country . Although our original seeds were not as diverse as we intended them to be , a comparison of the seeds versus the final sample -LRB- Tables 1 , 2 and 3 -RRB- shows that by using RDS , the characteristics of the final samples were often quite different from the initially selected seeds . Particularly striking was our finding that the overall samples in all three subpopulations were mainly lower socio -- economic status . A comparison of the RDSAT -- adjusted versus the crude estimates of the various socio -- demographic characteristics -LRB- Tables 1 , 2 and 3 -RRB- showed mostly little variation . The rapid rate of recruitment among all subpopulations suggests that the dual incentive system did work exceptionally well . We observed that the majority of the recruiters accompanied their recruits to the interview site . The reason for this was most likely that the recruiters wanted to collect their recruitment incentives immediately , but it also ensured that many of the recruited persons did in fact show up at the study sites in a relatively short amount of time . Not one FSWs or MSM subject used the phone number printed on the coupon to make an appointment . Telephone charges are relatively expensive , and mobile phones are not widespread among the general population in PNG . Therefore , it may have been easier and less expensive for recruits to simply show up at the research site than to have called ahead for an appointment . Thus the use of a telephone call to make appointments may not be necessary in this country in any future application of RDS for these or similar populations . The results of the comparisons between the RDS and hypothetical TLS samples -LRB- Tables 4 and 5 -RRB- suggest that RDS allowed for greater penetration and representation of more vulnerable segments of the FSWs and MSM target populations . The use of dual financial incentives associated with RDS is also believed to have been important for reaching less educated and unemployed segments of the FSWs and MSM populations because they were more likely to find this a motivating factor for participation . During the RDS field work , it was observed anecdotally that the more economically desperate participants with ample disposable time were more likely to try to recruit individuals who did not meet the study eligibility criteria . Careful planning , staff training , and preparation for the field work enabled us to handle the onslaught of recruits and ensure the smooth implementation of RDS among FSWs and MSM in Papua New Guinea . The procedures checklist13 and practicing with the coupon management system were particularly important in preparing for the research . We agree with the view expressed by others that RDS is relatively easy to implement and less costly in that it did not require exhaustive mapping exercise to construct sampling frames .2,16 In our experience , the dual incentive system of RDS helped to reduce non -- response rates and fuelled recruitment .13 Finally , in this study we relied on others to help select the original seeds . Some of the seeds failed to recruit any additional subjects . Half of the MSM seeds recommended to us simply did not recruit any other MSM , indicating that the recruitment of initial seeds in this study was not very effective . Problems were also encountered with potential recruits who misrepresented themselves in attempts to participate in the study in order to earn money . This was especially true in the MSM study , where many men who were not really MSM tried to participate . Similarly , a number of underage girls were refused entry into the study . This problem most likely resulted from the dual incentive system , in which a participant could potentially earn up to U.S. $ 15.00 , a significant sum in a poor country like PNG . However , the screening and interview process in place was sufficient to track and preclude repeat participation or recruitment of individuals who did not meet the inclusion criteria . For this study among FSWs and MSM in PNG , using RDS as the sampling methodology had numerous advantages in terms of collecting the required sample size in a short time period , minimizing study costs , and resulting in representative estimates of the target populations . Although there were a few problems in implementing a new research method in a resource -- poor setting , these were easily remedied , and we would recommend RDS for similar studies in PNG and other developing nations .

O O O O B O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O B I I I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I I I O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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Promising Practices in Preconception Care for Women at Risk for Poor Health and Pregnancy Outcomes Objectives : Two programs targeting urban African-American women are presented as promising models for preconception care , which includes interconception care . Methods : The Grady Memorial Hospital Interpregnancy Care -LRB- IPC -RRB- Program in Atlanta , Georgia , and the Magnolia Project in Jacksonville , Florida , are described . The IPC program aims to investigate whether IPC can improve the health status , pregnancy planning and child spacing of women at risk of recurrent very low birthweight -LRB- VLBW -RRB- . The Magnolia Project aims to reduce key risks in women of childbearing age , such as lack of family planning and repeat sexually transmitted diseases -LRB- STDs -RRB- , through its case management activities . Results : Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease . 21/21 women developed a reproductive plan for themselves , and none of the 21 women became pregnant within nine months following the birth of their VLBW baby . The Magnolia Project had a success rate of greater than 70 % in resolving the key risks -LRB- lack of family planning , repeat STDs -RRB- among case management participants . The black to white infant mortality -LRB- IM -RRB- ratio was better for the babies born to women managed in the Magnolia Project compared to the same ration for the United States . Conclusions : Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate . Outreach to women at risk and case management can be effective in optimizing the woman 's health and subsequent reproductive health outcomes . Introduction Current national level statistics demonstrate the potential for preconception care to improve the health of women and impact their reproductive health outcomes in terms of achieving optimally spaced , planned pregnancies and averting adverse birth outcomes . Each year in the United States , approximately 6 million pregnancies result in over 4 million live births . Almost half of all pregnancies are unintended , despite the fact that 62 % of the 62 million women of reproductive age use a contraceptive method -LSB- 1 -RSB- . Chronic diseases and adverse health behavior known to affect pregnancy outcomes are prevalent among women of reproductive age -LRB- 15 -- 44 years -RRB- . In 2002 , 9.3 % of women of reproductive age had diabetes , and 11.4 % of pregnant women smoked tobacco and 10.1 % of pregnant women consumed alcohol -LSB- 2 -RSB- . The U.S. Public Health Service has designated preconception care as a critical component of prenatal care -LSB- 3 -RSB- . Initiating interventions to address a woman 's health risks upon her entry into prenatal care is often too late to impact the outcome of pregnancy . For example , if a woman has her first prenatal visit after the first month of pregnancy , it is too late to prescribe folic acid supplementation to help prevent neural tube defects as the neural tube closes by the 28th day of gestation . Likewise , women who are advised to discontinue their use of potentially teratogenic medications at the first prenatal visit may have already sustained damage to the fetus , as most organogenesis is complete by day 56 following conception -LSB- 4 -RSB- . Preconception care is the care of women of reproductive age before a first pregnancy or between pregnancies -LRB- commonly known as interconception care -RRB- to ensure that conditions and behaviors which may pose a risk to mothers and infants are identified and managed . A specific element of interconception care is the identification and reduction of risks indicated by a prior adverse pregnancy outcome . The major components of preconception care are risk assessment -LRB- identification of conditions that may be amenable to intervention that adversely affect reproductive health outcomes -RRB- , education and health promotion , and medical and psychosocial interventions . There are varying concepts of preconception care ranging from a pre-pregnancy planning visit in the months prior to conception to a component of each health encounter for women . Ideally , preconception care would be an integral component of primary and preventive care for women of reproductive age . Presently , the status of preconception care in the United States is far from ideal . Approximately one of six obstetrician/gynecologists or family physicians had provided preconception care to the majority of the women for whom they provided prenatal care -LSB- 5 -RSB- . Given the diversity of women of reproductive age , the numerous health and psychosocial issues that impact reproductive health outcomes and the varied settings for delivery of health care , a single ` best ' model of preconception care for all women is unlikely . Rather , tailoring the delivery of preconception care interventions to women with specific circumstances and in specific care settings will be necessary . This paper describes two programs for delivering preconception care for women at-risk for poor health and pregnancy outcomes . One targets women whose risk status is defined by African-American ethnicity and delivery of a very low birth weight -LRB- VLBW ; < 1500 g -RRB- infant and , thus , specifically involves the provision of an interconception intervention . The other program targets women whose risk status is defined by African-American ethnicity and residence in Jacksonville-Duvall County , Florida , and involves the delivery of an intervention with preconception and interconception components . The grady memorial hospital Interpregnancy Care -LRB- IPC -RRB- program Background Georgia ranks among the 10 states with the highest feto-infant mortality rate . The largest contributor to Georgia 's comparatively high feto-infant mortality is the delivery of VLBW infants . VLBW delivery comprises only 2 % of births in Georgia , yet accounts for approximately 50 % of feto-infant mortality . African-American women in Georgia have 3 -- 4 times the rate of VLBW delivery compared to whites . Approximately 66 % of the observed racial disparity in feto-infant mortality rates between African-Americans and whites can be attributed to the higher rate of VLBW delivery among African-American women -LSB- 6 -RSB- . There is a close link between the poor health status of women and VLBW delivery -LSB- 7 -- 17 -RSB- . The poor health status of women in Georgia is estimated to account for approximately 60 % of Georgia 's excessive infant mortality -LSB- 18 -RSB- . With each subsequent VLBW delivery , there is an increased chance that the woman 's next pregnancy will result in recurrence of VLBW delivery -LSB- 19 -RSB- . In fact , the best predictor of whether a woman will have a VLBW delivery is her history of a previous VLBW delivery , with the rates of recurrence after a single VLBW delivery being approximately 1.5 times higher for African-American compared to white women -LRB- 13.4 % vs. 8.2 % , respectively , for non-teen mothers ; 26.8 % vs. 16.4 % , respectively , for teen mothers -RRB- . The reason for recurrence of VLBW delivery is likely that aspects of the woman 's pre-existing health status -- including untreated or poorly managed medical problems and unaddressed nutritional , social , and behavioral risk factors -- that may have contributed to delivery of the VLBW delivery persist after delivery and in subsequent pregnancies . In 1998 the Georgia Task Force on Perinatal Care was convened to make recommendations for reducing Georgia 's overall feto-infant mortality rate and racial disparities in feto-infant mortality . From its findings as outlined above , the Task Force specifically recommended that interpregnancy care be initiated and evaluated for women at risk for having recurrence of VLBW delivery . The Grady Memorial Hospital Interpregnancy Care -LRB- IPC -RRB- Program was initiated in response to the recommendation of the Task Force . Target population African-American women residing in Fulton or DeKalb counties , Georgia who qualify for county-supported indigent care services and who deliver liveborn or stillborn VLBW infants at Grady Memorial Hospital in Atlanta are considered eligible for the IPC program . Program description The Grady Memorial Hospital IPC program provides 24 months of integrated primary health care and dental services through enhanced nurse case management and community outreach via a Resource Mother . The Resource Mother is a layperson who is trained by the Fulton County Health Department using a specific set of objectives to facilitate life skills and health education acquisition to support high-risk women . The nurse case manager offers all women who deliver a VLBW -LRB- stillborn or liveborn -RRB- infant at Grady Memorial Hospital enrollment in the program during or soon after their delivery admission . Women who choose to enroll in the IPC program have their initial home visit with the Resource Mother within 1 -- 2 weeks of discharge from the delivery admission ; they are scheduled for their initial IPC clinical evaluation at a clinic within Grady Memorial Hospital at 4 -- 6 weeks postpartum . At the initial IPC clinical evaluation , the IPC program 's family physician or nurse - midwife performs a comprehensive survey of medical , obstetrical , nutritional , psychological , and social issues -LRB- using standardized assessment tools -RRB- ; a thorough physical examination including pelvic exam ; and laboratory evaluations to screen for anemia , nutritional deficiencies , sexually transmitted diseases -LRB- STDs -RRB- and reproductive tract infections . Standard postpartum care issues are addressed in the initial IPC clinical evaluation , thus eliminating a separate postpartum appointment . As part of the evaluation , the participant and provider explicitly discuss a care plan for the 24-month period of the program . For each woman , the care plan addresses the following seven areas epidemiologically linked to LBW delivery : 1 -RRB- Pregnancy intendedness and child-spacing through the provision of health education concerning the importance of achieving at least a 9-month -LRB- and preferably an 18-month -RRB- interpregnancy interval , assisting the woman to articulate her own reproductive plan and select a corresponding contraceptive method ; 2 -RRB- Management of chronic disease -LRB- if present -RRB- through the promotion of self-care and adherence to scheduled appointments in Grady Health System that are facilitated by nurse case management ; 3 -RRB- Screening and treatment for nutritional deficiencies ; 4 -RRB- Prevention , screening , and treatment for STDs and reproductive tract infections ; 5 -RRB- Treatment and referral for substance abuse -LRB- if present -RRB- including linkage with rehabilitation programs for illicit substance abuse , and support in and linkage with existing programs for tobacco and alcohol abuse ; 6 -RRB- Screening and treatment or support for depression , psychosocial stressors , and domestic violence ; 7 -RRB- Prevention , screening and treatment for periodontal disease . Subsequent visits to the IPC clinic are offered every 1 -- 3 months , depending upon the extent and severity of the woman 's health and social issues . Elements of the care plan are addressed at each subsequent visit to the IPC clinic . Peer group learning experiences are integrated with IPC health care visits and are modeled on the Centering Pregnancy concept of group prenatal care -LSB- 20 -RSB- . Resource Mother support services are focused on identification and management of psychosocial stressors , and life skills enhancement , including parenthood preparedness , safe housing , skills training , employment acquisition , and relationship issues . Resource Mother support is offered at least twice monthly in the form of home visits and telephone contact . Participants are able to contact the Resource Mother via her cell phone to request support , if needed . Providers Primary care and outreach services are delivered by a multidisciplinary team comprised of a family physician , an advanced practice nurse trained as both a nurse midwife and a family nurse practitioner , a periodontist , a nurse case manager , and a Resource Mother . Social workers affiliated with Grady Health System also support the IPC program and interface with the IPC team . Outcome objectives The purpose of the Grady Memorial Hospital IPC program is to investigate whether interpregnancy care can improve the health status , pregnancy planning and child spacing of women at risk of recurrent VLBW delivery . Findings will contribute to the field of primary health care of reproductive age women in several important ways : -LRB- a -RRB- the content of a successful IPC package for improving the health of high-risk women will be explored ; -LRB- b -RRB- the concept of IPC will be tested as a means of improving attainment of desirable interpregnancy intervals and decreasing the occurrence of subsequent adverse pregnancy outcomes for high-risk women ; -LRB- c -RRB- the cost of providing IPC to high-risk women will be studied . Funding The health care services rendered to IPC participants were provided through the services of the Grady Health System . Funding for the research and evaluation components of the IPC Program , including Vasser-Wooley Foundation , Healthcare Georgia Foundation , Centers for Disease Control and Prevention -LRB- CDC -RRB- , Rockdale Foundation , and March of Dimes . Results from the first year of the IPC program Enrollment During November 2003 through March 2004 , the feasibility phase of the IPC program was initiated by enrolling the first sequential 29 eligible women who gave their informed consent for participation . During the enrollment period , a total of 47 women delivered VLBW infants at Grady Memorial Hospital . Of these 47 women , nine were not African-American or did not reside in Fulton or DeKalb counties , four declined enrollment , three who wished to be contacted afterdischarge from the hospital were unable to be contacted , and two were discharged from the hospital within 24 h and before being offered enrollment . Participation Twenty-one of 29 enrolled women -LRB- 72.4 % -RRB- successfully completed the initial 12 months of the planned 24 months of follow-up . During the first 12 months , eight women became disenrolled from the program two moved out of state -LRB- and informed us of their move -RRB- , three electively disenrolled -LRB- two before prior to the initial home visit and the initial IPC clinical evaluation ; one after a single IPC clinic visit -RRB- , and three became lost to follow-up -LRB- two before the initial IPC clinical evaluation ; one after a single IPC clinic visit and four home visits -RRB- all of whom who had noted problems with cocaine abuse in their medical records during their pregnancy . Outcomes A detailed program description and final results for all evaluated outcomes for the full 24 months of follow-up will be published when all follow-up and outcome ascertainment is complete -LRB- anticipated June 2006 -RRB- . Important findings related to the health status of women in the IPC intervention cohort who had at least two visits during the first 12 months of IPC are given below : Chronic diseases that were previously unrecognized or poorly managed were identified for 7/21 participants , and include valvular heart disease -LRB- 1/21 -RRB- , sickle cell anemia -LRB- 1/21 -RRB- , hypertension -LRB- 2/21 -RRB- , diabetes -LRB- 1/21 -RRB- , asthma -LRB- 1/21 -RRB- , systemic lupus erythematosus -LRB- 1/21 -RRB- , prolactinoma -LRB- 1/21 -RRB- , panic attacks -LRB- 1/21 -RRB- , and generalized anxiety disorder -LRB- 1/21 -RRB- ; Reproductive tract infections were diagnosed and treated for 15/21 participants ; Iron-deficiency anemia was diagnosed and treated for 5/21 participants ; Concerns about finances , employment , and needs of the child are almost universal stressors ; Average annual outpatient charges per participant for IPC are $ 1,801 -LRB- average 4.6 visits , $ 389 per visit -RRB- . Important findings related to the reproductive outcomes during the first 12 months of IPC are as follows : With extensive case management and patient education , 21/21 women who had at least two visits during their first 12 months of IPC , stated a reproductive plan for themselves and initiated a contraceptive plan in accordance with their stated reproductive plan . Despite a stated desire to either avoid or delay a pregnancy -LRB- 21/21 women -RRB- , a significant number of barriers to effective contraception existed and were dealt with , including misinformation about contraceptive methods and reproduction , concerns about side effects of contraceptive methods , and perceptions of partners ' desires regarding child bearing and contraception.All of the women who had at least two visits during their first 12 months of IPC -LRB- 21/21 -RRB- achieved at least a nine-month interpregnancy interval -LRB- i.e. , none have become pregnancy within nine months of the index VLBW delivery -RRB- . For the 21 actively participating women , pregnancy ascertainment involved ongoing contact with the women and reviewing the Grady Healthy System medical record system for any evidence of health care visits or laboratory tests in which a pregnancy was diagnosed , incidentally noted , or treated . No pregnancies are known to have occurred within nine months of the index VLBW delivery for the eight women who became disenrolled , for which pregnancy ascertainment involved telephone follow-up , where possible -LRB- two women -RRB- , and review of the Grady Health System medical record system . It is possible that those women with whom contact was lost have had a pregnancy for which no care was sought or care was sought outside of Grady Health System . Barriers In the United States , a major barrier to studying the impact of interpregnancy care on the health status and reproductive outcomes of high-risk women has been the lack of financial coverage for the health care component of the IPC intervention . For the IPC program in Atlanta , the Grady Health System has provided the two years of primary health care and treatment of all identified diseases for all enrollees . Specific barriers exist for retaining participation in the IPC program . Women with substance abuse problems who do not enroll in formal substance abuse treatment programs are difficult to maintain in the IPC program . These women seem to have poor insight into the effects that substance abuse has on their repeated poor pregnancy outcomes . For some enrolled women , receiving health care services is less of a priority than securing employment , which negatively influences their health care seeking behaviors . Next steps Upon conclusion of the planned 24 months of follow-up , the final results for all evaluated outcome objectives from the feasibility phase will be reported . The IPC program is currently seeking grant support to conduct a randomized clinical trial to test the hypothesis of whether IPC can decrease the occurrence of subsequent adverse pregnancy outcomes for pregnancies conceived within 18 months of a VLBW delivery at Grady Memorial Hospital . The project plans to enhance participant retention by offering more opportunities for life skills enhancement , job training , and delivery of health care services via the community-based Grady Neighborhood Health Centers . The magnolia project Background In 1998 , infant mortality rates in Jacksonville-Duval County , Florida were increasing while statewide rates were declining . The Northeast Florida Healthy Start Coalition , Duval County Health Department and other community partners undertook a community assessment and identified racial disparities as a major factor contributing to the city 's high infant mortality . The Coalition utilized the Perinatal Periods of Risk -LRB- PPOR -RRB- and findings from its Fetal & Infant Mortality Review -LRB- FIMR -RRB- project to analyze linked birth and death data . The results of this analysis indicated the need for interventions that focused on the health of women , particularly African-American women , before conception . The Coalition used this information to apply for federal Healthy Start funding under a 1999 initiative to address racial disparities in birth outcomes . This funding was used to establish The Magnolia Project , which adapts selected Healthy Start program models to at-risk African-American women of childbearing age who are not pregnant , but sexually active and likely to become pregnant . The project is implemented in a five-zipcode area of Jacksonville-Duval County that accounts for over half of all African-American infant mortality and about 30 % of African-American births . Target population The Magnolia Project targets African-American women ages 15 -- 44 living in a socioeconomic high-risk area of Jacksonville-Duval County . The project focuses on women of childbearing age who are likely to become pregnant and have some identified risk factor associated with poor birth outcomes . The project also maintains a small caseload of pregnant women -LRB- < 10 % of patients -RRB- . Program description The Magnolia Project provides outreach , case management , risk reduction , support , well-woman prenatal care , health education , and community development . The project engages high-risk women through an empowerment model that promotes improved wellness and health , rather than future childbearing . Clinical services and health education are available to all eligible women in the target area . The project offers intensive case management to a subset of women who have specific risk factors identified through FIMR , including previous fetal or infant death or delivery of a LBW infant ; repeated STDs ; lack of family planning ; substance abuse ; first pregnancy before age 15 ; and lack of access to health care . The project 's intensive case management is a collaborative team approach that supports participants based on a comprehensive assessment and a client care and goal plan . The plan is developed in collaboration with each participant and reflects her choices , preferences , and goals for coordination of services and activities that address identified risk factors associated with infant mortality . Case management services include : A comprehensive assessment of each participant 's abilities and needs at program entry . This assessment includes completion of a problem checklist ; screening for depression and stress ; and evaluation of self-esteem . Participants are re-assessed periodically based on need and progress to determine resolution or recurrence of problems and risks , achievement of personal goals , and improvements in coping skills and self-esteem . Participant care and goal plan . This plan addresses the needs and preferences of each participant . The written plan is a collaborative process involving the participant and the case manager . It addresses health and social risks and outlines specific steps that the participant must follow to improve her health and well-being and to meet her goals for social , economic , and personal development.Ongoing monitoring and service coordination . The case management team monitors services to ensure that quality care is being provided , participants are addressing their care plans , and participants who are referred to another agency follow through and receive appropriate services . The risk profile -LRB- problem checklist -RRB- and other measures -LRB- stress , self-esteem -RRB- are updated at regular intervals -LRB- at 6 and 9 months -RRB- . Anticipatory guidance , health education and advocacy . Case management staff addresses participant risk factors , ensures compliance with services , and promotes achievement of personal goals . Educational support groups are organized monthly . Women receive an incentive -LRB- $ 50 gift certificate -RRB- for each six months that they remain in the program , provided they have made progress in addressing their goals . Providers The clinical component of the program is staffed by a nurse-midwife and related nursing , lab and support staff . The program has a full-time health educator who provides a brief counseling intervention on key issues -LRB- e.g. , use of multivitamins , nutrition , douching , and safe sex -RRB- to every woman who comes into the clinic . The clinic serves approximately 800 women annually . A team that includes a nurse , a social worker and two specially trained paraprofessionals provides intensive case management to about 75 women a year . Community development and outreach staff , as well as members of the Magnolia Project Community Council , who are indigenous neighborhood leaders , conduct outreach and community awareness activities . The project uses a collaborative , multi-agency staffing model . The Northeast Florida Healthy Start Coalition is the grantee and project administrator . Subcontractors include the Duval County Health Department -LRB- clinical care and case management -RRB- and Shands Jacksonville , a tertiary care and teaching hospital -LRB- case management and outreach -RRB- . Staff is co-located at a storefront community site within walking distance of six public housing complexes . The University of North Florida Center for Community Initiatives serves as project evaluator . Outcome objectives The project addresses all the outcome objectives required by the Maternal and Child Health Bureau of the Health Resources and Services Administration -LRB- HRSA -RRB- regarding birth outcomes -LRB- LBW , VLBW , infant mortality , adequacy of prenatal care , etc. -RRB- . However , because the project primarily focuses on women who are not pregnant , it has developed specific outcome objectives that examine its success in reducing key risks associated with poor outcomes through its case management activities . These include lack of family planning and STDs . Specific outcome objectives have been developed to measure the program 's success in addressing participant risks identified at program entry and closure . Funding The Magnolia Project is primarily funded through a grant from the federal Healthy Start program -LRB- $ 925,000 -RRB- . Additional funding is provided through Medicaid and other third - party reimbursement for prenatal , family planning and STD services ; state categorical funding through the health department -LRB- about $ 250,000 a year -RRB- ; and smaller community grants for special projects . Total 2004 -- 2005 budget was just over $ 1 million . Results to date From 2001 to 2005 , Magnolia Project clients were predominantly African-American -LRB- 83 % -RRB- and single -LRB- 82 % -RRB- . The average age of participants was 25 years old . More than half -LRB- 55 % -RRB- had less than a high school education . Based on patient history and assessment , case management participants had an average of 7.9 risk factors or problems -LRB- current or history of -RRB- that could potentially impact a pregnancy . Seventy-two percent of all current problems were social problems -LRB- alcohol use , drug abuse , depression , family planning , housing , stress , and domestic violence -RRB- . The remainder were medical problems -LRB- anemia , diabetes , hypertension , poor nutrition , previous poor outcome , STDs -RRB- . The most common risk factors addressed in case management were family planning issues , education/training , bacterial vaginosis , repeated STDs , stress , and poor nutrition . Table 1 identifies frequency of participant risks/problems . Table 1Frequency of risks/problems , case management participants , The Magnolia Project , July 2001 -- May 2005 Risk factor/problemPercentage with history -LRB- n = 1214 -RRB- Percentage with current -LRB- n = 1727 -RRB- Social problems Family planning issues2643 .5 Job placement8 .233.0 Education/training11 .327.3 Stress8 .721.7 Housing4 .115.7 Domestic violence7 .211.3 Depression8 .211.1 No source of care6 .78.7 Lack of exercise7 .08.7 Injury prevention/safety2 .88.0 Drug abuse10 .06.7 Transportation4 .45.9 Sexual abuse7 .04.4 Alcohol abuse6 .44.1 Medical problems Bacterial vaginosis12 .930.2 Poor nutrition17 .819.3 Repeated STDs12 .416.5 Tobacco use13 .215.5 Breast health3 .911.3 Douching8 .510.8 Abnormal pap9 .59.5 Overweight11 .69.5 Source : Magnolia Project database ; compiled by UNF Center for Community Initiatives , August 2005 . Two-hundred-forty-seven participants received at least three months of case management and were closed to care because they completed their care plans , voluntarily withdrew or were lost to service . For key risk factors , case management participants were most successful in resolving or managing issues related to domestic violence -LRB- 68 % -RRB- and poor nutrition -LRB- 63 % -RRB- . The project was least successful in addressing substance abuse by participants -LRB- 31 % -RRB- . In October 2004 , the HRSA Office of Performance Review conducted a site visit and assessment of Magnolia Project outcomes and activities . Its report noted that participants receiving case management services from 2001 to 2003 successfully addressed two priority risks : 86 % of participants with family planning issues were consistently using a method at closure ; 74 % of participants with repeated STDs had no recurrent STDs at closure . Barriers Insufficient funding has limited expansion of the Magnolia Project . Existing funding streams focus primarily on pregnancy , not women 's health . The Magnolia Project has successfully cobbled together categorical funding and Medicaid reimbursement for most clinical services , however , in Duval county , the delivery of most categorically funded services remains siloed -LRB- e.g. , STDs , primary care , prenatal care -RRB- . Additionally , case management/risk assessment is not universally accepted or valued in the medical model of health care , even though many of the risk factors associated with poor outcomes are social , rather than medical , in nature . More longitudinal evaluations are needed to determine the impact of preconception intervention on pregnancy outcomes . Longitudinal evaluations are not easily incorporated into service delivery projects that rely on short-term outcomes for continued funding . Finally , although outcomes have improved in the target area since the implementation of the Magnolia Project , infant mortality rates in the overall community remain high . The project is unlikely to affect these rates because of its comparatively small reach . Next steps The Magnolia Project is aggressively seeking funding for a longitudinal evaluation . Current program evaluation is limited to an assessment of how well the project is achieving short-term objectives and objectives set by the funding agency -LRB- primarily focusing on birth outcomes for the small number of pregnant women served by the project -RRB- . The CDC recently provided support to the Duval County Health Department for the initial design and piloting of tools for a longitudinal assessment of case management participants served by the project . Additionally , the project is working to interest local providers in replicating the intervention in other at-risk areas in Jacksonville-Duval County . Funding for replication is a significant challenge . Discussion The Grady IPC program and the Magnolia project use a classic public health model of care . They identify women at known risk for an adverse outcome and attempt to alter the woman 's risk status to improve outcomes . These programs deliver aspects of preconception care to women at risk for poor health and pregnancy outcomes . The programs do , however , target different categories of high-risk African-American women and utilize different sites for contacting and interfacing with them . The IPC program identified women at risk based on race/ethnicity , qualification for charity care -LRB- based on financial status and geographic residence in two counties of metropolitan Atlanta -RRB- through Grady Memorial Hospital , and a prior poor birth outcome -LRB- VLBW delivery -RRB- . The IPC program enrolled women soon after their VLBW delivery and provided interconception care in the clinical setting of the hospital -LRB- with community outreach -RRB- . The Magnolia project serves women at risk based on race/ethnicity and residence in Jacksonville-Duval County , Florida . It provides preconception care in a community-based storefront setting with enhanced interconception care for women with a previous LBW delivery or a previous fetal or infant death . Access to the Magnolia project is enhanced by offering evening clinics and walk-in Wednesdays . Both programs deliver services via a multidisciplinary team approach , though there are differences in the exact composition of the team . Inherent in the team approach of each program is attention to participants ' physical and psychological health and social well-being . The programs emphasize several comparable intervention strategies , including community outreach via lay persons ; psychosocial support ; group education and health promotion modeled on the Centering Pregnancy philosophy of care ; and provision of health services . Both programs also emphasize the provision of family planning services for helping women achieve intendedness of any subsequently conceived pregnancy . Each program offers unique strategies as part of the interconception intervention . Because of the link between periodontal disease and preterm delivery -LRB- almost all VLBW deliveries are preterm -RRB- , the IPC program incorporates the services of a periodontist to screen and treat women . To specifically enhance particpants ' life skills , the IPC program utilizes a layperson as a Resource Mother who has undergone a tailored training program through the local department of health . A unique feature of the Magnolia Project 's approach is its reliance on indigenous neighborhood leaders -LRB- e.g. , Magnolia Project Community Council -RRB- and community-based organizations to provide outreach , community awareness , and education . The Magnolia Project also has established a partnership with the Ryan White III program for STD/HIV/AIDS screening and treatment . Both programs have had success in accessing and providing services to the specific target group of women . Women who choose not to avail themselves of the services seem to have greater socioeconomic issues , such as substance abuse and lack of housing , jobs , and childcare . Due to the magnitude of some of the problems , maintaining contact is challenging and care often is not continuous . Existing literature supports the strategy of addressing family planning to improve pregnancy outcomes . Preterm delivery , the underlying factor responsible for most LBW and VLBW deliveries , is the leading cause of neonatal mortality and among the leading causes of infant mortality . Haas and colleagues examined whether a woman 's health status and risk factors before pregnancy are associated with her risk of preterm birth , independent of risk factors that occur during pregnancy . They found that , after adjusting for sociodemographic characteristics and prepregnancy and pregnancy risk factors , women who reported poor physical function during the month before conception were nearly twice as likely to deliver preterm . The authors concluded that a broader focus on the health of women before pregnancy might improve rates of preterm birth -LSB- 21 -RSB- . In a related editorial , Goldenberg suggests that reducing smoking , depression , and stress ; treating periodontal disease and genital tract infections ; and reaching a normal weight might all be necessary to substantially reduce the risk of preterm birth -LSB- 22 -RSB- . Goldenberg advocates for a Medicaid mandate that women who have had an adverse pregnancy outcome be eligible for continued medical coverage in the postpartum period to reduce risk factors and improve health status before the next pregnancy . Data from the 1999 PRAMS survey indicate that the prevalence of unintended pregnancies in the United States ranges from 34 to 52 % with 27 to 36 % of these pregnancies being mistimed , and 6 to14 % being unwanted -LSB- 23 -RSB- . In the United States , a clear causal association between unintended pregnancy and poor pregnancy outcomes has not been established . However , women with unwanted pregnancies are at greater risk for poor pregnancy outcomes than women with wanted pregnancies . Hogue asserts that one of the key approaches to prevention of high-risk pregnancy is assuring that the pregnancy is consciously desired , with adequate attention to preconception care -LSB- 24 -RSB- . Both programs demonstrate several components essential to any successful preconception care program : identification of risk factors amenable to change by the target population ; tailored interventions for the target population ; integration of preconception care into existing services ; incorporation of family planning counseling and clinical services , health education , and community outreach . Preconception care aims to promote the health of women of reproductive age before conception and thereby improve pregnancy-related outcomes . Both the IPC program and the Magnolia Project show promise in achieving this goal for their target audiences .

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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B I O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

preconception
interconception
birth outcomes
risk reduction
family planning