Less than high school. 9 24.3. High school. 9 24.3. General equivalency. 3 8.1 diploma. Trade/technical school training. 5 13.5. Some college. 10 27.0. College ...
IAtters to the Editor
more misleading than when so-called poor-quality population-level data are analyzed. For example, when an increase in new cases of tuberculosis and incidence are examined epidemiologically, research scientists frequently point to "high risk groups" and immigrants in particular. Figure 1 shows the 3-year running average for new cases in New York City from 1977 to 1990. In a press conference about the recent post-1991 slowing of the rate of increase of new cases of tuberculosis in New York City, Dr Lee Reichman, President of the American Lung Association, said that 27% of US cases in 1992 occurred among people who recently came from developing countries. Dr Thomas Frieden, Director of the New York City Tuberculosis Control Bureau, responded with "If we want to control TB in New York City, we have to control TB in the world."2 Figure 2 shows new cases of tuberculosis in Sweden from 1974 to 1990.3 It is a mirror image of the New York City graph. Yet, Sweden takes in 100 000 legal immigrants a year, mainly from developing, high tuberculosis-incidence countries (per a conversation with P.-G. Svensson, PhD, Director, Centre for Public Health Research, September 5, 1993). Sweden's population is close to that of New York City, about 8 million. The narrow view of public health research leads to this type of safe fingerpointing, which cannot reform the public policies underlying the public health deterioration under study. Too often, methodological criticisms such as the "ecological fallacy" are aimed at population-level
References 1. Drews CD, Yeargin-Allsopp M, Murphy CC, Decoufle P. Hearing impairment among 10-year-old children: metropolitan Atlanta, 1985 through 1987. Am J Public Health.
1994;84:1154-1156. 2. Harris S, Ahlfors K, Ivarsson S, Lemmark B, Svanberg L. Congenital cytomegalovirus infection and sensorineural hearing loss. Ear Hear. 1994;5:352-355. 3. Peckham S, Stark 0, Dudgeon JA, Martin JAM, Hawkins G. Congenital cytomegalovirus infection: a cause of sensorineural hearing loss. Arch Dis Chdd 1987;62:12331237.
Lady Beetles and Public Health Research: Geographic and Population Scales The October 1993 issue of Ecology included an article on lady beetles feeding on aphids that has profound implications for public health research: it addressed the problem of geographic and studypopulation scale. The authors came to the following conclusion: Taken together, these results demonstrate that although individual lady beetle response to aphid density is extremelyweak, the cumulative effect of many individuals can produce strong population-level aggregation of lady beetles in areas of high aphid density.'
Public health ideally concerns scales of the individual, groups of individuals, and functional populations. When only individual-level attributes are examined in public health research, results may be
studies inappropriately. Methods and methodological constraints appropriate to one scale of research do not necessarily apply to all scales. Analyses, cautions, and interpretations appropriate to case/control studies of individuals or small groups may not be appropriate for regional or population-level research. Reviewers who keep large-scale studies from being published because these studies do not conform to methods appropriate to individual and small-group research hamper public policy reform. American science does more research on the population-level impacts of destroying striped bass habitat than on the population-level impacts of destroying the homes of the urban poor. Yet some of the pressing questions in public health cannot be answered by the case/control individual or small-group scale approach. For example, the question of the relationship between the inner city and the surrounding suburbs with respect to the spread of human immunodeficiency virus (HIV) infection must be analyzed on a regional basis to reveal the teleprocesses. This question looms large in the face of widely held perceptions that inner-city residents are sociogeographically sealed off from residents of the suburbs. When geographic and ecological methods were applied to the question, the answer appeared clearly: the acquired immunodeficiency syndrome (AIDS) case rate incidence of the epicenter (the inner city) determined the AIDS case rate incidence of the surrounding suburbs, as modulated by the contact rate indicated by the
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79
80
81
82
83 84 85 Middle Year
86
87
88
89
___
40.-
74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 Year
Note: "Middle year" is that of the 3 years being averaged.
Source. Data are from Raviglione et al.3
FIGURE 1-Three-year running average of new tuberculosis cases In New York City, 1977 to 1990.
May 1995, Vol. 85, No. 5
FIGURE 2-Annual new tuberculosis cases in Sweden, 1974 to 1990.
American Journal of Public Health 735
Letters to the Editor
percentage of workers who commute to the city.4 In the absence of a better balance of the public health science literature, bizarre decisions rule the public policy arena. In 1979, I warned the New York City Department of Health in a paper (which was eventually published in 19845) that, in light of the vast destruction of poor people's housing in New York City, the possibility of a resurgence of tuberculosis should be considered seriously. The warning was discounted on the explicitly stated assumption that the appropriate focus was on individuals at high risk of tuberculosis, typically middle-aged to elderly Black men in Central Harlem who had been infected in their original homes in the South. We need to move beyond fingerpointing at "risk groups" with little or no regard to contexts at the various scales. Without a change in publication patterns, we will still be without effective contextoriented public policy for another 15 years. We will still be counting how many lady beetles dance on a single stem. O Deborah WaIlace, PhD
Requests for reprints should be sent to Deborah Wallace, PhD, Consumers Union, 101 Truman Ave, Yonkers, NY 10703.
References 1. Ives A, Kareiva P, Perry R. Response of a predator to variation in prey density at three hierarchical scales: lady beetles feeding on aphids. Ecology. 1993;74:1929-1938. 2. Garrett L. TB epidemic slows in city. New YorkNewsday. October 22, 1993. 3. Raviglione M, Sudre P, Esteves K, Spinaci S, Kochi A, Rieder H. TuberculosisWestern Europe, 1974-1991. MMAR 1993; 42:628-631. 4. Wallace R, Wallace D. The coming crisis of public health in the suburbs. Milbank Q. 1993;71:543-564. 5. Wallace D, Wallace R. Structural fire as an urban parasite: population density dependence of structural fire in New York City and its implications. Environ PlanA. 1984;16: 249-260.
Female Condom Use among Injection Drug- and Crack Cocaine-Using Women The Reality female condom is the first woman-controlled barrier method for prevention of pregnancy and sexually transmitted diseases, including human immunodeficiency virus (HIV) infection.' Although studies on the condom have supported its efficacy as a barrier 736 American Journal of Public Health
method,2-5 its acceptability by women who may be at high risk for exposure to sexually transmitted disease is unknown. Here, we report the results of a pilot study that used questionnaires and focus groups with female injection drug users and crack users to leam about their attitudes toward and experiences with female condoms. From a larger sample of 434 women participating in an acquired immunodeficiency syndrome (AIDS) research project in Dayton and Columbus, Ohio, we generated a list of women who reported the inconsistent use of male condoms. We restricted this list to inconsistent or nonusers of male condoms to avoid asking women to give up an effective barrier method with which they felt comfortable. Outreach workers then used convenience sampling techniques to recruit participants for the study. Of 46 women who were asked to participate, 37 (18 injecting drug users and 19 crack users) agreed; as reported by the outreach workers, refusals were generally based on the inconvenience of participation rather than on a stated dislike of the female condom. At baseline, subjects completed selfadministered questionnaires on drug and sex practices; they then participated in a 30-minute group session on the female condom conducted by counselor-educators. The purpose of the instructional session was to familiarize participants with the condom's effectiveness in preventing pregnancy and sexually transmitted diseases as well as to demonstrate its proper use. Educational materials used were developed by the product's manufacturer, Wisconsin Pharmacal. In addition, Ortho female pelvic models enabled participants to practice condom insertion. Women were given six female condoms (their availability at the time of the study-April 1994-being limited) and asked not to use them in place of, or together with, male condoms. Upon their return 3 weeks later, the women completed another questionnaire before engaging in hour-long focus groups. These groups were audiotaped, transcribed, and analyzed using content analysis techniques.6 Informed consents were executed. Participants were paid $10 for the first session and $15 for the second session. Table 1 highlights the sociodemographic characteristics of the sample. Of the 37 women who participated in the first session, 35 (94.6%) returned for the focus groups. Of these, 28 (80%) used the female condoms while 7 (20%) did not have an opportunity to do so. Of those
TABLE 1-Sociodemographic Characteristics of the Women Who Participated in the First Group Session (n = 37) Variable
No.
%
Marital status
Single Married Divorced/separated Widowed Ethnicity African American White
24 64.9 6 16.2 6 16.2 1 2.7
25 67.6 11 29.7 1 2.7
Other Age, y 7 18.9 20-30 19 51.4 31-40 41+ 11 29.7 Major sources of incomea 7 18.9 Salary 25 67.6 Public assistance 14 37.8 Social security Education 9 24.3 Less than high school 9 24.3 High school General equivalency 3 8.1 diploma Trade/technical school 5 13.5 training 10 27.0 Some college 1 2.7 College degree aCategories may overlap.
who used the condoms, 14 (50%) used them once, 10 (35.7%) used them twice, and 4 (14.3%) used them three or more times. Notably, 6 (21.4%) of the condom users reported getting high immediately before engaging in sex. Complaints about the female condom centered on the aesthetics of its protrusion outside the vagina, its being slippery and difficult to insert, the discomfort it produced when the male pressed its outside ring against the labia, and the quick-drying nature of the lubricant supplied with the condoms. Subjects' responses to Likert-type statements about the condom are summarized here: 20% of the women felt that, in general, the female condom was easy to use; 43% reported that it became easier to use with practice; and 14% responded that their sex partner(s) generally liked the device. More than 37% of the women perceived that the female condom gave them control in sexual situations; 20% said they would use the condoms all the time if available; 51% said they would use them with particular sex partners; and May 1995, Vol. 85, No. 5
