RESUMO
BACKGROUND: Little is known about healthcare providers' (HCPs) contraceptive views for adolescents in Haiti, who experience high rates of unintended pregnancy. We sought to describe HCPs' perspectives on barriers and facilitators to contraceptive care delivery in rural Haiti. METHODS: We conducted a cross-sectional survey and qualitative interviews with HCPs in two rural communities in Haiti from 08/2021-03/2022. We assessed demographics, clinical practice behaviors and explored contraception perspectives according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control (e.g., people's perceptions of their ability to perform a given behavior, barriers and facilitators of a behavior).15-17 We used descriptive statistics to report proportions and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through thematic inductive coding and team debriefing. RESULTS: Among 58 respondents, 90% (n = 52) were female and 53% (n = 31) were nurses. Most reported always (n = 16, 28%) or very often (n = 21, 36%) obtaining a sexual history for adolescents. A majority agreed/strongly agreed that clinicians should discuss pregnancy prevention (n = 45, 78%), high-risk sexual behaviors (n = 40, 69%), and should prescribe contraception (n = 41, 71%) to adolescents. The most frequently cited provider-level barriers (i.e., significant or somewhat of a barrier) included insufficient contraception knowledge (n = 44, 77%) and time (n = 37, 64%). HCPs were concerned about barriers at the patient-level (e.g. adolescents' fear of parental notification [n = 37, 64%], adolescents will give inaccurate information about sexual behaviors [n = 25, 43%]) and system-level (e.g. resistance to providing care from administration [n = 33, 57%]). In interviews (n = 17), HCPs generally supported contraception care for adolescents. Many HCPs echoed our quantitative findings on concerns about privacy and confidentiality. HCPs reported concerns about lack of contraception education leading to misconceptions, and community and parental judgement. HCPs expressed interest in further contraception training and resources and noted the importance of providing youth-friendly contraceptive care. CONCLUSIONS: While HCPs support contraceptive care, we identified actionable barriers to improve care for adolescents in rural Haiti. Future efforts should include increasing HCP knowledge and training, community and parent coalition building to increase contraception support and offering youth-friendly contraceptive care to offset risk for related adverse health outcomes in adolescents in rural Haiti.
Assuntos
Atitude do Pessoal de Saúde , Anticoncepção , Pessoal de Saúde , Gravidez na Adolescência , População Rural , Humanos , Feminino , Haiti , Adolescente , Gravidez , Estudos Transversais , População Rural/estatística & dados numéricos , Masculino , Adulto , Gravidez na Adolescência/prevenção & controle , Gravidez na Adolescência/psicologia , Anticoncepção/psicologia , Anticoncepção/métodos , Anticoncepção/estatística & dados numéricos , Pessoal de Saúde/psicologia , Pessoal de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Pesquisa Qualitativa , Conhecimentos, Atitudes e Prática em Saúde , Adulto Jovem , Comportamento Contraceptivo/psicologia , Comportamento Contraceptivo/estatística & dados numéricos , Inquéritos e Questionários , Gravidez não Planejada/psicologiaRESUMO
BACKGROUND: In 2015-2017, the Americas experienced a highly consequential epidemics for pregnancy and childbearing. Mainly transmitted by the mosquito Aedes aegypti, but also through sexual intercourse, the Zika virus poses the risk of congenital Zika syndrome to fetus, which includes microcephaly and other child development complications. When a public health crisis taps directly into reproductive health, typically a feminine realm, responses to the emergency may exacerbate deeply-rooted gender norms. This paper investigates the role of gender in two relational contexts: (a) the government-led response to the pandemic in terms of communication campaigns aimed at preventing Zika infections; and (b) an individual level of response to the emergency, concerning women's negotiation with their sexual partners with regard to the prevention of Zika as well as pregnancies. METHODS: We conducted content analysis of 94 unique pieces from public health communication campaigns produced by governmental agencies with the goal of promoting Zika awareness. Print and online materials were collected from May 2016 to August 2017, and included TV ads, Internet Pop-ups, and pamphlets. We also analyzed transcripts from 16 focus groups conducted with reproductive-aged women (18-40) in Belo Horizonte and Recife, two large cities differently affected by the Zika outbreak. Women answered open-ended questions connected to the epidemic, in areas such as personal knowledge and experiences with the Zika virus, experiences of their friends and acquaintances, their primary information sources, their perceptions of public health efforts toward containing the outbreak, as well as women's contraceptive use. RESULTS: Campaign pieces handling pregnancy and microcephaly were largely gendered. Pieces targeted women, placing on their shoulders the responsibility for protecting a potential fetus from the disease. Importantly, campaigns neglected addressing male's participation on Zika prevention and contraceptive management, while failing to take into account Brazil's large proportion of unplanned pregnancies. Women were placed in a double bind by being expected to prevent both pregnancy and Zika, in a context where gendered power imbalances often translate in women having little power/means for condom negotiation/avoiding unprotected sexual intercourse. CONCLUSION: Government and individual responses to the epidemics reinforced gender roles, situating pregnant women as responsible for averting mosquito bites and microcephaly. Further, prevention campaigns largely excluded men. Since low-socioeconomic status women possessed fewer resources to preclude infection, we also found that beyond the gender divide, this subgroup faced more pronounced Zika prevention challenges as they found it harder to negotiate condom use with their sexual partners and often could not access other types of contraceptives resulting in unplanned pregnancies.
Assuntos
Comportamento Contraceptivo/psicologia , Equidade de Gênero , Infecção por Zika virus/prevenção & controle , Zika virus , Adulto , Brasil/epidemiologia , Criança , Comportamento Contraceptivo/etnologia , Anticoncepcionais , Feminino , Humanos , Masculino , Gravidez , Gravidez não Planejada , Saúde Pública , Direitos Sexuais e Reprodutivos , Direitos da Mulher , Infecção por Zika virus/epidemiologiaRESUMO
INTRODUCTION: In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them. METHODS: A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews. RESULTS: Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications. CONCLUSIONS: As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.
Assuntos
Comportamento Contraceptivo/psicologia , Misoprostol/administração & dosagem , Assistência ao Paciente/métodos , Abortivos não Esteroides/administração & dosagem , Abortivos não Esteroides/uso terapêutico , Aborto Induzido/legislação & jurisprudência , Aborto Induzido/métodos , Aborto Induzido/tendências , Adulto , Colômbia , Comportamento Contraceptivo/estatística & dados numéricos , Feminino , Humanos , Misoprostol/uso terapêutico , Assistência ao Paciente/tendências , GravidezRESUMO
INTRODUCCIÓN: El cuidado anticonceptivo es importante una vez que se inicia la vida sexual, pero esto no ha sido medido en distintas realidades de Latinoamérica. OBJETIVO: Determinar los factores socio-educativos asociados al no uso de métodos anticonceptivos en universitarias de cuatro países de Latinoamérica. METODOLOGÍA: Estudio transversal analítico, se encuestó a estudiantes mujeres que ya habían iniciado su vida sexual, se le preguntó por el uso de condón (preservativo), método del ritmo, anticoncepción oral y anticoncepción oral de emergencia. Estas fueron descritas y asociadas a variables socio-educativas. RESULTADOS: El 7% (47) no usaba ninguno de los 4 métodos anticonceptivos; al realizar el análisis multivariado, no hubo diferencias estadísticamente significativas según el país, el año de estudios o si eran católicas/cristianas (todos los valores p>0,05), en cambio, las de universidades particulares tuvieron un mayor porcentaje de ausencia de uso de los 4 métodos anticonceptivos (RPa: 2,52; IC95%: 1,24-5,14; valor p=0,010). Según el uso de alguno de los 4 métodos, el país donde se encuestó tuvo muchas diferencias entre el uso de uno u otro método; el año de la carrera no estuvo asociado al no uso de alguno de los cuatro métodos; las que fueron católicas o cristianas usaron menos la anticoncepción oral (p<0,001) y las que estudiaban en universidades particulares usaron más el método del ritmo (p<0,05). CONCLUSIONES: Un porcentaje importante no usó ninguno de los cuatro métodos anticonceptivos más comunes, estando esto asociado al tipo de universidad.
INTRODUCTION: The care of contraception is important once you start the sex lives, but this hasn't been measured in different realities of Latin-America. OBJECTIVE: To determine the socio-educational factors associated with non-use of contraceptive methods in universities in four Latin American countries. METHODOLOGY: Cross-sectional study. Surveyed women students, who have started their sexual lives. They were asked about the use of condoms, rhythm method, birth control pills and next day pill. These're described and associated to variables socio-educational. RESULTS: 7% (47) did not use any of the 4 contraceptive methods; when performing the multivariate analysis, there were no statistically significant differences by country, the year of study or if they were Catholic/Christian (all values p>0.05), on the other hand, those of particular universities had a higher percentage of non- take care of yourself with one of the 4 methods (RPa: 2,52; IC95%: 1,24-5,14; value p=0,010). According to the use of one of the 4 methods, the country where it was surveyed had many differences between the use of one or the other method; the year of the degree was not associated with the non-use of any of the four methods; those who were Catholic or Christian used less oral contraception (p <0.001) and those who studied at private universities used the rhythm method more (p <0.05). CONCLUSIONS: A significant percentage did not use any of the four most common contraceptive methods, this being associated with the type of university.
Assuntos
Humanos , Feminino , Adulto Jovem , Estudantes/psicologia , Comportamento Contraceptivo/psicologia , Comportamento Contraceptivo/estatística & dados numéricos , Comportamento Sexual , Fatores Socioeconômicos , Universidades , Estudos Transversais , Análise Multivariada , Inquéritos e Questionários , Estudo Multicêntrico , Preservativos , Anticoncepção/métodos , Anticoncepção/psicologia , Anticoncepcionais , Escolaridade , América LatinaRESUMO
OBJECTIVES: to assess the relation of the locus of control with the adolescents' knowledge, attitude and practice (KAP). METHODS: this is a cross-sectional study with 1,192 high school students. Data were collected using the KAP questionnaire and the Levenson locus of control scale and analyzed by descriptive statistics, Mann-Whitney U test and Kruskal-Wallis H test. RESULTS: Women presented higher Externality Powerful Others locus of control than man (p=0.0015) and adolescents over 17, higher Externality Chance locus of control (p=<0.0001). Students who used contraceptive methods at the first contraceptive method had higher Externality Powerful Others (p=0.0107) and those who used coitus interruptus, had higher Externality Chance (p=0.0013). Internality was inversely proportional to the practice in relation to the dimensions of the locus of control. CONCLUSIONS: The dimensions of the locus of control were related to some contraceptive practices, but little or no relation to knowledge and attitude.
Assuntos
Comportamento do Adolescente/psicologia , Comportamento Contraceptivo/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Adolescente , Comportamento Contraceptivo/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Controle Interno-Externo , Masculino , Comportamento Sexual/psicologia , Inquéritos e QuestionáriosRESUMO
CONTEXT: No studies using longitudinal contraceptive histories have investigated whether having an unintended birth (i.e., one resulting from an unintended pregnancy) is associated with change in contraceptive behavior, including in Colombia and Peru, where levels of unintended fertility remain high. METHODS: Monthly reproductive history calendar data from the 2010 Colombia and 2012 Peru Demographic and Health Surveys were used to study contraceptive behavior among 13,373 and 7,425 women, respectively. Transition matrices and hazard models were utilized to identify associations between prepregnancy and postpartum contraceptive methods used, and to assess how these relationships differed between women who reported an unintended birth and those with an intended birth. RESULTS: Women who had been using a traditional, barrier or (in Colombia) short-acting hormonal method before pregnancy were more likely to choose a more effective method postpartum, than to use no method, if their birth had been unintended rather than intended (relative risk ratios, 1.2-1.3 in Colombia; 1.6 in Peru). Compared with their counterparts whose birth had been intended, women with an unintended birth who had been utilizing the most effective methods used in the country (IUD or implant in Colombia, pill or injectable in Peru) were less likely to resume using them postpartum than to use no method (0.7 in Colombia; 0.8 in Peru). CONCLUSIONS: Unintended birth is associated with change in contraceptive behavior. Efforts to understand postpartum contraceptive choices of women who have had an unintended birth should take into account contraceptive behavior at more than one point in women's reproductive lives.
RESUMEN Contexto: Ningún estudio basado en historias anticonceptivas longitudinales ha investigado si tener un parto no planeado (es decir, resultante de un embarazo no planeado) se asocia con el cambio en el comportamiento en el uso de anticonceptivos, incluso en Colombia y Perú, en donde los niveles de fecundidad no planeada siguen siendo altos. Métodos: Se utilizaron datos mensuales del calendario de historia reproductiva de las Encuestas Demográficas y de Salud de Colombia 2010 y de Perú 2012, para estudiar el comportamiento anticonceptivo de 13,373 y 7,425 mujeres, respectivamente. Se utilizaron matrices de transición y modelos de riesgo para identificar las asociaciones entre los métodos anticonceptivos usados antes del embarazo y posparto, así como para evaluar la forma en que estas relaciones diferían entre las mujeres que reportaron haber tenido un parto no planeado y aquellas con un parto planeado. Resultados: Las mujeres que habían estado usando un método hormonal tradicional, de barrera o (en Colombia) de corta duración antes del embarazo, tuvieron más probabilidades de elegir un método posparto más efectivo, en lugar de no usar ningún método, si su parto había sido no planeado en lugar de planeado (razones de riesgo relativo, 1.21.3 en Colombia; 1.6 en Perú). En comparación con sus contrapartes cuyo parto había sido planeado, las mujeres con un parto no planeado que habían estado utilizando los métodos más efectivos utilizados en el país (DIU o implante en Colombia, píldora o inyectable en Perú) tuvieron menos probabilidades de reanudar su uso que de no usar ningún método después del parto (0.7 en Colombia; 0.8 en Perú). Conclusiónes: El parto no planeado se asocia con un cambio en el comportamiento anticonceptivo. Los esfuerzos para comprender las decisiones anticonceptivas posparto de las mujeres que han tenido un parto no planeado deberían tener en cuenta el comportamiento anticonceptivo en más de un momento de la vida reproductiva de las mujeres.
RÉSUMÉ Contexte: Aucune étude de données historiques longitudinales sur la contraception n'a cherché à établir si une naissance non planifiée (résultat d'une grossesse non planifiée) était associée à un changement de comportement contraceptif, y compris en Colombie et au Pérou où les niveaux de fécondité non planifiée restent élevés. Méthodes: Les données de calendrier historique mensuel ayant trait à la reproduction, extraites des Enquêtes démographiques et de santé 2010 de Colombie et 2012 du Pérou, ont servi à l'étude du comportement contraceptif de 13 373 et 7 425 femmes, respectivement. Des tables de transition et des modèles de risque ont permis d'identifier les associations entre les méthodes contraceptives utilisées avant et après la grossesse, ainsi que d'évaluer la différence de ces rapports suivant que les femmes avaient déclaré une naissance non planifiée ou planifiée. Résultats: Les femmes qui pratiquaient une méthode traditionnelle, barrière ou (en Colombie) hormonale à courte durée d'action avant la grossesse se sont révélées plus susceptibles d'en choisir une plus efficace (plutôt que de n'en utiliser aucune) après la naissance s'il s'agissait d'une naissance non planifiée (par rapport à planifiée) (rapports de risque relatif de 1,21,3 en Colombie; 1,6 au Pérou). Par rapport à leurs homologues qui avaient eu une naissance planifiée, les femmes dont la grossesse ne l'avait pas été et qui avaient pratiqué les méthodes les plus efficaces utilisées dans le pays (stérilet/ DIU ou implant en Colombie, pilule ou injectable au Pérou) étaient moins susceptibles d'en reprendre la pratique après la naissance que de n'utiliser aucune méthode (0,7 en Colombie; 0,8 au Pérou). Conclusions: Les naissances non planifiées sont associées à un changement du comportement contraceptif. Les efforts déployés pour comprendre les choix contraceptifs post-partum des femmes qui ont eu une naissance non planifiée doivent tenir compte du comportement contraceptif à plus d'un moment de la vie reproductive des femmes.
Assuntos
Comportamento Contraceptivo/psicologia , Comportamento Contraceptivo/estatística & dados numéricos , Anticoncepção/métodos , Anticoncepção/estatística & dados numéricos , Gravidez não Planejada/fisiologia , Adolescente , Adulto , Colômbia , Anticoncepção/psicologia , Feminino , Humanos , Pessoa de Meia-Idade , Peru , Gravidez , Inquéritos e Questionários , Adulto JovemRESUMO
INTRODUCCIÓN la información sobre anticoncepción es importante antes que se inicie la vida sexual. OBJETIVO determinar el nivel de conocimiento y uso de métodos anticonceptivos por adolescentes en medio rural. MÉTODOS estudio transversal analítico, se encuestó a adolescentes de 15-19 años de edad de ambos sexos, que asistían a un centro de salud rural, 70% sin vida sexual y 30% que ya habían iniciado su vida sexual. Se empleó una cuestionario auto-administrado que incluyó variables sociodemográficas, socioeducativas y de uso de métodos anticonceptivos. RESULTADOS el nivel de conocimientos fue medio en 38% y bajo en 31%. El condón fue el método anticonceptivo más utilizado (88%) y del que se tenía más conocimiento. Tiene un conocimiento bajo el 48,7%, el 30% y el 29,7% de adolescentes de 15, 16 y 17 años respectivamente. El conocimiento va aumentando con la edad; es "medio y alto" en 48,7% y 86,6% a los 15 y 19 años, respectivamente. Se observa que a mayor conocimiento, mayor uso de métodos anticonceptivos. CONCLUSIONES es necesaria mayor información sobre el uso adecuado de los métodos anticonceptivos en la escuela y en la familia a nivel rural antes del inicio de la vida sexual, para prevenir las enfermedades de transmisión sexual y los embarazos no deseados.
INTRODUCTION information on contraception is important before sexual life begins. OBJECTIVE to determine the level of knowledge and use of contraceptive methods by adolescents in rural areas. METHODS analytical cross-sectional study, surveyed adolescents aged 15-19 years of both sexes, who attended a rural health center, 70% without sexual life and 30% who had already started their sexual life. A self-administered questionnaire was used that included sociodemographic, socio-educational and use of contraceptive variables. RESULTS the level of knowledge was medium in 38% and low in 31%. The condom was the most widely used contraceptive method (88%) and the most widely known. 48,7%, 30%, and 29,7% of adolescents aged 15, 16, and 17, respectively, have low knowledge. Knowledge increases with age; it is "medium and high" in 48,7% and in 86,6% at 15 and 19 years, respectively. It is observed that the greater the knowledge, the more frequent use of contraceptive methods. CONCLUSIONS more information is needed on the proper use of contraceptive methods at school and in the family at the rural level before the start of sexual life, to prevent sexually transmitted diseases and unwanted pregnancies.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Adulto Jovem , Conhecimentos, Atitudes e Prática em Saúde , Comportamento Contraceptivo/psicologia , Comportamento Sexual , Infecções Sexualmente Transmissíveis/prevenção & controle , Zona Rural , Estudos Transversais , Inquéritos e Questionários , Comportamento do Adolescente , Planejamento Familiar , Saúde Reprodutiva , MéxicoRESUMO
BACKGROUND: Infection by HIV and other STIs and unplanned pregnancies are among the most serious problems associated with sexuality. Male and female condoms are the only dual-purpose devices to control both unplanned pregnancies and STIs, and studying people's attitudes toward the use of these devices are excellent ways to predict their use. Therefore, the purpose of the present study was to adapt and validate the Female Condom Attitude Scale for Spanish language and to evaluate the use of female condoms in Colombian population. METHODS: For that purpose, a total of 387 Colombian women aged 23.68 years in average were asked to respond to the Female Condom Attitude Scale, the Sexual Opinion Survey, and the UCLA Multidimensional Condom Attitudes Scale. RESULTS: The use of female condom in Colombia is very low; only 5.10% of the surveyed women had used it at least once. On the other hand, results revealed a five-factor dimensionality (Sexual pleasure enhancement, Inconvenience, Improved prophylaxis, Sexual pleasure inhibition, and Insertion reluctance) with alphas between .81 and .96. The scale also showed adequate psychometric properties and criterion validity. No relationship was found between attitudes toward female condom and attitudes toward male condom. CONCLUSIONS: The Spanish adaptation of the Female Condom Attitude Scale was found to be reliable and valid in a sample of young women.
Assuntos
Preservativos Femininos/estatística & dados numéricos , Comportamento Contraceptivo/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Comportamento Sexual/psicologia , Inquéritos e Questionários/normas , Adulto , Atitude Frente a Saúde , Colômbia , Feminino , Humanos , Idioma , Psicometria , Reprodutibilidade dos Testes , Infecções Sexualmente Transmissíveis/prevenção & controle , Infecções Sexualmente Transmissíveis/psicologia , Traduções , Adulto JovemRESUMO
Objective: Improve knowledge, attitudes and reproductive behaviours through an educational intervention aimed at reproductive health in two groups of Mexican women. Materials and methods: We carried out an education program targeting two segments, indigenous women and marginalised adolescents, with a pre-test, immediate post-test and post-test six months after it was carried out. Instruments used: a reproductive health history was established (pre-test and post-test six months) and a questionnaire of knowledge, attitude and conduct related to reproductive health and condom use (pre-test, immediate post-test and post-test six months). Results: Improved test scores in reproductive health and condom use - knowledge, attitude and conduct, were notable in the group of indigenous women (p < .05). However, in the group of adolescents there was a significant increase (p < .05) only in reproductive health - knowledge and attitude; in condom usage, increase was only noted in knowledge and conduct, not in attitude (pre-test vs immediate post-test). Six months after post-test results there was a decrease in test scores in comparison with the immediate post-test results. They were however, higher than the pre-test scores. Conclusions: Both groups significantly increased short-term knowledge, attitude and conduct related to reproductive health and condom use through the implementation of an education program. Results show that this education program can contribute to the development of an effective education program.
Assuntos
Comportamento Contraceptivo/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Povos Indígenas/educação , Educação Sexual/estatística & dados numéricos , Populações Vulneráveis/psicologia , Adolescente , Adulto , Preservativos/estatística & dados numéricos , Comportamento Contraceptivo/estatística & dados numéricos , Feminino , Humanos , Povos Indígenas/psicologia , México/etnologia , Avaliação de Programas e Projetos de Saúde , Educação Sexual/métodos , Marginalização Social/psicologia , Populações Vulneráveis/etnologia , Adulto JovemRESUMO
OBJECTIVE: To verify the association between Social Determinants of Health and birth control methods used by women of childbearing age. METHODS: Documentary and retrospective study, performed at a Brazilian Natural Birth Center with evaluation of the medical records of patients seen between 2003 and 2011 (n=2410). Data were collected on identification and general history, gynecological, sexual and obstetric. RESULTS: Hormone birth control methods were the most used among participants (25.0%); followed by barrier methods (21.5%) and surgical methods (19.3%). Statistical associations were observed regarding age, menarche, onset of sexual activity, pregnancy, miscarriage, smoking, hypertension, marital status, gynecological care and schooling with the choice of methods. CONCLUSION: The results confirm the importance of studies involving Social Determinants of Health, since they interfere in the way women choose birth control methods and the risks that this choice may pose to their health.