Decision Making Cohort Study

Malawi 11 cropThe Role of Decision Making in Sexual and Reproductive Health Behaviors
(Principal Investigator: Dr. Alison Norris)

Understanding how women and men make health decisions, individually and within couples, is critical to increasing the use of existing health promoting and disease prevention technologies. While technologies to improve sexual and reproductive health and reduce morbidity and mortality exist (such as contraception, HIV testing, or antiretroviral medications) some individuals who would benefit are nevertheless not utilizing them. The lower-than-expected utilization of many health technologies worldwide led to the development of the UTHA Cohort Study.

This community-based project, conducted via home-based visits, aims to understand factors associated with diminished health among men and women living in rural Malawi. The UTHA Cohort Study is being developed to serve as a platform to test clinical and community-based interventions to respond to health needs. Our long-term goal is to create interventions to improve health decision making thereby reduce risk for adverse outcomes.

  • Wave 1 (2014-2015) was designed to measure health behaviors and risks relating to HIV testing and care, family planning, and safe childbirth, as well as many other self-reported measures of health. 1,030 women and 441 of their male partners participated.
  • Wave 2 (2016) included collection of biological samples from a sub-sample of Wave 1 participants, which we tested in Malawian laboratories, and established the prevalence of HIV and several other infectious diseases. These data have permitted us to assess associations between modifiable decision-making competencies, sexual and reproductive health behaviors, and biological outcomes.
  • Wave 3 (2016-2017) was designed to assess a variety of fertility and family planning behavior outcomes, including contraceptive knowledge, contraceptive need and barriers and facilitators to contraception, including side-effects.
  • Wave 4 (2017-2018) included measures of uncertainty and detailed questions about facilitators and barriers to use of individual contraceptive methods, and a contraceptive history. Recruitment was opened to women and men who had not participated in Wave 1, with a total of 1,159 women and 781 men participating.
  • Wave 5 (2019) was designed to examine fertility perception, infertility sigma, unintended pregnancy stigma, pregnancy intentions, and reproductive autonomy. 885 women participated.


Contraceptive use.  UTHA studies have examined why women who do not want to be pregnant remain with unmet need for contraception, and which factors are associated with contraceptive use. Our publications have illuminated novel findings about way that both users and nonusers of contraception experience barriers and facilitators to contraceptive use.

Sexual and reproductive health decision making.  While there are many technologies (e.g., condoms, contraception, quality obstetric care) available for improving sexual and reproductive health outcomes, an enduring gap remains between their existence and their utilization.  UTHA research has examined the influence of several decision-making characteristics, including numeracy, power between sexual partners, self-efficacy, and institutional structures on sexual and reproductive health behaviors and outcomes.

Social factors influencing sexual behavior and sexually transmitted infection risk.  UTHA scholars have examined the influences of socially-derived characteristics (both individual and contextual) on behaviors that increase risk for STIs.

HPV prevalence and self-collected samples.  UTHA research on HPV has focused on understanding women’s willingness to self-collect samples for HPV testing, as this testing modality is critical in resource-limited, high HPV-prevalence settings.  We assessed the validity of self-collected samples as compared to clinician-collected samples, and have investigated the relationship between hypothetical acceptability of self-testing with later uptake of self-testing.

Measurement of sensitive or stigmatized topics.  The topics we study, including HIV, contraception, infertility, sexual relationships, intimate partner violence, and abortion, can pose epidemiologic challenges to study design and measurement due to their sensitive nature.  Our work has included assessment and improvement of measurement quality across these substantive areas.

Please see a full list of UTHA publications here.