Pride of the Maya -- basic education project for Mayan girls in bilingual and bicultural manners.
Girls Education Project, a two-year program sponsored by the Japan International Cooperation Agency (JICA), seeks to address the educational needs of Mayan girls in rural Guatemala. The program is being implemented under the framework of the Japan-US Common Agenda for Cooperation in Global Perspectives. Preliminary fieldwork revealed the importance of ensuring that entire communities, including teachers and parents, appreciate the human right of rural girls to a basic education. The project team will conduct three-day workshops in each of the four pilot states in 1997 to discuss teaching methods, materials, and curricula to promote girls' participation and improve their achievement levels. Also planned is a three-day national seminar involving governmental officials and representatives from the public and private sectors, nongovernmental organizations, professional groups, universities, and ethnic and cultural groups. The bilingual/bicultural method selected for the intervention seeks to implement basic education for Mayan girls in both Spanish and the four main Mayan languages. Another focus is to encourage the students to maintain pride in their cultural heritage.
Abortion attitudes, gender, and candidate choice in presidential elections: 1972 to 1992.
The salience of the abortion issue to the outcome of the six US presidential elections from 1972 to 1992 was analyzed through use of data from the National Election Studies. Overall, the results indicated that the electorate has not been choosing between presidential candidates from a single-issue perspective on abortion. The Kelley-Mirer Model, used as the basis for the probit analysis, included measures of party affiliation, net candidate image, incumbent popularity, gender, and attitudes toward abortion. For every election, incumbent popularity was the strongest predictor of voting behavior, followed by political party identification. Abortion attitudes were significant in 1972, when abortion first surfaced as a political issue as a result of the Roe vs Wade ruling, but not again until 1992. To determine whether abortion politics are likely to exert a more decisive impact on future presidential elections, a detailed analysis was conducted for the 1992 election of mobilized voters (who voted in 1992 but not in 1988) and converted voters (who voted for one party in 1988 and another in 1992). Women and pro-choice voters predominated in both these subsets. Most significant in the 1992 election was the conversion of voters to the Democratic Party; however, there is no evidence such conversion was stimulated by the abortion issue alone.
Sexual behavior in pregnancy among Hong Kong Chinese women.
Changes in the sexual behavior of Hong Kong Chinese women during pregnancy were assessed through a retrospective study of 150 women randomly recruited from two teaching hospitals within 3 days after giving birth. The mean age of respondents was 28.7 years; 73.3% had had one lifetime sexual partner, while 20% reported two partners. Observed was a clear trend toward decreased sexual activity as pregnancy progressed. Before pregnancy, 116 couples (77.3%) were having intercourse less than three times a week. This statistic increased to 145 couples (96.7%) in the first trimester of pregnancy and 56 couples (37.3%) abstained from intercourse during this time. In the second trimester, no couples reported intercourse more than twice a week and 51 (34%) abstained. During the third trimester, 97 couples (64.7%) abstained. Concern about jeopardizing the pregnancy was the most commonly cited (62%) reason for the reduction in sexual activity. Frequency of orgasm and enjoyment of intercourse also decreased with advancing gestation. Although younger women were more likely than their older counterparts to experience both coitus and orgasm during the first trimester, there was no consistent relationship between age, parity, educational level, employment status, and sexual behavior either before or during pregnancy. These findings suggest that Chinese women living in Hong Kong are more conservative about sexual behavior during pregnancy than women in most cultures.
A multicenter study conducted in the UK confirmed the safety, efficacy, and acceptability of a mifepristone (RU-486)-prostaglandin regimen as an alternative to surgical termination of an early first trimester pregnancy. The 975 study subjects (median age, 24 years) were recruited from 13 hospital gynecologic units in Scotland and England; gestational age could not exceed 9 weeks. They received 600 mg oral RU-486 followed 48 hours later by vaginal gemeprost (1 mg). Of the 957 women for whom data were evaluable, 907 (94.8%) aborted successfully with no serious complications; surgical evacuation was required in another 5.2%. There was no association between efficacy and either gestational age or parity. Within 5 days of gemeprost administration, 660 women (75.6%) had ceased to bleed or had only light bleeding/spotting. Overall, 90 women (9.4%) complained of severe or excessive bleeding associated with the regimen. The incidence and severity of pain reached a maximum 2 hours after gemeprost, when 537 women (56%) complained of moderate or severe discomfort; 275 (28.5%) required narcotic analgesia. In the 4 hours after gemeprost insertion, 23.3% of women vomited and 11.2% had diarrhea. Since the majority of side effects recorded in this study were associated with gemeprost, the use of vaginally delivered misoprostol in conjunction with RU-486 may merit investigation.
Effect of Norplant implants on the pituitary-adrenal axis function and reserve capacity.
To ensure that Norplant contraceptive implants are not associated with a risk of pituitary-adrenal suppression, a series of laboratory tests were conducted in 15 women both before and 6 months after Norplant insertion. Comparisons of hormonal profiles before and after Norplant insertion revealed a significant drop in morning serum cortisol levels (404.33 +or- 84.07 nmol/l vs. 353.67 +or- 56.65 nmol/l, p < 0.05), but no significant change in evening readings. The observed changes in morning cortisol values were still within the normal range. Serum ACTH values and 24-hour urinary 17-hydroxy steroids, 17-ketogenic steroids, and 17-ketosteroids were not different after insertion compared to baseline. Before Norplant insertion, injection of synthetic ACTH resulted in a 259.59 +or- 169.53% increase in the mean level of serum cortisol 5 hours later; 6 months after Norplant insertion, the percent rise above baseline was 165.85 +or- 91.64%. The significantly lower adrenal response among Norplant users (although still within normal limits) is presumably due to a local inhibition of the adrenal itself and not of the hypothalamic-pituitary axis. Although these findings suggest a minimal suppressive effect of prolonged microdose release of levonorgestrel from Norplant implants, the suprarenal response to acute or prolonged stresses (e.g., surgical operations or shock) in Norplant users requires investigation.
Reports appearing in the mass media in October 1995 citing a two-fold increase in the risk of venous thromboembolism in users of third-generation compared to second-generation oral contraceptives (OCs) were followed, in Norway, by a 17% drop in total OC sales and a 70% drop in sales of the only third-generation OC (Marvelon) on the market. More than 25,000 Norwegian women discontinued OC use in November-December 1995. Abortion data from one Norwegian county, representing 6-7% of the country's population, showed no significant changes in the total number of induced abortions in the first quarter of 1996 compared to the first quarter of preceding years. However, the steady decrease in the abortion rate for women 24 years of age or younger recorded in 1992-95 was interrupted by a 36% increase during the first quarter of 1996 (5.7/1000, compared with 4.2/1000 in the first quarter of 1995). Most of the growth in abortion cases occurred among single, childless students--a subgroup in which OC use tends to be high. Although this finding suggests that the mass media's "pill scare" may have led many young women to discontinue OC use or switch to less effective formulations, evaluation of the full effect of this event cannot be completed without national data on induced abortion and the completion of birth registration.
Contraceptive practices of women requesting termination of pregnancy: a study from China.
A survey of 1520 consecutive Chinese women seeking induced abortion at eight hospitals in Zheng Zhou City, Hunan Province, during March-May 1996 revealed the presence of contraceptive failure in 1093 women (71.9%). The mean age of abortion seekers was 26.9 years; 235 women (15.5%) were unmarried and 871 (57.3%) had no children. 938 (61.7%) of these pregnancies were potentially predictable as a result of nonuse of contraception (427 women) or timely recognition of contraceptive failure (511 women). Condoms accounted for the highest proportion (29.7%) of contraceptive failures, followed by IUD (23.5%), and rhythm (15.9%). 77.1% of abortion seekers had previously used at least one contraceptive method, although only 299 (19.7%) used a method at first intercourse. Overall, 57.6% of contraceptive users had experienced contraceptive failure at some point. In most cases, these failures resulted from user noncompliance (e.g., forgetting to use condoms and missed or delayed pill-taking), suggesting a need for more thorough counseling. Only 10 women (1.1%) had used emergency contraception, but without success. If the remaining 928 women who either had unprotected intercourse or recognized contraceptive failure immediately had used the Yuzpe emergency contraception regimen, about 75% would not have become pregnant. These findings suggest that condom and rhythm users should be targeted for the introduction of an emergency contraception program aimed at reducing the high rate of abortion in China.
The results of a clinical study of 15 women suggest that Anuelle norethindrone (NET) biodegradable subdermal implants provide a promising alternative to both the pill and non-biodegradable implants. Study subjects were randomly assigned to receive either four pellets (174 mg NET) or five pellets (266.5 mg NET). An initial burst effect in 24-hour postimplantation serum NET levels was observed in both groups (to 3.17 +or- 0.39 ng/ml in the four-pellet group and to 3.71 +or- 0.37 ng/ml in the five-pellet group), followed by a decline, then sustained levels, and finally undetectability at 36-38 months. Menstrual cycles were normal in 65% of women in the four-pellet group and 47% of those in the five-pellet group; no subject dropped out due to abnormal vaginal bleeding patterns. The incidence of ovulation was 22% in the four-pellet group and 1% in the five-pellet group; no pregnancies occurred in either group in 24 months of observation. Plasma lipids showed reduced total and low density lipoprotein cholesterol and triglycerides. No major adverse local or systemic side effects were noted. Acceptability was good in terms of cosmetics, convenience of implantation, biodegradability, and ease of removal (if required) and most study participants expressed the desire to use NET implants as their contraceptive method of choice.
The pregnancy termination potency of varying doses of mifepristone, onapristone, and ORG 3806--alone and in combination with the estrogenic/antiestrogenic compound anordiol--was evaluated in adult rats. The antiprogestins and anordiol alone were administered to pregnant female rats on days 7, 8, and 9 of pregnancy and the presence or absence of embryos in utero was determined on day 16. ORG 31806 at a dose of 2 mg/kg/day, mifepristone at 4 mg/kg/day, and onapristone at 8 mg/kg/day terminated pregnancy in 100% of animals; 5 mg/kg/day of anordiol was required. Anordiol acted synergistically with all three antiprogestins. Antiprogestin doses that were either partially effective or ineffective became 100% effective when administered with a noneffective dose of anordiol. The combination of ORG 31806 (1 mg/kg/day) and anordiol (0.31 mg/kg/day) had the most potent pregnancy termination activity. The administration of antiprogestins in combination with anordiol at doses that effectively terminate pregnancy was associated with a significant, persistent reduction in serum progesterone, but no change in serum estradiol levels. The effectiveness of ORG 31806 and anordiol in terminating pregnancy should be evaluated in a non-human primate model to determine its potential clinical use.
A perspective on the concept of "risk".
Compared to the risks inherent in pregnancy and daily activities of living, the increased risk of nonfatal venous thromboembolism (VTE) among users of oral contraceptives (OCs) containing desogestrel and gestodene is relatively benign. About 20-30 cases of nonfatal VTE per 100,000 users of third-generation OCs containing these progestins can be expected compared to 10-15 cases per 100,000 users of levonorgestrel-containing OCs. Pregnancy, on the other hand, confers an increased risk of about 60 cases of nonfatal VTE per 100,000 women. Since OCs remain the most popular reversible method of birth control, their discontinuation because of VTE concerns would have serious public health consequences in terms of unwanted pregnancy prevention. Moreover, OCs confer a number of noncontraceptive health benefits, including protection against ovarian and endometrial cancer, osteoporosis, benign breast disease, ovarian cysts, and pelvic inflammatory disease. The lives saved by OCs should be considered in any analysis of the small VTE risk they may impart.
Coagulation and thrombosis with OC use: physiology and clinical relevance.
Recent studies suggesting that oral contraceptives (OCs) containing the progestins desogestrel and gestodene are associated with a two-fold increased risk of nonfatal venous thromboembolism (VTE) compared to earlier formulations have raised new issues for clinicians. The increased risk of 20-30 cases of VTE per 100,000 women annually compares with 60 VTE cases associated with pregnancy. Women with a documented history of unexplained VTE should not use OCs, and when there is a family history, physicians should weigh factors such as age of onset of thrombosis in the affected relative, the clinical setting (e.g., after surgery or trauma), and severity of the episode. The effects of OCs on procoagulants and anticoagulants are minor, except in the 5% of women with factor V Leiden mutation. A clotting assay can determine activated protein C resistance and a polymerase chain reaction test can identify the presence of this mutation; however, widespread screening of OC users is not recommended due to the low incidence of factor V Leiden and the low likelihood these women will develop clots. The present state of knowledge about OCs and VTE risk supports the application of informed clinical judgment.
Epidemiology of venous thromboembolic disease and OC use.
A review of recent epidemiologic studies that have detected an association between the use of oral contraceptives (OCs) containing the progestins gestodene and desogestrel and venous thromboembolism (VTE) risk suggests evidence of bias. Reviewed are five major case-control and cohort studies: World Health Organization Collaborative Study, Boston Collaborative Drug Surveillance Program Study, European Transnational Study, and the Leiden Study. Three major sources of bias could account for the increased VTE risk among users of third-generation compared to second-generation OCs: 1) selective prescription of newer formulations to higher-risk women; 2) the increased tendency for women with suspected VTE to be more likely to be referred for diagnostic testing and hospitalization if they are taking the newer OCs rather than older formulations; and 3) attrition of susceptibles. The lack of any proposed biological basis for the observed association between VTE and the new progestins, compared with previous knowledge about the responsibility of estrogen for increased VTE risk, raises additional doubts about the findings. Any evaluation should balance the effects of OCs on overall risk of cardiovascular disease against protection from pregnancy and noncontraceptive health benefits such as a reduced risk of certain cancers.
Major study finds no link between abortion and breast cancer.
A large-scale, methodologically rigorous Danish study has concluded that, among women of similar age and reproductive history, those who have had one or more induced abortion are no more likely than women with no abortion history to develop breast cancer. The reliability of previous studies of this association has been limited by many women's reluctance to be truthful about their abortion history. This potential source of bias was overcome, in the present study, through the linkage of data from the Danish Cancer Registry with information from the National Registry of Induced Abortions, which provides statistics on the patient's age at the time of a pregnancy termination as well as the duration of pregnancy at abortion. Although the relatively small group of women who had abortions after 12 weeks of pregnancy demonstrated a slightly increased risk of breast cancer compared with women with earlier terminations or no abortion history, the number of women involved was too small to permit any generalizations at this time.
Trial court blocks Iowa parental notification requirement.
A US District Court ruling has declared that parental notification requirements create a substantial obstacle to a young woman's access to abortion, in violation of US Supreme Court precedent. On January 3, 1997, Southern District of Iowa Judge Ronald Longstaff issued a temporary restraining order blocking enforcement of a new law that requires physicians performing an abortion on a woman under 18 years of age to notify one of her parents at least 48 hours before the procedure. Although the law contains a provision that the young woman may seek a court waiver to the notification mandate, the certification requirements threaten to subject physicians to criminal liability and do not guarantee confidentiality. The court order against enforcement will remain in effect until January 23, 1997, when Judge Longstaff will rule on a request for a preliminary injunction against the measure.
Appeals court invalidates Utah ban on late abortions.
On December 23, 1996, the US Court of Appeals for the Tenth Circuit ruled that a 1991 Utah law that bans all abortions after 20 weeks of pregnancy (except when necessary to save the woman's life, prevent "grave damage" to her health, or prevent the birth of a child with "grave defects") is unconstitutional. The three-judge panel reaffirmed that viability determinations must be left to a physician's medical judgment and not be dictated by the state. Typically, viability occurs between weeks 24-28 of pregnancy. According to a precedent established by the US Supreme Court in 1992's Planned Parenthood vs. Casey, a state may not unduly restrict access to abortion prior to fetal viability; even after viability, a woman's health must be the primary consideration.
The road to worldwide sexuality education [editorial]
The articles in this "SIECUS Report" document the organization's involvement in the development of sexuality education programs around the world. Topics covered by the articles in this issue include efforts by the Bolivian Government to increase understanding and acceptance of family planning methods, work with the Soros Foundation to train teachers to teach health education, a sexuality education pilot project in Russia, development of a culturally sensitive sex education program in Indonesia, and life education for youth in India. In the year ahead, SIECUS will implement country-specific programs in Nigeria, Swaziland, Russia, and India aimed at establishing frameworks for reproductive health, family planning, acquired immunodeficiency syndrome prevention, and population education programs.
Nigerian guidelines for sexuality education introduced at ceremony in Lagos.
The 1996 publication of "The Guidelines for Comprehensive Sexuality Education in Nigeria," a result of collaboration between SIECUS and Nigerian organizations, is a major step toward incorporating sex education into current reproductive health and population initiatives. A National Task Force of 20 key Nigerian agencies and institutions working in the area of adolescent health, education, and development prepared the document with technical assistance from SIECUS. Days before the document's public release, a workshop was held for members of the mass media to increase their understanding of adolescent reproductive and sexual health in Nigeria. 70% of males and 50% of females attending secondary school are sexually active before the age of 20 years; by the time they leave school, one out of every five Nigerian girls has terminated an unwanted pregnancy. The Guidelines seek to help Nigerian youth to acquire knowledge and develop responsible behavior to reduce high rates of unwanted pregnancy, complications from unsafe abortion, sexually transmitted diseases, and acquired immunodeficiency syndrome.
Survey supports arguments to start sexuality education in Russia.
In October 1996, Russia launched a 3-year sexuality education pilot project. A survey conducted in 1995 by the Transnational Family Research Institute confirmed both the need for such a program and widespread youth support. The survey found that 43.9% of 16-year-old boys and 24.0% of 16-year-old girls had had sexual intercourse; these rates were 62.7% and 46.9%, respectively, among vocational school students. Early initiation of sexual activity was associated with behaviors such as smoking, drinking, and using drugs as well as with lower grades in school. Almost 60% of young people surveyed believed that sexual relationships were as important as education or a career; 75% of females and 80% of males considered it necessary for a male to have sexual experience before marriage. Only 17% of sexually inexperienced and 30% of sexually experienced students considered their knowledge of sexuality to be adequate. Support for introducing sex education into the school curriculum was expressed by 74.9% of inexperienced males, 85.3% of inexperienced females, 78.9% of experienced males, and 90.7% of experienced females.
Reproductive Health is in Your Hands: the national media campaign in Bolivia.
To strengthen awareness of the National Reproductive Health Program, the Bolivian Government launched a mass media campaign aimed at low- and middle-income males and females 18-35 years of age. Specific objectives of the campaign were to increase positive attitudes toward reproductive health, knowledge of at least one benefit of reproductive health and where to obtain these services, knowledge of where to obtain family planning services, partner communication about reproductive health, and use of reproductive health services at health centers. To facilitate understanding of family planning decision making in Bolivia, 16 focus groups were conducted and all campaign materials were pretested. The campaign included 11 television spots, 44 radio spots, leaflets and posters, videos for clinic waiting rooms, and audiotapes for use on city buses. A survey conducted immediately after the communication campaign of 2354 men and women from seven urban areas indicated 85% had been exposed to the campaign; family planning was the most frequently remembered message. A positive attitude toward reproductive health increased from 86% at baseline to 91% after the campaign. The percentage of women 18-35 years old who reported speaking to someone other than their partner about reproductive health in the past 6 months increased from 71% to 82%, while the percentage of male respondents who stated they definitely intended to use or continue to use contraception in the future rose from 25% to 60%. Family planning use among those most exposed to the campaign increased from 5.4% to 8.7%. Given the success of this campaign, the challenge is to meet the increased demand for quality services.
Researching cultural backgrounds to establish effective sexuality education programs.
The sociocultural environment in Indonesia's Batam Island has been disrupted by tourism, trade, prostitution, temporary marriages with foreign businessmen, and a general infusion of Western values. To facilitate the design of an effective sex education and reproductive health program, the Perspective Foundation of Indonesia conducted a reproductive health survey of 125 men and women from 11 island villages. Polygamy was defended as an alternative to sex with prostitutes, although younger men had more favorable attitudes toward sex outside of marriage. Contraception is viewed solely as a means of pregnancy prevention, and many women expressed discomfort with side effects. Younger men use condoms for protection with prostitutes, but not with their primary partners. Human immunodeficiency virus is viewed as a homosexual disease spread by touching. Views about sex roles are traditional, and men are considered as not masculine if they support their partner's needs. Finally, islanders believe that the male sexual drive is designed for procreation and pleasure, while the female sex drive is strictly for procreation. On the basis of these findings, researchers have decided to incorporate sex education within the broader context of health promotion and disease prevention.
Making sense, talking sexuality: India reaches out to its youth.
To reduce the incidence of adolescent pregnancy, unsafe abortion, and sexually transmitted diseases (STDs) in India, Parivar Seva Senstha (PSS) Family Planning Programs has launched a program to provide family life education to young people. A preliminary survey administered to 236 South Delhi youths 12-20 years of age revealed widespread lack of knowledge about reproduction and STDs and a lack of comfort discussing sexuality. Based on the survey results, PSS designed curricula for ages 12-14, 15-17, and 18-20 years to be disseminated through schools and colleges, the National Service Scheme, Bharat Scouts and Guides, nongovernmental organizations, teacher training institutes, and a distance learning program. As the program evolved, a reproductive health hot line, face-to-face counseling sessions, workshops for engaged couples, and a radio question-and-answer program were added. Although teachers are supportive of the program, they remain inhibited about discussing sexuality with their students and prefer that PSS conduct the classes. At present, PSS is training trainers to teach the curriculum.
Strategies to build support for HIV-prevention and sexuality education programs. Fact sheet.
A needs assessment conducted by SIECUS of 150 education and health leaders from the US resulted in a set of suggestions for building support for human immunodeficiency virus (HIV) and sex education programs. The recommendations are grouped under eight general directives: 1) work with other groups, 2) develop models, 3) provide up-to-date information, 4) engage the media, 5) build community support, 6) organize public meetings, 7) prepare for challenges and conflicts, and 8) involve parents.
"Sluts" or "sleazy little animals"? Young people's difficulties with carrying and using condoms.
A survey of 105 young people (mean age, 18.3 years) from Perth, Western Australia, revealed significant obstacles to carrying and using condoms. Respondent were asked to describe their perceptions of what the opposite sex thinks of young women/young men who carry condoms. Although both men and women were concerned that carrying condoms would have a negative effect on their reputation, these fears generally were not matched by the responses of the opposite gender. 45% of men were positive about women carrying condoms, yet only 10% of women thought that men would be supportive; 40% believed that men would consider women who carry condoms "sluts," but only 18% of men had such negative views. Similarly, while only 24% of men believed women would support their carrying condoms, the actual rate was 36%. When asked to describe actual experiences with condom use, 71% reported negative experiences (e.g., condom broke while being put on or fell off during sex, loss of sexual arousal), 32% gave neutral responses, and only 5% were positive. Few respondents had used lubricated condoms. Recommended is the provision of inter-gender information to reduce the misperception that neither males nor females approve of the other sex carrying condoms and to promote the correct use of lubricated condoms.
Use of culture care theory with Baganda women as AIDS caregivers.
In Uganda, where up to 25% of urban residents in the sexually active age group are infected with human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) patients are largely cared for at home by women in their traditional role as family caregivers. To investigate the meanings, patterns, and expressions of care to Baganda women as AIDS caregivers, interviews were conducted with 12 key and 25 general Baganda informants from the rural Masaka/Rakai districts and the semi-urban areas of Kampala. Access to informants was gained through mobile AIDS home care nursing teams. The data analysis, grounded in Leininger's Culture Care Theory, identified six major themes: 1) for Baganda women, culture care means responsibility, love, and comfort derived from their kinship, religious, and cultural values and reinforced by their health beliefs and those of professionals; 2) culture care means survival to help secure a future for the next generation and is reinforced by education and land claims; 3) culture care means continuing on in the face of adversity and burden; 4) AIDS-related morbidity and mortality have created major changes in traditional gender roles; 5) culture care diminishes the void left by the death of a family member from AIDS; and 6) culture care means making the most of life for HIV-positive women. These findings can be used by health workers to provide culturally congruent nursing care to Baganda families affected by AIDS and to facilitate intergenerational care.
The risk factors for human immunodeficiency virus (HIV) infection were compared in a cross-sectional analysis of 370 general nurses, 370 nurse-midwives, and 370 office workers and teachers. Positive HIV tests were obtained from 163 general nurses, 146 nurse-midwives, and 156 office workers/teachers. Office workers and teachers were less knowledgeable about the routes of HIV transmission than nurses and nurse-midwives; only 31% of women in the former group, compared with 43% of those in the latter groups, had adequate knowledge scores. The only significant risk factor for HIV infection among nurse-midwives was blood transfusion (odds ratio (OR) 2.17, 95% confidence interval 1.13-4.14). Among general nurses, significant risk factors included a history of genital ulcers (OR 3.59, 1.30-10.85), history of a sexually transmitted disease after 1980 (OR 5.17, 1.60-15.05), and more than one sexual partner (OR 4.08, 1.54-13.0). Among office workers and teachers, the only significant risk factor was scarification (OR 1.66, 1.07-2.57). The variation in risk factors identified in these three groups suggests a need for HIV prevention interventions tailored to different sectors of the Zambian population.
HIV / AIDS related knowledge, attitudes, and preventive behavior of pregnant Korean women.
A cross-sectional survey of 409 women recruited from six prenatal clinics in Seoul, Korea, in 1993 indicated that Korean women are at risk for heterosexual transmission of human immunodeficiency virus (HIV) as a result of their husband's extramarital sexual encounters. In general, respondents had high knowledge levels regarding the major risk factors for HIV (mean knowledge score of 15.5 out of a maximum possible score of 22) and most reported adoption of at least one behavior that prevents HIV transmission (mean preventive behavior score of 19.4 out of a maximum possible score of 28). Preventive behavior was significantly associated with 12 or more years of education, having an acquaintance with HIV, urban residence, a high HIV-related knowledge score, and personal risk appraisal. Although 16% provided their husbands with condoms for extramarital sex, only 28% of respondents were aware HIV can be transmitted through heterosexual vaginal intercourse. Also alarming were findings that only 18% would continue relationships with friends who became infected and 90% believed children with HIV should not be allowed to attend school with noninfected children; on the other hand, 60% would not cut off a relationship with an infected family member and 45% agreed they would care for that relative until death. Overall, these findings suggest a need for an educational campaign focused on heterosexual transmission of HIV, self-protection, and increased acceptance of unrelated HIV-infected individuals.
Legal, socio-cultural and economic aspects of HIV transmission and prevention in Ghana.
Although policy makers in Ghana have conducted educational campaigns on the modes of transmission of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), insufficient attention has been given to the legal, sociocultural, and economic factors that hinder prevention and control efforts. Traditional medical practitioners, who provide care to 70% of the population, have not been incorporated into the national AIDS program. Women's low socioeconomic status, as well as biological factors and cultural norms, make them especially vulnerable to HIV infection, yet policies and laws have not been enacted to empower women. Moreover, laws that either legalize or ban prostitution fail to take into account the need for vocational and educational skills to make sex workers financially independent. A gag rule on issues related to sexuality has hindered discussion of heterosexual modes of transmission. To attach credibility to AIDS educational messages, influentials such as chiefs and elders should be actively involved. The speed with which the AIDS epidemic can be controlled in Ghana will depend on adoption of safe sex behavior, mobilization of financial and technical support, and mechanisms to assist HIV-infected persons.
Coercive sterilisation: its eugenical underpinnings and current manifestation.
Although the manifestation and implementation of coercive sterilization have changed throughout history, this practice has consistently disproportionately affected poor women, the disabled, and women of color. Sterilization can be considered coercive if an individual cannot legally give informed consent, due to mental incapacity or age, or is deceived or compelled to accept the procedure. Both feminists and eugenicists who pushed for birth control in the late 19th and early 20th centuries in the US, Canada, and the UK shared a racist, classist social ideology. Disguised as a science, eugenics provided support for the view that reproduction by certain groups of women would produce a deterioration in the moral and intellectual fiber of society. Through its exclusive emphasis on sexism, the contemporary feminist movement has ignored race and class oppression. Recent claims of a racial basis of intelligence, beliefs that poverty amelioration depends on the poor limiting their fertility, and proposals for human genetic engineering have created conditions for a resurgence of eugenics. The current practice in Canada of failing to fully inform Aboriginal and disabled women of their options before sterilization and promotion of Norplant implants are examples of continued reproductive abuse. Needed is an international feminist movement that advocates for all women's right to reproductive choice.
Cervical dysplasia treatment: key issues for developing countries.
Financial, technical, and logistical factors have impeded the establishment of effective cervical cancer control programs in many developing countries. Efforts are now underway to strengthen cytology services and identify simple, inexpensive, alternative screening strategies that will improve early detection of cervical intraepithelial neoplasia (CIN). As part of this effort, the Program for Appropriate Technology in Health (PATH) surveyed the CIN treatment practices and preferences of 110 health practitioners from 33 developing countries. The survey revealed widespread reliance on invasive inpatient procedures such as cone biopsy and hysterectomy and a tendency to treat all preinvasive CIN, rather than only high-grade or severe CIN. Simple, low-cost, effective (80-95%) outpatient procedures such as cryotherapy and the loop electrosurgical excision procedure (LEEP) were selected more widely in Asia, the Caribbean, and Latin America than in Africa, but remained underutilized relative to inpatient treatments. In many settings, colposcopes and other basic equipment were not available. Respondents identified hysterectomy, cone biopsy, and LEEP as the most effective treatments of severe dysplasia. Overall, these findings suggest a need for more efficient use of scarce medical resources. Cryotherapy and LEEP, combined with proper follow-up, are particularly appropriate for developing countries in cases where invasive cancer and endocervical involvement have been ruled out.
A review of available case-control and cohort studies suggests a causal association between certain types of human papillomavirus (HPV) and cervical cancer. Case-control studies using highly sensitive polymerase chain reaction-based assays have detected HPV DNA prevalences of 90-94% in women with invasive cervical cancer and odds ratios over 15. Of the 30 types of HPV that infect the uterine cervix, HPV 16 and 18 are associated with the highest proportions (50% and 12%, respectively) of cervical cancers. Prophylactic and therapeutic vaccines are now under development, although their efficacy and safety must be assessed in phase I, II, and III trials, and HPV typing is being integrated into pilot study screening programs in selected developed countries. Until a vaccine is available, HPV testing as a primary screening tool or to support cytologic examination remains the best approach for the control of cervical cancer in developing countries. Although there is no effective treatment once HPV is detected, cytologic surveillance of carriers of high-risk HPV types can be initiated.
Comparison of the cervical cytology test using the PAPNET method and conventional microscopy.
Comparison of cervical smear analyses conducted in Mexican laboratories through conventional microscopy with the results of quality control studies conducted by the National Institute of Epidemiologic Diagnosis and Reference (INDRE) using both conventional and automated (PAPNET) methods revealed an alarming lack of agreement. A total of 10,098 slides prepared by technicians working at state public health laboratories in 28 Mexican states and the federal district were reviewed. Most slides (about 78%) yielded negative results or an inflammatory process; 8-14% indicated mild or moderate cervical dysplasia, and 2-3% revealed severe dysplasia or cervical cancer. The Kappa correlation coefficient for agreement between positive and negative diagnoses made by the states and INDRE was 0.62, near the lower limit, while comparison of diagnoses made by INDRE and PAPNET produced a coefficient of 0.80, near the upper limit. Diagnostic agreement between state laboratories and INDRE was greatest (93%) with slides classified as normal or exhibiting inflammatory changes. Agreement rates were lowest when it was necessary to differentiate degrees of abnormality: unspecified carcinoma (13.3%), invasive carcinoma (51.4%), and moderate dysplasia (63.1%). PAPNET generated substantially more false-negative results than traditional microscopy performed either by INDRE or the states and underestimated the presence of human papillomavirus virus, Candida infection, and trichomoniasis. Inadequate fixing, staining, and mounting of the slides compromised PAPNET analysis. Overall, these findings indicate a need to improve the quality of cervical cytology diagnoses at state laboratories through increased training and supervision.
Predictors of African American adolescents' condom use and HIV risk behavior.
To facilitate identification of factors that place low-income African American adolescents at increased risk of human immunodeficiency virus (HIV), interviews were conducted with 312 youth 12-19 years of age attending a Public Health Service-funded clinic in Mississippi. The analysis was restricted to the 114 sexually active youth in this sample. The full variable set included age, gender, acquired immunodeficiency syndrome (AIDS) knowledge, condom attitude, perceived risk of AIDS, self-efficacy, social provision, church attendance, AIDS Risk Index, and Condom Use Index. Correlations between these variables were small to moderate (0.0 to -0.48). Separate regression analyses revealed significant relationships between the full variable set and the AIDS Risk Index (p < 0.0001) and the Condom Use Index (p < 0.02). Half of the teens reported unprotected intercourse in the preceding 2 months, yet most perceived themselves at low risk for AIDS. Multivariate analyses of variance revealed that variables most predictive of unprotected sex with multiple partners differed from those associated with condom use. Males who reported lower self-efficacy in avoiding AIDS and perceived themselves at greater risk were most likely to engage in high-risk behaviors. Consistent condom users were younger than intermittent and non-users and had more positive attitudes about condoms and higher AIDS knowledge scores. Interventions aimed at Black teens may need to expand beyond condom promotion to include broader media and community-based educational programs.
Multiple sexual partners and condom use among long-distance truck drivers in Thailand.
A 1992 survey of 327 long-distance truck drivers in Thailand revealed a negligible sense of vulnerability to AIDS despite widespread contact with commercial sex workers (CSWs). The study was conducted in Saraburi--the site of three large cement factories. The drivers' median age was 33 years (range, 15-54 years); 83% were currently married. Seven men (2.3% seroprevalence) were infected with HIV. 87% of truck drivers reported encounters with a CSW at some point; for 48%, a CSW was their first partner. In the 6 months preceding the survey, 23% of men currently living with a spouse had contact with a CSW, 13% had sex with a noncommercial partner, and another 8% reported both types of extramarital encounters. 78% of drivers whose first CSW experience occurred before 15 years of age had visited a CSW in the past year compared with 41% of those whose first contact was at 16-18 years and 34.5% of those whose first contact occurred at age 19 years or above. Only 58.5% of truck drivers who reported CSW encounters in the year preceding the study used condoms consistently; 28% claimed occasional use and 14% never used condoms. Only 3% of drivers perceived themselves to be at high risk of HIV infection; 62% claimed to be at no risk. Common were misconceptions about AIDS; for example, 25% felt they could not get HIV from someone who looked healthy.
Recent studies suggest that female pelvic actinomycosis occurs most commonly in IUD users. In such women, actinomycosis is considered to arise as an ascending infection originating in the perineum, or through ano- and orogenital contact. Actinomycotic infections related to IUD use range from mild endometrial inflammation to pelvic inflammatory disease with abscess formation. Most women who develop abscesses have been wearing an IUD for an average of 8 years, suggesting that risk increases with duration of IUD use. Other factors associated with actinomycosis in IUD users include the use of plastic rather than copper devices, lower socioeconomic status, and increased symptoms such as abdominal pain and vaginal discharge. The primary initial treatment should be high-dose penicillin for 6-12 months. The diagnosis of pelvic actinomycosis in an IUD user who presents with abdominal pain or a pelvic mass can be confirmed by aspiration, ultrasound, biopsy of involved tissue, or examination of tissue adhering to a removed IUD. Samples should be examined by standard histologic means, anerobic culture for 2 weeks, and immunofluorescence. Papanicolaou smears have been used for screening purposes; however, failure to detect actinomycosis on Pap smear does not exclude the possibility of an ongoing pelvic process and organisms detected through this means are often clinically insignificant, disappearing without treatment after IUD removal.
Two long-acting hormonal contraceptive options.
Careful acceptor selection and individual counseling can maximize efficacy and patient satisfaction with the long-acting progestin contraceptives Norplant and Depo-Provera. Both methods should be administered within 5-7 days of the onset of menstruation to ensure the patient is not pregnant. Method initiation also can occur immediately after induced abortion or childbirth, with no adverse effect on lactation. Pregnancy rates average 0.8/100 woman-years during 5 years of use for implant users and 0.3/100 woman-years for Depo-Provera. Menstrual changes are the most significant side effect of long-acting progestins. These methods may be especially suited for adolescents who have problems complying with a daily pill regimen and women in whom estrogen use is contraindicated; those with psychiatric problems or mental retardation may also benefit from their convenience. The 14 brief case studies accompanying this review cover concerns such as reduced libido, thromboembolism history, weight gain, anticonvulsant drug use, and uterine fibroids.
A risk-benefit assessment of the levonorgestrel-releasing intrauterine system.
The levonorgestrel-releasing intrauterine system (LNG-IUS) provides fertility control comparable to female sterilization, convenience, and complete reversibility. This method appears to combine the benefits of oral contraception and the IUD, while avoiding most of their side effects. The low level of LNG released (20 mcg every 24 hours) minimizes the systemic adverse effects associated with hormonal contraception. Unlike inert or copper IUDs, the LNG-IUS is associated with a profound reduction in the duration and quantity of menstrual bleeding and alleviates dysmenorrhea. Moreover, there is evidence that the LNG-IUS prevents the endometrial proliferation associated with estradiol therapy and induces regression of endometrial hyperplasia; its potential for regulating the growth of uterine fibroids and preventing pelvic inflammatory disease remains undetermined. Although large multicenter studies have not detected differences in cervical cytology or breast cancer incidence between copper IUD and LNG-IUS users, long-term epidemiological studies are needed to confirm this finding. Fundal positioning of the LNG-IUS is essential to ensure uniform exposure of the endometrium to the progestogen, prevent expulsion, and maximize efficacy. A promising future use for the LNG-IUS is in protecting the endometrium during postmenopausal hormone replacement therapy. Overall, the research suggests that the LNG-IUS comes close to meeting many of the requirements of an ideal contraceptive.
Depot medroxyprogesterone acetate and breast cancer. A review of current knowledge.
Although further epidemiological studies of the long-term effects of depot medroxyprogesterone acetate (DMPA) on breast cancer risk are needed, preliminary research results are reassuring. Pooled analysis of the results of two large case-control studies--the World Health Organization Study (involving women newly diagnosed with breast cancer in 1979-88 in Thailand, Kenya, and Mexico) and the New Zealand Study (comprised of women with breast cancer diagnosed in 1983-87)--has facilitated assessment of this association. Overall, 219 of the 1768 breast cancer cases and 1725 of the 13,905 controls had ever used DMPA (odds ratio, 1.1; 95% confidence interval, 0.97-1.4), with no increase in risk with increasing duration of use. Women under 35 years of age at diagnosis and those initiating DMPA use before 25 years of age had marginally statistically significant increases in breast cancer risk. The highest risks were recorded among women who had initiated DMPA use within 5 years of diagnosis. Risks declined with time since first use in all age categories. After 5 years since last use, DMPA use for more than 2 years was associated with a decreased risk of breast cancer. The raised relative risks in certain subgroups are difficult to interpret and may reflect surveillance bias. Enhanced understanding of the biology of breast cancer will aid interpretation of these results.
To evaluate the lipid and blood chemistry profiles associated with an experimental triphasic contraceptive (35 mcg of ethinyl estradiol and 7 days each of 0.18, 0.125, and 0.25 mg of norgestimate), 39 non-smoking female volunteers were enrolled in a 12-month study. Biochemical determinations of 21 variables were made at baseline and after 3, 6, and 12 months of exposure. There were no significant changes throughout the study period in the complete blood count, hemoglobin, hematocrit, or platelet count. Thyroxine increased, while resin uptake thyroxine 3 and urinary cortisol decreased--a finding consistent with hormonal contraceptive use. Slight increases in cholesterol and triglycerides were recorded, as well as nonsignificant increases in both high-density (HDL) and low-density lipoproteins (LDL). Most significant changes in chemistry profiles occurred in the 14 women with no previous history of oral contraceptive (OC) use. Overall, this low-dose triphasic contraceptive had a less deleterious effect on lipids than biphasic OCs and may provide some cardiovascular protection through its beneficial effect (17% increase) on HDL-cholesterol.
[Crisis and demographic transition in Africa]
The main task of CEPED, the French Center on Population and Development, is to deal with the relations between population and development. The center in this paper questions the nature of the demographic consequences of adjustment policy and reforms in developing countries. There is no doubt that such policies had important social consequences. The dearth of available statistical data, however, makes it difficult and even pointless to try and dissociate the effects of adjustment policies from the economic crises which put them in place. CEPED asked a group of experts to offer their views on to what extent the global economic crisis and the structural adjustment policies effected during the early 1980s affected demographic trends over the long term in sub-Saharan Africa. Whatever effects the economic crisis and the structural adjustment policies had upon the continent will remain to be felt for years to come. Further research is therefore warranted.
Trade Union Reform and Employment Rights Act 1993 [1 July 1993].
This document contains major provisions of the 1993 Trade Union Reform and Employment Rights Act. This Act contains many new and improved individual employment protection rights (many of which bring the UK in line with European Community directives). All pregnant employees have a new right to 14 weeks of maternity leave in addition to the existing right to return to work up to 29 weeks after child-birth. The law also strengthens the protection against dismissal or selection for redundancy on the grounds of pregnancy or child-birth. Additional protections cover sex discrimination in collective agreements.
Slide set for family planning course.
This slide set accompanies a family planning training course consisting of nine workshop modules. The course, which was field-tested in India, was developed to enhance the in-service reproductive health training of nurses/nurse-midwives and physicians in Asia, but is also applicable world-wide. These slides accompany modules one through eight, and the slides for the ninth module are available elsewhere.
Internal migration and urbanization.
This is a general review of contemporary trends in rural-urban migration and urbanization in developing countries. The author examines the reasons for and consequences of the rapid growth of cities in the developing world. Some possible solutions to the resulting problems of overurbanization are presented. (ANNOTATION)
World population growth: trends and prospects, 1960-2020.
"Using mostly United Nations estimates, [the author] outlines salient features of the most recent trends in global population growth and considers the determinants and likely future evolution of these trends. The focus of the discussion is on the six decades centered on 1990. Comments on demographic change in a more remote past and glimpses to more distant demographic futures are also offered to place the period 1960-2020 into a broader perspective....The discussion begins with comments on the demographic transition--a descriptive device that summarizes some common patterns of mortality and fertility that have driven population change over time in the modern era. This is followed by a description of recent regional trends in population growth and its main proximate determinants, mortality and fertility. The concluding sections interpret these trends and consider future population prospects." (EXCERPT)
Evaluation of standard mortality projections for the elderly.
"In this chapter we will discuss how the official population projections, made by governmental agencies, have treated mortality at higher ages, and evaluate how successful they have been in making projections of the future number of elderly people. Attention will be restricted to the experiences in developed countries and, in particular, to the situation in European countries....We first give an overview of the different approaches used in projecting mortality. In the next section, we will review the recent population projections made by the statistical agencies in Western countries, giving particular attention to how the highest age-groups are treated in these projections. We will then evaluate the accuracy of a series of population projections for the elderly population made in developed countries during the period 1950-90." (EXCERPT)
Mortality projections for Japan: a comparison of four methods.
"In this chapter, trends in death-rates for total and cause-specific mortality for Japan are examined in an attempt to forecast the future level and pattern of Japanese mortality. In particular, an attempt is made to answer the following questions: `Will life expectancy continue to rise in Japan, or will it reach an upper limit?' `How will the proportion of the Japanese population that is older than age 65 (or 85) change in the future?' `What causes of death will have the greatest influence on trends in total death rates?'" Particular attention is given to some methodological issues involved in making these mortality projections. (EXCERPT)
Future longevity among the elderly.
Probable future trends in life expectancy among the elderly in Europe are explored using national data on causes of death reported to the World Health Organization for the period 1950-1990. "The projections presented...try to follow an approach which will take into account the possible impact of the new life-styles of more recent cohorts on future mortality levels among the elderly. In particular, to take better account of life-styles and any changes which have occurred, these projections will be made with reference to specific causes of death, selecting those which play a crucial role in determining mortality trends among the elderly." (EXCERPT)
Social support, life satisfaction and survival at older ages.
The authors examine the effects of social support on both life satisfaction and survival at older ages, as well as the relations between life satisfaction and survival, in developed countries in general. The analysis is based on a review of the literature. They then use data from a longitudinal study of people living in the London borough of Hackney to analyze some of the factors associated with survival of the very old. The results are suggestive of a link between social support factors and survival in this elderly population. (ANNOTATION)
Comparative mortality trends among older persons in developed countries.
"The purpose of this chapter is to provide an overview of mortality levels and trends for 33 countries that are considered to be more `developed'....Major differentials by age, sex, and major causes of death are examined. An effort is also made to assess, using decomposition procedures, the relative importance of changes in age- and sex-specific causes of death that account for overall improvements in life expectancy. Although the chapter focuses on mortality and survival at older ages, in order to fully understand these trends it is necessary to place them within the context of changes that have been occurring at younger ages as well. The analyses are based on life-tables that have been prepared using recent World Health Organization (WHO) mortality data, which enable us to examine patterns through the year 1990 for most of the developed countries." (EXCERPT)
International population movements: imbalances and integration.
Global trends in international migration are analyzed in the context of underdevelopment, international inequalities, and the process of growing international political and social integration. The author concludes that developed countries must attempt to manage immigration rather than prohibit it, and to strive for full integration of those immigrants who are admitted. (ANNOTATION)
Some preliminary results from an ongoing survey of centenarians in France are presented. The objectives and methodology of the survey are first described. The characteristics of this population are then analyzed and life tables for centenarians presented. (ANNOTATION)
Strategies to maximize health and functioning and increase life expectancy.
This chapter explores ways to maintain good health and active function in the elderly population in a time of increasing life expectancy and demographic aging. The authors present "a model which represents the effects of nutrition, exercise, and other nontechnical interventions, societal conditions, and the interface of individual physiology and social conditions on functioning and survival. This model can be used to forecast changes in active life expectancy in developing and developed countries." (EXCERPT)
Prospect for extended survival: a critical review of the biological evidence.
The authors present a critical review of the logic behind competing estimates of human longevity in an attempt to establish why there are such large differences in estimates of future human life expectancy. They suggest that the study of longevity is an excellent subject for an interdisciplinary approach involving both biologists and demographers. They conclude that low-mortality countries are approaching the upper limits for life expectancy, and that a law of diminishing returns is likely to prevent further significant gains in longevity. (ANNOTATION)
"In this paper I...seek to contextualise the relationship between gender, education and autonomy within the family [in India], by asking how far familial considerations of feminine propriety, protection of female sexuality, feminine domain and social roles affect women's participation in education, its perceived benefits, the reasons for sending daughters to schools, and the type and amount of education received by women. More specifically, I explore three dimensions of autonomy, namely, husband-wife communication; mother's role in influencing decisions regarding children's education; and the twin issues of daughters' right to property and dowry demand." (EXCERPT)
Formal and informal care: new approaches.
In this chapter, the author reviews the Scandinavian experience in organizing available resources to provide for a growing elderly population. The focus is on care and services, rather than on pensions and other forms of cash transfer to the elderly. (ANNOTATION)
Strategies for the provision of social and health care services for the elderly.
The authors examine the impact of population aging on health and social services with respect to the need to reorganize financing, the types of services required, and the way the services are delivered. (ANNOTATION)
"We argue...that low fertility or mortality [in Kerala, India] cannot be a result of the higher level of autonomy among its women (since that predates the declines in fertility and mortality) unless this autonomy has also been increased by any of the other changes which took place in Kerala during the past 50 years. We therefore need to examine the levels of female autonomy among women in Kerala using a known set of indicators. Our data come from the [1991] Kerala Fertility Survey (KFS)...." (EXCERPT)
Regional variations in female autonomy and fertility and contraception in India.
"This chapter has three distinct objectives. Firstly, I outline an approach to women's autonomy by delineating analytical categories that can be measured in large surveys. Secondly, I present district level data, derived from surveys conducted in two Indian states--Gujarat in Western India and Kerala in South India--to understand whether the degree of female autonomy and gender relations are different in the two regions. Thirdly, I consider fertility and related measures for women enjoying different degrees of autonomy to understand the extent to which autonomy is associated with or can explain regional variations in fertility behaviour." (EXCERPT)
Malnutrition and human development.
Focusing on protein-energy malnutrition, this chapter explores the extent of nutritional deficiencies and their impact on child development around the world. The relationship between nutritional deficiency and poor development among succeeding generations is noted. (ANNOTATION)
The state of children's health in the developing world.
This is a general review of the factors affecting infant and child health and mortality in developing countries, with particular attention given to data for Pakistan. The author considers the negative impact of population growth on child health, the efficacy of breast-feeding in reducing infant mortality, and the link between infant mortality and birthrates. (ANNOTATION)
Disability and functional status among elderly people: cross-national comparisons.
The epidemiology of functional abilities and disabilities of elderly people living in urban areas of various countries around the world is described. Data are from four WHO surveys carried out between 1979 and 1986. Differences in the level of functional ability are analyzed by sex as well as culture. (ANNOTATION)
Trends and differentials in disability-free life expectancy: concepts, methods, and findings.
Some of the problems, concepts, and issues involved in the study of disability-free life expectancy are discussed in this chapter. Attention is given to the differences among total survival, handicap-free survival, disability-free survival, and impairment-free survival. Comparisons are made among selected developed countries with regard to differences in life expectancy and disability-free life expectancy. (ANNOTATION)
The health and survival of the elderly: evidence from the Gothenburg Longitudinal Study.
"This chapter presents research results mainly from a longitudinal study of 70-year-olds in Gothenburg, Sweden. The aim is to illustrate possible answers to some of [the] questions about health and mortality trends in the older Swedish population, as well as to shed light on some of the determinants of and implications for better societal planning for future generations of older people." (EXCERPT)
The impact of the demographic transition on government spending.
"The goal of this research is to determine the impact on government budgets of predicted changes in demographic structure in the United States over the next 90 years....Our basic approach identifies those government programs for which beneficiaries can be distinguished....We calculate the cost to taxpayers of maintaining the 1986 level of age/family-structure-specific payments for each of 22 government programs for which we could identify beneficiaries. We estimate these costs for 1990, and at 20-year intervals from 2000 to 2080. These programs include Social Security, Medicare, Medicaid, education, and a range of income support, welfare, and work-related government programs....In total, the programs we examine account for about 40 percent of all government expenditure. We find that maintaining the benefit levels for each age-specific family type would require quite dramatic increases in the total funds allocated to these programs." (EXCERPT)
This training pamphlet presents a hypothetical scenario in which the director of a family planning (FP) training program was told by the head of her region's largest FP nongovernmental organization (NGO) that clinic assistants who had completed her six-week training program continued to perform some basic tasks incorrectly. The training program director had relied on the high rating given the course by its participants, but now she recognized that the program has no way of evaluating its effect in the field. She decided to have some of the trainers form an impact evaluation team and accompany an NGO supervisor on field trips. The impact evaluation team planned to determine whether the clinic assistants were implementing their training by evaluating specific tasks, such as instrument sterilization and FP counseling. The evaluation would involve preparing evaluation instruments, determining the sample size, conducting visits, collecting data, and analyzing and interpreting findings. Recommendations based on the findings may include strengthening training modules by improving content, methodology, or trainers' skills. In addition, trainee qualifications for the course should be reviewed. If organizational factors rather than inadequate training were found to be affecting performance, recommendations should be made to the NGO to review its systems and procedures or to strengthen its supervision. Agreements for upcoming training courses should indicate which outcomes the training program will and will not be responsible for, a course summary, course logistics, criteria for trainee selection, resources the NGO will provide trainers, and a definition of acceptable results.
Assessing the impact of training on staff performance.
This pretested document was prepared as a management and reference tool for a world-wide audience of family planning (FP) policy-makers, program managers, service managers, and trainers. The report describes a training impact evaluation (TIE) process that helps managers identify and strengthen the links between training and staff performance. Introductory information deals with understanding training evaluation, the various types of training evaluation, and conducting a TIE. The following steps of the TIE process are then described: 1) identifying job performance issues (defining key job-related tasks and choosing indicators/setting standards); 2) collecting data (evaluation techniques and instruments, how to design an effective evaluation instrument, sample definition, and how to plan and organize the data collection process); 3) analyzing the data (tabulation, aggregation, cross-tabulation, and disaggregation); 4) interpreting the data (using a decision-tree); 5) reporting the findings (developing a written report and making an oral presentation); and 6) making changes (responsibilities for acting on recommendations, handling resistance to change, agreeing on a new or revised training course and/or changing organizational procedures or systems, and clarifying expectations for a training event). An example is provided of the process and results of a TIE conducted in the Central Asian Republics. The report ends with a discussion of ways to continue the TIE process, the comments of reviewers about various aspects of the process, and a checklist to use when making a TIE.
To assess the blood coagulation effects of an experimental triphasic contraceptive (35 mcg of ethinyl estradiol and 7 days each of 0.18, 0.215, and 0.25 mg of norgestimate), 39 non-smoking female volunteers were enrolled in a 12-month study. Coagulation variables were determined at baseline and after 3, 6, and 12 months of exposure. The increased risk of thromboembolism associated with some oral contraceptives has been linked to changes in the coagulation cascade. This new formulation produced no changes in overall hemostasis. Slight decreases were recorded in the intrinsic and common pathways of coagulation. There was a marked decrease in fibrinogen, especially in the 14 women with no prior exposure to hormonal contraception, and increases in several vitamin K dependent factors. Protein C antigen, a coagulation inhibitor, was elevated. The continual reduction over 12 months in fibrinogen activity recorded in this study should reduce the potential for fibrin deposition in the vascular system. Moreover, the slight activation of some clotting factors associated with low-dose norgestimate is effectively countered by the protein C increase.
Development of new immunocontraceptives -- industrial perspective.
Immunocontraception represents a promising new frontier for fertility control research and development. Advantages of such an approach include reversibility, lack of effect on the menstrual cycle, and the need for only one or two injections per year. The zona pellucida, a noncellular surrounding of all mammalian eggs, is a potentially feasible target for immunological interference with the fertilization process; however, animal trials have resulted in irreversible oophoritis. Human chorionic gonadotropin (hCG) vaccine has the advantage of attacking a target that is present only during pregnancy, but raises political issues related to abortion. An anti-sperm contraceptive vaccine is another possibility, although sperm antigens that result in a B-cell- rather than T-cell-mediated immune response have not been identified. Anti-trophoblast vaccine represents an alternate strategy, but the problem of mucosal immunity remains an obstacle. If an immunological contraceptive is developed, careful risk-benefit analyses must be performed.
A comparative study of four treatment regimens for women with a history of poor response to controlled ovarian hyperstimulation (COH) during attempts at in vitro fertilization (IVF) and embryo transfer suggested the feasibility of pretreatment with oral contraceptives (OCs). The 60 women enrolled in the study exhibited one or more of the following in an initial stimulated IVF cycle: three or fewer dominant follicles recruited, serum estradiol levels of 300 pg/ml or below, and/or a spontaneous luteinizing hormone (LH) surge prior to oocyte retrieval. Study subjects were assigned to one of four protocols: Group I--OCs for 3 weeks followed by COH; Group II--luteal phase leuprolide acetate with subsequent COH; Group III--short-flare Lupron with subsequent COH; and Group IV--COH alone. COH consisted of 150 IU/day of pure follicle-stimulating hormone (pFSH) and 150 IU/day of human menopausal gonadotropin (hMG). The mean age of women in each group ranged from 36.0 to 38.8 years. There were no significant differences among groups in terms of number of days of stimulation, total ampoules of hMG and pFSH required, peak serum estradiol and progesterone, number of oocytes retrieved and fertilized, and embryos transferred. However, the pregnancy rate was significantly higher (p < 0.05) in Group I (9/30, 30%) than in Group II (2/32, 6%), Group III (0/11, 0%), and Group IV (0/10, 0%). The good outcome associated with OC pretreatment may reflect production or alterations of local ovarian growth factors and/or changes in endometrial expression. Administration of exogenous estrogen may be particularly beneficial for perimenopausal women in their forties with ovarian follicular depletion.
In October 1995, all physicians in the UK were notified by the Chairman of the Committee on Safety of Medicines (CSM) of the substantially increased risk of venous thromboembolism associated with use of third-generation oral contraceptives (OCs) containing desogestrel or gestodene. At the time the CSM contacted physicians, none of the studies substantiating this risk was published; moreover, the CSM advice was reported in the mass media before physicians received their letters, creating considerable anger in the medical profession. Once the studies on which the CSM action was based were available, the British Medical Association concurred with the recommendation. Of concern, however, is the contrast between the UK Medicines Control Agency's regulatory action on grounds of safety against these third-generation OCs and the Department of Health's inertia regarding the even more hazardous risk posed by young women's smoking.
The lives of many adolescent girls are restricted by gender discrimination, poverty, illiteracy, poor nutrition and health care, violence, and premature motherhood. This sourcebook, intended for facilitators and trainers working with girls ages 12-20 years, is based on the principle that girls have the right and can develop the capabilities to make choices about their futures. Essential to choice-making are self-respect and self-esteem development, supportive peer relationships, expanded decision-making and negotiating skills, and access to resources. The 12 modules (48 sessions) in this volume cover the following topics: Me, Myself; Goals and Plans; Our Families; Community; Work; Friends; Marriage, Partnership, and Parenthood; Puberty and Reproduction; Health; Legal Rights; Environment; and Us, Together. Each session is based on an experiential learning model that emphasizes active participation, problem solving, and open expression. Specified for each session are an objective, time needed, activities, materials required, discussion guidelines, and ideas for action. The idea for this project emerged from the Center for Development and Population Activities' Better Life Options Program and was tested extensively in such groups in India, Mexico, Ghana, Nigeria, and Uganda.
Teen sex, AIDS, and contraception: part three [editorial]
The acquired immunodeficiency syndrome (AIDS) pandemic in the US is becoming increasingly similar to the scenario in the Third World, where almost half of all new infections occur in women. In the US, AIDS cases among Black women 25-44 years of age (most of whom became infected as adolescents) now exceed those among White men in the same age group. Although African Americans and Hispanics 13-24 years of age comprise only 27% of the US population, they represent 59% of AIDS cases. Despite findings that long-acting progestogens have a thinning effect on the vaginal epithelium in monkeys, facilitating transmission of simian immunodeficiency virus (SIV), Norplant and Depo-Provera continue to be promoted, especially for inner-city teenagers. Neither contraceptive provides any protection against sexually transmitted diseases (STDs) and may, if the SIV finding is applicable to humans, actually increase the risk of AIDS. Recent shifts in the class and racial background of AIDS patients raise concerns about whether the US government will continue to allocate the requisite resources for inpatient care, drugs, and hospice services. Urged is contraceptive research aimed at the development of a safe, effective method that provides protection against STDs as well as pregnancy.
Investigated, in this retrospective study, was an observation of hospital staff that use of gemeprost in mid-trimester pregnancy terminations was associated with a longer induction-delivery interval when the fetus had been diagnosed with a neural tube defect or hydrocephalus. The records of a consecutive series of 247 women admitted to Western Suburbs Hospital (Waratah, New South Wales) in the second trimester for gemeprost-induced abortion were reviewed and women were divided into three groups according to indication: Group A (n = 24)--fetal death (not from neural tube defect or hydrocephalus) diagnosed by ultrasound; Group B (n = 88)--all chromosomal and structural abnormalities other than neural tube defect and hydrocephalus; and Group C (n = 75)--neural tube defect and/or hydrocephalus diagnosed by ultrasound. The mean induction interval was 11.3 hours in Group A, 19.7 hours in Group B, and 31.7 hours in Group C. The percentages of women with an induction to delivery interval equal to or exceeding 24 hours were 4.8%, 15.9%, and 43.4%, respectively. The proportion of women requiring further surgical intervention was 4% in Group A, 14% in Group B, and 33% in Group C. These findings should be considered when counseling women who request pregnancy termination for fetal abnormalities. It was hypothesized that fetuses with a neural tube defect or hydrocephalus have a deficiency of the hypothalamic-pituitary-adrenal axis, resulting in decreased corticotrophin-releasing hormone release and difficulty initiating parturition. Use of RU-486, in addition to gemeprost or extra-amniotic prostaglandin, may be indicated in such cases.
Overdose and termination of pregnancy: an important association?
A retrospective review of the records of 1359 female patients 15-39 years of age registered with a general practice in the UK revealed an association between deliberate self-harm and induced abortion. 163 (12%) of these women had undergone pregnancy termination, primarily at age 19 years or younger, and 47 (3.5%) had a history of deliberate overdose; 15 women had a history of both of these events, generally within 2 years of each other. The association between induced abortion and overdose was significant (p < 0.01). Although abortions were more likely to follow than precede overdoses, this trend was not significant. It was speculated that both events are related to similar psychosocial factors, including socioeconomic deprivation and self-destructiveness. If this association is confirmed in larger studies, methods to identify women at risk should be explored.
Lessons from the Dutch abortion experience.
Not only does the Netherlands have the lowest induced abortion rate in the world, but Dutch youth have the lowest rates of both adolescent pregnancy and abortion. This record is attributed to a general stance of openness and acceptance of sexuality as a healthy part of life that emerged in 1965-75 in response to recognition of the public health impact of unwanted pregnancy. Modern contraceptives (excluding condoms) are provided at no charge by the national health service and are easily accessible to teenagers. Sex education, which begins at an early age, seeks to instill skills that enhance partner communication and negotiation. By the late 1980s, unplanned births represented only 6% of all first births. In 1992, 38% of Dutch women terminated their first pregnancy compared with 47% in the US; that same year, the Dutch adolescent pregnancy rate was 9.2/1000 women 15-19 years old compared with 95.9/1000 in the US. In 1995, 85% of Dutch youth used contraception at first intercourse (46% condom, 13% pill, 24% pill and condom, and 1% other method). Overall, the Dutch experience suggests that a less ambivalent public approach to sexuality might encourage more responsible reproductive behavior in the US.
Bellagio Consensus Meeting: a model for health policy development.
The Bellagio Consensus Meeting on the use of breast feeding as a family planning method represents a useful model for health policy development. The 1988 meeting, organized by Family Health International and attended by 25 researchers from around the world, aimed to obtain agreement on the level of protection from pregnancy conferred by lactational amenorrhea. The meeting resulted in consensus on the following statement: "During full or nearly full breast feeding as long as the mother remains in amenorrhea, then for up to a full 6 months, she will have 98% protection from pregnancy." Elements considered key to the consensus process included a single objective, good rapport among participants, a spirit of cooperation rather than competition, intensive pre-meeting preparation (required readings), and endorsement by influential organizations such as the US Agency for International Development and the World Health Organization. The consensus has been widely disseminated in the medical and scientific literature and presented to international family planning conferences. Moreover, numerous publications have set forth detailed guidelines for translating the consensus statement into policy change and program implementation.
Indicative of increased interest in breast feeding promotion on the part of the international donor community, United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) co-sponsored the first meeting of the Interagency Group for Action on Breast Feeding. This 1987 gathering was followed by an interagency needs assessment, establishment by WHO of an international data bank, and identification of successful breast feeding promotion programs. The long-term goal, however, is to influence high-level policy makers to support the goal of empowering all women to exclusively breast feed for 4-6 months and continue supplemented breast feeding well into the second year of life. One of the most effective ways to promote support of breast feeding is to convince governments that this practice decreases the incidence of diarrheal and respiratory disease and increases child spacing, thereby reducing infant mortality. A review of the efforts of selected countries to reverse declining trends of breast feeding initiation and duration is underway, and health care worker training programs are being developed. Two WHO-UNICEF publications--a Joint Statement on the role of health services and "Ten Steps to Successful Breast Feeding"--are facilitating implementation of breast feeding promotion activities.
Evolution of policy related to breastfeeding at the Agency for International Development (A.I.D.).
Breast feeding promotion in developing countries has been hindered by the absence of formal, explicit breast feeding policies and a lack of accurate knowledge on the part of health professionals. In response to these concerns, the US Agency for International Development (USAID) has strengthened country-specific breast feeding efforts in its sectors concerned with fertility, health, and nutritional status. All three sectors share the goals of optimizing child survival, maternal health, and promotion of the contraceptive effects of breast feeding. The USAID Child Survival Strategy incorporates breast feeding interventions into the control of diarrheal disease, malnutrition, and inadequate birth spacing through supportive birthing and hospital practices, improved information and support for health personnel and lactating mothers, integration of oral rehydration and breast feeding promotion, promotion of breast feeding in family planning programs, community support, and legislative and policy initiatives. Of the 72 long-term USAID-supported breast feeding projects in 30 countries, 47% are being implemented by local private voluntary organizations and 16 are national in scope. Current goals include evaluation of the quality and impact of USAID-assisted projects in this area, strengthening of existing field and centrally funded projects that address or have the potential to address breast feeding, and formulation of a BREASTECH project.
The Institute for International Studies in Natural Family Planning (IISNFP), based in the Department of Obstetrics and Gynecology at Georgetown University, has reformulated its breast feeding strategy to focus on three areas: policy change, health care provider development, and provider support for introduction of the lactational amenorrhea method derived from the Bellagio Consensus Statement. IISNFP is collaborating with other universities and research organizations to demonstrate the feasibility and efficacy of breast feeding interventions and develop curricula for health professionals. In addition, IISNFP distributes Institute Issues Reports aimed at policy and program decision makers and is collaborating with the IMPACT program to produce a booklet for policy makers entitled "Breast Feeding: Protecting a Natural Resource." Finally, through its role as Technical Secretariat to the Interagency Group for Action on Breast Feeding, the Institute is helping to forge an international breast feeding strategy for the 1990s and to develop a definitional schema that differentiates between levels of full and partial breast feeding.
Private voluntary organizations and breastfeeding policies.
Private voluntary organizations can influence breast feeding policies through their roles in education of Congress, support for and evaluation of breast feeding promotion projects, research on the determinants and consequences of breast feeding, and information dissemination about successful programs. Until policy makers accept breast feeding as an essential component of child survival and primary health care programs, interventions in this area will remain underfunded. Crucial is the dissemination of information to policy makers documenting that breast feeding programs save lives, are cost-effective, and can be successfully implemented. The Center to Prevent Childhood Malnutrition has estimated that breast feeding promotion can save 7-10 million lives each year through its prevention of malnutrition, diarrhea, and acute respiratory infections.
Reproductive preferences and fertility trends in post-transition Thailand.
Estimations, based primarily on the 1990 census, that Thailand's total fertility rate fell below replacement level in the late 1980s sparked alarm about extinction of the Thai race and calls to abandon public subsidies for family planning. Recent low total fertility is considered a temporary phenomenon, however, related to the rapid rise in age at marriage and first birth. Birth registration data suggest that the fertility decline levelled off, probably close to replacement level, during the first half of the 1990s and fertility is unlikely to fall below two children. Although the 1988 and 1993 Social Attitudes Toward Children Surveys documented a consistent trend toward declining family size preferences (64% of 1993 respondents, and 74% of women under 30 years of age, stated a preference for two children), only 5% desired fewer than two children. This lower limit of two children prevailed across regional, educational, and socioeconomic categories and appears to reflect a desire to have a child of each sex. In 1993, three-quarters of married women under 30 years of age expressed a preference for one son and one daughter. Despite this preference, Thai couples who fail to achieve this goal generally subordinate gender ideals to the prevailing preferred limit of two children. Although the Thai Government has succeeded in exhorting couples to reduce their family size, any abandonment of subsidized family planning programs could have a deleterious impact on poor families in rural areas.
A community-based investigation of avoidable factors for maternal mortality in Zimbabwe.
A community-based survey of maternal deaths in a rural province (Masvingo) and urban area (Harare) of Zimbabwe in 1989-90 revealed a high incidence of avoidable factors, both within and outside the health sector. During the 2-year study period, 109 maternal deaths were identified in Masvingo (168/100,000 live births) and 66 in Harare (85/100,000 live births). In Masvingo, the three leading causes of death were hemorrhage (25%), postabortion sepsis (15%), and puerperal sepsis (13%); in Harare, these causes were eclampsia (26%), postabortion sepsis (23%), and puerperal sepsis (15%). In Masvingo, the locations of maternal deaths included rural hospitals (50%), provincial hospitals (13%), home (13%), and travelling to or between health facilities (11%); all deaths in Harare occurred in central hospitals. One or more avoidable factors were identified for 90% of maternal deaths in Masvingo and 85% of those in Harare; these factors occurred at the community level in 47% and 38% of deaths, respectively. Among patient-related factors, delay in the decision to seek care for symptoms was most widespread (32% of deaths in Masvingo and 28% of those in Harare). Problems of access to transportation from home to health facility were implicated in 28% of deaths in Masvingo and 3% in Harare. Avoidable factors within the health sector were identifiable in 67% of Masvingo deaths and in 70% of Harare deaths. Notable was failure of health personnel to assess the severity of postabortion conditions and puerperal sepsis and initiate aggressive treatment. Recommended, to reduce maternal mortality in Zimbabwe, are community awareness of risk factors for pregnancy and delivery, collective emergency transportation mechanisms, maternity waiting shelters, appropriate obstetric management protocols, more effective identification and treatment of emergency conditions, and liberalization of existing abortion legislation.
This review of women's rights related to marriage, divorce, property, inheritance, child custody, evidence, and rewards and punishments as set forth in both the Quran and Islamic Law indicates that Islam fundamentalists have seriously misrepresented the spirit of these texts. Current claims of male superiority in Indian society are sociological rather than theological in origin. The Quran makes it clear that women are not to be treated as adjuncts to their fathers, husbands, or brothers. Although the Quran concedes a degree of superiority to men in their social context, it awards equal status to both sexes in the normative sense. It states that a man should maintain his wife and, in return, the wife must look after the children; there is no prohibition of a woman's right to work. The Quran never intended to place restrictions on women's movements or to require them to completely hide their faces while out of the home. Many current interpretations were formulated in the first century of Islam, when women were viewed strictly for their procreative function. Changed socioeconomic circumstances call for adoption of a common civil code to eliminate religious discrimination in laws related to women's status. An appendix contrasts marriage and divorce laws among Muslims, Christians, and Parsis.
This book compares the status of Muslim women in India according to Islamic law and in contemporary life (as revealed by survey data from the National Seminars). A review of the Holy Quran and the Traditions (sayings by the Prophet) suggests that current religious leaders have deviated from the principle of equality between the sexes outlined in these ancient writings. The Quran has been misinterpreted by Islamic fundamentalists to justify the imposition of restrictions on women's rights and freedom. In fact, the rise of Islam was associated with encouragement of women to participate in building up the social life of the Muslim community. Islamic conservatism has led many women to adopt permissive Western ideals, to the detriment of family honor and public decency. To close the gap between the Quran and reality, the government of India must fulfill its constitutional obligation to provide free and compulsory primary and middle education to all boys and girls; the Muslim minority should be given special funds to start its own schools for the education of Muslim girls; Muslim philanthropies should prepare books for teaching religious education at all levels; and modern education in areas such as the social sciences, medicine, and business management should be promoted to prepare Muslim women to participate effectively in development.
A critical review of sexual and reproductive health.
The 1990s marked a shift from family planning programs primarily intent on achieving fertility decline to a broader sexual and reproductive health approach to service delivery. At the 1994 International Conference on Population and Development, reproductive health was conceptualized as the capability to have a safe and satisfying sex life and to reproduce under conditions of personal freedom. Implementation of this approach requires family planning and health administrators to plan cost-effective, available, integrated programs of high quality tailored to the specific needs of diverse clients in different settings. Central is awareness of reproductive health as a gender issue. Gender- based inequalities create unwanted pregnancies, unmet needs for contraception, lack of access to prenatal care, higher risks of maternal mortality and sexually transmitted diseases, and female genital mutilation. Implementation of a reproductive health care approach has been hindered by a lack of clarity on issues such as whether sectors outside of health and family planning should be involved, top down versus participatory administrative structures, selection of the most feasible interventions, and the role of cost- benefit analysis in determining priorities; other obstacles include a lack of empirical research on reproductive health and of indicators that can serve as outcome measures for program evaluation. The few studies that do exist (reported in an annotated bibliography) suggest that community-based approaches are most effective when they involve both men and women in defining problems and identifying action strategies.
A critical review of structural adjustment and increasing women's economic participation.
Structural adjustment and stabilization programs, implemented after the worldwide economic crisis of the 1980s, have had a generally negative effect on women's role in economic development in the Third World. Recommended instead, for the poorer segments of the population, is a market-oriented strategy that improves access to employment opportunities and assets while raising the productivity of these assets. This article evaluates the results of projects in the agricultural and informal sectors aimed at promoting women's economic participation; an annotated bibliography is appended. In general, these projects have been hindered by failure to involve women at the beginning of the planning process and isolation of such projects from mainstream development activities and the broader macroeconomic environment. In the agricultural sector, attention should shift from developing employment opportunities or alternative income-generating activities for women to bringing more resources under the control of women to augment agricultural productivity. Also recommended are dissemination of information on mainstream agriculture, improved access to resources such as land and credit, increased productivity and marketing, child care provision, and enhanced water and fuel wood supply. A shift is essential from a women-in-development strategy focused on women's activities to a gender-and-development approach that strives for mainstreaming.
A critical review of women's status and rights.
Although a dismantling of the inequalities that subordinate women and prevent them from realizing their potential is essential to social progress, the benefits to society of a balanced approach to undoing injustice must be recognized as well. Contextual differences in women's positions relative to both men and women of other social classes and ethnic groups hinder global efforts to promote women's human rights. A key policy issue relates to how to bring about equal participation of men and women in the mainstream of development without resorting to separatist strategies (e.g., women's bureaus) that perpetuate the marginalization of women. Emerging is a less gender-segregated approach to gender inequalities that identifies strategies for involving men, both separately and with women. Given men's power, gender planning must be as explicit about men's interests as it is about women's interests, and it must address both gender conflicts and gender complementarities. Social planners are urged to find contextualized win-win solutions to gender inequalities that are perceived by both men and women as being in their combined interest. Appended to this review is an annotated bibliography of research on interventions aimed at improving women's status.
Although international donor agencies place an emphasis on infectious diseases, problems caused by reproductive tract infections (RTIs) during pregnancy are not only at least as serious as those caused by immunizable diseases, but interventions are often more cost-effective. To avert one case of gonorrhea and to avert one adverse outcome associated with syphilis during pregnancy would cost about US $1.40 and $12,00, respectively, compared with $40-150 to prevent an immunizable disease. In a typical developing country, an intervention for gonorrhea would cost about $65,000 for 1 million births and would avert 47,000 cases of gonorrhea. An intervention to test and treat for syphilis during pregnancy would cost about $900,000 for 1.5 million pregnancies and avert 75,000 adverse outcomes. Urged is a reallocation of resources toward RTIs and research into the most cost-effective approaches to syphilis, gonorrhea, chlamydia, herpes. In addition, research aimed at one or more specific organisms should be conducted to assess the efficacy of antibiotic treatment and the role of genital infections in ascending intrapartum infections and prematurity. A simulation model should be developed that could be used to estimate the effects of different prevention strategies on pregnancy outcome and child survival.
Economic impact of reproductive tract infections and resources for their control.
The economic costs associated with reproductive tract infections (RTIs) and their complications and sequelae in developing countries are substantial. Direct costs include the costs of diagnosing and treating the disease and preventing its spread, while indirect costs include the value of labor lost from morbidity, debility, and premature mortality, as well as the value of any labor diverted from other productive uses to care for the ill. The current lack of data on these economic consequences has contributed to the implementation of and allocation of funds for interventions in this area. Recommended, to better estimate the resources needed for RTI prevention and control, are the following: 1) development of strategies and priorities for RTI control, as well as a plan of action, by an ad hoc group of donors, women's health advocates, and health system specialists; 2) sensitizing of policy makers in governments, donor agencies, and RTI-related programs to RTIs and both a health and development issue; 3) immediate incorporation of selected interventions for RTI control into primary health care, family planning, maternal-child health, safe motherhood, and AIDS control programs; 4) development and evaluation of biomedical, behavioral, and societal interventions for RTI control and treatment in the developing world and an assessment of their cost- effectiveness; and 5) support of intervention-oriented research and the development of female preventive technology.
Previous studies have demonstrated the efficacy, in mice, of synthetic peptides derived from zona pellucida (ZP) glycoprotein in blocking fertility without ovarian dysfunction. This study used bonnet monkeys (closely related to humans in the primate evolutionary tree and less susceptible to summer amenorrhea than rhesus monkeys) to explore the design of an immunocontraceptive vaccine based on synthetic peptides, recombinant glycoproteins, or proteins corresponding to ZP. Immunization of female monkeys with pig ZP3 glycoprotein using adjuvants permissible for human use produced infertility. Although only half the animals conceived after antibody titres declined, monkeys that failed to conceive did not show any obvious ovarian changes. Mapping of the epitopes recognized by monoclonal antibodies against ZP3 alpha and beta and possessing contraceptive efficacy in vitro identified an N-blocked decapeptide from the N-terminus corresponding to 23-32 amino acids of the precursor protein of pig ZP3 beta. When DNA encoding bonnet monkey ZP3 was cloned and sequenced, the deduced primary amino acid sequence showed a 93.9% similarity with human ZP3. Bonnet monkey ZP3 corresponding to an internal 975 nucleotide fragment excluding the N-terminus signal sequence and the C-terminus transmembrane domain has been expressed in Escherichia coli.
Evaluation of zona pellucida antigens as potential candidates for immunocontraception.
Antibodies directed against the zona pellucida (ZP) have been demonstrated to interrupt sperm-egg recognition in vitro, yet the mechanisms by which anti-zona antibodies exert this contraceptive effect in vivo are unclear. Emerging evidence suggests that active immunity against zona antigens both induces infertility through an antibody-mediated interruption of sperm-egg interaction and disrupts normal ovarian function. This study used the marmoset monkey to assess the consequences of inducing active immunity against purified recombinant human ZP3 and human ZP3 peptides. Although recombinant human ZP3 induced infertility in these animals, it was associated with suppression of folliculogenesis and depletion of the primordial follicle pool. Immunization with continuous human ZP3 peptides, identified by epitope mapping studies, did not induce ovarian dysfunction, but the antibody titers were insufficient to suppress fertility significantly and consistently. Future homologous active immunization trials will depend on generation of epitope maps of the marmoset ZP3 sequence.
Working women and health problems. Identity of a nurse.
Working women in India are forced to perform dual roles, wage earner and household manager, to the detriment of their health. Depending on their profession, working women may face stresses such as shift work (including night duties), transportation problems, frequent job transfers, and lack of child care near the workplace. That they are unable to be fully attentive to the physical and mental development of their children can cause considerable distress. Women's labor force participation has been linked to emotional depression, chronic fatigue, malnutrition, high blood pressure, adverse pregnancy outcomes, and musculoskeletal disorders. The burden of ill health associated with women's employment in India impedes both family life and national development. Nurses are promoting community services in the areas of immunization, nutrition, and family planning. Recommended is extension of the Maternity Benefits Act to one year to enable working women to regain their health after pregnancy. The goals of health for all, universal literacy, and poverty elimination can be achieved only if women's health concerns become a priority.
Epidemiology of syphilis in pregnancy in rural South Africa: opportunities for control.
A case-control study involving 200 pregnant South African women indicates that maternal syphilis infection has a substantial impact on pregnancy outcome. The first 50 women diagnosed with syphilis at booking for antenatal care in Hlabisa Health District in KwaZulu/Natal served as cases; 3 women who tested negative for syphilis and who presented for antenatal care at the same time and to the same clinic as each case served as controls. The overall prevalence of syphilis in the 7723 women booked for antenatal care at district clinics in 1994 was 6.5%. Multiple logistic analysis identified 2 independent risk factors for maternal syphilis: gravidity 3-5 (odds ratio (OR) 2.3, 95% confidence interval (CI) 0.9-5.8 when compared to gravidity 2 or less and OR 3.2, 95% CI 1.0-10.3 when compared to gravidity 6 or more) and previous perinatal death (OR 3.1, 95% CI 1.0-8.8). 6 of the 8 perinatal deaths (4 early neonatal deaths and 4 stillbirths) in this study involved women with syphilis; all 4 of the stillbirths were to cases. The OR for an adverse pregnancy outcome in women with syphilis was 11.8 (95% CI 2.0-67.4). Only 22 women with syphilis received all 3 recommended doses of penicillin. Women who had 0-1 dose of penicillin had a greater risk of perinatal death than those who received 2-3 doses (OR 19.4, 95% CI 1.7-944.6). On-site screening for syphilis and immediate initiation of penicillin treatment could have a substantial impact on pregnancy outcomes in this district.
The sensitivity and specificity of reproductive morbidity data (obtained, first, through questionnaires administered by female lay interviewers and, 1-2 weeks later, through physician interviews, physical examination, and laboratory tests) were compared in a cross-sectional study conducted in Istanbul, Turkey. The 696 female respondents were sampled from a clinic-based community register. The presence or absence of 5 morbidities (reproductive tract infection (RTI), urinary tract infection (UTI), menstrual disorders, pelvic relaxation, and anemia) was determined by algorithms. The prevalence of medically diagnosed morbidities was 7% for UTI, 16% for menstrual disorders, 20% for RTI, 27% for pelvic relaxation, and 33% for anemia. Except for anemia, questionnaire replies were more specific than sensitive in detecting morbidity, presumably due to acceptance of many of these conditions as normal. Specificity was 93% for home reports of menstrual disorders, 95.7% for pelvic relaxation, 81.2% for RTI (abnormal discharge and pain), 80.7% for UTI, and 41.7%% for anemia. The corresponding sensitivity rates were 45.4%, 17.3%, 49.3%, 17.3%, and 58.3%. Reliability between the interviews was highest for pelvic relaxation (66.1%) and lowest for menstrual disorders (39.9%). Perceived symptoms of ill health were reported more frequently to physicians than to lay interviewers. Overall, these findings suggest that questionnaire-based information is useful for assessing perceptions of ill health, but it has limited utility for identifying medically defined conditions.
In a comparative study designed to investigate the effect of cervical anesthesia on the perception of pain during IUD insertion, 102 women presenting for IUD insertion at a community family planning clinic in Leeds, England, were randomly assigned to 1 of 3 groups: A, no pretreatment, B, pretreatment with 2% lignocaine gel (Instillagel) applied to the cervical canal, and C, pretreatment with an inert gel. Pain scores for women in groups A and C combined were significantly higher (p < 0.025) than those in group B. The percentages of women reporting the most intense pain (scores of 5-7 on a 7-point scale) were 26.3% in group A, 18.2% in group B, and 35.0% in group C. There were no significant differences in pain perception between nulliparous and parous women overall or by group. Postinsertion symptoms attributable to cervical stimulation (e.g., pallor, lightheadedness, transient brachycardia) were noted in 9 of 58 women (15.5%) in groups A and C combined, but in only 2 of 44 women (4.6%) in group B. These results suggest that the Instillagel system has potential for reducing the pain and discomfort experienced by IUD acceptors at insertion. Recommended, however, are additional studies to determine whether a greater analgesic effect could be obtained from a longer delay between gel installation and insertion and to compare this method with paracervical infiltration.
Postnatal contraceptive advice -- midwives' attitudes.
A survey conducted among midwives working in the Maternity Unit of Billinge Hospital (UK) assessed the postnatal family planning counseling provided by these health workers. All 67 respondents indicated they discussed contraception with their clients before discharge from the hospital; 75% directed their clients to family planning clinics, 64% referred them to their family practitioners, and 37% provided leaflets listing family planning clinics in the area. Although 52% of midwives presented all contraceptive methods, 37% discussed only those methods with which they were familiar (e.g., barrier methods, the pill, and Depo-Provera). 96% of midwives perceived themselves as the most suitable professional to provide such counseling due to their established relationship with their clients. The immediate postpartum period was identified by 79% as the most appropriate time for this service. The effectiveness of midwives in this role would be facilitated by both further training in the range of contraceptive methods and the availability of initial contraceptive supplies.
Human immunodeficiency virus transmission and oral contraceptives [letter]
A recently published study by Plourde et al of 600 women attending a sexually transmitted disease clinic in Nairobi, Kenya, identified oral contraceptives (OCs) as a significant risk factor in human immunodeficiency virus (HIV) infection. The odds ratio of HIV for women using OCs for 12 or more months was 1.9 (95% confidence interval, 1.04-3.6) compared to OC use for under 12 months when adjusted for number of lifetime sexual partners and 1.9 (95% confidence interval, 1.05-3.6) when adjusted for condom use. This analysis is flawed, however, by the inclusion of women with no history of OC use in the < 12 months of OC use group. Also suggestive of methodological bias is the finding of an odds ratio for condom use (adjusted for OC use) of 3.02 (95% confidence interval, 1.6-5.6). The high correlation among OC use, condom use, prostitution, and genital ulcers present in this study creates potential for bias and misclassification. The finding of another case-control study that OC use confers a 60% reduction in HIV risk suggests a need for further research in this area before OCs are designated a risk factor for HIV.
Human immunodeficiency virus transmission and oral contraceptives. Reply [letter]
The authors, in this reply to Nicolosi's letter to the editor, concur with his identification of potential sources of bias inherent in their study of oral contraceptives (OCs) as a risk factor in human immunodeficiency virus (HIV), and they urge cautious interpretation of their findings. The high correlation noted by Nicolosi of HIV with condom use was entirely due to the behavior of prostitutes. When prostitutes were excluded from the analysis, this correlation disappeared. Although further HIV transmission studies are needed to assess factors such as the impact of duration of OC use, it is likely that OCs strongly interact with sexually transmitted diseases such as genital ulcers, facilitating heterosexual HIV transmission. Since OCs are not effective in the control of sexually transmitted diseases, family planning programs should promote concurrent use of a barrier method.
HIV and commercial sex in Cambodia.
Population shifts, socioeconomic change, and an influx of foreign business and tourism are stimulating an increase in commercial sex activity in Cambodia and the rapid spread of human immunodeficiency virus (HIV). HIV seropositivity rates are over 40% among commercial sex workers in the country's western provinces and seaports; nationally, this rate is 33%. In this culture, commercial sex is sanctioned as an essential part of the male experience; 60-70% of Cambodian men are estimated to visit prostitutes. Most commercial sex workers are young, uneducated, unskilled, and have limited economic opportunities. Government- sponsored programs aimed at shutting down brothels or registering commercial sex workers have been ineffective, pushing the industry underground and deterring visits to government sexually transmitted disease clinics. Most effective are programs that gain the support and participation of the communities they serve. Local and international voluntary agencies are working with brothel-based prostitutes to provide condoms and acquired immunodeficiency syndrome (AIDS) education. However, even if commercial sex workers are motivated to use condoms, fear of abuse by brothel owners or offers of more money by clients obstruct their decision making power. Recommended is the social marketing of condoms for family planning purposes in order to reduce their association with illicit sex.
An evaluation of dipstick-dot immunoassay in the detection of antibodies to HIV-1 and 2 in Zimbabwe.
The Program for Appropriate Technology in Health has developed a simple, inexpensive dipstick enzyme-linked immunosorbent assay (ELISA) to detect antibodies to human immunodeficiency virus (HIV)- 1 and 2 that requires no specialized washing or reading equipment. To evaluate the reliability of this test under local conditions, stored sera from a factory worker cohort of blood donors in Zimbabwe were tested. Before storage, the sera had been tested by Abbott recombinant peptide HIV-1 and 2 ELISA and Enzygnost synthetic peptide HIV-1 and 2 ELISA. Thawed sera were tested concurrently with the Abbott method and the synthetic peptide dipstick assay (ICLD). The 546 sera were classified into 3 groups: 266 true negatives (defined as negative by all 3 ELISAs); 250 true positives; and 30 problematic sera (discrepant results between the 2 pre-storage ELISAs). When compared with the concurrently run ELISA, the overall accuracy of the ICLD was >98% Both the sensitivity and specificity of the ICLD were 99.6% when using sera that were true positives or negatives. When discordant sera were analyzed, the ICLD concurred with findings of Western blot and p24 antigen detection. The cost of the ICL Dipstick is less than US $2.00, compared to $3-3.50 for conventional ELISAs. The accuracy, low cost, and ease of operation of the ICLD suggests that this test has an important role in detecting HIV antibodies at a district level in developing countries.
HIV infection and vaginal douching in Central Africa.
Previous research has suggested that frequent vaginal douching modifies vaginal flora and increases the risk of cervical infections -- a probable risk factor for human immunodeficiency virus (HIV). To assess the association between HIV infection and vaginal douching, 397 women attending a sexually transmitted disease clinic in Bangui, Central African Republic, during 1994-95 were interviewed regarding their sexual behavior and vaginal douching practices in the preceding 3 years. The overall HIV prevalence rate was 34%. Douching, primarily for hygiene or treatment of a vaginal discharge, was reported by 195 women (49%); its mean weekly frequency was 7 times. A commercial antiseptic was used by 140 women (72%); 48 (25%) used a noncommercial preparation (largely herbs) and 7 (3%) used water. The analysis was restricted to women who used commercial or noncommercial preparations at least once a week (104 and 32 women, respectively). 25 (21.7%) of the 115 HIV-positive women reported use of commercial antiseptics compared with 79 (35.4%) of seronegative women (odds ratio, 0.6; 95% confidence interval, 0.4-0.9 after adjustment for condom use, lifetime number of sexual partners, and marital status). Use of noncommercial preparations was reported by 17 (14.8%) seropositive and 15 (6.7%) seronegative women (adjusted odds ratio, 1.7; 95% confidence interval, l.0-3.0). Although these findings should be considered preliminary, it is speculated that the antifungal and bacteriostatic properties of commercial antiseptics used after sexual intercourse may reduce the inoculum of HIV through a flushing mechanism or reduce the frequency of sexually transmitted diseases that serve as co-factors for HIV infection. Moreover, the agents used in noncommercial preparations may irritate vaginal mucosa, enhancing HIV transmission.
Adherence to tuberculosis preventive therapy among HIV-infected persons in Chiang Rai, Thailand.
A prospective study of 412 men and women infected with human immunodeficiency virus (HIV) who were enrolled in a hospital-based tuberculosis prevention program in Chiang Rai, Thailand, identified factors that contribute to non-adherence. Program participants were provided a 9-month supply of isoniazid, which has been shown to be effective in reducing the risk of developing clinical tuberculosis among asymptomatic HIV-infected individuals. Of the 412 individuals enrolled in the program, 286 (69.4%) completed the treatment regimen, 109 (26.5%) defaulted by failing to take the medicine for more than 60 consecutive days, and 17 (4.1%) developed acquired immunodeficiency syndrome (AIDS) or died. Among defaulters, 20 restarted the regimen and eventually complied with treatment, raising the completion rate to 74.3%. Married people, women, outpatients, surviving spouses, the self-employed, and those with no history of physical symptoms were more likely to be adherent. The primary reasons for default included outmigration for job search, denial of HIV status, perceived drug side effects, and confusion about the duration of treatment. Although this study suggests that good adherence to a tuberculosis prevention regime is possible among HIV patients, it highlights factors that should be considered (especially migration potential) in the selection of participants.
HIV-1 infection among female commercial sex workers in rural Thailand.
A retrospective study of 821 commercial sex workers attending a sexually transmitted disease (STD) clinic in northern Thailand's Chiang Rai Province from 1989 to 1993 revealed an explosive epidemic of human immunodeficiency virus (HIV). The overall seroprevalence among the 556 women for whom antibody tests were available was 52.3%. However, a dramatic increase in HIV-1 seroprevalence occurred from 1989 (29.3%) to 1990 (54.1%), followed by a leveling off through 1993. Among the 96 (36.2%) initial seronegatives who underwent subsequent testing, 64 seroconverted over a mean follow-up period of 5.9 months, yielding an incidence rate of 12.6/100 person-months. Incidence increased from 12.0/100 person-months in 1989 and 1990 to 17.0/100 person-months for 1991, and then declined to 9.3/100 person-months in 1992-93. The cumulative risk of seroconversion was 57% at 6 months after initial testing and 77% after 12 months. Diagnosis of chancroid during follow up was the only factor significantly associated with seroconversion. Although the retrospective nature of this study limits analysis of predictors of HIV infection in this population, the findings suggest a need for improved STD management.
An association between HIV-1 subtypes and mode of transmission in Cape Town, South Africa.
Investigations of the genetic heterogeneity of human immunodeficiency virus (HIV) -1 are important both to monitor the spread of the virus to new population groups and to the development of vaccines the efficacy of which could be influenced by virus variations. This study analyzed serum samples from 61 HIV-1 infected individuals recruited from clinics in Cape Town, South Africa. The mode of transmission was male homosexual in 26 cases, heterosexual/vertical in 32 cases, blood transfusion in 1 case, and unknown in 2 cases. Proviral HIV-1 DNA was subtyped by heteroduplex mobility assay (HMA) based on the 700 base-pair V3-V5 region of the env gene or by sequence analysis of the p17 region of the gag gene. This process identified 3 subtypes: B, C, and D. A fourth env subtype (E) was also identified by HMA. Subtypes were significantly (p < 0.001) associated with the mode of HIV transmission. Subtype B viruses were found in 96% of male homosexual sera and subtype C viruses were identified in 81% of the heterosexual/vertical transmission group. Subtype B viruses were also identified in 4 heterosexuals, 1 person infected through blood transfusion, and the 2 cases where the mode of transmission was unknown. Subtype D viruses were found in 1 male homosexual and 1 heterosexual, while a subtype E virus was identified in a heterosexual patient. These findings imply that heterosexual and homosexual HIV-1 epidemics in South Africa were independent. Both epidemiological and molecular data suggest that the initial epidemic in South Africa was, in part, a result of the introduction of HIV-1 by homosexuals who had sexual contacts with men in the US or Europe. The second, heterosexual epidemic was most likely a result of regional spread.
Initial research on the genetic variability of human immunodeficiency virus (HIV)-1 has indicated that HIV-1 envelope subtype B is dominant in Western countries where homosexuality and injecting drug use are the major risk factors, while env subtypes A, C, D, and E predominate in Africa and Asia where most transmission is heterosexual. Data from South Africa and Thailand suggest that, due to limited mixing of population subgroups, largely independent HIV epidemics caused by different genotypic subgroups may co-exist in a given geographic area. On the other hand, the possibility that HIV-1 subtypes differ in transmission efficiency by exposure mode also has some support. For example, subtypes E and C appear to be better adapted to penile-vaginal transmission, while subtypes B, E, and C may be transmitted efficiently through blood. Factors such as sexual mixing patterns (e.g., commercial sex work) and the prevalence of sexually transmitted diseases must also be considered when examining HIV-1 subtype transmission differences. The use of new assays that allow for the accurate measurement of viral levels in plasma, semen, and genital secretions should complement epidemiologic estimates of transmission efficiency for various HIV-1 subtypes.
An overview of HIV prevention in central and eastern Europe.
HIV and AIDS present a major challenge to the countries of central and eastern Europe. The manner in which this is being addressed differs from country to country, depending upon historical traditions and prevailing public health practices, social values and political priorities. This paper provides an overview of HIV prevention policies in six central and east European counties: Russia, Romania, Hungary, the Czech Republic, Poland, and Lithuania. By homing in on particular aspects of these policies, the paper aims to highlight some of the more interesting contrasts that exist within this region. The paper concludes that, while significant comparisons can be made between the countries, tight parallels cannot. (author's)
AIDS and hospital bed occupancy: an overview.
In several countries of sub-Saharan Africa more than 10% of the adult population are infected with HIV, while in large towns such as Kampala, Lusaka, Blantyre, Kigali, and Harare this proportion exceeds 25%. One of the most obvious consequences is the increased occupancy of hospital beds by patients with HIV infection, perhaps to the exclusion of patients with other ailments. This paper gives an overview of several hospital occupancy studies. (author's)
13 isolates from African AIDS patients and from the environment in Zaire were identified as members of the Mycobacterium avium complex by phenotypic tests. RFLP analysis showed that the isolates belong to a genetically homogeneous cluster. The 16S rRNA sequence analysis suggests a close relationship with the P-49 strain (ATCC 35847), a reference strain for the serotype 7 of M. avium complex. This work shows the close relationship between certain M. avium complex strains responsible for disseminated infection in AIDS patients and M. avium complex strains isolated from the environment in Zaire. Further, the authors' findings confirm that atypical mycobacteria may disseminate in AIDS patients in Africa and suggest that infection in these patients probably originates in their environment. (author's)
Disease ecology and a reformist alternative: the case of infant mortality.
This paper attempts to shed some light on the recent debate between those who advocate a reformed medical geography and those who respond that reform is not necessary. The authors show that disease ecology and a reformist alternative display certain tendencies in the ways in which they address issues of health and disease. They use the example of geographic variations in infant mortality rates to show how two non-positivist perspectives from social theory, political economy, and humanism support a reformist viewpoint, while also acknowledging the value of a complementary disease ecology approach. Two concepts, the social construction of health and illness and social relevance, are used to portray the political economy approach; humanism is described in terms of the meaning of individual experience and the importance of place. The paper concludes with a discussion of the respective roles of disease ecology and a reformist approach in models of infant mortality and a summary of the main differences between the two perspectives. (author's)
The narrative of AIDS among the Tonga of Zambia.
The Tonga of Southern Zambia usually refer to a traditional disease, kahungo, when talking about AIDS. Such an association of AIDS with a traditional disease could easily be interpreted as a cultural obstacle to an understanding of AIDS and thus to a change of behavior. However, a close investigation shows that this association is not the result of categorical thinking, but rather of narrative logic. What people are actually articulating when they associate AIDS with kahungo is a narrative about order, disorder, and respect for existing rules and values of the society. The paper investigates how the dynamic notion of narrative may help us to get a better understanding of how people work towards a shared understanding of a new disease, and the implications this may have for AIDS education. It is argued that such local versions of the "story about AIDS" should be taken seriously and that they may contain as much "truth" as the version of the "North" which is usually promoted in AIDS education. AIDS education should, rather than being a transfer of knowledge, be an exchange of narratives and an attempt to "set a story in motion," that hinders that spread of AIDS. (author's)
Reconditioned bicycles donated from Japan to family planning associations (FPAs) in the West Indies and the Caribbean are being used to assist the promotion of reproductive health/family planning services at the grass roots. The FPAs of St. Vincent, Belize, Grenada, and St. Lucia, respectively, received 75 bicycles each with spare parts in mid-1996. The bicycles were donated through the Municipal Coordinating Committee for Overseas Bicycle Assistance, an association of Japanese local governments and JOICFP. A low-cost, non-fuel means of transport, the bicycles are a convenient means for mobilizing grass-roots health agents and motivators. The St. Lucia Planned Parenthood Association distributed the bicycles to field workers conducting educational activities on sexual and reproductive health, home visits, group activities and counseling throughout the island. Peer counselors are also using the bicycles to assist with peer educational activities in schools, home visits and for other social activities. The Grenada Planned Parenthood Association is utilizing the bicycles to assist with youth activities. The bicycles are mobilizing key personnel of the Under Twenty Clubs (UTCs) who assemble youths in weekly meetings, and peer educators who provide counseling to their peers on sexuality and personal development. The bicycles donated to the Belize Family Life Association have bolstered the activities of the community workers who provide community outreach services, organize community meetings, and conduct educational sessions. The bicycles also support peer education activities by helping youths reach out to their peers to recruit them for the education program and to distribute educational materials. (full text)
Longer life span for Copper T 380 A.
Copper T 380 A, the intrauterine device (IUD), has now been clinically approved by the US Food and Drug Administration (FDA) to have a longer lifespan. According to a population council news release, the device, which originally had a 4-year term duration, has been found out to be effective for 6 years. The extension was based on data from a study conducted by the World Health Organization (WHO) and submitted to the FDA by the Population Council, developer of the IUD. This extension will undoubtedly have many advantages, as the less frequently the device is replaced, the fewer the risks of pelvic inflammatory disease, perforation, and other complications that occur mainly soon after insertion. More so, less frequent insertions will cost less and be more convenient. The president of the Population Council, Mr. George Zeidenstein, welcomed the FDA action and said "when we licensed Cynopharma (the sole distributors of the product) to introduce the Copper T 380A IUD in the US 3 years ago, we knew it was a superior, long-acting reversible method that would expand contraceptive options. The fact that this IUD is approved for 6 years makes it an even more attractive option for women choosing a contraceptive method." (full text)
India: fostering male participation in reproductive health.
"A cart needs two wheels to move"--this is the spirit behind new UNFPA efforts in India to involve not just women but also men in reproductive health programs. In Mahindaragarh and Rewari, men who had initially been reluctant to talk to strangers about matters such as safe sex and reproduction opened up at a series of goshti, or chit-chat sessions, organized by UNFPA. Discussions during the goshti revealed that many men did not feel a sense of involvement in health issues, even those concerning the birth of their own children. Nor was there a full understanding of the importance of practicing family planning and safe sex. Women have been holding their own sessions, called jagriti mandilis, or awakening groups, to tackle similar issues. Projects such as these fulfill the essential requirement of involving both partners in reproductive health. Says UNFPA representative Wasim Zaman, "In a country like India, where lack of education leads to certain mindsets and barriers to development and growth, it is becoming increasingly clear that a holistic view that encompasses both the sexes... is what will pave the way to women's empowerment, and, consequently, real development." (full text)
Preparing to meet Sri Lanka's reproductive health needs.
"Swept over a crest of the ICPD wave, UNFPA expects to help the Government of Sri Lanka to become a success story in reproductive health," says the country's UNFPA Representative, Suneeta Mukherjee. A new special program on reproductive health has been developed which calls for the setting up of 300 Well Women Clinics, among other measures. Sri Lanka is poised to reach replacement-level fertility, but its needs in the area of reproductive health remain great, especially among vulnerable groups such as migrating women and their families, internally displaced persons, prostitutes, and adolescents. Sri Lanka faces high abortion levels, estimated at roughly 750/day. While the average age of marriage is high--at over 25 for women and 29 for men--the government-run national population program does not provide services to unmarried adolescents. In addition, the ongoing armed conflict in the North-East of the country prohibits government action there. The special program will aim to meet these challenges. In order to ensure broad-based participation in designing the special program, a national workshop was held outside Colombo during August 2-4 which served as a forum for researchers from area universities and other experts to speak on the importance of reproductive health. After extensive discussion, the proposed projects were approved by the National Coordinating Council on Population. (full text)
Clinton renews family planning fight.
On February 1, President Clinton touched off the first abortion-related fight of his new term, by issuing a finding that lack of funding has had a "negative impact on the proper functioning" of international family planning programs. Congress now must vote by the end of February on whether to approve the finding, which would begin to release the US$385 million for the program approved by Congress last year but withheld under the terms of a complicated compromise between abortion opponents and family planning advocates. "In the balance are the lives and well-being of many thousands of women and children and American credibility as the leader in family planning programs around the world," said the President in a statement. Abortion foes have charged that the President is on a "crusade to legalize and promote abortion" by permitting funding of organizations, such as the International Planned Parenthood Federation, which support the procedure. Family planning advocates counter that current US law already prohibits US funds from being used to perform abortions and that starving international family planning efforts will result in more rather than fewer abortions. Under terms of last year's agreement, none of the funds appropriated can be released until July 1, 1997, unless Congress vote to approve the President's finding--in which case funding could begin March 1. In neither case, however, could more than 8% of the funds be allocated in any single month. (full text)
Oral contraceptives are drug of choice for menorrhagia in the Netherlands [letter]
John Bonnar and Brian L. Sheppard studied, in an academic setting, only 81 patients selected from a population of over 400 (referred?) patients complaining of heavy menstruation. Unfortunately, they supply insufficient information to make general practitioners reconsider their policy on treating menorrhagia. We are members of a group of Dutch general practitioners that worked on a national guideline on the diagnosis and treatment of abnormal vaginal bleeding in primary care. For menorrhagia we consider oral contraceptives to be the drug of choice, reducing blood loss by half. To our surprise, Bonnar and Sheppard do not mention this treatment, even in their paragraphs titled "comparison with hormonal treatment." We consider tranexamic acid to be a powerful but third ranking treatment option, as it has more side effects than oral contraceptives and prostaglandin synthetase inhibitors such as naproxen. A promising treatment not mentioned in the paper is the levonorgestrel releasing intrauterine device, which reduces blood loss by 80-90% and became available to all Dutch doctors this year. The authors' conclusion that ineffective medical treatment contributes to the large number of hysterectomies in Britain supposes a causal relation that is not supported by the study's results. It is also wrong for the authors to base their conclusion on a comparison of Britain and Scandinavia. Traditional values and cultural factors, not prescribing behavior itself, explain the huge differences in the rates of operative procedures among Western countries. (full text)
Iowa trial court blocks parental notification law.
The US District Court for the Southern District of Iowa issued a preliminary injunction on January 22 that prohibits enforcement of that state's parental notification requirement for young women seeking abortions. Under the law, which was passed by the Iowa legislature in March 1996, one parent of a woman under the age of 18 must be notified at least 48 hours before the procedure (see RFN V/6). Alternatively, the young woman may seek a court waiver of the mandate. Judge Ronald Longstaff found that the women's health care providers challenging the law were likely to prevail in their claim that the statute presents an unconstitutional obstacle to young women's right to choose abortion. Affirming findings made in a temporary restraining order that prevented the law from taking effect earlier in the month, Judge Longstaff held that the law would put doctors who provide emergency abortions to young women at risk of liability, a possibility that could discourage physicians from providing abortion services (see RFN VI/1). The court also found that the judicial bypass laid out in the statute failed to sufficiently protect a young woman's confidentiality or guarantee an expeditious procedure. The plaintiffs in Planned Parenthood of Greater Iowa vs. Miller are represented by Dara Klassel and Roger Evans of the Planned Parenthood Federation of America, CRLP's Priscilla Smith and Michael Erdos, Mark Lambert of Planned Parenthood of Greater Iowa, and Randall Wilson of the Iowa Civil Liberties Union. (full text)
A model district action plan for control of visceral leishmaniasis, a serious public health problem in north-east Bihar, was developed in late 1989 and implemented in 1992 in district Vaishali. A 2-year implementation resulted in a decline in cases and deaths due to visceral leishmaniasis to the extent of 65.32% and 46.51%, respectively, in 1993 as compared to 1992, and 41.13% and 44.93%, respectively, in 1994 as compared to 1993, with an overall decrease of 79.58% in cases and 70.54% in deaths in 1994 as compared to 1992. The implementation of the action plan not only established declining trends in morbidity and mortality due to visceral leishmaniasis in the district but also successfully contained the cases unresponsive to first-line treatment with sodium stibogluconate by reducing the prevalence of such cases from 12.42% in 1992 to 8.59% in 1994. Various components of the action plan, the implementation strategy, and the consequent impact on disease situation are presented in this paper. (author's modified)
AIDS as a paradox of manhood and development in Kilimanjaro, Tanzania.
When AIDS emerged in the Kilimanjaro region in 1984, many Chagga (the predominant ethnic group in the region) viewed it as a 'disease of development'. Whereas AIDS was commonly seen in the West as a form of punishment for nonreproductive and nonproductive lifestyles, in East Africa it represented paradoxes in reproductive and productive life--especially for young, mobile men. This article discusses the emergence of the conditions of risk for HIV among young adults in the 1980s and 1990s, and then explores the perceptions of local actors about the historical and demographic processes that have surrounded the symbolic associations of AIDS. The themes that AIDS evoked were different for men and women; from one perspective, AIDS was seen as an attenuated crisis of the productive and reproductive labors of manhood. For people in northern Kilimanjaro, this disease illuminated contested issues in historical dialogues about social change and the moral value of male participation in idealized forms of work and prescribed male/female unions. The implications of these cultural and demographic realities for AIDS prevention are discussed in the conclusion. (author's)
This study examines the contribution of socio-cultural and behavioral factors in mosquito-borne lymphatic filariasis transmission in southern Thailand. Research was conducted in Nakorn-srithamarat province, which is noted for having the nation's highest Brugia malayi filariasis morbidity rate. Factors examined include traditional knowledge and cultural beliefs concerning etiology, transmission, and symptomatology; perceived susceptibility and severity; social stigma; social support in disease prevention and control; and behavioral risk factors and illness behaviors. Data were collected through a multi-method, predominantly qualitative-based approach, including rapid survey and mapping, group interviews, focus group discussions, in-depth interviews, and participant observation. Results indicate that poor knowledge and lay, indigenous, traditional belief systems contribute to high-risk behaviors, and inappropriate preventive, illness, and treatment choice behaviors. Behavioral models for explaining filariasis risk, preventive, illness, and treatment choice behaviors are presented. Finally, recommendations for more effective health education programs are offered. (author's)
HIV prevention among Zambian adolescents: developing a value utilization / norm change model.
Peer-led interventions are effective in reducing risk for HIV among adolescents. A pre-intervention study was conducted to determine how to successfully carry out a possible future intervention to reduce HIV risk among adolescents in urban Zambia. Ethnographic and sexual data were collected on 276 males and females both attending and not attending secondary school during a 14-month period in 1992-93. Additionally, several focus groups were conducted. This paper reviews the cultural background of Zambian adolescents and presents an overview of the study results. Among the findings, it was learned that most of the male and female adolescents (average age of 17) are sexually active, very few routinely use condoms, less than half of sexually active adolescents have ever used a condom, AIDS is omnipresent in Zambia, the threat of HIV infection is a very real concern for most of the adolescents, there is a strong desire to protect themselves from HIV infection during sex (but condoms are often seen as ineffective and other forms of safer sex are not discussed), nearly all of the sexually active females and some of the males have received money or gifts for sex, and some of the out-of-school females are engaging in very risky sex (e.g., unprotected anal intercourse and anilingus) with adult men. The ethnographic data, including a brief trial risk reduction workshop, suggests that the core values and social norms of the adolescents may shape behavioral change. A value utilization/norm change (VUNC) model is developed, which is intended to provide a conceptual framework for understanding how to utilize selected core values of the adolescents to strengthen or alter norms within the social networks in order to elicit desired HIV risk reduction. (author's)
Unwanted teenage pregnancy and the attendant morbidity and mortality necessitate an understanding of the factors influencing adolescent sexuality and the implementation of programs designed to improve their knowledge and reproductive behavior. A randomized controlled study on reproductive health knowledge and behavior was undertaken among adolescent pupils drawn from a multi-stage random cluster sample. A self-administered questionnaire was used to assess aspects of reproductive health knowledge and behavior at baseline followed by a health education intervention, except for control schools. Results are based on 1689 responses made up of 1159 intervention and 530 control respondents. There as a significant increase in correct knowledge about aspects of menstruation in intervention as compared with control schools [odds ratio (OR) = 4.5, 95% confidence interval (CI) = 3.4-6.1]. Significantly (OR = 2.0, 95% CI = 1.1-3.9) more pupils from intervention than control schools scored correctly on practice relating to menstruation. Pupils from intervention schools were more likely (P < 0.001) to know that a boy experiencing wet dreams could make a girl pregnant and that a girl could get pregnant at her first sexual intercourse (OR = 1.4, 95% CI = 1.1-1.9). Knowledge of family planning was low in both groups at baseline, but was high at five months follow-up in the intervention schools. The findings point to the need for early school-based reproductive health education programs, incorporating correct information on reproductive biology and the subsequent prevention of reproductive ill health. (author's)
Severe anaemia in children living in a malaria endemic area of Kenya.
Severe anemia is an important cause of morbidity and mortality in African children, but the causes, particularly falciparum malaria, are difficult to determine. The authors assessed the contribution of falciparum malaria to anemia in Kenyan children by clinical examination and measurement of parasitemia and hemoglobin (Hb) concentration in 559 children in the community and in 2412 children admitted to Kilifi district hospital during a 2-year period. The authors also attempted to characterize severe malarial anemia by examining the causes and pathophysiology of anemia in 101 children admitted with Hb concentration of 50 g/l or less during a 1-year period. Plasmodium falciparum infection was associated with reduced Hb concentration in children in the community and in those admitted to hospital irrespective of diagnosis. Falciparum malaria was the primary cause in 46 cases (46%) of severe anemia admitted to hospital. There was no difference in the frequency of hemolysis or dyserythropoiesis in the children with malarial anemia and those with anemia from other causes, such as iron deficiency or sickle cell disease. The mortality rate in the children with severe malarial anemia was 8.6% compared with 3.6% in children with severe anemia due to other causes. Falciparum malaria does not present with a characteristic clinical or hematological picture, but is a major cause of the morbidity and mortality in children with severe anemia who live on the Kenyan coast, a malaria endemic area. (author's)
Adolescent sexuality: the gender gap.
The aim of this paper is to determine gender differences as regards adolescent sexuality, in order to improve the adjustment of prevention programs to boys' and girls' specific needs. Data were collected as part of the Swiss Multicentric Adolescent Survey on Health. Anonymous questionnaires were distributed in school classes among a national representative sample of about 9300 adolescents (15-20 years old). About 45% of the total sample reported a previous sexual experience. Differences between boys and girls were identified by means of bivariate and multivariate analyses. A higher proportion of Swiss girls report intra-family discussions about sexuality, having had a previous sexual experience, having sexual intercourse regularly, having had only one partner, and using contraception regularly. A higher proportion of Swiss boys report positive attitudes towards condoms and using condoms regularly. Variables independently associated with the occurrence of first sexual intercourse before 15 years of age also show gender differences, notably as regards health behaviors and social adjustment. The findings suggest that prevention programs should emphasize, among boys, responsibility in contraception and the need for protection in situations of multipartnership, and among girls, a positive attitude towards condom use and an increased familiarity with condoms presented both in a perspective of contraception and prevention of STDs. (author's)
The overall prevalences of infection with Schistosoma mansoni, S. hematobium, or both species among 6122 children from 27 schools in the former White Nile Province of Sudan (now divided into the Kosti, El Getaina, El Gebelein, and El Duem Provinces) were 10.1%, 21.4%, and 4.5%, respectively. Geometric mean egg counts in the pure S. mansoni and pure S. hematobium infections were 97.7 eggs/g feces and 12.9 eggs/10 ml urine, respectively. There were marked differences in levels of endemicity between provinces and also between schools within each province. School-specific prevalences and intensities of infection were positively correlated, both for S. mansoni and for S. hematobium. Prevalences and intensities of infection were generally similar in male and female subjects and in the different age groups into which they were split (i.e., 5-9, 10-14, and 15-19 years). Community-based surveys of all age groups in two villages showed typical patterns of infections with S. mansoni and S. hematobium, with indices peaking in those aged 10-19 years, both in males and females. Observations on snail-related aspects of transmission revealed that transmission of both S. mansoni and S. hematobium was highly focal and also seasonal, taking place during the hot, dry, and post-rainy seasons. (author's)
HIV prevalence among blood donors correlates with hospital STD rate in Maharashtra, India [letter]
Maharashtra is one of the 35 states of India, with a population of 75 million. The Directorate of Health Services of Government of Maharashtra embarked on an AIDS prevention and control program in 1989. The program has effectively established HIV screening activities for all registered blood banks in the state. The STD control activities, namely, case diagnosis, management, case recording and reporting, have been established at all the 30 district STD clinics in 1994. Due to a strong private health care sector, only 20-30% patients with STD attend the government-run district STD clinics. The STD rate for a selected 10 district clinics was calculated using adult outpatient attendance as the denominator. The HIV prevalence among voluntary blood donors at the districts correlated with the STD rate at all except 2 district hospitals, namely, Thane and Wardha. Poor STD control activities in the latter 2 districts may explain the lack of correlation of STD rate with HIV prevalence. This suggests that STD rate, like HIV prevalence among voluntary blood donors, can be used as surrogate for community HIV prevalence in most developing countries in the early phase of HIV epidemic. In the later phase of the epidemic, however, the declining STD rate may not correlate with the community HIV prevalence. With limited resources in developing countries, HIV prevalence is not available for blood donors in rural areas. These results suggest that rural areas with a high STD rate should be considered at risk for high HIV prevalence and targeted for crash AIDS prevention and control activities. (full text)
Population policies reviewed and assessed.
Local and international population experts at a recent workshop in Hanoi have proposed to adjust some relevant policies for a better population program in the years to come. At the workshop, held on November 28-30 to review and assess the national population policy, representatives from UNFPA-Hanoi, NCPFP, UNFPA country support team (CST), and a number of senior policy makers and officials from concerned ministries and branches were of the view that the population program has undergone good changes over the last year such as the drastic drop of birth rates. They, however, proposed some adjustments for the population policies to make it suitable to the national changing conditions. First of all, they proposed to update out-of-date population policies and, if possible, to turn them into an ordinance or a population law on the basis of the workshop's review and evaluation. They also proposed that research be conducted to achieve a well-prepared policy on reproductive health; to push up the implementation of the reproductive health program; to provide convenience and people's accessibility to reproductive health/family planning services; to improve quality of services for adolescents' health so as to prevent unwanted pregnancy. Further, they proposed to complete a management mechanism and to define responsibility of each concerned ministry and branch in coordinating, implementing, managing, and monitoring the RH/FP program for improvement of RH/FP services. Finally, they proposed to better integrate communication, education, and counseling into service provision. This means that a counselor should be trained with psychological, medical, or physical knowledge. (full text modified)
Contraceptive choice and reproductive morbidity in Istanbul.
A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of their bearing a considerable burden of ill health, with 81% reporting at least one episode of illness in the 3 months prior to the interview. Current IUD users were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small degree of switching between methods suggests that most users tended to stay with the same method, once chosen, and that health concerns played an important part only in the initial choice of the method. (author's modified)
The reliability of reporting of contraceptive behavior in DHS calendar data: evidence from Morocco.
This report addresses the consistency of reporting in the contraceptive calendar in the 1992 and 1995 Morocco Demographic and Health Surveys. Because a panel design was used in these surveys, the same women were interviewed in both years, providing a unique opportunity to examine the reliability of responses. Measures of reliability for various aspects of contraceptive use dynamics are computed, and the impact of reporting errors on contraceptive failure, discontinuation, and switching rates is estimated. Results suggest that reporting of contraceptive behavior in Moroccan DHS calendar data appears to be relatively reliable at the aggregate level. Individual respondents, particularly those whose contraceptive patterns have been complex, have a lower level of reliability. The observed inconsistencies do not appear to affect aggregate-level estimates of contraceptive prevalence; however, measures of contraceptive use dynamics are less stable. (author's)
Direct and indirect estimates of maternal mortality in rural Burkina Faso.
A retrospective study of maternal mortality was conducted in Nouna, a rural area of Burkina Faso in 1992. Strong evidence was found of a major mortality decline among children and young adults over the 50 years preceding the study: the estimated life expectancy of 36 years around 1945 rose to 58 years in 1991. Direct and indirect (using the sisterhood method) estimates of the maternal mortality ratio (MMR) were compared. Overall, the direct estimate of the MMR (389 deaths/100,000 live births) for women aged 15 years and older was slightly lower than the indirect estimate (428 deaths/100,000 live births). Taking into account the biases involved in the use of information obtained from sisters, the direct estimates indicated a marked decline in maternal mortality over time from 569 deaths/100,000 live births around 1941 to 305 deaths/100,000 live births around 1987. The validity of both data and approach, as well as the discrepancies between the direct and indirect methods, are discussed. (author's modified)
Do family planning programs affect fertility preferences? A literature review.
A literature review finds few studies about whether family planning programs have reduced fertility preferences. The strong and surprising evidence from Matlab, Bangladesh, demonstrated that this intensive program did not decrease preferences; however, it did crystallize latent demand for fewer children, resulting in a demand for contraception. One cross-national multivariate study was consistent with this finding. A few intracountry multivariate studies found small program effects, decreasing the number of children that couples want. An intensive multimethod study in India found plausible larger effects. Most studies of program media effects are flawed by possible selection bias, but one longitudinal study avoids this pitfall and finds large effects for one country. Program feedback effects are plausible but not yet demonstrated empirically. The effects of a coercive program are plausible, at least in China, but not definitively demonstrated. Several promising unpublished studies may strengthen the case for program effects in reducing fertility preferences, now often based on plausible but not conclusive evidence. Stronger generalizations require better studies of a wider range of locations. (author's)
Sexual activity and contraceptive knowledge and use among in-school adolescents in Nigeria.
Among 2460 secondary school students surveyed in two southeastern Nigerian states, only 36% could correctly identify the most likely time for conception to occur. Female students were considerably more likely than males to understand the timing of conception (46% vs. 25%); less dramatic differences emerged by students' residence and grade in school. Among students who supplied information about their sexual activity, 40% had had intercourse; the proportion who were sexually experienced climbed from 26% of 14-year-olds to 54-55% of 18- to 19-year-olds. While 36% of the young women had had sexual partners who were roughly their age, 25% had been involved with older businessmen; the young women said they have intercourse more frequently and are less likely to restrict intercourse to the safe period of their cycle when they are involved with older partners than when they have boyfriends their own age. Only 17% of sexually active students had ever used a contraceptive method other than abstinence. In focus groups and in-depth discussions, students expressed a strong desire for better education about contraception and the consequences of sexual intercourse, and recommended that both schools and parents participate in educating young people about reproductive health. (author's)
Avoiding unintended pregnancy in Peru: does the quality of family planning services matter?
An analysis linking data on pregnancy intentions from the 1991-92 Peru Demographic and Health Survey with information from a 1994 follow-up survey found that among 1093 women from Nor-Oriental del Maranon and Lima who participated in both surveys, 20% had a mistimed or unwanted pregnancy in the 29 intervening months. In all, 15% had an unintended pregnancy ending in a live birth and 5% had an unintended pregnancy with another outcome. The proportion having an unintended pregnancy was 32% in rural Nor-Oriental, 24 in urban Nor-Oriental, and 13% in Lima. Unintended pregnancies were predominantly attributable to failure of a traditional contraceptive method (35% of such pregnancies) or nonuse of any method (26%). The proportion of women who failed to meet their reproductive goals between surveys declined as their education and the quality of available family planning services, as measured by a 1992 situation analysis, improved. The effect of quality of care on women's ability to avoid unwanted fertility was significant in logistic regression models including only service factors and women's demographic characteristics. In models including rural-urban residence and region, neither these variables nor quality of care had a significant effect. (author's)
Husband-wife communication about family planning and contraceptive use in Kenya.
According to couple data from the 1989 Kenya Demographic and Health Survey, both knowledge and approval of family planning are virtually universal in Kenya: among 98% of couples, one or both partners know of at least one modern method, and among 85% of couples both partners approve of family planning. Discussion with the partner about family planning was reported by 82% of couples. However, only 67% of wives and 75% of husbands correctly predicted their spouse's approval of family planning. Knowledge and approval of family planning, husband-wife communication, desire for more children, and ideal family size are all significantly associated with current use. Multiple logistic regression analyses show that husband-wife communication, particularly the wife's perception of her husband's approval of family planning, is highly associated with current contraceptive use (odds ratio, 4.2). Dialogue appears to increase the effectiveness of communication: specifically, one spouse's perception of the other spouse's approval is more likely to be correct if they have discussed family planning than if they have not, and this relationship significantly affects contraceptive use. (author's)
National and regional estimates of the incidence of induced abortion in Brazil, Colombia, and Mexico from the late 1970s to the early 1990s indicate a clear rise in the abortion rate in Brazil and increases in the abortion ratio in all three countries. Cross-sectional analysis showed no significant correlation between the abortion rate and contraceptive use, except in Mexico in the early 1990s, where a strong positive association was observed. Longitudinally, the abortion rate increased as contraceptive use increased in most regions of Brazil and Mexico throughout the study period, and in parts of Colombia until the mid-1980s. In Colombia and the most urban region of Mexico, the abortion rate declined as contraceptive use stabilized or increased. The abortion ratio was positively associated with contraceptive use over time in nearly every region of each country. The role of abortion in fertility decline was greatest in Brazil, where the general fertility rate would have been nearly 13% higher in the early 1990s if the abortion ratio had not increased from its level in the late 1970s. Abortion tended to have a greater impact on fertility in regions where contraceptive use was low. Overall, contraceptive use appears to have been a more important determinant of fertility than abortion, but abortion has played an important subsidiary role in determining fertility levels and trends in these countries. (author's)
Empowerment of women in self-employment programs: a study to conceptualize empowerment.
The notion of "empowerment" emerged as a goal of Women in Development in the late 1970s and is currently very popular. However, the concept of empowerment has not yet been clearly defined. This thesis explores the concept of empowerment through a commonly planned intervention scheme--income generation/small enterprise projects. Empirical data were collected from an equivalent intervention scheme, self-employment creation programs for women in poverty in the mid-Michigan area in the US. Focus group discussions with the women entrepreneurs who graduated the programs and interviews with the program directors revealed that empowerment consists of four dimensions: economic, social, psychological, and political. These four dimensions are interrelated. The data also showed that empowerment is a process which starts from awareness within individual consciousness, grows into action, and broadens to the collective level. Empowerment also is a bottom-up process involving challenge to the social structure by the marginalized. It is a transformational process in which a victim becomes an agent of change. Some implications of the empowerment of Third World women are also drawn out of the American women's experiences. (author's modified)
Urinary tract infections in young women [letter]
The study by Hooten et al. (Aug. 15 issue) of risk factors for urinary tract infections in young women was very interesting and informative, but what about the contraceptive methods they used? I was surprised not to see any mention of condoms. With the current concern about AIDS and the transmission of the human immunodeficiency virus, I would expect some of these young women to have used condoms as an adjunct to safe sex practices. I believe other studies have shown an increased incidence of urinary tract infection with condom use. Did the authors look at that? If so, what did they find? (full text)
Urinary tract infections in young women [letter]
In his editorial on sex and urinary tract infections, Dr. Ronald mentions a variety of methods for the prevention of postcoital cystitis. There is no suggestion that the couples should simply wash themselves with soap and water, as is the practice among Muslims. Is there any proof that washing with soap and water helps? No. But, if washing one's hands before and after seeing a patient makes a difference in the risk of transmitting infections, then washing must also decrease the bacterial flora of the skin of the genital area and the risk of infection. (full text)
A malaria study was undertaken in 98 rural communities of the Pacific coast of Ecuador (n = 14), Colombia (n = 22) and Nicaragua (n = 62). In-depth interviews on people's knowledge and practice regarding malaria etiology, symptoms and treatment were conducted and complemented by formal household interviews. On the basis of this information, an educational program was set up which included the training of village health promoters and community workshops organized by the health workers and used a set of methods of interactive learning. After the baseline survey the communities were paired and randomly allocated to the intervention and control groups. Malaria education took place only in the intervention communities. At the start of the project people's knowledge about malaria-transmitting mosquitoes and malaria symptoms was correct and widespread in those areas where the community exposure to formal health services was pronounced. However, knowledge of the recommended dose of chloroquine was poor everywhere, and self-treatment of malaria episodes deficient. The educational intervention achieved a high level of participant satisfaction which was expressed in a high and continuous attendance rate at the monthly workshops. The knowledge of malaria etiology and symptoms was 33-61% better in the intervention group that in the control group. Knowledge of the recommended doses of chloroquine increased significantly (34% in Ecuador, 93% in Colombia, but not in Nicaragua) and correct use of chloroquine in the treatment of malaria episodes also improved (26% in Ecuador, 85% in Colombia). In Nicaragua the results were less satisfactory due to the short period of promotional activities and the health services' policy of delivering only supervised treatment to the population. It is concluded that health education should play a major role in malaria control. (author's)
Risk factors for deaths in under-age-five children attending a diarrhoea treatment centre.
Few case-control studies have examined possible risk factors for diarrheal deaths in children under age 5 in the developing countries. The authors analyzed data from the surveillance system of their diarrhea treatment center/hospital for the period 1990-94 on 928 children under 5 years of age. In univariate analysis, 11 factors were significantly associated with death: lack of breastfeeding, severe malnutrition, complicated diarrhea, pneumonia, xerophthalmia, duration of diarrhea 7-14 days, moderate or severe dehydration, recent history of measles, Shigella flexneri infection, maternal illiteracy, and very low household income. Rotavirus diarrhea was negatively associated with fatal outcome. In the assessment of severe malnutrition, weight-for-height measurement discriminated mortality risk better than weight-for-age or height-for-age indices. Only two factors (severe malnutrition and non-breastfeeding) retained their significance in the multivariate analysis, with adjusted odds ratios (95% confidence interval) of 84.2 (9.1, 775.9) and 4.2 (1.3, 13.2), respectively. (author's modified)
Maternal perception of cause, signs and severity of diarrhoea in a suburban West African community.
With the aim of investigating perceived morbidity and care seeking behavior, a household survey was conducted, where 319 episodes of diarrhea were followed by interviews every second day. The chance of consultation increased with the number of symptoms reported by the mother. The appearance of the eyes and how the child breast fed were early warnings that mothers recognized best. By contrast, there was an 80% reduction in the likelihood of seeking consultation when the mother perceived the diarrhea as caused by teeth eruption (n = 96). Children with "teething diarrhea" were, however, just as likely to develop signs of dehydration as children with non-teething diarrhea. The authors conclude that health education concerning diarrhea should emphasize early signs of dehydration and the discouragement of "teething" as an explanation of natural diarrhea. (author's)
Oral contraceptives in women with systemic lupus erythematosus.
Oral contraceptives (OCs) are generally not prescribed for women with systemic lupus erythematosus (SLE) due to the widely-held view that they may activate disease. This practice is based on the greater incidence of SLE in women than in men, biologic abnormalities of estrogen metabolism, murine models of lupus, several anecdotes of patients having disease flares while receiving exogenous hormones, and a single retrospective study in patients with preexisting renal disease. In contrast, recent retrospective patient surveys, albeit limited by the absence of formal analyses of disease activity, suggest that the rate of flare is not significantly increased in patients taking OCs. The preexisting data are insufficient to warrant the dismissal of a potentially important birth control option in a disease which predominantly affects women in their reproductive years and whose fertility is not altered by the disease. In counseling patients regarding lupus and pregnancy, there are clinical predictors of pregnancy outcome; patients in remission tend to do well. The same principles may be true regarding advice on the use of OCs; patients with inactive or stable/moderate disease and at low risk for thrombosis may benefit without a change in lupus activity. OCs with the lowest estrogen content should be used and consideration given to progestin-only pills in situations where there is some risk of increased clotting. Large prospective double-blind placebo-controlled studies inclusive of all ethnic groups should provide the basis for more definitive recommendations. (author's)
Sixteen-year-old oral contraceptive users in Finland, 1981-1993.
While adolescent fertility and abortion rates continue to decline in Finland, regional variations in teenage pregnancies persist, particularly among 16-17 year olds. The authors studied differences in the use of oral contraceptives (OCs) among 16-year-old girls according to sociodemographic variables between 1981 and 1993. Questionnaires were mailed to national samples (N = 462-1594) of 16-year-old girls biannually, giving response rates ranging from 86% to 91% (the Adolescent Health and Lifestyle Survey). The increasing trend in OC use leveled off in 1989 at around 17-19%. OC use was most frequent in the lower socioeconomic groups, least frequent in the rural areas, but did not vary significantly according to region of the country. The pace of adopting OCs did not vary across the socioeconomic groups or regions. The socioeconomic and regional distributions of OC use were consistent with previous studies on teenage sexual activity. The results suggest equal accessibility of family planning services; regional variation in pregnancy rates cannot be explained by unequal distribution of OC use. (author's)
The comparison of malaria indicators among populations that have different genetic backgrounds and are uniformly exposed to the same parasite strains is one approach to the study of human heterogeneities in the response to the infection. The authors report the results of comparative surveys on three sympatric West African ethnic groups, Fulani, Mossi, and Rimaibe, living in the same conditions of hyperendemic transmission in a Sudan savanna area northeast of Ouagadougou, Burkina Faso. The Mossi and Rimaibe are Sudanese negroid populations with a long tradition of sedentary farming, while the Fulani are nomadic pastoralists, partly settled and characterized by non-negroid features of possible caucasoid origin. Parasitological, clinical, and immunological investigations showed consistent interethnic differences in Plasmodium falciparum infection rates, malaria morbidity, and prevalence and levels of antibodies to various P. falciparum antigens. The data point to a remarkably similar response to malaria in the Mossi and Rimaibe, while the Fulani are clearly less parasitized, less affected by the disease, and more responsive to all antigens tested. No difference in the use of malaria protective measures was demonstrated that could account for these findings, and sociocultural or environmental factors do not seem to be involved. Known genetic factors of resistance to malaria did not show higher frequencies in the Fulani. The differences in the immune response were not explained by the entomological observations, which indicated substantially uniform exposure to infective bites. The available data support the existence of unknown genetic factors, possibly related to humoral immune responses, determining interethnic differences in the susceptibility to malaria. (author's)
HIV-1 pol sequences from India fit distinct subtype pattern.
HIV-1 isolates are classified phylogenetically in several subtypes or clades according to env and gag coding sequences. Viral subtypes tend to cluster geographically. DNA sequences encoding the p51 subunit of reverse transcriptase were obtained by nested polymerase chain reaction from peripheral blood mononuclear cells of 2 HIV-1-seropositive individuals from New Delhi and 3 from Pune, in northern and western India, respectively. These isolates were previously characterized as subtype C according to their env sequences. Based on phylogenetic analysis, the reverse transcriptase coding region of these isolates is distinct from those of subtype A, subtype B, subtype D, and group O of HIV-1 viruses. The nucleotide divergence of these Indian pol sequences (3.3%) is similar to that of existing sequences for subtype B and subtype D viruses. This result supports the epidemiologic data of a more recently introduced HIV-1 epidemic in India. Based on the corresponding env sequences, the pol sequences described in this report are subtype C. (author's)
Oral contraceptives do not raise risk of heart disease.
Low-dose oral contraceptives (OCs) do not appreciably raise the risk of myocardial infarction, reports a US study this month. Investigators identified all myocardial infarctions occurring from May 1991 to August 1994 in women aged 15-44 enrolled in Kaiser Permanente Medical Care Programs in California (Obstet Gynecol 1996; 88: 939-44). They found 187 such patients over 3.6 million woman-years of observation, an incidence of 5.2/100,000 woman-years. 57 patients were excluded from the study for various reasons, including pregnancy and the menopause. The remaining 130 women were matched with three control groups: current users of OCs, formers users, and women who had never taken birth-control pills. After adjusting for all major risk factors, the investigators found that current OC use raised the risk of myocardial infarction by less than one case per 100,000 woman-years--i.e., fewer than three cases per million women per year. "Even if there was a slight increase in risk, the resulting number of cases of myocardial infarction would still be far fewer than any complications of pregnancy," says Stephen Sidney, the article's lead author. The risk factors most closely associated with myocardial infarction in the study were cigarette smoking; occasional or no consumption of alcohol; and hypertension, diabetes, or hypercholesterolemia severe enough to warrant treatment. "This is a well-done study with good results," says Alan DeCherney, professor of obstetrics and gynecology, University of California Los Angeles School of Medicine, US. But he notes that the actual occurrence of myocardial infarction in women in this age group, even with one or more risk factors, was so low as to be "almost a rarity." Since women with these risk factors often have problem pregnancies, he adds, "I would err on the side of prescribing OCs even in the high-risk group, because the risks associated with pregnancy are so much greater." (full text)
Making it happen: the programme. Breaking the rules.
I have always believed that women should be given equal recognition and treatment. My upbringing, observation and experience taught me that I would get nowhere unless I broke the rules. Equal recognition happens only when women are consciously encouraged to reflect and led to understand their worth by looking at their own lives. I use the strategy of sharing my own experience to open dialogue with rural women. For example, in India I helped poor tribal women to go to the Tribal Commissioner when they were being cheated out of tribal rights over land. Appealing to the law makes women stronger, more assertive, and more aware of their rights. Land titles were restored to a few women and they became leaders and supported other women in the same predicament. This change was possible because of a commitment of resources, the attitude of the authorities, and my presence as an Oxfam project officer. As a woman manager I am proud to have helped to create an office environment which in sensitive to women's needs and the way women operate. I have consciously fostered the space for a diversity of ways of working. I can do that because of my management position, and support from other structures, like AGRA and the Gender Unit. It has not been easy as a woman manager in a male dominated, technical program, and as a non-white woman from the South. But with decision-making authority it has been possible to keep women's participation and gender on the agenda. (full text)
Making it happen: the programme. Collective action for change.
To bring about change in the lives of poor women, I set up the program working with women in urban areas (PROFEMU), and introduced gender components into program for which I am responsible, as well as working with the Senegal team to implement the gender policy in our funding and non-funding work. Some of the blockages to change on gender have been a lack of collective intervention at a national level. There are many actors, many approaches, and agencies in competition. Work pressure, changes in structures, and a lack of understanding of the new gender orientation in the field have been other problems. I set up and support women's networks, and work as a resource person with national NGOs to ensure a focus on poor women's interests. I have taken part in setting up a more gender-focused women's network, Collectif Dakar 94 - Beijing 95, and work on building women's leadership and awareness. (full text)
Factors affecting the most recent fertility rates in urban-rural Bangladesh.
This paper reports on a study which has been undertaken using data from the 1989 Bangladesh Fertility Survey (BFS) to determine the significance of influences on the probability of birth in the year preceding the survey. In the survey a total of 11,905 ever-married women of reproductive age were asked a battery of questions relating to fertility aspects of women. Variables selected in this study were grouped into demographic, socioeconomic, cultural and decision-making variables. Findings from the study indicate that the mother's age, whether contraception has ever been used, the death of a child at any time, whether the woman has ever worked, religion, region of residence, and female independence are the important covariates for explaining recent fertility in Bangladesh. Models are developed for the probabilities of a woman giving birth in urban and rural areas, dependent on her demographic and socioeconomic conditions. Also developed are models for contraceptive use in urban-rural Bangladesh. This modeling contributes to a better understanding of fertility changes in Bangladesh and the differentials between urban and rural fertility. It is indicated that a continued fertility decline is likely. (author's)
Randomised controlled field trial of two antenatal care packages in rural south India.
A randomized community intervention trial was undertaken in 12 subcenters in Karur health unit district, Tamil Nadu, to compare the efficacy of two antenatal care packages. A newly recommended 'high-risk' strategy package and a uniform package recommended by the Tamil Nadu Government were each implemented in 4 randomly selected subcenters by the study team, and the latter was also delivered by routine health services in the 4 remaining subcenters. Analyses were based on 294 pregnant women on the high-risk package (HR), 242 on the Tamil Nadu Government (TNG) package, and 335 women in the control series. The HR package reduced the differences between the high-risk women and the others in mean hemoglobin and the percentages with preventable neonatal morbidity and low birth weight, and consequently the overall outcome was better in the HR series than in the TNG series. Finally, the results with the TNG package were better when it was implemented by the study team than by the routine health services, in terms of preventable maternal morbidity and preventable perinatal morbidity, but there was no impact on birth weight. (author's)
This study assessed the relationship between self-reported acquired immunodeficiency syndrome (AIDS) behavioral change and human immunodeficiency virus (HIV) serostatus among injection drug users. The study sample involved 4419 injection drug users recruited from drug abuse treatment and nontreatment settings in 11 cities in North America, South America, Europe, Asia, and Australia. The World Health Organization multisite risk behavior questionnaire was used, and either blood or saliva samples for HIV testing were obtained. Subjects were asked, "Since you first heard about AIDS, have you done anything to avoid getting AIDS?" The protective odds ratio for behavioral change against being infected with HIV was 0.50 (95% confidence interval = 0.42, 0.59). While there was important variation across sites, the relationship remained consistent across both demographic and drug use history subgroups. Injection drug users are capable of modifying their HIV risk behaviors and reporting accurately on behavioral changes. These behavioral changes are associated with their avoidance of HIV infection. (author's)
Population density and spatial differentials in child mortality in Zimbabwe.
Large regional variations in under-five mortality exist within many sub-Saharan countries. Population density as a potential explanatory factor for these regional variations has seldom been considered despite it being implicated as a determinant of mortality at other spatial scales. In Zimbabwe, the "Ndebele provinces"--Matabeleland North and South--have significantly lower levels of under-five mortality than the other ("Shona") provinces. This regional differential is explored using the Zimbabwe Demographic and Health Survey and census data. Factors other than population density that may contribute to the differential are examined. After controlling for the effects of potentially confounding socioeconomic, demographic, and environmental variables using Cox regression models children aged 1-4 years living in the Ndebele provinces continued to have a level of mortality 45% lower than their counterparts in the Shona provinces. The possibility that regional variations in health care provision and/or cultural factors contribute to the mortality differential is also examined and rejected. Population densities in the Ndebele provinces are of a far lower order than in the Shona provinces. The main causes of child mortality in Zimbabwe in the time period under consideration were diarrhea, ALRI, measles, and malaria. How population density may affect the transmission of these infections and, hence, mortality is discussed. It is suggested that population density may provide an explanation for the spatial variation in child mortality in Zimbabwe. The implications of changing population densities for child health in urban and rural sub-Saharan Africa are briefly considered. (author's)
In an urban community in Guinea-Bissau, the authors followed a cohort of human immunodeficiency virus type 2 (HIV-2) seropositive individuals (N = 47) and seronegative controls (N = 82). T-lymphocyte subset determinations were done in 1988, 1990, and 1992. Serial determinations of CD4 percentages, CD8 percentages, and CD4/CD8 ratios for the same individual were stable for 31 seropositive and 51 seronegative individuals with repeated measurements. The authors found no significant differences in the changes during a 2- or 4-year period in CD4 percentages, CD8 percentages, absolute CD8 T-lymphocyte counts, CD4/CD8 ratio, white blood cell counts, lymphocyte percentages, and absolute lymphocyte counts for HIV-2-seropositive compared with HIV-2-seronegative individuals. Only absolute CD4 T-lymphocyte counts changed more for HIV-2-seropositive than for HIV-2-seronegative individuals (p = 0.037). HIV-2-infected individuals who lived with an HIV-2-infected spouse had a lower CD4/CD8 ratio and had higher mortality than HIV-2-infected individuals who lived with an uninfected spouse. However, there were no significant differences in immunological and hematological values for the 8 HIV-2-seropositive individuals who died and the 39 who survived in the 8-year follow-up period. In conclusion, progression of immunosuppression in HIV-2 infection seems to be slower than in HIV-1 infection and may not be inevitable in all individuals. (author's)
Risk factors for HIV infection at enrollment in an urban male factory cohort in Harare, Zimbabwe.
Between March 1993 and March 1995, volunteers at 40 Harare factories were interviewed regarding sociodemographic characteristics and behavior; HIV serostatus was also determined. Among 2691 men enrolled, HIV prevalence was 19.4%. Prevalence rose 2-fold with each year of age in young men (<23 years). In a multivariate logistic model that included sociodemographic and behavioral variables, compared with those between 25 and 44 years, both younger men (OR = 0.51) and older men (OR = 0.49) were less likely to be HIV positive. In addition, marriage (OR = 2.01), history of sexually transmitted disease (STD) (genital ulcer, OR = 4.93; urethral discharge, OR = 1.75), multiple partners (OR = 1.58), cash payment for sex (OR = 2.55), and condom use (OR = 1.35) were all independent risk factors for HIV infection. Home ownership conferred lower risk. Self-reported condom use was seen as a marker of correct personal risk assessment: men who used condoms reported more risk behavior and had a higher prevalence of HIV, either because condom use was not consistent or because infection occurred prior to adoption of condoms. This study confirms established risk factors in a general population sample not selected for high risk of HIV infection. It suggests rapid acquisition of infection among young men and the importance of marriage (and separation of spouses) as correlates of HIV infection. (author's)
Public perceptions about unplanned pregnancy.
A nationally representative telephone survey in 1994 of 2002 adults indicates that 60% believe that unplanned pregnancy is a very big problem in the US, and virtually all (90%) say it is at least a somewhat big problem. Two-thirds mistakenly believe that a larger percentage of women have unplanned pregnancies now than 10 years ago. A decline in moral standards is cited by 89% of respondents as contributing very much or somewhat to the problem. Lack of education is mentioned as a significant factors by 87% and 88% see any of three barriers to contraceptive use--knowledge about use, access, or cost--as being important factors. Never-married women with children, women in general, low-income respondents, Hispanics, and those aged 65 or older are the most likely to believe that barriers to contraceptive access contribute very much to unplanned pregnancy; they are especially likely to cite cost or an inability to obtain contraceptives. (author's)
Repeat abortions in Canada, 1975-1993.
In Canada, 20% of women who obtained an abortion between 1975 and 1993 had had at least one previous abortion. An analysis of data on 1.2 million abortions shows that the proportion of abortion patients undergoing repeat procedures increased from 9% to 29% over the 19-year period. The proportion was above average (22-28% for all years combined) among women who were in common-law marriages, those aged 25-39, and those who had previously had children. In 1993, 27 women per 1000 who had ever had an abortion underwent another one, while 13 women per 1000 who had never had an abortion obtained their first one; among teenagers, the repeat rate was four times the rate of first abortions (81 per 1000 vs. 19 per 1000). During the study period, the repeat rate rose sharply among women younger than 25 but fell among those aged 30 and older. In 1993, fewer than 2% of abortions were obtained by women who had had three or more previous procedures, suggesting that abortion is not widely used as a primary method of birth control. (author's)
Emergency contraception: a national survey of adolescent health experts.
In a survey of 167 physicians with expertise in adolescent health, 84% said they prescribe contraception to adolescents, but only 80% of these prescribe emergency contraception, generally a few times a year at most. Some 12% of respondents said they believe that providing emergency contraception to adolescents would encourage contraceptive risk-taking, 25% said they think it would discourage correct use of other methods, and 29% said they think repeated use of the method could pose health risks. Physicians who were more likely than their colleagues to prescribe emergency contraception included obstetrician-gynecologists (92%), those who graduated from medical school after 1970 (77%), and those who describe their practice as being in an "academic" setting (76%). Physicians may restrict use of the method by limiting treatment to adolescents who seek it within 48 hours after unprotected intercourse (29%), by requiring a pregnancy test (64%) or an office visit (68%), or by using the timing of menses as a criterion for providing the method (46%). While 41% of physicians who provide emergency contraception counsel adolescents about the method during family planning visits, only 28% do so during visits for routine health care; 16% counsel women who are not yet sexually active about the method. (author's)
The consistency of recalled age at first sexual intercourse.
It is widely believed that people can remember the age at which they first had sexual intercourse. Questions about age at onset are routinely asked in population sexual behavior surveys and in clinical history-taking. However, there are limited test-retest data, especially with regard to individual differences in unreliable recall. In this study, telephone interviews and follow-ups an average of 15 months later were conducted with 570 non-virgin subjects aged between 28 and 73 years. Test-retest correlations for recalled age at first intercourse were 0.85 for females and 0.91 for males. Consistency was slightly lower among older people and women with a history of sexual abuse. There were no significant associations between consistency of recall and measures of personality, educational background, or history of alcohol dependence and depression. (author's)
A study of urinary schistosomiasis in Umueze-Anam, Anambra State, Nigeria, showed a Schistosoma haematobium infection of 26% (85) among school children, with no significant difference by sex except when age as a variable is introduced. 11% (37) of the 333 children were positive for hematuria; all these 37 children lived within 1 km of the water sources. Of the 85 infected children, swimming and laundering accounted for 65% and 48% of all water contact activities, for boys and girls, respectively. One-third of the 230 adults interviewed believed hematuria to be a venereal disease and 20% thought it was a sign of maturity. Individual perception of causation and seriousness of hematuria differed by level of education and by sex. Less than 2% of the respondents knew that snails transmitted the disease. The effect of social restrictions on the epidemiology of infection is discussed. (author's)
To examine the genetic and antigenic characteristics of HIV-1 in Indonesia, samples from 19 HIV-positive volunteers were studied. By a combination of PCR typing and DNA sequence analysis, 12 of the 19 volunteers were determined to be infected with HIV-1 clade B and 7 with clade E. 6 of the 7 Indonesian clade E isolates were from volunteers associated with the Indonesian Military during a peacekeeping mission in Cambodia. Infectivity reduction neutralization assays showed that the Indonesian E viruses were effectively neutralized by Thailand clade E HIV-1 antisera but not by US clade B antisera. The Indonesian clade B virus tested was neutralized by US clade B antisera and not by the Thailand E antisera. Using a previously described serologic typing ELISA based on clade B and E V3 peptides, genetic clade was accurately determined in 8 of 8 sera tested. This is the first report of the genetic and antigenic analysis of HIV-1 isolates from Indonesia. The data indicate that at least two genetic and antigenic HIV-1 clades (clade E and B) circulate in Indonesia. (author's)
Coinfection or superinfection of more than one viral genotype (genetic population) is indicated by the coexistence of multiple human immunodeficiency virus (HIV) strains belonging to different phylogenetic lineages in a single person. Recently, there has been well-documented evidence of double infection with HIV-1 and HIV-2, and with different clades of HIV-1 as well as recombinational events between viruses belonging to different clades of HIV-1 or HIV-2. Here, we present evidence of triple HIV-1 infection with a highly divergent group O virus and group M viruses of clades A and D. The patient studied was a 23-year-old single Cameroonian woman diagnosed with AIDS. Her blood samples were collected twice at an interval of 12 months in 1994 and 1995. Sera were screened by particle agglutination (PA) test (Serodia-HIV, Fujirebio, Tokyo, Japan) and examined by Western blotting (WB) assay (New Lavblot HIV-1 and HIV-2; Sanofi Diagnostics Pasteur, Marnes la Coquette, France). Both specimens were dual reactive for HIV-1 and HIV-2 by PA and WB. The sera were then discriminated using a peptide-based assay (Peptilav HIV-1 and HIV-2; Sanofi Diagnostics Pasteur) and judged as HIV-1 positive. The viral strains obtained in 1994 and 1995 were designated as CMR61 and CMR709, respectively. A part of the env gene (C2, V3, and C3 regions, 390 bp) was amplified by nested polymerase chain reaction from peripheral blood mononuclear cells, and their sequences were analyzed. Phylogenetic analysis of the env region revealed the presence of three different HIV-1 strains belonging to HIV-1 group O and HIV-1 clades A and D in both CMR61 and CMR709. Clades A and D were determined using the same primer pair for detecting group M viruses in the env region. HIV-1 group O was also detected using a different primer pair in the corresponding env position designed specially for group O viruses. Thus, the coexistence of three different sequences in the env region clearly testifies the first case of triple HIV-1 infection. Since the patient had no history of blood transfusion, we conclude that she underwent a superinfection with three HIV-1 strains, although a possibility of simultaneous infection cannot be excluded. Further studies would provide useful information concerning the host's immune response against highly divergent superinfecting viruses. (full text)
The study investigated whether homosexual men are, on average, born a shorter time after their next-older siblings than are heterosexual men. Because of mixed evidence that birth intervals are longer after a male child, the sex of the next-older sibling was included as a control variable. The probands were 220 heterosexual and 183 homosexual men with at least one older sibling examined in Southern Ontario in 1994-95. These completed a self-administered, anonymous questionnaire concerning their family background and other biodemographic information. The results showed that birth interval was negatively correlated with sibship size, positively correlated with maternal age, and uncorrelated with paternal age. They also confirmed that birth intervals are longer after a male than after a female child. The mean birth intervals preceding heterosexual and homosexual males, however, were virtually identical, indicating that the association of short birth intervals with decreased sex hormone levels in cord blood is unrelated to the development of sexual orientation. (author's)
Measuring contraceptive effectiveness: a conceptual framework [letter]
Steiner et al. have made a valuable contribution toward the understanding of contraceptive effectiveness, but I wish to raise two concerns with their proposed definitions for efficacy and effectiveness. First, because both these definitions depend on estimates of the expected pregnancy rate for a given frequency and timing of intercourse, it is vital that the best possible data be used for the probability of pregnancy by cycle day. A highly relevant biologic marker for the probability of pregnancy on any given cycle day is the quality of the vaginal mucus discharge present on that day. This discharge, which is highly correlated with cervical mucus production, not only provides information on the timing of ovulation, but also on the probability of sperm survival. Thus, future studies of effectiveness and efficacy should take into account vaginal mucus discharge patterns. A second and more fundamental concern is that this framework does not adequately evaluate the use of fertility awareness or natural family planning to avoid pregnancy. This method involves periodic abstinence from genital contact on days with significant probabilities of pregnancy (based on observations of vaginal mucus discharge and/or temperature measurements); it does not alter the natural probabilities of pregnancy throughout the cycle. Therefore, during its use, the observed and expected pregnancy rates will always be precisely equal to each other. As a result, the efficacy and effectiveness will always be zero, regardless of the coital pattern. It is clear that these particular measures of contraceptive effectiveness cannot be meaningfully applied to methods of natural family planning, which cooperate with, rather than suppress, the natural probabilities of pregnancy. (full text)
Donovan [Vol. 54(11), 1995, p. 575], in discussing condoms and the prevention of sexually transmitted diseases, omitted to mention the following facts: Population Reports (1990), in discussing attempts at developing a condom made of plastic, stated: "While a more expensive material than latex, plastic is more uniform with fewer pinholes or variations in thickness." The same journal mentioned that people using condoms faced a risk about two-thirds that of nonusers of developing gonorrhea, trichomoniasis or chlamydia infection, and gave a relative risk for the transmission of human immunodeficiency virus (HIV) of 0.4 for people using condoms. A survey of people experienced in using condoms from a family planning clinic in Manchester reported that "52% of respondents had experienced condoms bursting or slipping off in the previous 3 months. We were surprised to find how commonly our clients had experienced "accidents", even those who had apparently relied on condoms as their method of choice for contraception" (Kirkman et al., 1990). The senior author of that report also criticized the statement that "most condom failure is due to incorrect usage" (Kirkman, 1990). A study from a genitourinary clinic in London has shown that although condom use had increased from 4% to 21% between 1982 and 1992, this had failed to control viral sexually transmitted diseases (Evans et al., 1995). The editorial in the New England Journal of Medicine in which the de Vincenzi (1994) study was published stated "The sample was not large enough to exclude the possibility of a transmission rate of up to 1.5 per 100 women-years among the consistent condom users." (full text)
The purpose of this study was to test, in an animal model, two potentially suitable materials for nonsurgical selective tubal sterilization. A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed in four rabbit fallopian tubes, and a proprietary collagen glue was placed into three rabbit fallopian tubes by means of transvaginal fluoroscopic fallopian tube catheterization. As controls, 11 tubes were catheterized without sterilization material injection. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. Histologic analysis was performed. The short-term contraception rate was 100% in the hydrogel group, 33% in the collagen glue group, and 0% in the control group (P < .001 hydrogel group, P not significant in collagen group). Inflammation was minimal in the three groups (P not significant). The collagen glue had an insufficient contraceptive effect and should be abandoned. The hydrogel used proved effective and biocompatible, and long-term studies of this compound are warranted. (author's modified)
The role of smoking and other risk factors for cervical neoplasia was investigated in a population-based case-control study of 586 women with histologically verified cervical squamous-cell carcinoma in situ (CIS), and 59 women with invasive squamous-cell cervical cancer from Copenhagen. Controls were randomly selected from the general female population using the computerized Danish Central Population Register. After adjustment for a variety of confounding variables, which were all significantly associated with CIS risk and included age, number of partners, proportion of sexually active years without barrier contraceptive use, years with IUDs, number of births, and age at first episode of genital warts (as a proxy measure for human papillomavirus exposure), current cigarette smoking was found to be significantly associated with CIS [adjusted relative risk (RR) = 2.4; 95% confidence interval (CI): 1.7-3.4]. Ex-smokers had a lower, but still significantly increased risk (RR = 1.6; 95% CI: 1.0-2.7). A dose-response relationship was present, especially for number of cigarettes smoked per day. In contrast, the crude estimates showed a weak association between invasive cervical cancer and smoking, which however disappeared after confounder control. The results of the present study support the hypothesis implicating smoking as a risk factor for CIS. (author's modified)
Comparison of four different treatment regimes in hirsutism related to polycystic ovary syndrome .
Polycystic ovary syndrome is the most common endocrinological problem associated with hirsutism. The objective of this study was to compare four different treatment modalities for hirsutism related to this syndrome. Pelvic ultrasonography was performed on all patients who were referred to our Reproductive Endocrinology Outpatient Clinic because of complaints of hirsutism. After exclusion of hyperandrogenism caused by endocrine abnormalities other than polycystic ovary syndrome, 141 patients were included in the study. Patients were divided into four groups in regard to the drug chosen for treatment. Group 1 (n = 48) received low-dose combined oral contraceptive. Group 2 (n = 65) was treated with cyproterone acetate (100 mg daily) for the first 10 days of a 21-day cycle with an oral contraceptive containing 2 mg cyproterone acetate, Group 3 (n = 12) with spironolactone (100-200 mg daily), and Group 4 (n = 16) with ketoconazole (400 mg daily). All patients were followed frequently with respect to side effects, hirsutism scoring, and lipid and hormonal levels. All four drug regimens were effective in the treatment of hirsutism related to polycystic ovary syndrome, but the most effective seemed to be ketoconazole. The decrement level in hirsutism scoring was the largest in the ketoconazole group, followed by the cyproterone, oral contraceptive, and spironolactone groups (34.6 +or- 2.2%, 20.1 +or- 2.7%, 18.1 +or- 2.7%, and 12.8 +or- 3.7%, respectively; p < 0.05). Although high-density lipoprotein-cholesterol levels increased in all groups, this increment was smaller in Group 4 than in Groups 1 and 2 (5.1 +or- 2.8%, 34.1 +or- 5.5%, and 29.1 +or- 4.9%, respectively; p < 0.05), but not statistically different from that in Group 3 (22.3 +or- 5.9%). The free testosterone levels decreased after treatment in all groups, but the decrement ratios did not differ significantly among groups, although the decrease in free testosterone levels with treatment seemed to be higher in the ketoconazole group than in Groups 1, 2, and 3 (57.0 +or- 2.5%, 22.7 +or- 10.2%, 26.7 +or- 6.5%, and 9.5 +or- 19.9%, respectively). In conclusion, ketoconazole seems to be an excellent alternative to more-recognized therapies, but its effect on lipoprotein profile requires further study, because the hyperandrogenism, and the other problems related to hyperandrogenism besides hirsutism, should also be treated. (author's)
Setback for French antiabortionists.
Antiabortion activists had their arguments rejected last week by the criminal chamber of the Paris court of appeal, the highest court of appeal in France. The activists claimed that the 1975 legislation authorizing abortion was incompatible with several international agreements signed by France. The decision is seen as a setback for antiabortion campaigners, many of whom had benefited in the past from legal loopholes and lenient courts, despite a 1993 law that makes it an offence to impede a voluntary abortion. The appeal had been filed by 17 people who had been fined and given suspended prison sentences by different courts for having participated in antiabortion activities, mostly chaining themselves to furniture in hospital rooms where abortions are performed. They claimed that the right to voluntary abortions contravened the New York convention on the rights of children, the European convention for the safeguard of human rights, the international pact on civil and political rights, and the Geneva convention against slavery. The court, presided over by Judge Chrisian Le Gunehec, countered these arguments one by one. In addition, it recognized the right of the French Women's Union to sue antiabortionists because "the defense of the right and dignity of women ... necessarily included the right of women to have access to contraception and abortion." (full text)
Desogestrel, gestodene contraceptives may carry greater thromboembolic risk.
Combination oral contraceptives that contain desogestrel or gestodene may carry about a two-fold greater risk of nonfatal venous thromboembolism than do older low-dose combination oral contraceptives, reported the US Food and Drug Administration (FDA). FDA advised women to "discuss these contraceptives with their health care providers and make an informed choice based on the benefits and risks and individual preferences." The agency did not recommend that women stop using the products. FDA's conclusion is based on analysis of data from three studies: one sponsored by the World Health Organization, a trial conducted through the Boston Drug Surveillance Program, and a European study coordinated by investigators from McGill University in Canada. Gestodene-containing oral contraceptives are not available in the US. Desogestrel is marketed in combination with ethinyl estradiol. According to FDA, the average annual risk of nonfatal venous thromboembolism is 4 cases/100,000 for healthy women who are not pregnant and not taking hormones, 10-15 cases/100,000 for women taking older low-dose oral contraceptives, and 20-30 cases/100,000 for women taking products that contain desogestrel or gestodene. (full text)
Abdominal actinomycosis associated with intrauterine device: CT features.
Abdominal actinomycosis is a severe and progressive peritoneal infection, due to an anerobic gram-positive bacterium, Actinomyces israelii. The presence of a long-standing IUD is a well-known risk factor in young women. The authors report two cases of pelviperitoneal actinomycosis appearing in two young women with acute low abdominal pain. Abdominal CT demonstrated multiple solid or encapsulated peritoneal masses with marked contrast enhancement and infiltration of the adjacent mesenteric fat. Laparoscopy confirmed the presence of intraperitoneal abscesses which contained Actinomyces israelii. High doses of amoxicillin and clavulanic acid (Augmentine) were given and following CT scan after 2 and 6 weeks showed a slow, but complete, resolution of the lesions. Although the radiologic presentation of actinomycosis is nonspecific, the diagnosis should be raised in the presence of pseudotumoral mesenteric infiltration, particularly in young women with an IUD. Abdominal CT is a useful method for diagnosis and for follow-up. (author's)
[Law No. 93-73 of 12 July 1993 amending certain articles of the Code of Criminal Procedure]
Tunisia's Law 93-73 of 12 July 1993 modifies certain articles of the code of criminal procedures pertaining to juveniles. Article 224 states that cases of children over 13 and under 18 charged with infractions will be heard by the judge of minors or the criminal court of minors. Exceptionally, when circumstances and the personality of the delinquent warrant, a penal sanction may be pronounced against a minor over age 13. The sentence in this case will be carried out in a specialized establishment or in the section reserved for minors. Violations committed by minors over 13 are assigned to the juvenile judge sitting alone, unless the interests of the minor require him to be present. If the violation is established, the minor may be reprimanded, fined, or placed under supervision, excluding imprisonment. A social study of the moral and material situation of the family or a medical or psychological examination of the minor may be ordered. The juvenile may be placed in a center for observation, with a report to be furnished to the juvenile judge within one month. The juvenile may provisionally be committed to the care of the parents or guardian, an observation center or shelter, a public or private institution, children's center, hospital, or educational or vocational institution. Juveniles over age 13 accused of a misdemeanor or crime can be sent to a house of arrest only if such a course seems indispensable or if no other measure is possible. The judge is advised in writing by two counselors specialized in juvenile affairs, but their opinions are not binding. The record of the minor should be reexamined at least every six months.
The text and an analysis are presented for Colombia's Law 82 of November 3, 1993, which provides special protections to women heads of household. Among other directives, the government will define regulations giving women heads of households and their families access to the social security system, perhaps including free provision of services in exceptional cases. Educational establishments will provide school books to minor dependents of women heads of household who are in need. The national government may create a fund to aid in this function, possibly with contributions from the private sector as well. Health and educational services are not to be denied to children or other dependents of women heads of household solely because of their status. Primary and secondary educational establishments are to give preference in admission to children dependent on women household heads who meet the requirements. The government through its own or private agencies will create free training programs and develop small businesses of different kinds to provide income generating opportunities for women heads of household. Technical assistance and access to credit will be provided for organizations comprised primarily of women household heads. Access to housing will be provided through encouragement of housing organizations, simplification of requirements, promotion of housing plans that facilitate access by women household heads, and other means. A major shortcoming of the new law discussed in the analysis is that, to meet its proclaimed objective of strengthening the family, it focused exclusively on one class of family, neglecting the large majority of Colombian families of limited resources in need of special protection that are not headed by women.
Bolivia's demographic problems are diagnosed and principal guidelines for a national population policy are suggested in this work. 42.3% of Bolivia's economically active population is in agriculture and 38.8% is in the tertiary sector. Population policies can contribute to the national goal of stimulating economic growth while improving the living conditions of the most disadvantaged sectors. Bolivia's average rate of population growth between 1976 and 1992 is estimated at 2.03%. 43% of the population was under 15 in 1991. Bolivia's infant mortality rate of 91/1000 live births remains the highest in Latin America, although it declined by 40% between 1976 and 1991. About 1/3 children under age 3 are believed to be chronically malnourished. The exact maternal mortality rate is not known but believed to be high. The total fertility rate declined from 6.5 in 1976 to 5 in 1989 and to 4.6 in 1991, but rural-urban differentials remain strong. Bolivia was predominantly rural until recently. Rural-urban migration has been the main factor in urban growth. In 1992, 58% of the population was considered urban. Bolivia's population is projected to increase from 6.3 million in 1992 to 7.5 million in the year 2000. The median age will increase from 18.4 in 1992 to 20.4 in 2000, and the proportion urban will be 70% if present trends are maintained. The rate of enrollment in basic education was 78% overall in 1988 for both sexes, but it was 84% in urban and about 75% in rural areas. The considerable changes that Bolivia has experienced in infant mortality and fertility rates and in urbanization did not result from explicit population policies. The general objective of a population policy for Bolivia should be to restore balance between population dynamics and the process of economic and social development. Specific objectives of the policy should be to contribute to decline in infant and maternal morbidity and mortality, increase knowledge of fertility and reproductive health through IEC campaigns, improve spatial distribution, control the negative environmental effects of population growth and urbanization, and establish institutional mechanisms to coordinate population policies.
[Law on equality of opportunities for women, 13 August 1993]
Venezuela's Law of Equality of Opportunities for Women, passed by decree of the Congress in August 1993, contains 69 articles organized in 7 titles setting forth basic steps to be taken to assure women equal opportunity. Title 1 declares that the objective of the law is to guarantee women the full exercise of their rights, which are to be equal to those of men. Its article 6 defines discrimination against women. Title 2 provides guidelines and describes conditions for assuring that the educational, employment, economic, and social rights of women are respected. In the area of education, for example, teaching methods are to be modified to eliminate sexist teachings and to combat stereotypes and prejudices based on ideas of the inferiority or superiority of one or the other sex. Women are to enjoy equal opportunity in employment, and are not to be sanctioned or discharged because of pregnancy. They are to participate in civic, labor, and political organizations in conditions equal to those of men. Their economic participation is to be promoted and encouraged in rural and urban areas. Title 3 creates the National Institute of Women to be the permanent organ charged with defining, executing, directing, coordinating, supervising, and evaluating policies and matters related to the condition and situation of women. Among its other activities it will maintain an information center and database. Title 4 creates the National Defender of the Rights of Women, which will monitor observance of laws relating to women's rights. Title 5 discusses women's right to protection against violence and abuse, and title 6 provides for representation of Venezuelan women in international events and organizations concerned with women's rights.
This Decree has the objective of establishing in Honduras the necessary mechanisms to promote agricultural modernization with the goal of supporting increased production, internal and external sales of products, agro-industrial development, and the rational use of renewable natural resources. Among other things, the Decree deals with administrative re-organization within the agricultural sector, mechanisms for the coordination and execution of policies, the production of food and other agricultural goods, commercialization and exportation of agricultural products, the creation and transfer of technology, credit for agricultural projects and government financing, land tenure and redistribution of land, the leasing and disposition of land, land cooperatives, land titles, the use and commercialization of forest products, and forest management. Accord No. 2124-92 of 18 October 1992 sets forth regulations on the disposition of land under Decree No. 31-92 (La Gaceta, Diario Oficial de la Republica de Honduras, Vol. 116, No. 26888, 6 November 1992, pp. 1-5). Accord No. 2125-92 of 19 October 1992 sets forth regulations on agrarian contracts under Decree No. 31-92 (La Gaceta, Diario Oficial de la Republica de Honduras, Vol. 116, No. 26891, 10 November 1992, pp. 1-2). Accord No. 01431 of 27 June 1991 sets forth regulations on family agricultural groups and agricultural production committees (groups consisting of at least five family agricultural groups) (La Gaceta, Diario Oficial de la Republica de Honduras, Vol. 115, No. 26515, 13 August 1991, pp. 1-3).
Federal Capital Territory, Abuja Customary Court of Appeal Decree 1991 [27 June 1991].
This decree establishes a Customary Court of Appeal as a superior court of record to hear appeals in civil matters from Upper Area Courts and Area Courts in Nigeria on cases involving customary, as opposed to statutory, law. Consisting of a president and a maximum of six other judges, the court is competent under the decree to decide customary law questions relating to marriage (its validity or dissolution, family relations, and guardianship of infants); gifts, wills, and succession; maintenance and guardianship of the physically or mentally handicapped; and other matters in which all parties involved request the court to make a determination in accordance with customary law. The decree also gives the court president the authority to make rules on matters of court fees; the execution of decrees, judgments, orders, warrants, and service of process; and a number of matters relating to estates, among other things.
[Decree-Law No. 2/92 of 11 January 1992]
This Decree-Law regulates the disposition by lottery of housing owned by the State and other public organizations in Cape Verde. This disposition is undertaken in part to guarantee the right of Cape Verde citizens to suitable housing and gives preference to renters and their families. Further provisions of the Decree-Law deal with the disposition of housing that is vacant and preferences given to certain groups, calculation of the price to be paid for the housing, and access to credit for purchasers, among other things. Decree-Law No. 57/92 of 23 May 1992 provides that, if housing purchased under the Decree-Law No. 2 is used as the personal and permanent home of the purchaser, no transfer tax will have to be paid. See Boletim Oficial da Republica de Cabo Verde, No. 21, 23 May 1992, p. 334.
[Organic Law No. 4/1992 of 5 June 1992]
This Law amends the Law on Courts for the Protection of Minors with respect to competency and procedures. It conforms with the decision of the Spanish Constitutional Court of 14 February 1991 finding Article 15 of that Law unconstitutional. The amendments are designed to strengthen constitutional guarantees for minors who have committed acts that could be considered as crimes. They aim to establish a flexible framework that takes into consideration the interests of the minor; to maintain the impartiality of judges, who are given ample authority to agree to the termination of a case in order to avoid the damage that such a case could produce; and to establish a time limit on detention and allow the revision of sentencing in light of the development of circumstances surrounding the minor.
This Law sets forth the functions, organization, and administration of the Nicaraguan Institute of Agrarian Reform. The Institute has the principal objective of directing and applying the policies of agrarian reform and rural development. Further provisions of the Law set forth the composition of the Directing Council of the Institute, among other things. Accord No. 175-92 of 24 June 1992 creates a Research Commission on Agrarian Reform with the objective of formulating proposals and recommendations for strengthening the existing legal framework with respect to agrarian property and presenting them to the President of Nicaragua (La Gaceta, Diario Oficial, Vol. 96, No. 125, 1 June 1992, pp. 1384-1385). Decree No. 35-91 of 19 August 1991 creates and sets forth the functions of the Office for Territorial Systemization (La Gaceta, Diario Oficial, Vol. 95, No. 157, 23 August 1991, pp. 1565-1568). The objective of the Office is to help in determining the ownership of real property in accordance with current laws and, in particular, make revisions based on acquisitions and transfers of real property brought about under Laws 85 and 86 of 29 March 1990. Decree No. 26-91 of 14 June 1991 repeals Decree No. 16-90 of 26 May 1990 and Article 2 of Decree No. 368 of 2 June 1988 relating to the ownership of vacant property in the city of Managua and reinstates the Law of 4 December 1981 on the expropriation of such property (La Gaceta, Diario Oficial, Vol. 95, No. 112, 19 June 1991, p. 1117).
[Decree No. 39-92 of 26 June 1992 on the forest moratorium]
This Decree prohibits the cutting of any species of tree in Nicaragua for commercial purposes. Exempted from the prohibition are a) trees cut on the property of the owner for domestic uses; b) trees cut under management plans already approved; and c) trees cut for the purpose of producing energy, if permission is given. Violations of this Decree are to be handled under existing law.
[Law No. 23.967 of 29 August 1991]
This Law provides that certain land that is the property of the national Argentine Government, its agencies, and decentralized bodies or of a body in which the Government holds all or a majority of the capital or makes all or a majority of the decisions shall be transferred to the states and the City of Buenos Aires. This land must contain permanent or vacant housing suitable for the development of social housing and land plans and must not be necessary for the operations of the Government. It is to be sold to the actual occupants or incorporated into the social housing plans of the states for families with few resources. Further provisions of the Law deal with the setting of prices for the land, the duties of an executing organization to be established in each state, agreements for the transfer of the land from the national Government to the states and their requirements, and the creation of a Congressional Commission to coordinate activities carried out under the Law, among other things. Decree No. 591/92 of 8 April 1992 (Boletin Oficial de la Republica Argentina, Vol. 100, No. 27368, pp. 8-9) approves regulations to the Law.
This Decree regulates the issuance of authorizations to stay or reside in Andorra and work. It provides that a) an authorization to stay and work in Andorra will be issued for six months and can be renewed at one year intervals; and b) an authorization to reside in Andorra and work on a temporary basis will be issued for two years and can be renewed every two years. A person who has held an authorization under item b) for four years is eligible for an authorization to reside in Andorra and work on a regular basis. This authorization is valid for five years. A person who has held this authorization for the five-year period is eligible for an authorization to reside in Andorra and work on a privileged basis. An Edict of 25 July 1991 sets forth the taxes to be collected upon issuance of one of the above authorizations. See Butlleti Oficial del Principat d'Andorra, Vol. 3, No. 31, 31 July 1991, p. 600.
[Decree No. 20618-MIRENEM of 12 July 1991]
This Decree amends Decree No. 19886-MIRENEM (La Gaceta, 13 September 1990), which set forth Regulations for Costa Rica's Forestry Law. The amendments relate to the definitions of terms, the division of duties between the General Forestry Directorate and regional forest offices, the organization of the General Forestry Directorate, the duties of various officials and departments in the Directorate, forestry regions, forestry taxes, ecological tourism, research, management plans, private non-profit forestry organizations, authorization to carry out certain forest activities, applications for technical assistance in controlling diseases affecting forests, reforestation projects, and financial aid provided by the Directorate for certain projects.
[Decree No. 92/069 of 9 April 1992 on government organization. Excerpt]
Among other things, this Decree provides that one of the ministries of the Government of Cameroon is the Ministry of Social Affairs and the Status of Women. This Ministry is responsible for formulating and implementing policies for social assistance and prevention of social problems; promoting individuals, the family, and respect for the rights of women; and promoting women in society, free from any kind of discrimination and with a full guarantee of equal political, economic, social, and cultural rights. To this end, it is, among other things, to research and propose to the Government, in cooperation with any interested ministerial department, measures designed to make the rights of Cameroon women respected and improve the conditions of their employment. Further provisions of this Decree describe the other ministries within the Government and their responsibilities.
Vietnam and Britain agree to forced return of Vietnamese boat people in Hong Kong.
On 29 October 1991, the Governments of the United Kingdom and Viet Nam reached an Agreement on the return of certain categories of Vietnamese "boat people," i.e., persons who fled from Viet Nam to Hong Kong. Under the Agreement, Vietnamese who arrive in Hong Kong after the date of the Agreement and who do not qualify for refugee status will be returned first. The determination of such status is to occur within six weeks of their arrival. Later, Vietnamese in Hong Kong who have already failed to qualify for refugee status will be returned. The Agreement follows an Agreement earlier in October to return Vietnamese arriving in Hong Kong who are known as "double backers," i.e., persons who had previously voluntarily been repatriated to Viet Nam only to return to Hong Kong.
State of Maharashtra v. Madhukar Narayan Mandikar [1990].
The defendant was a police officer whose employment was terminated after a police tribunal found that he had, while in uniform, tried, unsuccessfully, to force a woman to have sex with him. After he convinced the High Court to quash the dismissal, in part on the ground that the woman who had accused him of attempted rape was herself a woman of "easy virtue" and a kept mistress whose testimony was suspect, the Government of Maharashtra appealed to the Supreme Court of India. This Court reversed the decision of the High Court, ruling that the testimony of the woman was corroborated by material facts. In reaching its conclusion, it made the following statement about the privacy rights of women: "Even a woman of easy virtue is entitled to privacy and no one can invade her privacy as and when he likes. So also it is not open to any and every person to violate her person as and when he wishes. She is entitled to protect her person if there is an attempt to violate it against her wish. She is equally entitled to protection of the law."
Council Directive of 28 June 1990 on the right of residence.
This Directive of the Council of the European Communities provides as follows: "1. Member States shall grant the right of residence to nationals of Member States who do not enjoy this right under other provisions of Community law and to members of their families as defined in paragraph 2, provided that they themselves and the members of their families are covered by sickness insurance in respect of all risks in the host Member State and have sufficient resources to avoid becoming a burden on the social assistance system of the host Member State during their period of residency..." "2. The following shall, irrespective of their nationality, have the right to install themselves in another Member State with the holder of the right of residence: a) his or her spouse and their descendants who are dependents; b) dependent relatives in the ascending line of the holder of the right of residence and his or her spouse." Further provisions of the Directive define the term "sufficient resources" and institute a residency permit to evidence the right of residence. They also provide that the spouse and dependent children of a national with a right of residence within a Member State are entitled to take up any employed or self-employed activity anywhere within a Member States even if they are not nationals of a Member State.
[Decree No. 4-89 of 7 February 1989]
This Decree sets forth the Law of Protected Areas in Guatemala. It provides that it is in the national interest to restore, protect, conserve, and manage forest life, and, to this end, it creates a system of protected areas. Provisions of the Decree deal with the scope of application of the Law, the definition of protected areas, the management of protected areas, the conservation of plants and animals, fiscal incentives for conservation, the rational exploitation of flora and fauna, violations of the Law and associated penalties, the creation of a National Council to oversee the application of the Law, and the organization, administration, responsibilities, and finances of the Council, among other things. The Law designates a number of areas as protected areas. Governmental Accord No. 759-90 of 22 August 1990 sets forth Regulations for the Law of Protected Areas. It contains provisions on the definition of terms used to describe protected areas, categories of management, procedures for designating an area as a protected area, contracts to exploit protected areas, the propagation of forest life, fiscal incentives, administration, and registers, among other things. See Diario de Centro America, Vol. 239, No. 51, 27 June 1990, pp. 1209-1216.
This Law has as its objective the regulation of the protection of the rights of minors and the social adaptation of minors whose conduct has contravened the criminal laws. Its application is guided by the principles of strict respect for human rights and the just and humane treatment of minors who are accused of committing crimes. Minors are defined as persons between the ages of 11 and 18. The Law creates a Minors Council as an autonomous administrative agency to oversee the application of the Law. Further provisions of the Law set forth the composition, organization, administration, and functions of the Council; create an Agency for the Defense of Minors to defend their interests before the Council and other administrative or judicial organs and an Agency for the Treatment and Prevention of Problems with Respect to Minors; and outline procedures to be followed with respect to minors during all official proceedings. The Law also deals with the investigation of offenses; appeals, suspension of proceedings, dismissal of proceedings, and restitution of damages caused by minors; evaluation of the biological, social, and mental state of minors and means to reorient minors so that they do not commit further crimes; treatment of minors to achieve their integration into society; and follow-up, among other things.
Convention on the Elimination of All Forms of Discrimination against Women [ratification status].
The following countries ratified, acceded to, or succeeded to the Convention on the Elimination of All Forms of Discrimination Against Women in 1993: a) Armenia, 13 September 1993; b) Bahamas, 6 October 1993; c) Bosnia and Herzegovina, 1 September 1993 (suc.); d) Czech Republic, 22 February 1993 (suc.); e) Gambia, 16 April 1993 (rat.); f) India, 9 July 1993 (rat.); g) Maldives, 1 July 1993; h) Morocco, 21 June 1993; i) Slovakia, 28 May 1993 (suc.); j) Suriname, 1 March 1993; and k) Tajikistan, 26 October 1993. Under this Convention, the parties agree to take steps to eliminate discrimination against women in the political, social, economic, and cultural areas of life and with respect to education, employment, health care, and the family, among other things. The Convention also creates a committee to review individual reports that individual countries are required to prepare on their progress in implementing the Convention.
[Outline of China's Child Development Program for the 1990's. 1992].
The first part of this outline of China's Child Development Program for the 1990s contains introductory material that notes the importance of improving child development, China's accomplishments in this area, and the challenges remaining. Part 2 lists the major goals for the 1990s regarding reducing infant and child mortality, morbidity, and malnutrition; improving the water supply and sanitation; increasing educational opportunities; and reducing the birth rate of disabled children. Part 3 relays the strategies and measures that will be followed in the areas of population and family planning; health care and nutrition for women and children; environmental protection, sanitation, and natural resources; basic education and elimination of illiteracy; community and family development; protecting children; and prenatal, postnatal, and parental care. Part 4 describes the ways in which child development programs fit into China's overall development scheme and how these effort will be organized and supervised.
Constitution of the Third Republic, December 26, 1992. [Excerpts].
This document contains major provisions of the 1992 Constitution of Niger. Among the human rights guaranteed by articles 11-36 of the Constitution are equality without regard to sex or social, racial, ethnic, or religious background and the right to life, health, liberty, security, physical well-being, education, and instruction. Marriage and the family are considered the basis of human community and are protected by the state, which also extends its protection to minors, the elderly, and handicapped persons.
Constitution of the Republic of the Congo passed by referendum 15 March 1992. [Excerpts].
This document contains major provisions of the 1992 Constitution of the Congo. The document opens with a listing of major events in 1991-92 leading up to the approval of the constitution. The Table of Contents then lists the subjects of the 17 titles. The texts of titles 2, 3, 9, and 10 are reproduced in their entirety. Title 2 sets forth the fundamental rights and liberties protected by the constitution. Among these are the right to life, protection from discrimination before the law and in employment, the right to citizenship, and the right to freely choose place of residence. Freedom of information is guaranteed, censure is prohibited, and access to information is to be free. The state guarantees public health, and citizens have the right to a standard of living that meets basic needs. Social protection is extended to aged and handicapped persons. Citizens have the right to free public education, and marriage and the family exist under the protection of the state. Children are protected from economic and social exploitation, and children must be 16 years old to work. Title 3 contains the duties of citizens, title 9 describes judicial authority, and title 10 creates the Constitutional Council.
This 1992 Act of Singapore amends the 1985 Infectious Diseases Act. After inserting a definition of AIDS into the Act in Section 2, Section 7 is amended to allow the Director of Medical Services to conduct epidemiological surveys of any infectious disease. During these surveys, people may be required to furnish information and to submit to medical examinations. Any person diagnosed with HIV/AIDS may be required to undergo counseling and to comply with precautions and safety measures. Individuals who know they have HIV/AIDS may not have sexual intercourse unless the other party has been informed of the risk of contracting HIV/AIDS from the infected party and has voluntarily agreed to accept that risk. People who know they have HIV/AIDS may not donate blood or engage in any act which is likely to transmit HIV/AIDS to another person. If, as a result of this Act, a person is aware or has reasonable grounds to believe that another person has HIV/AIDS or is infected with a sexually transmitted disease, this information will be held in confidentiality except in special circumstances, including informing another medical practitioner treating the person; informing a blood, organ, semen, or breast milk bank that has received a product from the infected person; and informing the victim of sexual assault by the infected person.
This document summarizes major provisions of the 1992 resolution of the Chief State Sanitary Physician of Uzbekistan, which introduce measures to prevent the introduction and spread of quarantinable diseases and HIV/AIDS. The regulations require every citizen planning to travel abroad to have a medical certificate. Individuals coming from countries in which quarantinable diseases and AIDS are prevalent may be placed under medical surveillance. People going to such countries will receive training about personal protective measures as well as immunization when appropriate. The provisions also prevent citizens from countries where AIDS is prevalent to enter Uzbekistan unless they have certification that they have been tested for HIV. After a month in Uzbekistan, such persons must undergo a new test. Aliens with HIV/AIDS are to be deported immediately. The health of tourists is to be safeguarded, and the tourists may be placed under medical surveillance. The national airline is responsible for providing a place to isolate sick passengers suspected of being infected by quarantinable diseases.
This document contains major provisions of a 1992 Italian law providing compensation for persons whose health has been irreversibly damaged by compulsory immunizations, blood transfusions, or the dispensing of blood derivatives. Health damage includes contracting hepatitis as a result of a transfusion and illness occurring in nonimmunized persons as a result of contact with an immunized person.
This document contain the text of a 1991 Albanian law governing the employment of Albanian citizens in foreign countries. Albania citizens have the right to work outside the country but must submit a request to do so to the competent state agency. Some citizens, (including those under age 18, with outstanding army service, prisoners, debtors, with unsettled family disputes, or members of the armed forces) will not be permitted to work outside the country. Other aspects of labor migration, including pensions, taxes, costs, time limitations, and registration issues are also covered.
HIV infection in females dependent on drugs.
The vulnerability of injecting drug users to human immunodeficiency virus (HIV) was confirmed in a survey of 171 consecutive women 14-50 years of age (median age, 31 years) court-ordered to the Female Drug Rehabilitation Center in Malaysia's Kelantan State. The median duration of drug use in this sample was 7.4 years (range, 1-27 years). Involvement in commercial sex work was reported by 82 women (48%); condoms were not used in 60.1% of all sexual encounters. Overall, 24 (14%) of these rehabilitation center patients were HIV-positive; however, of the 75 women with a history of intravenous drug use, 21 (28%) were seropositive, and such a history was present in 20 (83%) of the 24 HIV-positive respondents. 36 (48%) of the intravenous drug users were sharing injecting equipment, reportedly because of an inadequate supply of needles and syringes, and only 16 (44%) of needle-sharers were using the correct method for cleaning. HIV infection was significantly associated with age 31-40 years, low educational status, a history of at least one prison term, syphilis infection, intravenous drug use, and sharing of injecting equipment; however, only the latter two factors retained significance in the analysis of variance. Women-oriented programs aimed at preventing drug injection, or at least decreasing needle sharing, are needed to curtail the spread of HIV infection in Malaysia.
The reliability of application of the Transtheoretical Model to condom use patterns was assessed in a study of 2864 low-income women from 5 US cities who were considered at high risk of human immunodeficiency virus (HIV) due to their sexual and drug use behaviors. This model posits 5 stages of change: Precontemplation, Contemplation, Ready for Action, Action, and Maintenance. Three scales (self-efficacy, perceived advantages or pros, and perceived disadvantages or cons) of 3 outcome measures (use of contraception, use of condoms with a main partner, and condom use with other partners) were assessed. Over 50% of respondents expressed confidence in their ability to follow through on birth control and condom use, with the pros perceived as more salient to decision making than the cons. However, scale characteristics that were adequate for reliably measuring the pros were not adequate for the cons, suggesting that the latter is a more complex construct. In general, women with HIV risk characteristics and those who did not use birth control/condoms had higher cons scores and a greater variance for each item. Over 40% of respondents were in the Action and Maintenance stages for birth control/condom use with other partners, but only 18% were in these stages for condom use with their main partner and 60% were in the Precontemplation stage. For all 3 behaviors, self-efficacy scores increased significantly (p < 0.05) with stage of change. The crossover point when pros came to outweigh cons occurred at the Ready-for-Action stage for birth control and at the Contemplation stage for both condom use behaviors.
Although South Africa has identified school-based acquired immunodeficiency syndrome (AIDS) preventive education as a priority, program implementation has been hindered by controversy over content and approach. To facilitate the development of an appropriate, acceptable AIDS program for secondary school students and ensure involvement of the target community, formative research was conducted during 1990-91 at a secondary school in Cape Town. Qualitative research methods (focus groups, free attitude interviews, and participant observation) were used to understand students' sexual experiences and sexual health needs, develop a partnership with teachers, and explore the impact of cultural and religious values on AIDS education. An initial breakdown of collaboration occurred when Muslim teachers, who strongly oppose premarital sex and homosexuality, voiced resistance to teaching protective behaviors against sexually transmitted diseases and pregnancy. Although students expressed an urgent need for education on sexuality, parents and teachers expected the AIDS curriculum to promote Muslim values. To resolve this conflict, religious leaders were consulted for endorsement of the project and guidance on an acceptable approach to AIDS education for youth. The program content was modified to incorporate value clarification and the amount of information presented by teachers on condoms was reduced; material on condom use and a nonjudgmental approach to homosexuality was conveyed, instead, through a photo-novella based on authentic student experiences. By listening to those involved, researchers were able to discern what was likely to be acceptable in the school context and what was likely to be offensive and ineffective before money was wasted implementing an inappropriate program.
The Centers for Disease Control and Prevention's Prevention of Human Immunodeficiency Virus (HIV) in Women and Infants Demonstration Projects, underway in 8 US cities, use behavioral theory to guide the design and evaluation of community-based interventions. The first collaborative project is using street-based interventions and the diffusion of preventive messages through women's social networks to reduce HIV transmission and unplanned pregnancy among high-risk women; the second seeks to influence reproductive decision making through peer advocacy and the placement of preventive services in facilities women attend for other needs (e.g., homeless shelters, drug treatment centers). Both projects are informed by the Transtheoretical Model of Behavior Change (also known as Stages of Change), which views risk reduction as a gradual, continuous, dynamic process. Structured interviews were conducted with 238 women from 7 of the 8 project sites to assess the applicability of this model to contraceptive and condom use and to develop stage algorithms. Most women fell into the Precontemplation, Preparation, and Maintenance stages. Condom use was significantly more likely with casual or paying partners than with main sexual partners. Cognitive and emotional processes, including increased awareness of the impact of risk behaviors on self and others, were facilitative of change in the Precontemplative stage, while behavioral processes such as skills building and self-efficacy were salient in later stages. Trained peer advocates were able to arrive at accurate stage assessments in 94% of cases.
The effectiveness of barrier methods of contraception in preventing the spread of HIV.
The effectiveness of barrier methods of contraception in preventing sexually transmitted diseases (STDs) such as human immunodeficiency virus (HIV) has been assessed in vitro studies and epidemiologic research. Both types of studies have indicated that consistent use of high-quality latex condoms confers substantial protection against HIV transmission. Less certain is the capability of nonoxynol-9 to inactivate HIV. Of concern are several studies indicating that 1-8% of female nonoxynol-9 users experience signs and symptoms of tissue irritation, which can facilitate HIV transmission. These findings may reflect overenrollment of women with a high incidence of STDs and above-average (more than one per day) spermicide doses. Meetings sponsored by the World Health Organization and the US Public Health Service during 1993-94 reached consensus on five ethical and methodological principles to govern studies investigating whether currently available nonoxynol-9 spermicides reduce the incidence of HIV infections: 1) a randomly allocated controlled trial in which all participants are given male condoms; 2) allocation of half the women to an active spermicidal product and the other half to a placebo product; 3) counseling participants to use both a condom and the vaginal product at every coital act; 4) sufficient study size to measure HIV rate ratios within frequency strata; and 5) inclusion of colposcopic examinations and regular appraisal of participant safety by a data and safety monitoring board. Studies of less irritating yet effective spermicidal compounds, the determinants of consistent use of barrier methods, and the impact of social marketing are also recommended.