Development of a comprehensive district HIV prevention and AIDS care programme.
In sub-Saharan Africa, the district is the key administrative unit for implementation of health and development programs, including HIV/AIDS prevention and care programs. In Tanzania's Magu District, for example, the AIDS program was initially developed under the primary health care committee. When this body proved to be too large to plan and oversee program implementation, a smaller, action-oriented district AIDS team was established composed of the district planning officer, district AIDS control coordinator, department heads of relevant sectors, and representatives from nongovernmental organizations. Presented, in this chapter, are the steps essential to develop a district-level AIDS program: situation analysis, formulation of a plan of operations and a plan of action, implementation of the activities and interventions, and monitoring and evaluation. The situation analysis provides a basis for future work, including a description of the magnitude of the HIV/AIDS problem, the knowledge level and sexual practices present in the community, the location and nature of high-transmission areas, and the current state of interventions and resources. Activities should be integrated into an overall AIDS program strategy as well as linked with other health interventions. Also important is working with the community in a participatory way, beginning in the planning stage, and with attention to gender issues. To maximize the potential for success, it is often advisable to prioritize areas where collaboration already exists and a management structure is in place. An excellent indicator of program effectiveness is the extent to which communities are actively involved and contributing to AIDS program activities.
Situation analysis for a district HIV / AIDS programme.
A situation analysis provides a basis for developing a feasible, district-level HIV/AIDS program in sub-Saharan African countries. Such an analysis not only identifies high-transmission areas and key resources, but also offers an opportunity to mobilize the community and community-based organizations. The health, education, community development, information, and planning sectors must be represented on the situation analysis team and women should comprise at least one-third of group members. The district situation analysis includes the following elements: population data, estimations of the prevalence of HIV and other sexually transmitted diseases, potential high-transmission areas (e.g., transport routes and roadside villages), assessment of the consequences of AIDS mortality (e.g., orphans, economic disruption due to deaths of agricultural workers), and district resources (personnel, financing, and equipment) that can be mobilized to reduce HIV transmission and cope with the consequences of the epidemic. Data on condom availability and current use levels are also important. The information garnered through the situation analysis forms the basis for development of an HIV/AIDS action plan.
Epidemiologic methods are useful to the development of HIV/AIDS programs in sub-Saharan Africa. Such methods can help to detail the natural history of HIV, identify its causes and determinants, assess its social consequences for the community, and provide a basis for the design of effective interventions. This chapter presents some simple epidemiologic techniques health workers and planners can use at the district level for tasks such as estimating the overall HIV prevalence in a community. A sentinel surveillance system can be used to monitor trends in HIV prevalence. For example, quarterly sentinel surveillance of HIV prevalence among women attending a large antenatal clinic in Tanzania's Mwanza District revealed a stabilization at around 12%. However, this procedure cannot specify the numbers of new infections or of people who have already died of AIDS. Incidence is more difficult to measure, since it requires establishment of a cohort that can be followed over time. In later stages of the HIV epidemic, behavior changes and interventions may lower the HIV incidence rate, but prevalence will remain high for several years. Much valuable epidemiologic data are contained in routine health records kept at hospitals, health centers, and dispensaries. Finally, studies that assess the association between risk factors and HIV infection in a community are essential to the design of interventions targeted at high-risk groups. Simple risk-related questions, combined with HIV test results, can be used to determine the HIV prevalence in relation to the level at which a particular risk factor is absent or present in a district.
Anthropological research on AIDS.
A wide range of anthropological methods are available for research on sexual behavior and HIV/AIDS. Of salience to AIDS-related social research are the following issues: sexual behaviors and attitudes, knowledge and perceptions of AIDS, local etiologies and treatment-seeking behaviors, social organizations, customs and norms, underlying socioeconomic factors, and community strategies for coping with AIDS and its consequences. Potential research methods include participant observation, field journals, tape recordings, interviews with key informants, narratives, life histories, questionnaires, role plays and performances, focus group discussions, peer research, classification and semantic differential rankings, nonverbal techniques, and triangulation. This chapter outlines each of these methodologies, with examples of their application from Tanzania's Mwanza Region. In this region, multi-instrument anthropological research among both primary school students and fishing village residents has provided a comprehensive picture of AIDS-related factors and facilitated the design of AIDS programs. In addition, a prospective cohort study of 2500 workers in a large textile factory and their spouses has provided large amounts of rich data and enabled the findings from one research method to be used to cross-check the reliability of the findings from another.
Gender sensitivity must be an essential component of the planning, implementation, monitoring, and evaluation of district-level HIV/AIDS programs in sub-Saharan Africa. A gender-informed situation analysis seeks to identify the differential effects of HIV/AIDS and sexually transmitted diseases on men and women through use of health, demographic, epidemiologic, sociocultural, and economic frameworks. In Africa, the large age difference between spouses, promoted by cultural factors such as polygamy and bride wealth, is a driving force behind the AIDS epidemic, since younger women have even less decision making and sexual negotiation power. Moreover, a study conducted in Mwanza, Tanzania, revealed that women who died of AIDS were, on average, 27.8 years of age, while their male counterparts averaged 33.8 years. Other factors that enhance African women's HIV risk include widow inheritance, patrilineal descent, sexual violence, the greater ease of male-to-female HIV transmission, women's likelihood of receiving blood transfusions (e.g., for anemia or complications of pregnancy), the importance placed by men on "dry sex," economic inequalities, and the low availability of female-controlled barrier methods. Included, in this chapter, is a checklist of questions for health personnel to assess the gender sensitivity of AIDS prevention programs.
Program monitoring and evaluation has been a weak component of HIV/AIDS interventions in sub-Saharan Africa. At the district-level, the primary focus should be on input and output indicators and assessments of community involvement. It is essential, however, to begin with clear objectives, measurable targets, and baseline data. If resources are available, small-scale surveys can be conducted to collect information on indicators covering the effects of program interventions. In many cases, elaborate data collection, analysis, and feedback systems fail because of inadequate staff training and supervision and a lack of computer facilities. Staff involvement in all phases of the monitoring and evaluation process, combined with proper feedback and discussion of the results, helps motivate health workers to both collect and make use of data. Participatory monitoring is a low-cost means of stimulating the involvement of the target group and enhancing community commitment to the AIDS program. Although the best indicators of program effects are changes in sexual behavior (e.g., decreases in numbers of sexual partners and increased use of condoms in high-risk encounters), such data are not always reliable, as people tend to report the behaviors they think the interviewer wants to hear. The monitoring and evaluation methodologies described in this chapter are illustrated through examples of their application in Tanzania.
Community level interventions.
Mobilization of community members and organizations is an essential component of HIV/AIDS programs in sub-Saharan Africa. Community participation is more likely when AIDS is perceived as a community problem rather than a problem of isolated individuals in high-risk groups. Lessons learned in the context of rural development and primary health care programs about the importance of respect for community priorities and felt needs are equally salient to AIDS programs. Also important is attention to gender relations and economic security issues, given the strong association between high-risk sexual behaviors and the unemployment of youth and women. The role of outside consultants should be limited to a facilitative function in problem analysis and program planning and to the training of groups involved in the campaign in effective ways of delivering motivational messages. If resources are available, a participatory rapid appraisal provides a means of establishing a participatory learning process. In all cases, the village government should be consulted about which village institution is most suited to coordinate and supervise AIDS prevention and care activities. Involvement of local cultural groups always enhances program acceptance. Experiences in Tanzania suggest that a mix of culturally familiar popular drama forms is most effective for delivering behavior change messages.
Working in high-transmission areas: truck routes.
The targeting of resources to high-transmission areas is essential to curtailing the spread of HIV/AIDS in sub-Saharan Africa. A national intervention program developed in Tanzania in 1993 uses peer educators to reach high-risk groups such as long-distance truck drivers, bar/guesthouse workers, travelers, miners and fishermen, businessmen, and workers at major construction sites. Steps involved in establishing programs in project sites included community entry and sensitization, physical and social mapping, community motivation and support for the intervention, a target group meeting, selection of peer educators, and training of educators. Among the program activities were condom promotion and distribution, dissemination of educational materials, role plays, and small group discussions. Programming in high-transmission areas also presents a number of obstacles. For example, target populations such as truckers, commercial sex workers, and fishermen tend to be transient, temporary community members, impeding program continuity and evaluation. Addressing the entire community, rather than high-risk groups, reduces stigmatization and increases the potential for program sustainability. Given concerns a truck stop AIDS project along a major Tanzanian highway was not likely to be sustained after external funding reductions, project staff established AIDS advisory committees, women's health groups, and income-generating activities based on condom social marketing, and attempted to integrate AIDS interventions into existing health structures such as village health committees.
Addressing gender and gender-related issues.
District-level HIV/AIDS programs in sub-Saharan Africa require special attention to the specific needs of women. This includes promotion of gender awareness, advocacy directed toward mobilizing resources to enhance women's socioeconomic status, and integration of all reproductive health services. Discussion groups, group interviews, and mapping exercises are specific techniques for increasing gender sensitivity. As a first step, information should be gathered on gender inequalities from health, cultural, and socioeconomic perspectives. HIV infection is often directly linked to poverty, unemployment, wife inheritance, male alcohol abuse, sexual violence against girls and women, and the dependence of women on sex work and multiple partners for their economic survival. Exchange of information on AIDS and communication about gender issues can be facilitated by working with or establishing district women's groups. Members can be mobilized and trained to become community educators or help organize home-based AIDS care programs. Such mobilization is best achieved through use of women's drama troupes that are also trained to help women's groups develop AIDS action plans. In Tanzania, short role plays are presented at community meetings to depict gender-related HIV risk behaviors and identify solutions.
Condom promotion and distribution.
Condom promotion is an essential component of HIV/AIDS prevention programs. Although free condoms are available in Mwanza, Tanzania, increases in consistent condom use are proceeding slowly and there are too few consistent users in high-risk groups. Obstacles to more widespread condom use include low motivation, alcohol abuse, their prevention of conception, women's lack of power to negotiate condom use, misconceptions, religious opposition, and erratic contraceptive supplies. Condom promotion should emphasize the relational aspects of protection rather than present condom use merely as a technological solution. The obstacles to condom use need to be understood for each target group, and these groups should be encouraged to suggest possible distribution outlets. In Mwanza, condoms are provided to all guesthouse rooms, and peer educators distribute condoms to high-risk groups such as sex workers, truck drivers, and fishermen. Role plays can be effective in getting people to begin thinking about condom use. Since condom promotion interventions create an interest in condom use, it is imperative that condoms are available for distribution at the same time. Districts need to learn how to ensure that adequate numbers of condoms are available within their areas. This chapter outlines methods for estimating yearly demand for condoms in a district from past consumption, population-based data, or program targets.
The effectiveness of HIV/AIDS programs depends on adequate training of health staff, community leaders, and school personnel. A study in Tanzania indicated health workers who had attended training had significantly more knowledge and more positive attitudes about HIV/AIDS than untrained workers. Communication skills, attitudes, and the ability to work as facilitators are as important to the training curriculum as the provision of up-to-date scientific knowledge. Training must address the beliefs, attitudes, and prejudices of the health workers themselves, their fears of infection, and ways to deal with sensitive topics such as sex and death. If, through AIDS training, health workers learn participatory, problem-solving approaches, these skills can be utilized in other community mobilization activities. Study groups, independent learning, distance learning, classroom teaching, and workshops are all potential training strategies. Suggested modules for an independent AIDS learning program in Tanzania include basic facts and feelings about HIV/AIDS, how to find out about AIDS in the community, HIV infection and AIDS counseling, review of infection control in health units, and AIDS home-based care. Experience in Tanzania's Mwanza Region has indicated that group teaching facilitates team work and motivation.
STD control efforts in health units.
Sexually transmitted diseases (STDs) increase the risk of HIV infection in sub-Saharan Africa, especially for women. Since STD patients are more likely than others to be HIV-infected, proper case management is essential to prevent community transmission. Components of STD case management include privacy and confidentiality, a caring attitude on the part of health workers, evidence-based diagnosis, syndromic treatment with effective drugs, health education to avoid future infection, condom promotion and provision, partner notification, recording and reporting, and assessment of treatment outcomes. However, a substantial proportion of patients with STDs do not seek treatment from health facilities; in many other cases, infections are asymptomatic. Because of the serious implications of STDs for women's health, all women who come into contact with the health system (at antenatal, family planning, and under-five clinics) should be screened for STDs. A combination of history taking, risk assessment questioning, simple genital examination, and at least one blood sampling during pregnancy is recommended.
Although effective sexually transmitted disease (STD) control can greatly reduce the number of new HIV infections in sub-Saharan Africa, it places an immense burden on the health care system and district economy. The district health management team must ensure the five essential components of STD control: promotion of primary prevention, induction of improved treatment-seeking behavior, facilitation of proper case management at health units, establishment of effective control activities in high-risk groups, and collaboration with the STD reference clinic and laboratory. In many African communities, although up to 50% of sexually active women may be infected with an STD, only half are likely to be symptomatic. Among women with symptomatic STDs, less than half may seek treatment from a health clinic and many will not comply with the treatment regimen. Moreover, high-risk groups such as commercial sex workers are unlikely to use STD services within the formal health sector. More feasible strategies include IEC for bar and guesthouse managers, peer education, mobile STD case screening and management, drop-in women's health centers close to work places, and health education directed at clients such as truck drivers. A district STD control coordinator must be appointed to ensure effective case management and supervision at peripheral health units, train health staff, and ensure a reliable supply of drugs and their cost-effective utilization.
HIV testing at district level.
This chapter outlines the minimum requirements for HIV screening at district-level health facilities in sub-Saharan Africa. HIV testing is feasible only if enough samples (more than 10 units of blood per week) are anticipated and adequate space and trained staff are available. A health facility with a poor laboratory and limited financial resources should not undertake HIV screening. Four types of test kits are available for clinic use: rapid assays, enzyme-linked immunosorbent assays (ELISA), immunoglobulin G antibody captured particle adherence tests (GACPAT), and Western blots. The World Health Organization has recommended testing strategies based on whether the subject is a blood donor, a symptomatic or asymptomatic patient, and the area's HIV prevalence. One test is sufficient for blood donors, but three tests are required for asymptomatic persons in areas with an HIV prevalence of 10% or less. Since the costs of available tests range from US $1 to $5, the need for confirmatory testing can drain hospital resources. Costs can be reduced, however, through pooling, re-use of tests, and GACPAT use. Appropriate counseling and strict confidentiality are essential.
Medical care-related transmission.
There are four situations in which HIV infection can occur during medical care: from patient to patient (mostly by injections), from donor to patient in blood transfusions, from health worker to patient, and from patient to health worker. Although medical care-related HIV transmission comprises a small proportion of HIV transmission in sub-Saharan Africa (estimated at less than 0.4% of total incidence in Tanzania's Mbeya Region), districts should ensure a safe blood supply and safe injection and sterilization practices. A small survey of health facilities can provide information on current injection and sterilization practices in a district and may suggest a need for interventions to reduce the demand for and number of injections administered, improve sterilization practices, improve supervision, and increase stocks of reusable syringes and needles and sterilizing equipment. These interventions can be introduced through local training workshops for health workers, with retraining every two or three years. Although the risk of patient-staff HIV transmission is minimal, inadequate supplies of protective and hygienic equipment are a concern, especially for traditional birth attendants. This chapter includes a protocol for reducing the risk of occupational HIV exposure.
Reducing HIV transmission via blood transfusion: a district strategy.
The high demand for blood transfusion in sub-Saharan Africa, especially among children and women of childbearing age, increases the risk of HIV transmission. Blood that is not screened for HIV antibodies before being transfused accounts for an estimated 10-15% of HIV infections in sub-Saharan Africa, and this rate may be higher among children. Thus, it is essential that standard procedures are followed to ensure a safe blood and blood products supply. Recommended are the following measures: establishment of a well-organized blood bank based on a system of regular voluntary donors; recruitment of blood donors from among low-risk groups, e.g., secondary school students; the use of screening questions to identify voluntary high-risk donors; testing blood units for HIV; minimizing the number of blood transfusions by adherence to blood transfusion guidelines and supervision of the implementation of these guidelines; and use of autologous (the patient's own) blood transfusion, wherever possible. A study conducted in the eight hospitals in Tanzania's Mwanza Region indicated that 23-39% of blood transfusions were potentially avoidable.
AIDS care and counseling, an increasingly important need at the district level in sub-Saharan Africa, can be most effective when based on a continuum of care model. This includes a set of linkages connecting home care to health facilities as well as improved referral mechanisms. Those living with HIV and AIDS require emotional support, access to common drugs, family counseling, support for surviving children, legal advice, food, clothing, household help, and financial assistance as well as clinical care. Comprehensive HIV/AIDS services must be provided not only in times of crisis, but in all phases of HIV infection and the bereavement process, and focus on the patient, surviving family members, and the broader community. Such care entails four responses to the needs of people living with HIV and their families: clinical management, nursing care, counseling, and social support. The care continuum should be linked through networking or coordination so that an active referral for more comprehensive care can be made at any point in the help-seeking process. A multisectoral approach involving clinical, nursing, social welfare, religious, and community groups can reduce the burden of HIV/AIDS on the health sector and community. Obstacles to community- and home-based AIDS care include sustainability problems when external funding is decreased or withdrawn, irregular supplies of donated items such as clothing and food, the stigma and fear that remain attached to the disease and promote isolation of persons with AIDS, and problems maintaining confidentiality.
Tuberculosis control and AIDS.
In a sub-Saharan African country with a HIV prevalence of 10%, 30-40% of all tuberculosis cases are likely to be attributable to HIV infection. Given the synergistic interaction of these two infections and limited funds and staff, it seems feasible to merge national tuberculosis and AIDS programs, or, at least, to integrate as many of these programs as possible. At the district level, coordinators for tuberculosis programs can become involved in AIDS control activities such as patient management and counseling, pre- and post-HIV test counseling, and condom promotion, while AIDS program coordinators should be actively involved in tuberculosis case finding. Health workers' knowledge of both HIV and tuberculosis should be updated regularly through workshops at different levels of the health care delivery system. Health workers must be taught how clinical and radiologic manifestations of HIV-related tuberculosis differ from those of non-HIV-related tuberculosis. The occurrence of tuberculosis in HIV-infected patients poses additional problems in terms of adverse drug reactions, the need for streptomycin injections, drug resistance, and the need for expensive isoniazid chemoprophylaxis. Among the factors likely to increase district-level expenses are tuberculosis drugs, the need for more counselors and expanded laboratory facilities, increased hospital admissions, and the need for health education materials and training workshops.
Consequences of the AIDS epidemic for children.
The HIV/AIDS epidemic among children in sub-Saharan Africa has been fueled by the large number of infected women in the childbearing age group, child sexual abuse, the near-universal practice of breast feeding, and frequent use of blood transfusions for child health problems such as anemia. Methods under investigation to reduce mother-to-child transmission include vaginal disinfection with virucide before delivery, vitamin A supplementation, and antiviral drugs. Most HIV-infected children become ill during their first year of life, but symptoms may resemble those of other childhood diseases. Moreover, a positive HIV antibody test is reliable only after 18 months of age. Estimated AIDS-related increases in child mortality range from 3% to 26% in African countries. Parental HIV infection compromises family income, the quality of child care, and the likelihood of preventive medical care; it further creates AIDS orphans and street children. Districts in sub-Saharan Africa are addressing the staggering increases in AIDS orphans through orphanages, direct support for basic needs and school fees, and feeding posts and child care centers. In Zimbabwe, where 18% of households include orphans and 13% of children have been orphaned, the majority of children receive adequate care within extended families or through adaptations of community coping methods. Support for such existing mechanisms may be the best approach to orphan care in sub-Saharan Africa. However, special programs may need to be designed for poorer children and households in urban and peri-urban areas.
Costs of district AIDS programmes.
At the district level in sub-Saharan Africa, limited resources must be targeted to increase the impact and cost-effectiveness of HIV/AIDS interventions. Comprehensive HIV prevention activities aimed at high-transmission areas have a higher cost-effectiveness than diffuse low-intensity interventions covering the entire district. By 1993, AIDS expenditures were already absorbing 20-60% of government health budgets in sub-Saharan Africa. This chapter uses data from Tanzania's Mwanaza Region to evaluate and compare the cost-effectiveness of the following interventions: promotion of safer sexual behaviors (general population, youth, and high-transmission areas); sexually transmitted disease (STD) control (general population and core group); condom promotion and distribution; reduction of HIV transmission through blood transfusions and through injections; training of health workers in AIDS care; counseling; care for AIDS patients; and survivor assistance. Although priorities may change as the epidemic progresses, this analysis suggests that reducing HIV in high-transmission areas, condom distribution, STD control, safer sex promotion for youth, and ensuring a safe blood supply are the most cost-effective interventions. A table accompanying the chapter sets forth AIDS programming options at different district funding levels. For example, a total budget of US $25,000 per year enables assurance of a safe blood supply, a $50,000 budget allows for expansion of interventions in high-transmission areas and initiation of a youth program, and a $100,000 budget permits comprehensive programs for high-transmission areas, sex education for youth, and improved STD services in health facilities.
Integration and sustainability.
HIV/AIDS prevention and control programs in developing countries are increasingly moving toward an integrated approach involving government, nongovernmental organizations, the private sector, and traditional medical practitioners in the cooperative delivery of comprehensive health services. In the African context, health issues such as tuberculosis, sexually transmitted diseases, prevention of infertility, antenatal care, family planning, and even child survival may provide a better entry point for HIV prevention than HIV/AIDS alone. In sub-Saharan Africa, integrated district-level programs can both address the problem of declining health budgets and strengthen district management. District-level administrators are more sensitive than the central government to the needs of local people and in a better position to encourage intersectoral cooperation. However, the cost-effectiveness of district-level AIDS programs demands the conceptualization of a way to realize maximum benefits from minimum resources. Equally important to program sustainability are the involvement of local communities and the mobilization of their resources. Sustainability depends on how well the knowledge, attitudes, practices, and technology introduced through the AIDS program take root in the district and facilitate community participation. This chapter concludes with a checklist for AIDS program managers on factors conducive to program sustainability.
United Nations Population Fund (UNFPA) program activities during 1996 were strengthened by the implementation of a new resource allocation approach based on progress in achieving the goals established at the 1994 International Conference on Population and Development (ICPD). In 1996, the 27 Group A countries (those most in need of assistance to reach ICPD goals) received 73.7% of total allocations. In terms of program areas, reproductive health activities received 71% of total allocations, population and development strategies accounted for another 18%, and advocacy was allotted 11%. The country programming process was accompanied by management reviews to streamline operations and strengthen program delivery, to improve the coordination of activities under the Fund's decentralized programming approach, and to compile a comprehensive set of guidelines and policies covering areas such as programs, administration, procurement, personnel, staff development, and financial issues. Total contributions in 1996 reached a new high of US $302.5 million, pledged by 95 governments, while total income generated through multi-bilateral arrangements was $18.3 million. Program priorities included reproductive health (including family planning and sexual health), adolescent reproductive health, female genital mutilation, HIV/AIDS, population and development strategies, advocacy, and women's empowerment and gender issues.
The International Planned Parenthood Federation (IPPF), the world's leading voluntary family health care organization, seeks to promote and provide sexual/reproductive health and family planning services and to develop public support for sustainable population, environment, and development policies. This annual report reviews program activities and highlights of 1995-96 in Africa, the Arab countries, east/southeastern Asia and Oceania, Europe, south Asia, and the western hemisphere. In 1995, IPPF's total income was US $125,014,000, of which $83,248,000 represented unrestricted income from governments. Also presented in this report are brief special reports on female genital mutilation in Kenya, the over-reliance on induced abortion in Russia, adolescent sexual health in Indonesia, a Girl Child Project in Pakistan, Iraq's Family Planning Association, and working with voodoo priests in Haiti.
Women and HIV: a time for change.
A large number of women who become infected with HIV through heterosexual transmission are married or in committed relationships. An analysis of more than 300 televised public service announcements (PSAs) from 36 countries revealed that women are being denied the information they need to protect themselves from HIV. Half the PSAs analyzed did not include any women, even in country settings where as many women as men were HIV-infected. Moreover, the PSAs featured twice as many male as female authorities, 3 times as many male celebrities, and 10 times as many male narrators. When women were depicted, it was in a care-giving role as wife, mother, or friend of someone with AIDS or as commercial sex workers. By directing PSAs at men, television is reinforcing men's traditional role as the sole sexual decision maker. Both men and women equate condom use with sex with casual partners. PSAs are failing to address women's tendency to believe and trust their regular sexual partners and neglecting the need to teach women how to ask the right questions to assess their personal risk. Recommended are AIDS-related PSAs specifically for women focused on effective partner communication. Educational messages could demonstrate how to use humor to bring up sensitive topics, how to question men directly rather than indirectly about their health, and how to be assertive in ways that enhance rather than threaten relationships. The premise that a woman has the right to take care of herself and to communicate this to others must be conveyed.
A comparative trial of labor induction with misoprostol versus oxytocin.
A study conducted at the Hospital Loayza in Lima, Peru, compared the efficacy and safety of intravaginal misoprostol (50 mcg every 4 hours) and continuous intravenous oxytocin in cervical ripening and the induction of labor. Enrolled were 120 pregnant women who required labor induction but had no known obstetric complications. Labor was considered successful if vaginal delivery occurred within 24 hours of initiation of misoprostol or oxytocin administration. The interval between induction initiation and vaginal delivery was significantly shorter in the oxytocin group (8.4 +or- 4.1 hours) than in the misoprostol group (11.3 +or- 6.9 hours). Labor induction was successful in 45 of the 57 women (78.9%) in the misoprostol group compared with only 37 of the 63 women (58.7%) in the oxytocin group. 12 women (21.1%) in the misoprostol group, but only 5 (7.9%) in the oxytocin group, suffered intrapartum complications (e.g., hyperstimulation, fetal distress, tachysystole). There were no significant differences in Apgar scores or neonatal weight. The induction cost was lower in the misoprostol group (1 tablet cost US $1 and most women required only half a tablet) than the oxytocin group ($25). This study corroborates previous findings that misoprostol is a good alternative in developing countries for avoiding cesarean section when an unsuccessful labor induction with oxytocin occurs.
Is the fetus safe when spermicides fail?
Studies of the association between vaginal spermicides and adverse fetal outcomes have produced conflicting results. Meta-analysis allows data from different studies to be combined so that appropriate statistical power can be achieved. Nine studies investigating teratogenicity met the inclusion criteria. The Mantel-Haenszel summary odds ratio was 1.02 (95% confidence interval, 0.78-1.32), suggesting that maternal use of spermicides is not associated with fetal malformations or any other adverse fetal outcomes. Meta-analysis is recommended as the standard for evaluating reproductive outcomes after exposure to drugs, chemicals, radiation, and infections during pregnancy.
Use of volatile anesthetic agents such as halothane, enflurane, and isoflurane during first-trimester suction curettage abortion had been associated with increased bleeding due to depressed myometrial activity. In a comparative study conducted in the UK, 44 abortion patients were randomly assigned to receive either propofol induction followed by standard propofol infusion or propofol induction followed by maintenance with 1% isoflurane. Blood loss was estimated by atomic absorption spectrometry. Mean blood loss was significantly lower (p = 0.0011) in the propofol group (18.8 ml) than in the isoflurane group (40.4 ml). Although total blood loss was relatively low in both groups in this study, there may be more significant clinical implications for hemorrhage during third-trimester cesarean section under general anesthesia.
Laparoscopic tubal anastomosis.
A retrospective evaluation of 22 cases of laparoscopic tubal anastomosis performed during 1987-91 identified factors associated with subsequent conception. The 2-stitch method of Swolin was used as a model in the first 20 cases. The average operating time was 150 minutes (range, 65-240 minutes); there were no intraoperative or postoperative complications. Anastomosis was deemed impossible and abandoned in 2 cases; 5 women were lost to follow-up. The intrauterine pregnancy rate was 35% (6/17); there were also 3 ectopic pregnancies (18%). 3 women had more than 1 pregnancy. 3 women who did not conceive after 6 months underwent subsequent laparotomy anastomosis and 2 eventually did conceive. 2 of the 3 women with segmental tubal occlusion secondary to pelvic inflammatory disease conceived. Pregnancy occurred in 5 of the 14 women who had tubal ligation. Conception occurred in 3 of the 7 women with balloon cannulation, 3 of 9 with distal stents, 1 of 2 with laparoscopically placed stents, and none of the 4 women who had tubal cannulation by hysteroscopically placed double-pigtail stents. This series suggests that a 2-stitch technique is not adequate for sterilization reversal. Recommended, to enhance the likelihood of conception, is placement of a double-lumen balloon catheter into the peritoneal cavity through the original intraumbilical laparoscopic incision adjacent to and beneath the laparoscopic trocar sleeve.
Cervical cerclage in the treatment of cervical incompetence in Zambian women.
A prospective study conducted among 207 pregnant women at Nkana and Wusikili Mine Hospitals in Kitwe, Zambia, during 1989-94 indicated that McDonald's cervical cerclage is effective in the treatment of cervical incompetence. All patients had a history of 2 or more midtrimester spontaneous abortions with indications of cervical incompetence. Cervical cerclage was performed before 18 weeks of gestation in 129 women (62%) and at 18 weeks or later in the remaining 78 women (38%). Cerclage sutures were removed at 35-36 weeks' gestation or whenever labor became established. The overall success rate was 90.8%, including 159 full-term pregnancies (76.8%), 29 premature deliveries (14%), and 19 abortions (9.2%). Mean gestational age at delivery was 34.5 +or- 10.9 weeks. There were significantly more abortions in the group of women who had cerclage performed before 18 weeks compared with those who had the procedure at a later point in pregnancy (13.1% versus 2.5%, respectively). The post-cerclage survival rate was 87.4% and the overall fetal salvage ratio was 1.68. The most frequent complications were uterine contractions and rupture of the membranes. These findings confirm earlier recommendations that cervical cerclage is most effective when performed at 20-24 weeks' gestation.
Complications of cervical cerclage in rural areas.
A retrospective review of 16 cervical cerclage procedures involving 13 women treated for cervical incompetence at a rural hospital in Central Tanzania during 1990-95 suggests that the high rate of maternal complications associated with this procedure contraindicates its use in remote rural areas. All study subjects had a history of 2 or more late spontaneous abortions or very premature births. Cervical cerclage was performed at 16-20 weeks of gestation. There were 10 live births (62.5%) in this series. 7 women delivered after 37 weeks' gestation and preterm deliveries (including 6 stillbirths) occurred in 9 women. 2 of the stillbirths occurred a week after cerclage. 11 women went into labor before the cerclage could be removed, resulting in 4 cases of severe lacerations of the cervix and 1 case of uterine rupture. Another woman arrived at the hospital in hypovolemic shock due to severe blood loss. In Tanzania, only 45% of the rural population lives within 5 km of a facility that offers antenatal care and half of deliveries occur at home without a trained attendant. Delay in reaching the hospital in cases of preterm delivery with the cerclage still intact could lead to life-threatening maternal complications.
Maternal mortality due to obstructed labor.
An analysis of 36 maternal deaths due to obstructed labor indicates the impact of young maternal age on obstructed labor. These 36 deaths were among the 95 maternal deaths recorded at Mansa General Hospital in Zambia from August 1, 1993, to July 31, 1995. In 89% of cases of obstructed labor, the main cause was cephalopelvic disproportion. 28 women (78%) who died as a result of obstructed labor had used herbal medicines provided by traditional birth attendants to strengthen contractions and accelerate labor. At admission, 29 (81%) had uterine rupture, 26 (72%) had sepsis, 21 (58%) were in shock, and 14 (39%) had acute anemia. The major cause of death was sepsis due to prolonged labor and uterine rupture. Maternal mortality was associated with labor exceeding 48 hours, use of traditional herbs, and uterine rupture. In addition, 15 (42%) of the maternal deaths due to obstructed labor involved women under 20 years old, 7 (19%) involved women 20-24 years old, and 8 (22%) were to women 25-29 years of age. Parity was also a significant risk factor; 16 maternal deaths (44%) involved nulliparous women. Reduced distance to antenatal and delivery services, regulation of the practices of traditional birth attendants, and increases in the age at marriage would improve maternal outcomes in Zambia.
Neonatal respiratory distress syndrome in Karachi: some epidemiological considerations.
A prospective study of the prevalence of respiratory distress syndrome (RDS) among newborns at the Aga Khan University Hospital in Karachi, Pakistan, revealed that this syndrome, also known as hyaline membrane disease, is a significant cause of morbidity and mortality in preterm infants. In the period January 1987 to December 1993, there were 10,134 births and 2003 admissions to the hospital's Neonatal Intensive Care Unit, of which 599 were primarily because of neonatal respiratory distress. 127 of these infants had a radiologic evidence and blood gas parameters indicative of RDS, giving an overall RDS prevalence of 12.1 cases per 1000 births in this cohort. The overall prevalence of RDS among low-birth-weight (2500 grams or under) infants was 12.8%. By birth weight category, the percentage of infants with RDS was as follows: 1000 grams or under, 25%; 1001-1500 grams, 51%; 1501-2500 grams, 45%; and over 2500 grams, 6%. The most common clinical features and complications among infants with RDS included cyanosis at presentation (76%), acidotic at admission (61%), grunting at presentation (59%), apneic since birth (28%), hypothermic at admission (27%), and patent ductus arteriosus (21%). Maternal risk factors included pregnancy-induced hypertension (28%), antepartum hemorrhage (21%), intrauterine growth retardation (17%), diabetes (5%), and prolonged rupture of the membranes (16%). There were 47 deaths among infants with RDS (39% mortality rate); the highest mortality (68%) was recorded among infants weighing 1000 grams or less at birth. The 1.2% RDS prevalence rate identified in this study is comparable to that in Western countries.
The female condom (Femidom) -- a study of user acceptability.
A study of the acceptability of the female condom (Femidom) conducted among 52 nurses, secretaries, doctors, and domestic workers at Groote Schuur and Somerset Hospitals in Cape Town, South Africa, indicated that initial resistance to this device can be overcome with practice. Although the intent was to enroll 100 study participants, many hospital employees declined participation because they found the female condom unappealing or did not think their male partner would cooperate. The mean age of study participants was 30.51 years; half were married. Although each participant was provided with 10 female condoms, only 23 used their entire supply. The major reasons given for discontinuing Femidon use were opposition from husband or male partner (18 women) and device-related factors (e.g., it was uncomfortable, clumsy/difficult to insert, intrusive) (13 women). Overall, 27 women (51.9%) reported sex was the same or better with the device and 34 (65.4%) rated Femidom as acceptable or very acceptable. 26 women (50%) and 23 male partners (44.2%) reported Femidom was as good or better than the male condom. Complaints that the device was aesthetically unappealing, clumsy, and difficult to insert were reduced with practice. The female condom is most suitable for women who are not in a stable or monogamous relationship and want protection against sexually transmitted diseases that is within their control. Perfect use of the Femidom may reduce the annual risk of acquiring HIV by more than 90% in women with an infected male partner who will not use the male condom.
Oral contraception and smoking. Time trends for a risk behaviour in Finland.
The findings of three national postal surveys conducted in Finland during 1975-93 suggest that current medical guidelines that cigarette smoking is an absolute contraindication for oral contraceptive (OC) use in women over 30 years of age and a relative contraindication in younger women are not being followed. The data were collected through the biannual Adolescent Health and Lifestyle Survey of 16- and 18-year-old girls conducted during 1981-93, annual surveys of 20-39 year old women conducted by the National Public Health Institute during 1978-93, and data from the 1975 Finnish Twin Cohort Study of 20-39 year old twins. The data indicate OC use sharply increased among adolescents and women younger than 30 in Finland during the 1980s. Smoking increased among adolescents through the 1980s, but decreased slightly among women under 30 years old. Between 1981 and 1993, OC use rose from 7% to 17% among 16-year-olds and from 22% to 38% among 18-year-olds. Among adult women, OC use rates for 20-24 year olds, 25-29 year olds, and 30-34 year olds were 21%, 15%, and 12%, respectively, in 1975 and 49%, 36%, and 18%, respectively, during 1990-93. The prevalence of smoking was 23-27% in the various age groups. The proportion of women combining OC use with smoking has increased over time among women under 30 years of age. Between 1981 and 1993, this rate rose from 3% to 9% among 16-year-olds and from 9% to 13% among 18-year-olds. From 1975 to 1993, combined OC use and smoking increased from 9% to 13% among 20-24 year olds, 6% to 9% among 25-29 year olds, and remained constant at 4% among 30-34 year olds and at 3% among 35-39 year olds. Of concern is a trend for both OC use and smoking to begin at ever-younger ages, thereby increasing the lifetime duration of combined use and potentially increasing cardiovascular risks.
A WHO collaborative study of maternal anthropometry and pregnancy outcomes.
To assess the degree to which maternal anthropometric measurements predict maternal and fetal outcomes, the World Health Organization (WHO) conducted a meta-analysis of 25 studies from 20 developed and developing countries covering more than 111,000 births. Effect size for each of 5 indicators was expressed as an odds ratio (OR) based on the frequency of the outcome occurring in the lowest quartile of the indicator distribution compared with that occurring in the highest quartile. Attained weight indicators from pre-pregnancy through 9 lunar months demonstrated high ORs for both low birth weight (LBW) and intrauterine growth retardation (IUGR); most LBW reported is due to IUGR rather than to preterm birth (PTB). The strongest effect size (OR, 4.0) was provided by attained weight at 24-28 weeks of gestation for IUGR when applied to women of below-average pre-pregnancy weight. This suggests that weights taken at pre- or early pregnancy and 5 or 7 lunar months are useful indicators of LBW and IUGR; their ability to predict PTB is limited, however. Neither maternal height nor arm circumference were effective indicators for any of the fetal outcomes analyzed. The ability of study indicators to predict the 3 maternal outcomes was weaker. Maternal height as a predictor of assisted delivery showed the highest positive OR (1.6), but did not meet the screening criteria. These findings suggest a single measurement of attained weight at 16-20 or 24-28 weeks is the most practical screening instrument for LBW and IUGR in most primary health care settings. At this stage of pregnancy, however, identification of IUGR may not allow sufficient time for fetal growth to be improved by food supplementation.
Failure of the abdominal skin incision to heal is a major source of morbidity after cesarean section. A prospective study of all 164 women undergoing cesarean section at Cumhuriyet University Hospital in Sivas, Turkey, in a 16-month period during 1995-96 evaluated the effect of the depth of subcutaneous tissue at the operative site and closure of the subcutaneous tissue on wound disruption. Women were grouped on the basis of whether they had 2 cm or less (group A, 70 women) or more than 2 cm (group B, 94 women) of subcutaneous fat and randomized to tissue closure including Camper's and Scarpa's fasciae or no closure. 7 women (10.3%) in group A had superficial wound disruption, including 4 (11.4%) in the closure subgroup and 3 (9%) in the no-closure subgroup. 17 women (18.7%) in group B had wound disruption: 5 (10.6%) in the closure subgroup and 12 (27.2%) in the no-closure subgroup. It is hypothesized that potential space in subcutaneous fat results in superficial wound disruption by increasing the risks of seroma and hematoma formation and wound infection. Routine closure of subcutaneous tissue after cesarean section is recommended for all women with more than 2 cm of subcutaneous fat to reduce the risk of wound disruption.
Natural family planning -- better prospect of contraception.
Natural family planning (NFP) provides an alternative for couples who want to regulate their fertility without use of hormonal or mechanical contraceptive methods. NFP can be used both to avoid or achieve pregnancy. Summarized, in this article, are the main NFP methods: rhythm or calendar, cervical mucus, Basal Body Temperature, and Symptothermal. These methods are based on naturally occurring signs and symptoms of the fertile and infertile phases of the menstrual cycle. Effective use of NFP requires a higher degree of motivation on the part of both partners, couple communication, and discipline than other family planning methods due to the need for daily record keeping and a period of sexual abstinence. The method further requires detailed instruction by trained NFP teachers. NFP methods have a theoretical failure rate of 1-5%, depending on the method, but this rate is increased by user failure. Implementation of NFP services should include planning addressing the needs of the community, individual services to be offered, available resources, the infrastructure for service delivery, and cultural factors.
Global warming and developing countries. The possibility of a solution by accelerating development.
Economic development in developing countries may occur without impacting global warming worldwide. The proposed model assumes technology transfers, rapid economic growth, energy conservation in all countries, carbon taxes on all developed economies (including China's in the near future), and declines in the growth of energy demand. The growth rate of population and the economy are treated as endogenous (not independent of each other) variables. The model provides a business as usual (BAU) simulation and a sustainable development (SUSD) one. The analysis relies on 7 regional models of gross domestic product (GDP), population, energy demand, and carbon dioxide (CO2) emissions during 1990, 2000, 2010, 2030, 2050, 2070, and 2100. Final energy demand is given for each form of energy, and, separately, for iron/steel manufacturing and vehicle transportation. Fossil fuel mix is determined by the development stage and relative prices. Energy prices reflect the resource/price ratio and other factors. Four development stages characterize changes in the industrial structure, economic growth rate, population growth rate, and energy use. The model considers the options for energy conservation, the demand for arable land to produce grain and biomass, and energy supply/demand and the role of price. The BAU scenario results show a population of 11.7 billion in 2100, GDP growth of 2.5% and 2.0% in the first and second halves of the century, crude steel production of 221 kg/person, and a shift in mid-2100 to coal and renewables. CO2 emissions will be 18.9 billion tons. Temperature will increase about 2 degrees. Arable land needs will be 2.9 billion hectares. Grain production is assumed to increase by 0.2% per year under BAU and SUSD. The SUSD model results in a world population in 2100 of 9.9 billion, 2.2% growth in GDP, solid fuel declines, 23% lower primary energy demands than BAU, and 9.9 billion tons of emitted CO2.
Desertification: its human costs.
This article discusses some causes and costs of desertification. The spatial effects of desertification are particularly severe in Africa. The UN estimated that in 1991 desertification occurred in 74% of Africa's rangeland, 61% of rain-fed cropland, and 18% of irrigated land. The UN estimated that in 1986 almost 170 million rural people (33% of Africa's population) were directly affected by desertification in the Sudano-Sahel, Mediterranean Africa, and areas south of the Sudano-Sahel. Management practices may determine the extent to which drought and dessication lead to desertification. The human causes include overcultivation, overgrazing, irrigation, deforestation, soil erosion, and other patterns, including land tenure, poverty, public policies, and civil conflict. Desertification is a product of long-term, global climatic changes; short-term, regional climatic variability; and short-term local human actions. Desertification leads to reduced crop yields, which lead to lower income and eventually to hunger, malnutrition, starvation, high infant mortality, and rural migration. The effects of the great drought in the early 1970s in the Sudano-Sahel were over 250,000 deaths and mass migrations to urban areas. The effects of the drought and civil conflict in 1982-85 were 1 million deaths. The drought in 1991-92 affected spatially almost 700 million hectares or 1.7 billion acres of land. Annual losses from soil erosion in Madagascar amount to about $100-150/hectare, or 50-100% of average annual income. When fuelwood is unavailable, dry dung is used, and the soil becomes less fertile. The hardships of women include longer distances to travel for fuelwood, which were an estimated 250-300 working days per year in Tanzania. Disease, displacement, loss of livelihood, and social unrest are other effects of desertification. There should be sustainable development in African drylands that places traditional communities of herders and farmers in the center of the process.
Sex preference versus number preference: the case of Korea.
The author argues that the effect of sex preference must be disentangled from the effect of number preference in Korea. This study tests--with hazard models--the effect of the number of previous children on the next birth according to the sex composition of previous children. Data were obtained from the 1974 Korean Fertility Survey. This paper also analyzes the timing of childbearing in recent periods in order to determine whether replacement-level fertility is temporary or permanent. The ideal number of children declined from 3.9 children in 1965 to 2.1 in 1991. The age-specific fertility rates for ages 20-24 years declined rapidly during the late 1980s. The fertility rates among women aged 25-29 years and 30-34 years increased during 1985-90. The proportion of fertility among women aged 20-29 years increased from 67.9% in 1975 to 86.6% in 1984. Women born in the late baby boom period of the late 1950s to mid-1960s reached prime reproductive age during the late 1980s and 1990s, but the crude birth rate remained about the same during 1985-92. A higher percentage of women (22.4%) born during 1955-59 remained single in 1990. During 1960-90, the percentage of women aged 20-24 years who were married declined. These trends indicate later age at childbearing and an explanation for the temporary nature of below-replacement fertility in the late 1980s. Korean women did not want to have more than 2 children, and the interval between first and second births increased since 1985. Among pregnancies of parity 2 conceived since 1985, over 90% of women with at least one son ended subsequent pregnancies by abortion compared to only 59% without sons. Hazard models of 1974 data reveal that son preference had an important effect on fertility. Fertility was higher among women with only daughters. Findings suggest that the value of sons must be measured at the societal and not at the individual level.
An international labour migration to developing countries in Asia: a case study of Korea.
This study is based on a random sample of 431 temporary migrant workers from developing countries in Korea. Interviews were conducted from mid-October 1995 to mid-March 1996 with 105 Pakistanis, 77 Filipinos, 71 Sri Lankans, 67 Bangladeshi, 40 Indonesians, 26 individuals from Myanmar, 22 Chinese, 16 Nepalese, 2 Iranians, 2 Kazakstanians, 1 Malaysian, 1 Vietnamese, and 1 Ghanaian. Migration follows legal and illegal patterns. Legal trainee migrants leave before their contract time due to low pay, inadequate living conditions, forced overtime work, and lack of freedom. Trainees tend to be ethnic Koreans born in China and Chinese nationals. The number of illegal migrants is increasing. Foreign workers gain entry illegally through smuggling networks and legally through industrial work or tourist visas. Sample data reveal that the average age ranged from 26 to 32 years. Almost 70% were unmarried, and most were males. Filipinos tended to be older and show gender and marital balance. Age, marital status, religion, and education varied widely by ethnic group. Indonesians and Sri Lankans had lower household income than Pakistanis and Filipinos. Pakistanis tended to come from larger families. Total travel costs ranged from $3000 to $5000. Korea is one of four rapidly developing countries that shifted from being a major exporter of labor to a major importer of workers. Shortages of workers accompanied the shift. This case study illustrates that the traditional structural paradigm does not explain some unique features of international labor migration (ILM) in Asia, including the encouragement of illegal migration. The clandestine networks are different from those in developed countries. State policies mediate the flow of ILM.
Are megacities viable? A cautionary tale from Mexico City.
This article describes the poor environmental and living conditions in Mexico City due to its huge size. Mexico City's size is a challenge to sustainability, and the outcome is unknown. Mexico City and the geographic basin surrounding it included about 18.5 million population in 1995. The basin and surrounding volcanic ranges include nine major environmental zones. Urban growth followed four stages. Different cultures applied different solutions to water supply problems. The basin shifted from self-sufficiency to reliance on 31% of supplies from external watersheds. The water table is declining and canals are polluted. Irrigated agriculture is disappearing. There is an average water deficit of over 800 million cubic meters per year. Mexico City is actually sinking due to groundwater exploitation. There is bacterial contamination of wells due to improper seals. About 75% of the population has access to wastewater treatment and sanitation, but sewage treatment plants operate at under 50% efficiency and treat only about 7% of the total wastewater. Atmospheric pollution from suspended particles has been a problem for decades. Ozone was the most significant air contaminant in 1994. Lead was the most harmful pollutant in 1986. Air pollutants may be the source of submucosal inflammations. Industrial areas are contaminated with suspended particles and sulfur dioxide. High traffic areas have high carbon monoxide levels. Atmospheric pollution has affected the quality of the rainwater. The city survives by importing food, energy, wood, water, building materials, and other products. The development model aims to improve quality of life. The city has been the center of political power since Aztec times, and its preeminent position forces government action. The author concludes that there are limits to urbanization, which the city is approaching rapidly.
This study examines life patterns among women living in squatter settlements ("gecekondu") or apartments in Ankara, Turkey. Most people living in squatter housing were rural migrants. Most apartment housing was occupied by the lower middle class. The study relies on participant observation, formal and informal interviews, journals, photographs, and grounded theory to determine significant themes. The squatter study site of Cukurca was settled in the 1960s on the slopes of a hill south of the city. Paths connected detached houses, which had access to electricity and city water. Housing was not connected to a sewage system. A paved road connected people to the city. Economic status varied. The apartment study area of Bagcilar was situated a 20-minute walk away from Cukurca. Roads were under construction. Buildings had access to electricity, water, transportation, and stores. The quality of housing was low. Most women were not engaged in waged labor. The areas between houses in the squatter settlement were used for vegetable gardens and other intensive uses. Women gathered outdoors to converse and work on needle crafts and gardening. The women were very social and there was intimacy and companionship. The larger community negatively evaluated squatter communities. Women who were oriented to modern urban life dressed better and paid attention to outward appearances at all times. Other women only changed their attire when outside the squatter settlements. The women valued neighborliness in either settlement, but apartment living created more formal relations between women due to the lack of common space and residential heterogeneity. Home privacy was greater, and parents had greater control over child rearing. A move to an apartment signaled progress toward a better social status. This study revealed the active role women had in shaping their home environments and, for migrant women, ways of adapting to a new environment.
Sex differences in mortality among young children in the Sahel.
This study examines sex differences in early child mortality in Mali, Burkina Faso, and Senegal. Data were obtained from EMIS surveys conducted in Bamako (Mali) and Bobo-Dioulasso (Burkina Faso) and in the rural areas of Fissel and Thienaba (Thies region of Senegal) during 1981-85. The surveys were of a cohort of children born to mothers during a one-year period in the early 1980s. The author reviews prior research on the biological causes of death; the reasons for differential treatment by gender; and demographic, socioeconomic, and cultural factors. Empirical findings confirm the general trends of declining risks of mortality in the first few months of life and increased risks after 5 months. Mortality peaked at around 10-12 months and declined until about age 20 months, after which it rose again. Children in Bamako faced the lowest risks; those in rural Senegal faced the highest. There were no significant differences between male and female mortality risks for the age span of 1-23 months. Excess female and male child mortality was evident in smaller age groups. Excess female mortality was significantly higher among children aged 1-8 months in rural Senegal and among children aged 6-15 months in the combined urban areas of Bamako and Bobo-Dioulasso. Excess male mortality occurred among children aged 16-23 months in Bamako. It is argued that the smaller age groups take advantage of the variation in mortality by sex. Findings in Bamako of excess female child mortality confirm earlier available reports. The analysis reveals that there were no gender differences by cause of death, access to health care or nutrition, or socioeconomic or demographic factors in any areas or age group. Ethnic affiliation was the most important determinant of mortality levels and changes by gender across small age groups. Sample selectivity probably did not greatly affect results.
This study examines the influence of women's status in the household on family size and use of family planning in rural Kenya. The study relies on the theoretical framework of power relations of Lappe and Schurman (1990). The structure of decision-making power within the family, village, community, national governments, and international institutions influences the choices open to people. The power structure refers to the rules that determine who is allowed to participate in decision-making processes and how their views are part of the final decision. The study sample includes three ethnic groups: the Abaluhya of Sabatia region, Vihiga district; the Abagusii of Nyamachee division, Kisii district; and the Masai of Kilgoris division, Narok district. The random sample includes 200 currently married women aged 15-49 years among each ethnic group. Analysis is based on participant observation, interviews, and in-depth focus groups among selected women and elderly key informants. Findings indicate that 47.7% had high status, 40.5% had moderate status, and 14.5% had low status. The mean number of children was 4.5. The mean number of children was 4.1 for wives with high status, 4.4 for wives with moderate status, and 5.8 for wives with low status. This childbearing pattern applied in general and for both the Abagusii and Abaluhya ethnic groups. Among the Masai, women had the same number of children regardless of their position. Findings suggest that wives' participation in decision making about family size, family planning, and management of income is likely to have a dampening effect on fertility. Wives participation in income generation activities improved their status and self-confidence. The results suggest that married women's status is not static, unified, and unchanging, but flexible, modified continually, and reinterpreted in an adaptive process.
Mississippi selected facts about teenage pregnancy.
This article describes trends in adolescent pregnancy in Mississippi during 1994 and compares the rates of teenage pregnancy by race among the 10 US states with the highest adolescent birth rates in 1992. In 1994, 22% (9265 births) of all births (41,938 births) were to adolescent mothers, of which 32% were second or subsequent births. 80% of adolescent mothers were unmarried, and about 44% were under 17 years of age. About 85% of adolescent pregnancies resulted in births. Mississippi leads the nation in the percentage of births to teenagers. Other states with high teenage birth rates were Arizona, New Mexico, Texas, Louisiana, Arkansas, Georgia, California, Alabama, Nevada, and Tennessee. States that ranked high on Black teen births had only 15% or fewer Blacks in the state total population. In Mississippi, 36% of the population is Black, and it ranked 20th in birth rates among Black teens. The highest teen birth rate was in Wisconsin among Blacks and in Arizona among Whites. In Mississippi, the number of teen births declined from 11,089 in 1992 to 10,802 in 1994. Mississippi teen births, as a percentage of all births during 1974-94, mostly followed the national trends. Mississippi teen births have declined since 1987. The number of births to unmarried teens remained constant, but the proportion of unmarried teen births increased from 46.7% in 1974 to 79.7% in 1994. Births have tripled among unmarried White teens in the past 20 years and have only slightly increased among unmarried Black teens. In 1994, teen mothers were 74.0% more likely to experience an infant death than adult mothers. The infant mortality rate in 1994 was 16.7 deaths/1000 live births among mothers aged under 20 years. Low birth weight (LBW) among teen births followed the same pattern, but it was not as severe. The LBW rate for teens was 122.2/1000, compared to 91.9/1000 for adults.
Spousal agreement, women's status and family planning in Nigeria.
This study examines how spousal agreement affects fertility and the use of family planning among five ethnic groups in Nigeria. It is assumed that women's power in decision making is derived from membership in the ethnic group and conditioned by education, employment, and income. The aim is to show how social context shapes and constrains marital interactions and to evaluate Beckman's thesis that couples with consensus are more effective in establishing reproductive preferences. Data were obtained from a 1991 survey among the Hausa, Ibo, Ijaw, Kanuri, and Yoruba ethnic groups. All five ethnic groups have a strong patriarchal structure, but the Kanuri and Hausa are more gender restrictive. The study examines spousal agreement on demand for children, spousal communication, wife's input concerning family size, and the use of family planning. Controls include number of children, current pregnancy status, polygyny status, and area of residence. Findings indicate that in the pooled sample 42.9% of spouses agreed that they wanted more children. 56.2% agreed that they had talked about family planning in the past year, 35.4% agreed that the wife had no input concerning family size, and 32.5% agreed that the wife had some input concerning family size. Kanuri spouses were more likely to agree on God's will (28.4%) when it comes to demand for children. Never talking about family planning ranged from 78.3% among the Kanuri to 27.3% among the Ibo. Findings indicate that the Ibo, Ijaw, and Yoruba were open to family planning, while the Kanuri and Hausa were resistant. Husbands' secondary education had a stronger impact on family planning than wives' education. Wives' power, expressed as ethnic membership, had an important effect on family planning. Only work before marriage increased spousal agreement on family planning. These findings have implications for how to approach family planning use among ethnic groups in Nigeria.
Family planning among rural Moslem women in Israel.
This study examines contraceptive usage and sources of information on family planning among a sample of 429 Arab Muslim women who had given birth and were living in villages in Galilee and central districts of Israel. Interviews were conducted during August 1988 to April 1989. Findings indicate that 34% of women did not use any form of contraception. 28% relied on traditional methods and 37% used modern methods. 45% of users relied on the IUD. The diaphragm was the least popular method. 91% had received information on family planning. 52.8% had received contraceptive information from a nurse at a family health care center and 50.0% had heard about contraception via the radio or television. 38.7% had discussed family planning with a doctor at a family health care center. 32.5% had talked with friends and 37.9% had read written materials about family planning. 26.4% had talked to a sister or sister-in-law; 14.3% had talked to a mother or mother-in-law. Only 1.7% had approached husbands as a source of information. 23% of nonusers had never used contraception and did not intend to use any in the future. The most important objections to contraceptive use included: examination by a male physician, insufficient knowledge, side effects, religious reasons, partner's objection to pregnancy prevention, and health. The levels of contraceptive use among rural Arab women was higher than among women in other Arab countries. The type of contraceptive method preferred varied among Arab countries. It was found that rural Arab women in Israel preferred the IUD because it was provided at the family health care centers at low cost.
Women, paid-work and the family: in the Islamic Republic of Iran.
This study relies on census data, interviews, and focus groups to examine women's wage work and their position in the gender division of labor in Iran. Findings suggest that the impact of paid work on women's lives and families is complex. Women face difficulties and are disadvantaged in wage employment, but the outcome is a more enhanced position at the microlevel. Iranian women are limited in their ability to negotiate and must rely on family and their personal network to perform multiple tasks. In 1986 there were 11 million men and women employed in the formal sector, of which 50% were wage and salary employees. 9.4%, or 504,582 persons, working in wage employment were women. 80.7% of female wage employees worked for the government, and 19.3% were employed in the private sector. In 1971, and before the Islamic Revolution, there were 243,000 women employed in the private sector. By 1986 there were only 97,293 women working in the private sector for wages. The decline is in accord with the decline in the private sector's role in the economy. In 1986, 29% of men and 48% of women were illiterate. 95.9% of women working in the government sector were literate, and many had higher levels of education (one in four with a university degree). Male wage workers in the government sector had lower educational levels. Only 10% had a university degree. 52.6% of women working in the private sector were illiterate. 3.4% of women working in the private sector had a university degree. In 1986, 57.3% of wage-earning women were teachers; 10.9% were in health care occupations; and 33% worked in clerical and other low-paid jobs. Under 9% in the private sector held specialized positions, such as teachers, accountants, and office managers. All surveyed women had control over their earned income.
The purpose of this BASICS trip report was to observe the 1996 National Immunization Days (NIDs) in Kenya (first round) and in Zambia (second round). In Kenya, the aim was to improve social mobilization, logistics, and delivery and to determine what needed to be evaluated. In Zambia, the aim was to help tailor the draft process instruments for the NIDs, train staff in monitoring methods, assist in documenting the process, review and analyze second round reports, and recommend improvements in supervision. The consultant spent the first several days talking with the NID secretariats and participated in preparatory meetings at the national and district levels in Zambia during the two days preceding the NIDs. Several days during and after the NIDs were spent assisting the secretariat. In Kenya, the technical officer went to the eastern province with the KEPI national NID coordinator and participated in final planning meetings in Embu and Mwingi districts. The technical officer assisted with immunization activities in Mwingi, Embu, and Mbere districts. Key findings in this report are reported for planning, logistics, and vaccine handling; social mobilization; staffing and supervision; training; target population; process monitoring; and incentives for health workers and volunteers. In Zambia, provinces varied in the level of preparedness. All provinces had NID coordinators for managing planning and immunization activities, representative specialized committees, plans for vaccine distribution to all immunization posts, and sufficient staff. Supplies and the cold chain were adequate. Vaccine vial monitors were missing for polio vaccines. Immunization coverage in the first round ranged from 43% to 154% by district, and 20 out of 59 districts had under 70% coverage. Fuel was inadequate for deliveries due to funding shortages. Another problem was the discarding of opened, but unused, vials at the end of the day.
This BASICS report presents the outcome of a trip by two technical advisors to the meeting of the Advisory Group on Social Mobilization for Polio Eradication in the Africa Region, held in Brazzaville, Congo, during February 4-6, 1997. The aim of the meeting was to finalize the social mobilization plan for the African region and to identify the roles for participating partner organizations. The Advisory Group oversees progress on the global, regional, and national levels for social mobilization in Africa in 1997. The current strategy is to use football and sports media and celebrities and high-level political leadership to endorse the polio eradication effort. The social mobilization campaign should not forget to reach mothers at the community and national levels with regard to having their children immunized. BASICS serves an important role in the promotion of documentation of the best practices and message design and delivery from the National Immunization Days (NIDs). The report provides an executive summary, a statement of the purpose of the visit, background, specific activities, and a discussion of the potential involvement of BASICS. BASICs could have a role in coordinating a meeting/s of key social mobilization persons, facilitating the documentation of best practices, fielding country-level requests for technical assistance to support the NIDs, reviewing and developing materials, and monitoring and evaluating. It is concluded that a coordinating role between who prepares the materials and other program effort is needed for implementing the overall campaign. General messages were developed, but substrategies are still needed. Institutions need to be identified that will build on the polio NID experience to strengthen public health communication. BASICS should promote the use of social mobilization at all levels in order to sustain interest in the expanded program of immunization.
The purpose of a trip during February 1-15, 1997, was to assist the Uganda Expanded Program on Immunization (EPI) in reviewing and preparing a report on the first national polio immunization campaign. The national workshop for this activity was cancelled, so that this activity was not performed. The second aim was to develop Uganda's EPI's approach for implementing district planning and strengthening polio or acute flaccid paralysis (AFP) and other EPI disease surveillance at the district and local levels. The appendix includes a checklist for assessing capacity and for initiating a planning process on disease surveillance at the district level. This checklist was developed and field-tested by a working group. The list of priorities for the working group is included in the appendix. The priority is to involve districts in their own planning for an effective and sustainable disease surveillance system. The Uganda EPI asked BASICS for help in consolidating data collection on district assessments for developing a district guide on developing disease surveillance strategies. BASICS was also asked to develop training materials for district and health facility staff. This report includes an executive summary, a statement of the trip's purpose, background on Uganda's immunization program and disease surveillance, and observations and recommendations on polio/AFP surveillance and vitamin A. The appendices include a contact list, the expected number of AFP cases by district, notes on working group sessions, and commentary on the plans for surveillance and the EPI's management information system. The technical officer made nine recommendations and follow-up requests and opportunities. For example, it is recommended that EPI consolidate surveillance plans into one document; the National Polio Laboratory should be incorporated into the EPI program and budget.
This report discusses a trip to Senegal during April 5-18, 1997, for making improvements in the supervisory system of the Senegalese National Nutrition and Food Program (SANAS). The scope of work included developing and testing a supervisory instrument, developing a training guide, identifying trainers, training trainers, running a two-day workshop for national-level supervisors, and recommending adaptation of other existing instruments for regional and district staff. At the beginning of the visit it was determined that the scope of work was not feasible for the time allocated. Only the first objective was fulfilled. The trip involved a review of current SANAS supervisory practices and tools and sources of data for monitoring and evaluating programs. A list of key indicators was taken from BASICS program objectives, the GOS-USAID negotiated Results Package, and information needs expressed by program managers. The trip activity was hampered by the periodic absence of SANAS staff responsible for, or experienced in, supervision and of Division of Statistics staff. The technical officer recommended that the revised supervisory data collection tool included in the appendix be used to compile quarterly data from each health facility. National-level supervisors would fill out forms during district and regional visits. The instrument is a manual, paper-based one that allows collection of key data on control of diarrheal diseases and nutrition programs in a timely and periodic fashion at various levels of the health system. The instrument does not rely on central level analysis and feedback and allows for valid comparisons between districts and public health posts. The first-level supervisor has the primary responsibility for primary data analysis. The use of the instrument reinforces its value and utility and generates a respect for information. The proposed tool will require field testing.
This report presents the summary findings and tables and charts from the 1996 Madagascar Household Child Health and Nutrition Survey conducted by BASICS and the Ministry of Health and Population's (MOHP) Division of Preventive Medicine. The survey was conducted in Antsirabe II and Fianarantsoa II districts among a representative sample of 720 mothers of children aged 0-23 months. Findings are presented for population characteristics, access to and use of prenatal care, childbirth practices, vaccination practices and coverage, breast feeding and nutritional status and practices, morbidity and health practices, water and hygiene conditions, family planning use, and access to the media. The report indicates key findings and recommendations. A major finding is that MOHP prenatal care was provided in an erratic fashion to mothers. Although attendance at clinics was high, rates of coverage with tetanus toxoid, distribution of nivaguine, and distribution of iron supplements were low. Services should be improved to provide consistent and appropriate care. Findings reveal high levels of infant and child malnutrition and chronic malnutrition in both districts. Malnutrition is attributed to infant feeding and breast feeding practices. Vaccination coverage is insufficient to prevent common diseases, such as maternal and neonatal tetanus, measles, pertussis, polio, tuberculosis, or diphtheria. Mothers are not very knowledgeable about symptoms of serious common childhood diseases, such as diarrhea or acute respiratory infections, and are unaware of prevention and home-based treatments. There were demands for modern contraceptives and family planning services that were not being met. BASICS, for example, should collaborate with donors and MOHP to improve the availability, organization, and delivery of family planning services and develop a maternal IEC strategy to address malnutrition.
This trip report pertains to a visit on January 12-17, 1997, to Honduras for the purpose of working on the development and evaluation of integrated child health programs (AIN) within the Ministry of Health's (MOH) Division of Maternal and Child Health. The scope of work included a review of the results of the child feeding study and finalizing the report, a review of the draft counseling cards and assurances of the integration with the feeding study, work on the implementation guide and monitoring manual, beginning discussions about training, and a review of AIN institutional norms. The technical officer worked with Aida Maradiaga on disaggregating the data by age in order to prepare a useful analysis for interventions. It was found that there were two interventions that were feasible for mothers that would close the gap between the caloric intake needed and consumption for children aged 6-9 months. The analysis must proceed accordingly for all age groups before the final report is due on February 7, 1997. Counseling cards could not be evaluated until the analysis of data from the feeding practices study was more advanced. The discussion of the counseling guide was postponed until there were definite recommendations. Two days were spent with the AIN team and consultants Gustavo Corrales and Patricio Barriga on the implementation guide and monitoring manual. The appendix includes the outline of the agreed-upon manuals for implementation and monitoring. The appendix also includes a memo on new responsibilities, the time required, and a time line. BASICS must review consultants' work load, and MOH people must be aware of the timeline. It was proposed that BASICS support a local training consultant. Candidates were identified. Work on the institutional norms was delayed due to the lack of revisions. All the documents need to be sent to BASICS and quickly reviewed according to the timeline.
Briefing on IMCI for MOH and USAID leadership, October 1996.
This trip pertains to a visit in October 1996 to brief the Guatemala Ministry of Health and USAID on integrated management of childhood illnesses (IMCI) and the negotiation of BASICS support for the MOH Integrated Health Care System (SIAS). The 2-day trip involved briefings with officials, interviews with potential candidates for work on the MOH Integrated Community Health Care System (SIAC), and review of the scope of work. Ministry of Health officials in Guatemala were more appreciative of the role of IMCI in the total health program. Officials recognized that IMCI was not in competition with the MOH's SIAC. BASICS would develop a list of candidates for the positions for SIAS and would discuss these candidates with the SIAC team. The briefings focused on how IMCI could be adapted to Guatemala's needs and circumstances and in-depth exposure to IMCI protocol and training methods with actual exercises from training modules. The briefing included the Vice-Minister of Health, the head of the SIAS team, the PAHO epidemiologist, the USAID/Guatemala health officers, the USAID/Guatemala population program manager, the head of MotherCare in Guatemala, and others. It is recommended that further USAID and BASICS negotiations be approached with cautious optimism. BASICS should move quickly with the technical directive for SIAS and contract Dr. Fidel Arevalo and a local team. The appendices include a list of contacts, the materials used in the briefing, and the scope of work.
Workshop on IMCI orientation in Togo, Lome, Togo, April 7-12, 1997.
This BASICS trip was devoted to the conducting of an orientation workshop on Integrated Management of Childhood Illness (IMCI) in Lome, Togo, during April 7-12, 1997. The 3 days prior to the workshop were spent finalizing the agenda and developing guidelines to help child survival program managers with the presentations. The BASICS regional director in conjunction with the WHO/AFRO CDR/IMCI regional advisor conducted workshop activities and facilitated plenary sessions to bring about consensus on IMCI implementation. Togo will be implementing IMCI as one of REDSO/FHA project countries. BASICS met with Togo Ministry of Health officials. The workshop was attended by 65 persons from central and regional levels. Presentations included detailed information about IMCI, IMCI strategies and implications, implementation steps, child health status in Togo, and the coordination between child survival programs. Three working groups discussed the following issues: health system organization, referral, program coordination and financing, and donor interventions; the availability of program policy and directives, case management directives, and the availability of essential drugs; and training and supervision strategies and funding options. Each group identified problems, determined causes, and proposed solutions. Plenary and group sessions were devoted to open discussion and critiques. The workshop ended with consensus that Togo should implement IMCI. Implementation was dependent upon other donors besides BASICS, a dynamic technical committee, and the availability, leadership, and full commitment of persons involved in the implementation in Togo. An official MOH statement of commitment will be forthcoming. A technical committee should be appointed, and a timeline should be determined.
This report pertains to the field trials of recommended improved feeding practices among 56 households in Fianarantsoa II and 53 in Antsirabe II districts in Madagascar conducted during October 4-25, 1996. The aim was to find out which improved feeding practices were most acceptable to mothers and their children. Survey findings indicate that feeding practices in the two districts were similar. Most mothers were willing to try and adopt the recommendations. The following practices were recommended: exclusive breast feeding, which required an end to other solid or liquid feeding of infants aged under 4 months; breast feeding at least 10 times in 24 hours for infants aged under 6 months; breast feeding until the breasts are empty; thickening of rice porridge; enriching the child's diet with other foods; mashing the food that accompanies the child's rice meal; increasing the number of feeds; increasing the amount of food per serving; encouraging the child with a poor appetite to eat more often and giving preferred foods; and reducing sugarwater, tea, or coffee and replacing it with breast milk or nutritious foods. Mothers mentioned the lack of money to buy nutritious foods. Findings were used to draft feeding recommendations for age groups 0-6 months, 6-12 months, and 12-24 months. This report includes a description of current feeding practices, the draft feeding recommendations, findings from the household trials, and revised recommendations and suggestions on the "food box" and "counsel the mother" WHO programs. Appendices include feeding recommendations, estimated child energy consumption, the interview guide, and draft recommendations for the food box and mother counseling guides.
This report is one of 10 strategy papers prepared by BASICS consultants and produced on February 12, 1997, on the Nutrition Components of Health strategy in Zambia. The report identifies the gaps remaining in achieving program targets for a selected group of nutrition interventions. The report helps to determine priorities for USAID support. Participants in meetings on the Nutrition Components of Health strategy included representatives of the World Bank, the National Food and Nutrition Commission, WELLSTART, the Central Board of Health, UNICEF, and BASICS staff. Program interventions are based on the data that sustained health improvements in Zambia can be accomplished only with changes in the existing and extensive inappropriate practices in infant feeding. Over 40% of all child mortality is attributed to malnutrition. Only 26% of infants aged under 4 months are exclusively breast fed; this low breast-feeding rate is a contributing cause of mortality from diarrhea and acute respiratory infections. A large proportion of children are stunted, low-weight, vitamin-A-deficient, or iodine-deficient. Pregnant women are frequently anemic. The first section describes the nutrition problem, program accomplishments, government priorities, the institutional structure, and technical resources of USAID-supported agencies for nutrition. The second section identifies policy relevant issues related to the nutrition problem and summarizes the main focus of government-sponsored health and nutrition programs. The third section describes technical operations and identifies the gaps in promotion, prevention, and case management. The final section makes recommendations on priority interventions and strategies and for child health and nutrition programs and reproductive health programs. The analysis excludes the policy issues of food availability and food security.
This trip report pertains to BASICS facilitation of an Integrated Management of Childhood Illness (IMCI) course, facilitator training, and training of health workers during May 13 to June 14, 1996, in Lusaka, Zambia. The objectives were to train health workers in IMCI to prevent very high child mortality and to train workers to train other workers. The appendices include the course outline for the IMCI workshop, the course outline for the facilitators' training, the program for coordinating facilitators' training, the list of participants and facilitator groups for the workshop for trainers, and the program for trainers. A full report is included on the IMCI workshop, including objectives, observations, achievements, and recommendations. The BASICS technical officer missed the first day of the workshop due to trip formalities. Plans included visiting three outpatient clinic sites for observing clinical practice, but one site was dropped due to the low patient load. Times were rearranged at other sites. Participants were able to observe an adequate number and variety of cases for inpatient and outpatient clinical practice. The course was well received and mastered by participants. 75-100% of performance was accurate. Deficits were apparent only in the assessment of dehydration and severe malnutrition. Participants saw 417 sick children. The average number of patients seen per participant was 19.85 children. There was a need for more trained inpatient and outpatient clinic facilitators to answer technical questions. There was some confusion surrounding Zambian adaptations of IMCI and accepted international practices, such as prescribing antibiotics for chronic ear infections and timing of OPV-O, DPT-1, and DPV-1 administrations. Eight participants were selected for facilitator training to be conducted after the workshop. The facilitator training session was too short.
This trip report pertains to a visit during February 15 to March 3, 1997, to Addis Ababa and Awassa, Ethiopia. The purpose of the visit was to review and revise the junior public health nurses' curriculum, with particular attention to the community health nursing component at the Awassa Health Professionals Training Institute (HPTI) in the Southern Nations, Nationalities, and Peoples' Region (SNNPR), which receives major BASICS support. This region faces widespread infectious disease and malnutrition. Training courses occur over one academic year. The curriculum includes practical experience in the final 12 weeks of the course. The BASICS consultant visited in Awassa with staff from the Regional Health Bureau and training institutions and with representatives of nongovernmental groups operating in the region. The visit included trips to a local mission hospital, health center, and one of BASIC's focus woredas. Curriculum was discussed, and final drafts of documents were presented. The curriculum put insufficient emphasis on public or community health, partially due to the many topics covered. The consultant found the curriculum to be too ambitious for a student with no prior training and recommends a training focus on maternal and child health issues, including immunization, family planning, and pediatrics; nutrition, with an emphasis on breast feeding, malnutrition, and micronutrient deficiencies; communicable disease control; basic epidemiological skills and use of data for health decision making; and environmental health. The curriculum should provide for practical experience in shorter time segments and related to theory units. The team training experience is too open-ended. Principals of HPTI do not rearrange course components or change syllabi or time allocations, which is a constraint. There were some constraints to collaboration between the Health Ministry and nongovernmental groups.
This trip report pertains to a visit during September-December 1996 to Zambia to aid in the design and implementation of a Health Management Information System (HMIS). The HMIS development team included the BASICS consultant, the Danish International Development Agency, USAID, and the Ministry of Health's Health Reform Implementation Team (HRIT). HRIT additionally requested information technology and a draft of the procedures manual for instrumentation and collection of health indicator data. The procedures manual is still under development, and the draft is included in the appendix. The Ministry adopted the plan as policy. The team was asked to continue work through the implementation phase and scheduled start in 1997. The plan emphasized the support of reform implementation. The HRIT during the course of development became the national Central Board of Health, which operates with "decentralized, timely, action-oriented management of health care resources." The plan emphasizes monitoring and evaluation and includes an early warning indicator of when the system is not operating adequately. The system includes the facility for health systems research, sentinel surveillance, and other data collection and evaluation techniques. The plan emphasizes 70 indicators on health status, drugs and supplies, finances, assets, human resources, and systems performance, and tools for analyzing data. The plan details monthly stages of progress toward full operation by January 1, 1998. Budgets and estimates of training requirements for automation of the system are included in the plan. The plan includes a community-based system scheduled for completion by the end of 1997. The HMIS is described in the appendix.
Family Life Education Project, Busoga Diocese, Uganda: cost analysis report, January 1997.
This report presents a study of the unit cost of service delivery for a Family Life Education Project (FLEP) in Bugosa Diocese in Uganda. FLEP provides family planning services, curative services, and sexually transmitted disease (STD) treatment services. The study assesses efficiency and the impact on cost of service delivery for integrating STD and HIV infection treatment into existing family planning services. The study sites include the Nawansega Clinic and the Nasuuti Clinic. Clinics operate without laboratories. Unit costs were computed by type of service, including community-based distribution (CBD). Estimates for one clinic include the value of clerical services that were provided free of charge. Unit costs are calculated per visit and per couple-year of protection for family planning services. Costs are based on actual use of drugs and other supplies and the time it takes staff to deliver the services. Total unit costs differentiate between costs under the control of the clinic management and staff costs paid by the head office. Findings reveal that curative costs were lower per visit in Nasuuti due to the higher volume of patients and the lower average consumption of drugs. Both clinics had similar costs for clinic-based family planning services. Unit costs for maternal and child health services were higher for Nasuuti due to the higher volume of clients and the higher staff costs. Maternity cases filled in staff time during slack periods in Nawansega. CBD-FP costs were USh3106 per visit in Nawansega and USh6736 in Nasuuti. Differences were due to the low volume of clients served by village health workers in Nasuuti. These findings are constrained by actual or potential data errors. Clinics could save money through use of less expensive staff time, lower congestion of facilities, reducing duplication of record keeping, a higher volume of clients, and receipt of user fees.
This trip report pertains to a consultant's visit to the Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia to assess the planning and budgeting processes and their effect on financing of the health sector. The assessment aims to indicate how the BASICS/ESHE project can contribute to health financing initiatives in SNNPR and nationally. The consultant spent four days in Addis Ababa reviewing documents and several days in SNNPR with a team from the Ministry of Finance and Ministry of Development and Cooperation that were studying the health and education budgets as part of a USAID project. There were meetings with officials from the regional, zonal, and woreda levels. Visits were made to health facilities to observe approaches to cost recovery and community participation. It is concluded that the planning and budgeting processes are not working very well. Part of the problem is the lack of uniformity in the system and insufficient trained manpower for improved efficiency. Ineffective budgeting and inefficiencies are mainly due to gross deficits in the recurrent budget, lack of control over capital investment at the regional level, and priorities. Capital investment tends to be overbudgeted and returned to the Ministry of Finance, and service delivery suffers from shortages of funds. There is an imbalance caused by central control of finances and decentralized planning. A new health care financing strategy for Ethiopia is awaiting approval. BASICS could assist by testing some of the theoretical assumptions that the new strategy relies on. Rapid appraisal methods for assessing incomes in rural areas would be useful for assessing the ability of people to pay, particularly among the rural poor. Other revenue sources should be tested. There is a need to evaluate the currently operating cost recovery schemes. The role of the private sector in urban areas should not be ignored.
Cost effectiveness analysis of FPPS clinics, Mombassa, Nairobi, and Naivasha, Kenya, December 1996.
This report presents a study of the cost effectiveness of integrating sexually transmitted disease (STD) treatment with maternal-child health/family planning (MCH-FP) services in Kenya. The study aims to identify the potential for improving the quality of care through better cost control in family planning clinics. The study sites included the Mtongwe CMAK Clinic in Mombasa, Dagoreti MIHV Chandaria Clinic in Nairobi, and Sulmac Hospital in Naivasha. The study focused on computing the costs per user by methods of family planning for personnel, expendables, and identifiable overheads. Costs do not include the costs of commodities provided by the Ministry of Health. Visits were made to clinics to observe the data collection and client workload. Interviews were conducted with service providers. The main findings were that the "crude" average cost per client in Sulmac was twice the cost at the other two clinics. Staff costs were twice as high as in the other two clinics. Nurses were used 57.23% of the time at Sulmac, 60.27% at Dagoreti, and 5.61% at Mtongwe. The main cost of expendables was for gloves and lotion used for examinations. Procedures require a minimum order of lotion regardless of the number of clients served, and thus could be a cost-saving item. The allocation of overhead costs for family planning is unfairly distributed. The costs of STD care appear to be higher in Sulmac due to its more expensive laboratory facilities. Other sites use conventional diagnostic approaches that are cheaper. Clinic-specific reports in the appendix provide costs of staff time, materials, drugs, direct costs, and indirect costs for STD treatment and family planning. Analysis at a staff meeting found that staff time could be better spent and nurses could be trained to offer more services. There is a need to standardize procedures in service delivery. A number of questions were raised about materials use and procurement.
This trip report pertains to the participation of a BASICS official during February 22-28, 1997, at the regional seminar on health care financing in Eastern Africa. The BASICS official presented findings on country studies in equity and the impact of user fee systems on the poor. These studies were supported by BASICS. The seminar aimed to help Eritrea, Ethiopia, Kenya, Tanzania, and Uganda organize, structure, finance, and manage health services. The seminar was funded by three donors in the region (USAID/REDSO, the Economic Development Institute of the World Bank, and the WHO Regional Office for Africa). The WHO Regional Office for Africa planned the seminar. The seminar theme was how to implement health sector reform and sustainable financing by regionalizing and decentralizing health services at the regional and district levels, by improving efficiency and containing hospital costs, by fostering growth and sustainability of nongovernmental providers of health care, and by increasing access to basic health services among the poor. By the end of the seminar, it was expected that participants would be able to speak a "common language" of reform and sustainable financing, to assess how their national systems rated on the four dimensions of sustainability, to appreciate alternatives, and to understand the steps for achieving reforms. There was an emphasis on country case studies and shared experiences. Participants reviewed achievements and problems and identified small-scale pilot projects that could provide solutions. There were three outcomes of the seminar: 1) participants were more knowledgeable about the practical side of reform; 2) the seminar generated sufficient examples of pilot projects as solutions to problems; and 3) the seminar papers will be published and distributed. The appendix includes the information provided by the BASICS presenter.
Silences and choosing to hear: perceptions of violence against women.
This document summarizes the first paper presented and discussed during a session on psychosocial and historical perspectives of violence against women held during a workshop in India in 1995. This paper dealt with varying perceptions of violence which govern the acknowledgement of its existence. An attempt was made to determine if perceptual and attitudinal differences led to different treatment of victims of violence based on the sociodemographic status of the victim or on perceptions about the nature of the crime. It was found that discourse changes during treatment of a case often led to a new understanding of events. Two of the four cases presented in this session are summarized in this document. In one, a women who was continually beaten by her husband was rescued by her neighbors after he doused her with kerosene and threatened to kill her. In the other case, an abuse victim ultimately disappeared from the system without receiving help. This case indicates that abuse cases are not receiving adequate follow-up. In each case, the acts of violence were underreported either by the victim or by the agency. The two additional cases not reviewed in this document indicated how violence is viewed from a vantage point which privileges the sanctity of the family and makes it difficult to question male dominance. Discussion of the paper centered on such issues as the need to create definitions of "violence" and "victim," the role of social expectations as a basis for action, double standards, women's status, cultural violence, staff training needs, and mental violence. The ultimate question was whether to place responsibility on the victim, the agencies designed to help victims, or on society.
Psychologising dissent: psychiatric labelling and control.
This document summarizes the second presentation in a session on psychosocial and historical perspectives of violence against women held during a workshop in India in 1995. This presentation stressed the difficulties in counseling abuse victims. Counselors must avoid the pitfalls of "psychologizing" which may lead them to view a real account as delusionary, hide their inability to handle a situation, or address the symptom and not the cause of the problem. Psychologizing may allow society to convince itself that a crime has not occurred. This occurred in the case of a young married woman who was poisoned. After two courts sentenced the husband to death, the Supreme Court reinterpreted the evidence and decided that the wife committed suicide. How a case is labeled has a great deal to do with how it is examined, analyzed, and decided. Labeling can lead to disempowerment for women, and it is rarely acknowledged that many situations lead to the legal category of mental unsoundness. Discussion centered on the fact that the legal system will remain inadequate as long as seeking counseling can be held against a woman.
They wanted to die: women, kinsmen and the partition of India.
This document summarizes the third and last presentation in a session on psychosocial and historical perspectives of violence against women held during a workshop in India in 1995. This session provided a historical analysis of how women experienced violence associated with the partition of India in 1947. In these cases women were subjected to violence at the hands of their own kin as men killed their women relatives to protect their notion of individual, community, and national honor. This occurrence was illustrated with three cases. In the first, a young girl overheard her male kin plan to burn her and her female kin to death. Her response was to try to enjoy what life she had left as much as possible (she survived). In another case, all of the women in a family were encouraged to poison themselves or jump into the river when the family was attacked. Some of the women were killed outright by their male kin. A third case involved a man who claimed to have killed 50 women, starting with his wife. He relayed that the women insisted that they be killed rather than fall into the hands of the Muslims. This violent resolution to a problem is part of a continuum of violence created by a patriarchal consensus which seeks to control women's sexuality and achieve their silence. Thus, cases of women who committed suicide during the Partition are held up as examples of valor. Discussion of this presentation included women's insistence on victimhood, patriarchy, and the designation of women as the sexual property of men.
Sexually transmitted Ureaplasma urealyticum, Mycoplasma hominis, and Chlamydia trachomatis infection was examined in young women under the age of 30 years. The screening was done in high schools, vocational schools, and among primigravidas in Budapest. The specimens were taken by a swab from the cervical canal and were sent for laboratory processing to the National Dermatological and Venereological Institute and the Capitol State Public Health Service. 46% of the 400 women screened (including 86 primigravidas) were infected and 52.3% of the pregnant women were similarly infected with the above pathogens. Among 179 infected women, 11% carried Mycoplasma hominis, 44.75% carried Ureaplasma urealyticum, and 7.75% carried Chlamydia trachomatis. Among 139 nonpregnant positive women, 96.4% had Ureaplasma urealyticum, 41.75% had Mycoplasma hominis, and 16.76% had Chlamydia trachomatis. 106 women had one infection, 29 had two infections, and 4 had three infections. 45 of the 86 pregnant women were positive: 9 for Mycoplasma hominis, 43 Ureaplasma urealyticum, and 5 for Chlamydia trachomatis. 34 were infected by one pathogen, 10 by two pathogens, and 1 by three pathogens. 22.07% of the women in the 15-17 age group were positive vs. 30% who were negative; compared to 46.1% positivity and 41.25% negativity among women aged 18-20. A self-administered questionnaire revealed that 89 women started sexual activity at age 13-15 years, 184 at age 16-18 years, and only 41 at age 19 or older. Only infected women had 6 partners or more in the previous half year. 42.2% of women with positive findings were taking oral contraceptives vs. 33.12% of those with negative findings. Positivity was more frequent among those with several sexual partners and those not using condoms regularly. The high infection rate by such pathogens may be one of the main causes of urogenital inflammations, fertility problems, and premature deliveries. The ever earlier debut of sexual activity mandates more effective sex education for young people.
[The third epoch, the Third World and the third millenium]
The UN projection of the world's population forecasts a minimum of 7.1 billion to a maximum of 7.8 billion people for the next 20 years, meaning about 700 million more people during this time span. In contrast to the rapid growth of the populations of Asia and Africa, the populations of Europe will be stagnating or even decreasing. The aging of the population will also increase in Europe and North America: people of age 65 or older made up 13.7% of the population in Europe in 1990 and their share will grow to 22.4% in 2025. 18 of the 20 countries with the highest proportion of older people are in Europe with 13.2-17.9% of the total population. The proportion of women in postmenopause was 220 million in the world in 1950. By the year 2030 there will be 1200 million such women, 912 million of them in the Third World countries. The rapid increase of older people in developing countries will probably augment the numbers of those living in poverty. The epidemiological dimension in these countries is that the causes of death are infectious and parasitic diseases (41.4% vs. 1.2% in developed countries), circulatory system diseases (10.7% vs. 46.7% in developed countries), and malignant neoplasms (8.9% vs. 21.6% in developed countries). Every year approximately 50 million people die globally: 39 million in developing countries and 11 million in developed countries. The UN projects that by the year 2000 7.1 million cancer deaths will occur globally, of which 4.3 million will be in developing countries. In the developing world there will be more malignant cancers of the gastrointestinal tract than of the reproductive tract, except for cervical cancer: in 1990 there were 183,000 deaths caused by it in developing countries vs. 32,000 in developed countries. Most disability in the Third World in older women is caused by such diseases as cerebrovascular and ischemic heart conditions, chronic respiratory ailments, diabetes, and tuberculosis.
According to the World Health Organization there are over 3 million people infected with HIV in India today [1997], and it is estimated that there will be 12 million by the year 2000. The situation is similar to that of Zambia, where infected people started to die from tuberculosis and opportunistic infections. In India the most frequent type of HIV is HIV-1 with subtype C. On the other hand, parasitic diseases such as toxoplasmosis are more frequent in Bombay than in Africa. 14% of all HIV cases in India are infected with both HIV-1 and HIV-2. A study from the city of Pune showed that 12% of patients with venereal diseases become infected with HIV every year. 80% of Bombay's 60,000 prostitutes are infected, but it is also more common among the newborn. In Bombay, 3 of 100 pregnant women carry the virus, and 200,000 adults in the city with 14 million inhabitants are infected. The increasing epidemic means that the 48,000 hospital beds of the state of Maharashtra are not sufficient for the almost 80 million inhabitants. Only Maharashtra, Tamil Nadu, Manipur, and Kerala have drafted a strategy to tackle the epidemic in spite of backing from the World Bank. Some voluntary organizations supported by the Ford Foundation work among prostitutes handing out condoms and doing social work. Unconventional methods used by Population Service International, such as videos featuring film stars and shown in bars, have proved to be widely popular AIDS information messages. Project Child provides assistance to families with HIV, especially those who become orphans and who are placed in foster homes. Half of India's 960 million inhabitants are illiterate, and talking about sexual matters is scorned at; therefore, it is very difficult to provide information about AIDS for the masses. Some even feel that the battle against AIDS has been lost because of apathy and lack of foresight.
[Generalization about promiscuity in the African culture (letter)]
In response to a previous article published in 1997 by Harold Sihm reviewing the situation of the HIV/AIDS epidemic in sub-Saharan Africa, it is stated that the alleged acceptance of promiscuity in African culture lacks verity. This accusation derives from the lack of social and economic resources, widespread migration, and accepted cultural norms purportedly sustaining such promiscuous behavior especially among men. It is worrisome that Harold Sihm, albeit unintentionally, also contributes to the colportage of already well-established prejudices and myths in relation to the HIV/AIDS epidemic in Africa. First, in Africa there is not one uniform culture; rather, there are several hundred different cultures. Only in Kenya there are about 50 quite dissimilar cultures, within which the populations' attitudes about sexual and reproductive health present a particular heterogenic picture. The author spent 12 years as a doctor in 9 different African countries, but he could not find one African culture which accepted promiscuity. Casual multiple sexual contacts occur among select migrating subgroups and many women are forced into prostitution because of extreme poverty in many African cities. But the generalization of these observations to mean that they are representative of the continent's population is entirely unjustified and can only strengthen the stigmatizing myths.
[Thromboembolic complications of oral contraceptive use (editorial)]
In 1997 there were about 300,000 users of oral contraceptives in Denmark and about 70 million worldwide. These figures translate into 27% and 6.4% of women in the 15-44 age range in Denmark and the world, respectively. The first reports about thromboembolic complications among OC users were published in 1961, although such complications among younger women were rare. Several British epidemiological investigations at the end of the 1960s indicated that these were not coincidental occurrences. In 1968 it was stated in the British Medical Journal that it was proven that the use of OCs increased the risk of both venous thrombosis and cerebral thrombosis. The Danish lead articles from 1969 correctly stressed that there is no metabolic confirmation that the use of OCs should increase the risk for thromboembolic disease, just like it should be considered that the risk of death under pregnancy is significantly higher than the risk of death from thromboembolic disease associated with OCs. In the last 25 years several thousand scientific articles have been published about this issue. The recent finding that the so-called inherited resistance to protein C activity (APC resistance) plays a significant pathogenetic role in the development of venous thrombosis is the most important. Epidemiological studies have demonstrated that both estrogen and gestagen doses play a role in the risk of thromboembolism, but in the last 30 years the dosage has been reduced sharply, whereby the risk has decreased significantly. It is estimated that these low-dose preparations increase the risk of venous thrombosis 3-4 times, but the relative risk for cerebral complications is less than 2 times. New epidemiological studies also suggest that the second-generation gestagens (levonorgestrel, norgestrel, and norgestimate) can cause a higher risk of arterial complications and lower risk of venous complications than the third-generation gestagens (desogestrel and gestodene).
[Tuberculosis and the HIV pandemic. Risk of nosocomial tuberculosis infection]
Approximately 4 million people are infected with tuberculosis (TB) in the world, of whom 3.5 million live in sub-Saharan Africa. The incidence of HIV infection among TB patients in several African countries ranges from 20% to 60%. During 1989-92 both American and European major cities reported an increasing number of TB cases among younger people. Studies from New York and San Francisco also revealed that 40% and 30% of newly registered TB cases, respectively, were attributed to new infections rather than the reactivation of latent infection. A study of 6546 patients diagnosed with AIDS during 1979-89 in Europe also found that 14% of them had TB at some time during the course of the disease, mainly in southern Europe and among drug users. Multidrug-resistant Mycobacterium tuberculosis (MDRTB), which is resistant to isoniazid and rifampicin, increased in the US from 0.5% to 3.5% during 1982-91, with 19% of all MTB isolates reported to be MDRTB in New York in April 1991. Among patients not treated earlier, the multidrug-resistant isolates were more frequent among HIV-positive than HIV-negative patients (16% vs. 3%). During 1990-92 there was also a number of nosocomial TB cases reported in the US. The outbreak affected about 200 patients, most of them HIV-positive, and the mortality rate was high (72-89%). In the US, at least 20 health care workers were infected with MDRTB, and 9 (7 of which HIV-positive) died. In a Michigan substance-abuse facility an AIDS patient with MDRTB transmitted the illness to 15 (21%) of 70 health care workers during a 5-week hospitalization. In a Florida hospital, 36% of health care workers were infected during a 2-year period in a unit with HIV-positive patients, whereas none were infected in a thoracic surgery division. The prevention of MDRTB transmission was accomplished by isolating the patients with MDRTB as well as by rapid diagnosis and treatment.
[Breast feeding as family planning in a global perspective]
The contraceptive effect of lactation has been recognized for a long time, but detailed knowledge concerning the size and duration of this effect and necessary preconditions have been lacking. Research on the lactational amenorrhea method has given new insight into this issue. The World Health Organization's 1988 consensus statement in Bellagio, Italy, concluded that women are protected against a new pregnancy during the first 6 months postpartum provided they practice exclusive breast feeding and remain amenorrheic. The duration of postpartum amenorrhea increases with maternal age. It also seems to be associated with maternal malnutrition, socioeconomic status, lactational habits, and seasonal variations. The lactational amenorrhea method (LAM) became part of the family planning programs after the Bellagio Consensus. An important limitation of the method is that some women have very short postpartum amenorrhea phases, even if they practice both longterm and intensive breast feeding. Another beneficial effect of LAM is that the survival chances of the child also increase. LAM is controlled by the woman herself, making her independent of other products and distributors. LAM is also recommended because, for example, in Bangladesh only 30% of women continued contraceptive use for more than 1 year, and during the amenorrheic period women have time to consider a contraceptive method. In 1995 another Bellagio conference concluded that LAM could be used longer than 6 months (9 or 12 months) and that breast feeding continues to have a contraceptive effect even after menstruation has returned; but this conclusion is too uncertain to be used in systematic family planning. Nevertheless, LAM should be integrated into family planning programs.
[Brazil National Demographic and Health Survey, 1996]
The Brazilian National Demographic and Health Survey of 1996 (PNDS 1996) collected information from 12,612 women 15-49 years of age as well as from 2949 men aged 15-59 years. The information gathered from the women concerned 4782 children under the age of 5 years. The rate of total fertility for the period of 1994-96 was 2.5 children: 3.5 in rural and 2.3 in urban areas. 80% of married women did not want another child. About 75% of married women and men used some type of contraception and 74% of women had undergone sterilization during delivery. The infant mortality rate was 42/1000 live births in urban and 65/1000 in rural areas. 54% of children aged 12-59 months had been fully immunized. During the 5 years prior to the survey 81% of the children had received prenatal care. Approximately 13% of the children had experienced diarrhea during the 15 days prior to the survey, with less than 1% having blood in the stool. 22% of the children whose mothers had no education had diarrhea, while only 5% of the children of mothers with higher education had such ailments. Up to 93% of the children were breast fed for an average duration of 7 months. Chronic malnutrition reached 11% and maternal mortality was 8 deaths per 1000 women of reproductive age during the previous 10 years. The PNDS 1996 also revealed great differences between the subgroups in the interior. In the rural regions of the North and Northeast about 55% of women received assistance by a physician during labor vs. 90% in the developed regions. Infant mortality was 74/1000 in the Northeast vs. 25/1000 in the South. 30% of rural women did not receive prenatal care, especially those with low educational level. In the Northeast 26% of the births occurred without having received prenatal care. Although 90% of deliveries took place in the hospital system, only 70% of women with little or no education gave birth in the health system. It is recommended that investments be made to reduce the regional differences.
An epidemiological survey was carried out in the city of Pelotas in southern Brazil in order to study the prevalence of various contraceptive methods among 677 women in the age range of 20-49 years. The study was conducted to follow up on a previous study carried out during March-June 1992. A cross-over investigation was also done involving 296 women from 852 households from 25 sectors of the city to ascertain the use of oral contraceptives. Structured and precoded questionnaires were employed for the analysis by trained medical students who collected data on contraceptive use, socioeconomic and educational status, smoking, hypertension, and concerning the question of who recommended the contraceptive. Inappropriate contraceptive use was defined to include women who smoked, who were aged over 35, and/or had arterial systemic hypertension. 445 (65.7%) were currently using some type of contraceptive method: 296 (66.5%) were using oral contraceptives (OCs), 82 (18.4%) had undergone surgical sterilization, 10 (4.3%) were using IUDs, 18 (4.0%) were using condoms, 11 (2.5%) were using the calendar method, 6 (1.3%) had undergone hysterectomy, 8 (1.8%) were using injectables, and the mates of 3 (0.7%) had undergone vasectomy. The use of OCs decreased with age, whereas the use of other methods increased with advancing age. Tubal ligation rates increased starting at age 30. Among OC users, 67 were in the 20-24 age group, 70 were in the 25-29 age group, 59 were in the 30-34 age group, and 58 were in the 35-39 age group. With regard to tubal ligation, 23 women were in the 30-34 age group, 26 were in the 35-39 age group, and 17 were in the 40-44 age group. When asked who recommended the contraceptive method, 349 (78.4%) women reported that it was the physician, 82 (18.4%) indicated that it was their own initiative, and 14 (3.2%) mentioned other persons. Bivariate analysis examined inadequate use of contraception in relation to social class and education. It was revealed that 22.7% of women among the traditional bourgeoisie, 17.4% among the newly rich, 14.1% among the nontypical proletariat, 21.3% among the proletariat, and 28.6% among the sub-proletariat were not using adequate contraception.
The Panamerican Health Organization warns that by the year 2000 there will be a minimum of 10 million cases of AIDS and 40 million people infected with HIV worldwide, of whom 10 million will be children. An AIDS prevention program involving adolescents from grades 5-8 of a state elementary school in Porto Alegre during the first half of 1994 was organized. The objective was to encourage preventive behavior by means of health information and education to reduce the transmission of HIV. Groups of 18-20 adolescents aged 11-19 years (a total of 161 students from a low socioeconomic area) took part in the investigation. A workshop took an average of 3.5 hours in six stages. The coordinator stimulated the discussion by questions concerning the feelings and experiences of the participants, their interpretation of the reaction of each participant, the relationship between the technique and the reality, and expected action. The method used participation techniques for relaxation, discussion, and reflection on topics in the group. Collective evaluation after the workshop was performed by a questionnaire listing 5 questions: 1) What do you know about AIDS? 2) What causes AIDS? 3) What is the mode of transmission of AIDS? 4) How can it be prevented? 5) What is safe sex? The responses were grouped into three categories: 1) the objective was achieved; 2) the objective was not achieved; and 3) no response. 60.2% were aware of the importance of AIDS; 30.8% did not respond in a satisfactory way. 70.4% of the pupils identified the causative agent of AIDS and knew about the consequences of the disease, while 23.6% failed to answer this question. 90.6% could enumerate the modes of transmission of AIDS, while 9.4% could not. 92.6% could describe preventive methods, and 73.2% knew about the significance of safe sex. Preventive action could be encouraged through reflection on the HIV disease process and its serious repercussions for public health.
[Malaria and AIDS: the great genocides (editorial)]
At the beginning of the 20th century malaria was a major problem of tropical medicine until eradication campaigns succeeded in reducing its occurrence. Its recent epidemic resurgence in Madagascar, Namibia, Sao Tome and Principe, and Sudan shows the vulnerability of populations. The World Health Organization estimates that 110 million cases of malaria occur annually, most of them in Africa (90 million cases in sub-Saharan Africa). 1-2 million people die because of malaria. The matter is complicated by the resistance of Plasmodium falciparum to chloroquine and other drugs. In some parts of the world the mosquitos have developed resistance to insecticides, which makes vector control more difficult. This serious situation prompted a ministerial conference on malaria in Amsterdam in 1992, which resulted in the declaration that the fight against malaria necessitates the participation of the community concerning water resources, sanitation, and general development. The transmission of AIDS is connected to sexuality having social, behavioral, and ethical aspects. The first cases occurred among hemophiliacs, homosexuals, and intravenous drug addicts. HIV-1 was identified in 1983 and HIV-2 in 1987. In June 1994 the number of AIDS cases were approximately 4 million in the world, more than 2.5 million of them in sub-Saharan Africa. In Mozambique, in June 1993, a total of 826 cases had been diagnosed. In the area of treatment, inverse transcriptase inhibitors and the use of azidothimidine (AZT) are promising, the latter having prevented maternal-fetal transmission during pregnancy and labor. The toxicity of AZT is a major drawback. There is hope that eventually a vaccine can be developed. WHO developed a global strategy for the prevention and fight against AIDS in 1985, which was revised and adopted in 1987 by the World Health Assembly. The strategy aims to prevent HIV infection, to reduce its social and individual impact, and to gather national and international forces.
[Women and AIDS: questions of gender]
During 1987-89 the proportion of women with AIDS to men with AIDS was 17:1; in 1994, this ratio had decreased to 3:1. In Sao Paulo, AIDS is among the main causes of death for women. Between 1987 and 1990 the main risk factor for women with AIDS was the use of drugs; but, beginning in 1989, the major risk factor became transmission via sexual contact. The majority of women does not perceive the risk of HIV infection, and women often do not use condoms because they are associated with infidelity, clandestine sex, and promiscuity. Also, declining to use a condom before losing her virginity is considered to be a woman's demonstration of love. Safe sex workshops may be the answer to this dilemma: teaching women and their companions about negotiating safe sex with the use of condoms despite the oft-cited objection of loss of enjoyment. These workshops made it clear that for women it is very difficult to assume an active role in negotiating condom use and talk about sex, pleasure, AIDS, and fidelity with their partners. Men knew more and talked more about sex than women. It was peculiar that in most workshops the women negotiated condom use within the context of seduction by convincing their partners that sex with the condom would be more enjoyable; however, this was also accompanied by strong sentiments of shame, uncertainty, and fear of being regarded by their partners as women "trained" in the knowledge and practice of sexual pleasure. For most women who participated in the workshops sex was a means of recovering energy, while for men it was a means of discharging energy and releasing tension. The research with women indicated that the risk associated with exercising their sexuality is correlated with their feminine identity, with high socioeconomic and cultural costs if she runs that risk.
In a cohort study, the effect of blood malaria parasite density on fever incidence in children was studied in an endemic area with 9 days' follow-up of children aged 1-12 years during two time periods: the end of the dry season (May 1993: n = 783) and the end of the rainy season (October 1993: n = 841) in Bougoula, West Africa (region of Sikasso, Mali). The number of registered children was 928 in the dry season and 998 in the rainy season. Complete follow-up and information were available for 835 children in the dry season and for 964 children in the rainy season. The 9-day cumulative fever incidence (body temperature above 38.0 degrees Celsius) increased from 2.0% in the dry season to 8.2% in the rainy season (p < 0.0001). In the rainy season, the risk of fever increased in children aged 1-3 years (relative risk [RR] = 2.5; 95% confidence interval [CI], 1.6-4.1); in those with an initial parasitemia greater than 15,000/mcl (RR = 2.7; 95% CI, 1.4-5.4); in those with an enlarged spleen (RR = 2.0; 95% CI, 1.2-3.3); or in those with anemia (hematocrit <30%: RR = 1.8; 95% CI, 1.1-2.9). In the dry season, anemia (hematocrit <30%) was the only predictor of fever incidence with a cumulative incidence of 10.0%. In nonanemic children, a parasite count of >2000/mcl was the next best predictor. In the rainy season, the best predictors of fever were age (<4 years), enlarged spleen, and high parasite density (>1/mcl). Even in the higher risk groups, the cumulative incidence was <20%. Most children with high parasite density do not develop fever subsequently. The association between parasite density and fever varies according to age and season. Since even high levels of parasite density do not reliably predict fever incidence, parasite density should be considered not so much a direct marker of an ongoing attack but as just one indicator of the likelihood of a current or imminent attack or even one just passed.
Treatment of multidrug-resistant tuberculosis in Thailand.
There has been a slight change in the total number of TB cases notified since 1985, when the first case of HIV was reported. Although there has been an increase in the incidence of TB in HIV-infected cases, the percentage of multidrug-resistant tuberculosis (MDRTB) in this group is the same as in the HIV-negative group (2.7%). The multidrug-resistant (MDR) rate in 1988 was nearly 2% in Thailand, increasing to 5% in 1994. The factors that promote MDRTB in Thailand include irregular drug taking, high initial drug resistance, the prescription of inappropriate regimens, and drug intolerance. The percentages of total initial drug resistance, four-drug resistance, and MDRTB have increased to 22.4%, 1.4%, and 4.8%, respectively. Comparable figures for acquired resistance are up to 2.5-, 10-, and 6-fold, respectively. Duration of treatment for 24-30 months depends on severity, previous therapy, and the number of drug resistances. Surgery is suggested for persistent positive case with localized lesions and good cardiopulmonary reserve. Quinolones are among the most promising drugs for second-line therapy against MDRTB. Quinolone and ofloxacin are promising drugs for MDRTB, achieving a sputum conversion rate of 59-79%. A prospective study showed a success rate of 67% with no adverse effects. However, when different regimens were examined, it was found that at least four anti-TB drugs are required. In current multicenter, controlled, prospective trials in Bangkok, 600 mg ofloxacin daily is combined with pyrazinamide, p-aminosalicylate, amikacin, and ethambutol, with a treatment duration of 18-24 months with a 2-year follow-up. No adverse effects were reported for the ofloxacin 300 mg/day regimen in several studies done. Optimal MDRTB treatment requires appropriate organization for planning and implementation and directly observed therapy. Guidelines developed in April 1996 call for at least 3-4 culture-sensitive drugs given for either 2-2.5 years or until negative sputum cultures have been present for at least 1 year.
An evaluation of the 1993-94 Bangladesh Demographic and Health Survey within the Matlab area.
The 1993-94 Bangladesh Demographic and Health Survey (DHS) reported substantial declines in vital rates, especially the fertility rate, which needed confirmation. The demographic database of the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) contains the birth and death records for 200,000 people whose households have been visited every 2 weeks since 1966. In addition, the system kept records on the pregnancy and contraceptive use status of women of reproductive age since 1977. A validation study was conducted, which entailed the comparison of fertility and infant mortality rates from a special DHS survey conducted in the Matlab treatment area in 1994, with rates obtained by the Demographic Surveillance System (DSS) over the 5 years prior to the survey and also the comparison of the current contraceptive use rate. The records of 2628 women were examined. The Matlab DHS was found to be accurate in estimating fertility both in the treatment and comparison areas. The Matlab DHS infant mortality rates for the 5 years prior to the survey were also consistent with the estimates derived from the DSS. However, the Matlab DHS seemed to have underestimated contraceptive prevalence, which underestimate was substantial for modern temporary methods, especially pills and injectables. Since contraceptive prevalence may also be higher at the national level as a result of this, the total fertility rate for Bangladesh of 3.4 children/woman may be plausible. Although the Matlab DHS figures on vital rates seem to be reliable, the national level DHS estimates may not be as reliable, because women elsewhere in the country may not have reported their children's births and deaths as accurately as did women in the Matlab area.
Environmental concerns and international migration.
According to Nobel, the definition of the contemporary refugee has been modified by the UN High Commission for Refugees (UNHCR) to include well-founded fear of being persecuted for reasons mentioned in the Geneva Convention as well as external aggression, occupation, foreign domination, and massive human rights violations. Additionally, Olson's definition includes physical dangers (floods, volcanic eruptions) and economic insufficiency (drought, famine). The term environmental refugee has gained wide usage lately. Richmond's model recognizes the predisposing factors: the nature of the biophysical environment, structural constraints, facilitating factors, precipitating events, and the feedback effects of the environmentally induced migration. As to environmental factors as a cause of migration, a global survey of natural disasters for the period of 1947-1980 indicated that the overall number of disasters is increasing and 86% of the lives lost occurred in Asia. China and India dominated in the number of environmental refugees during 1976-1994. Furthermore, the droughts of 1968-73 and 1982-84 led to millions of environmental refugees in Africa. There were 1 million environmental refugees in Burkina Faso alone. The precipitating events and conditions were population growth, widespread poverty, food production efforts, loosened regulations, lacking environmental legislation, and climate change. The bulk of refugees move within the national boundaries, but there has been an increasing trend of South-North international migration in the last decade and the emergence of an international immigration industry. The environmental impacts of international migration has surfaced in Australia because of detrimental effects on the national ecology, but resource management policies could handle environmental concerns. Ethical and policy implications mean that much of contemporary environmental degradation in developing countries are rooted in colonial expansion and the problem will require a global solution.
Arthritis associated with HIV infection in Zimbabwe.
Patients with arthritis referred to the rheumatic disease clinic at the University of Zimbabwe or seen in consultation over a period of 4 years were studied. All 64 patients were assessed by a rheumatologist and standard laboratory tests were performed. There were three common clinical presentations. 1) Oligo- and polyarticular arthritis (22 men, 4 women). HIV infection had not previously been diagnosed in 24 of these patients, but persistent generalized lymphadenopathy (85%) and weight loss (42%) were present. Joints commonly involved were ankles (65%) and knees (54%), often with associated enthesitis (31%) and dactylitis (23%). Follow-up data in 18 patients showed that arthritis resolved completely in 9 patients (one subsequently recurred), improved by >50% in 5 patients, was unremitting in 3 patients, and recurred frequently in 1 patient. None of 7 patients tested possessed HLA-B27 or one of the B7 cross-reacting group (B7-CREG) of antigens. 2) Reiter's syndrome (RS) (21 men, 3 women: incomplete RS, 18 patients; complete RS, 6 patients). Lymphadenopathy was present in 19 patients (79%), and 4 patients were previously known to have HIV infection. Involvement of knees (80%) and ankles (58%) was common, as were enthesitis (29%) and dactylitis (13%). Follow-up data in 21 patients showed that 14 resolved (5 with recurrences), 2 improved by >50%, and 5 had continued arthritis. HL-B27 was not found 13 patients tested, but a cross-reacting antigen was found in 6 patients. 3) Symmetrical polyarthritis (4 men, 4 women). Symmetrical arthritis of the wrists (8 patients) and peripheral interphalangeal (PIP) and metacarpophalangeal (MCP) joints (7), as well as lymphadenopathy (5), nodules (4), rheumatoid factor (3), and erosive radiographic changes (1) were seen. Other types of arthritis included 3 patients with psoriasis and arthritis and 1 patient each with Beheet's disease, Salmonella septic arthritis, and secondary syphilis. All patients were treated with a nonsteroidal anti-inflammatory drug (NSAID), most commonly indomethacin, with the addition of low-dose prednisolone (5-10 mg for 4 patients) and/or chloroquine (150 mg base daily for 11 patients) if clinically indicated. In patients in whom arthritis improved, the effect was gradual over 3-6 months.
Cholera in Africa. Summary background (1970-1990).
Since 1970, the year in which cholera hit Africa, Vibrio cholerae has gradually spread to most of the continent. The epidemic started in Guinea and was caused by V. cholera O1, biotype El Tor, serotype Ogawa, the source of which was unknown. From there, it spread along coastal areas and soon thereafter towards the interior, carried by river and road traffic. In the years that followed, cholera cases were reported from countries throughout the whole of Africa. The number of countries reporting cholera ranged from 11 to 21 each year, with case-fatality rates ranging from 4% to 12%. It became apparent that cholera was present in all regions, including desert environments and other unfavorable conditions. It was clear that cholera had become endemic in Africa. Since 1982, Africa has reported the highest incidence rates of cholera in the world. In 1991, the recrudescence of cholera occurred in Africa. A total of 20 countries reported severe cholera outbreaks with a total number of 153,367 cases and 13,998 deaths. The case-fatality rate in Africa (13%) was much higher than that reported in the Americas (<1%), where 391,220 cases occurred during 1991. In 1992, 91,081 cases and 5291 deaths were reported in Africa; in 1993, a total of 76,713 cases and 2532 deaths. In 1994, cholera was present in more African countries than ever before, with 28 countries reporting 161,983 cases. Around 700,000 refugees entered Zaire in 1994 and were living in areas with poor sanitation where a total of 58,057 cases and 4181 deaths were reported. In 1995, a decrease of about 44% in the number of cases had been observed over the previous year owing to improved control of diarrheal diseases by governments and international agencies. However, in 1996, 84,976 cases were provisionally reported for Africa, a figure which surpassed the total reported in 1995.
Attitudes toward condom use among female college students.
The aim of the study was to explore attitudes toward condom use, identify the frequency of condom usage, and examine the relationship between attitudes and condom use among sexually active female college students. From the end of February 1996 through March 1996 all sexually active female college students aged 18-24 years attending an upstate New York rural county family planning clinic for reproductive services and birth control supplies were approached to fill out a self-administered questionnaire containing the Condom Attitudinal Scale with total possible scores from 11 to 55. 47 female college students returned the questionnaire. 42 were Caucasian. Their mean age at first intercourse was 16.2 years. 14 students reported using only condoms, 16 reported using a combination of condoms and birth control pills, and 13 reported using only birth control pills. The scores on the Condom Attitudinal Scale ranged from 29 to 54, with a mean of 45.9. Those who never used condoms (n = 9) had a mean score of 44.11; those who sometimes used condoms (n = 26) had a mean score of 44.96; and those who always used condoms (n = 12) had a mean score of 49.5. Students who reported always using condoms scored significantly higher in their attitudes toward condoms than those who sometimes or never used condoms (p = 0.04). Respondents who reported condom use only as a method of birth control had a mean condom attitude score of 48.0. Those who used condoms in combination with pills had a mean condom attitude score of 46.1, while those who used birth control pills only had a mean condom attitude score of 42.6. Students who reported a sexually transmitted disease (STD) history had a significantly earlier age at first intercourse (p = 0.39) than those with no STD history, and they also had a higher number of sexual partners. Students reporting condom use at last intercourse had a greater mean number of partners during the 6 months than those who did not use condoms at last intercourse (p = 0.000).
Pneumocystis carinii pneumonia simulating as pulmonary tuberculosis in AIDS.
The case of a 25-year-old male agricultural laborer with HIV infection and Pneumocystis carinii pneumonia (PCP) is described, whose radiological lesions simulated pulmonary tuberculosis. He presented with loss of weight and appetite of 6 months' duration, cough with expectoration and minimal hemoptysis for 2 months, chest pain, diarrhea with fever, and odonophasia for 1 month. He had received antitubercular treatment (rifampicin 450 mg and isoniazid 300 mg) 2 months prior to admission. He had been promiscuous, having had multiple sexual contacts with prostitutes. General examination demonstrated marked emaciation, pallor, dyspnea, and oral candidiasis. Auscultation indicated fine medium pitched crackles in both infraclavicular regions. Blood for ELISA and immunocomb test were positive for HIV-1 antibodies. Hemogram revealed Hb 6 gm%, and TLC with polymorphs 63%, lymphocytes 30%, eosinophils 5%, and basophils 2%. The total lymphocyte count was 2100/cu. mm. Chest roentgenography revealed bilateral diffuse homogenous infiltrative lesions involving both lungs, with evidence of multiple bilateral cavitation. Therapy included antitubercular treatment with ethambutol, isoniazid, rifampicin, and pyrazinamide, along with Gentian violet mouth paint and ketoconazole orally, 200 mg bid. The patient developed progressive respiratory distress and died on the 7th day after admission. Limited autopsy of both lungs showed foamy eosinophilic material filling the alveolar space, and Grocett's methenamine silver staining showed cyst walls of P. carinii as black. There was no evidence of pulmonary tuberculosis. In the present case, the diagnosis of PCP should have been kept in mind to increase median survival time (25.9 vs. 12.6 months without treatment) with the treatment of choice of trimethoprim plus sulphamethoxizole in doses of 20 and 100 mg/kg/day. Early diagnosis and treatment will improve the mean survival time in cases of PCP with HIV infection.
In developing countries, the proportion of Pneumocystis carinii pneumonia (PCP) cases, compared to other opportunistic infections associated with AIDS, is low partly because of underdiagnosis. PCP cases are reported that were diagnosed by bronchoalveolar lavage (BAL) cytology and transbronchial lung biopsy (TBLB) in 3 out of 5 HIV-positive adult patients presenting with interstitial pneumonitis at the Department of Chest Medicine, KEM Hospital, Bombay. One of these patients was serologically positive for HIV at the time of presentation and the remaining 2 patients were detected to be HIV-positive on follow-up after the diagnosis had been established. All patients had elevated erythrocyte sedimentation rate. CD4+ lymphocyte analysis was done in 1 patient and revealed 360 CD4+ cells/cu. mm. BAL cytology using Giemsa stained smears confirmed the presence of cysts diagnostic of Pneumocystis carinii. TBLBs of the 3 patients who revealed P. carinii in their BAL fluid also evinced foamy intra-alveolar eosinophilic exudates, and the GMS stain showed the presence of ovoid or cup-shaped structures consistent with P. carinii within these exudates. Biopsies from the 2 PCP-negative, HIV-positive patients showed evidence of interstitial pneumonitis. All 3 patients were treated with cotrimoxazole (20 mg/kg body weight). Only 1 patient recovered and was discharged; another patient improved with treatment and was started on cefotaxime (50 mg/kg body weight) and amikacin (15 mg/kg body weight), but died after jugular vein cannulation. The third patient developed cryptosporidial diarrhea and died. The remaining 2 PCP-negative patients with nonspecific interstitial pneumonitis treated with prednisolone and bronchodilators recovered and were discharged from the hospital. BAL cytology and TBLB were useful tools in detecting PCP, one of the few treatable AIDS-related infections.
Treatment of acute infantile diarrhoea with a commercial rice-based oral rehydration solution.
A randomized clinical trial compared the efficacy of an oral rehydration solution (ORS) formulated with commercial rice powder at 50 g/l (case group of 13 boys and 11 girls) with that of glucose-based WHO/UNICEF-recommended ORS (control group of 13 boys and 11 girls) in the management of 48 patients aged 3-24 months with acute dehydrating watery diarrhea in the pediatric ward of the Universidad Catolica Clinical Hospital, Chile. Enteropathogens were found in 94% of the patients. Rotavirus was present in 85% of the patients, either as a single pathogen (58%) or in association with other agents (27%). Enteropathogenic Escherichia coli (EPEC) was recovered in 33% of the patients; in 8% of the cases it occurred as a single pathogen and in 25% of the cases it was associated with rotavirus. 7 patients (29%) in the control group and 4 (17%) in the study group required intravenous fluids at some point in the course of the study. Mean fecal losses were generally higher in the rice-ORS patients throughout the study. The stool output (ml/kg) in the first 24 hours was 213 (153-353) [geometric mean (95% confidence interval)] in the rice-ORS group vs. 146 (108-232) in the glucose-ORS group, while the total stool output was 455 (298-933) vs. 307 (209-625) (p value not significant). The mean [+or- standard deviation (SD)] duration of diarrhea in hospital was: 72 +or- 10 hours in the study group vs. 77 +or- 12 hours in the control group (p value not significant). The ORS formulated with a commercial rice powder used in this trial is not superior to the standard glucose-ORS advocated by WHO/UNICEF in the treatment of infants with watery non-cholera dehydrating diarrhea. In some cases, ORS formulated with the commercial cereal-based products might actually increase the stool losses in infants with high-output non-cholera diarrhea.
Prescribing pattern by doctors for acute diarrhoea in children in Delhi, India.
During June-September 1993 two investigators visited the Infectious Disease Hospital 2-3 times a week to interview parents (mostly mothers) of 264 children aged under 5 years with acute watery diarrhea about their children's age, clinical symptoms, and the type of treatment received before hospitalization in Delhi, India. 107 and 46 were found positive for Vibrio cholera 01 and 0139, respectively. The remaining 111 had non-cholera watery diarrhea. Among the 46 patients with V. cholerae 0139, 17 received ORS, 34 received drugs, and 22 received iv fluids; among the 107 patients with V. cholerae 01, the respective figures were 20, 66, and 45, while among the 111 patients with non-cholera diarrhea the figures were 22, 68, and 39. The difference in administration of ORS to 0139 cholera patients vs. 01 cholera patients was significant (p = 0.01). 49% of the 59 cases who received ORS were treated by private physicians, as compared to 46% of the patients who were treated by government physicians. Significantly more cases were prescribed drugs by private doctors (57%) than by government doctors (41%). Only 22% of the cases were given prescriptions for oral rehydration solutions (ORS), whereas 64% of them were given drugs, including antibiotics and antidiarrheals, and 40% were given intravenous fluids. The difference among the treatment groups was highly significant. The government and private doctors were equally responsible for the low rate of prescription of ORS. The confidence of health professionals in ORS appears to be very low, as they preferred to prescribe antibiotics and antidiarrheals rater than ORS for the treatment of acute watery diarrhea. This phenomenon indicates the need for a high-profile continuing education program for both types of physicians to encourage ORS prescription in Delhi.
Treatment of diarrhoea in infants by medical doctors in Balochistan, Pakistan.
Diarrhea is an important public health problem in Baluchistan, the western province of Pakistan. Although the use of oral rehydration solution (ORS) has been widely promoted, no studies have been reported on the actual uses of ORS in treating infant diarrhea by the doctors in this region. The medical practices of 30 doctors in the cities of Quetta and Loralai were surveyed. The surveyors posed as the mothers of three infants aged 6-8 months with diarrhea. The questions asked by the doctors, the physical examinations performed, and the treatment regimens prescribed were recorded. The outcome indicated that the case histories and physical examinations were incomplete as performed by most practitioners. None of the doctors asked about the frequency of stools, the time of the infant's recent urination, or the health of family members. Most physical examinations were severely deficient. Only two doctors performed adequate examinations (taking of temperature, pulse, respirations, skin pinch, evaluation of fontanelle and mucus membranes, and abdominal examination). Two doctors ordered laboratory tests: both requested stool examination for parasites, ova, and leukocytes, dipstick urinalysis, and blood leucocyte count with differential. 24 doctors (80%) prescribed drugs, usually a kaolin preparation, to treat diarrhea, although only 11 of them gave instructions on how to take the medication. 46% of the doctors prescribed commercially prepared mixtures of kaolin and pectin or neomycin and pectin, while two doctors prescribed streptomycin. Other medication prescribed included: fosfomycin, amoxycillin, co-trimethoxazole, metronidazole, paracetamol, vitamin drops, and colic drops. However, 18 of the 30 (60%) practitioners also prescribed ORS for treating diarrhea, and most of them gave some recommendations about ORS use. 14 doctors (46%) recommended breast feeding to prevent diarrhea, while 6 (20%) commented on food hygiene, recommending hand washing and clean drinking water. Ongoing education programs and refresher courses would likely improve the use of ORS further in this region.
Dominican, Mexican, and Puerto Rican prostitutes: drug use and sexual behaviors.
HIV-related behaviors are reported in three groups of Hispanic prostitutes recruited in the US: 77 Dominicans recruited in the Washington Heights/Inwood section of New York City; 151 Mexicans recruited in El Paso, Texas; and 48 Puerto Ricans recruited in East Harlem, New York City, during 1989-91 in streets and brothels. Ethnographic interviews were conducted with a subsample of subjects (10 Puerto Ricans, 20 Mexicans, and 20 Dominicans) to examine the cultural meaning of risk behaviors. Structured interviews based on the NIDA AIDS Initial Assessment were conducted with the subjects to describe demographic characteristics and summarize levels of risk behaviors. Qualitative data showed that for the Mexican women in El Paso poverty, violence, drug dealing and transport, tourist clients, and an environment of illegality were the realities more than for the Dominican and Puerto Rican prostitutes. The Dominican sample in New York City transported to their new environment strong family values and proscriptions against drug use as well as prostitution in brothels on account of poverty-related motivations for the support of their children. The Puerto Rican women reflected acculturation evolved in two locations, as well as illicit drugs, violence, and abuse. 92% of the Dominican women, 71% of the Mexican women, and only 25% of the Puerto Rican women were born in their native countries. Only 10% of the Puerto Ricans, 36% of the Mexicans, and 53% of the Dominicans always used condoms. 58% of the Puerto Ricans, 21% of the Mexicans, and 13% of the Dominicans reported ever having a sexually transmitted disease (p < 0.001). Of those tested by the project, only 2% of the Mexicans vs. 8% of the Dominicans were HIV positive. Among drug-addicted Puerto Ricans, the HIV seroprevalence rate was 40-50%. 79% of the Puerto Rican prostitutes were sex partners of iv drug users. For effective prevention, cultural diversity must be taken into account.
Recent fertility trends and prospects in India.
The most recent census conducted in India in March 1991 determined a population of 846.30 million. Since 1951, when the first post-independence census was taken, the population of the country has increased by 485.22 million, more than twice the 1901 population of 238.40 million. India's population grew by 162.97 million people during 1981-91. However, in terms of the rate of growth during 1981-91, India's population increased 2.12% annually, slower than the 2.20% experienced during 1961-71. Population growth was at 1.97% in 1991. The rate of fertility decline has indeed increased across large portions of the country in recent years. Changing levels of natural fertility and contraceptive use have directly effected fertility change, while levels of female literacy and infant mortality have indirectly effected change. The total fertility rate in India should be 2.9-3.0 by 2001 and 2.00-2.13 by 2011. The growth in female literacy will have a major impact upon future fertility levels.
Birth rate and death rate of Tripura (1971-1989): a study of time series.
Birth and death rates are two major components of population growth. A time series analysis of birth and death rates in Tripura state was conducted during 1971-89 using rates taken from the Basic Statistics of Northeastern Region, Northeastern Council Secretariat, Shillong. The analysis found that both birth and death rates in the state were changing over time in both urban and rural areas. The birth rate, however, is declining more slowly than the death rate. Birth rates in the state over the period for the overall population, rural areas, and urban centers are more than twice as large as the death rates in any given year, one of the main reasons for population growth in Tripura state. A high rate of immigration from the neighboring country is another likely reason for rapid population growth in the state.
A random-effects model for cycle viability in fertility studies.
The authors describe a random-effects fertility model based upon the assumption that the menstrual cycle viability probability varies from couple to couple according to a beta distribution. An EM algorithm is used to fit the model. The proposed estimating procedure is fully expandable to allow covariate effects on the beta variate. The method can be applied generally whenever dependency among Bernoulli trials is induced by a susceptibility state and the outcomes can be observed only in the aggregate. Based upon data from a cohort of 221 couples with no known fertility problems who were attempting pregnancy, cycle viability was found to be heterogeneous among couples. Stratification on the presence or absence of prenatal exposure of the woman to her mother's cigarette smoking revealed a statistically significant difference in the two-cycle viability distributions. Differences are discussed in the interpretation of the beta model compared to the marginal approach based upon generalized estimating equations.
Demographic responses to economic shocks: the case of Latin America.
People have long studied the relationship between economic trends and demographic parameters. However, in so doing, it is important to distinguish between the direct and usually short-term effects of economic change on demographic variables and longer-term, generally indirect, associations between economic and demographic conditions. This paper discusses the mechanisms through which economic recession and adjustment programs may affect demographic outcomes; implements a simple procedure to assess the magnitudes of the short-term economic effects of the recession on nuptiality, fertility, and mortality; and applies a technique using successive census age distributions to estimate the magnitude of past fertility and mortality fluctuations. To provide additional evidence of demographic responses to past crises, those indirect estimates are then compared with more direct ones obtained from historical records.
Demographic transition theory.
Demographic transition theory states that societies which experience modernization progress from a pre-modern regime of high fertility and high mortality to a post-modern one in which both are low. Modernization is not defined and does not include the important questions about causation which form the subject of much modern demographic literature. For some, transition theory is at the center of modern scientific demography, while for others, it is a non-theory to be dismissed as an unproven generalization not worthy of much discussion. The origins of demographic transition theory and early scholars' debates, demographic transition theory, the historical record, the European Fertility Project, reasons for mortality decline, economic theories of fertility decline, Caldwell's restatement of transition theory, cultural and ideational theory, historians' views, the role of government, the role of diffusion, the current state of the transition, and the institutional background of transition theory are discussed.
[Treatment of HIV infection. Current state of the art in 1996 and future possibilities]
In the past 2 years there have been significant advances in our understanding of the biology and pathophysiology of HIV infection, which, in addition to the development of new highly potent drugs for the treatment of HIV, have changed our approach to the treatment of HIV. Not long ago, the standard management was monotherapy with zidovudine, and therapy was not initiated until the patient was symptomatic or else showed significant immunodeficiency. Currently, the authors have seven antiviral drugs with activity against HIV, which, together with data from studies using various combinations of these drugs and in particular combinations that incorporate one of the more potent protease inhibitors, leads the author to believe that HIV infection may be treated in the near future as a complex but manageable chronic infection that would not be invariably fatal. (author's modified)
Oral versus vaginal misoprostol for cervical priming [letter]
We read with interest the article by Lawrie et al. (1996) again emphasizing the use of misoprostol for cervical priming before suction termination of pregnancy. We were concerned about the timing of administration of oral misoprostol. This drug is rapidly absorbed following oral administration, with peak plasma levels of the active metabolite (misoprostol acid) occurring after about 30 minutes. The plasma elimination half-life of misoprostol acid is 20-40 minutes (ABPI Compendium of Data Sheets and Summaries of Product Characteristics 1996/97). It is perhaps not surprising, therefore, that two women in the orally treated group experienced an incomplete abortion at home before their admission and a further woman required early admission because of heavy bleeding. We also wish to seek clarification regarding the decision to allow the women to take the oral misoprostol at home on the day prior to admission. Misoprostol has a well recognized abortifacient effect, and in this trial it was prescribed specifically to achieve that end. We would have thought that it therefore needed to be prescribed and administered on licensed premises in order to comply with the 1967 Abortion Act. Rapid absorption of misoprostol should make oral administration at the time of admission for day case suction termination of pregnancy realistic. We believe that the optimal route, dose, and timing have, however, yet to be established and warrant further study. (full text modified)
Cuba shows jump in HIV positives.
Cuba experienced a substantial increase in the number of HIV cases in 1996 due primarily to a growth of foreign tourism and an increase in prostitution, health officials said. The Juventud Rebelde newspaper said that since HIV/AIDS testing began in 1985, government-run hospitals and clinics have detected 1609 HIV-positive cases. In 1995 the total was reported at 1196, meaning that 413 new cases were detected in 1996. This compared with only 97 new cases reported during 1995. HIV infection among the island's 11 million inhabitants has remained relatively low due to a massive testing program and a public health infrastructure that provides universal and free medical treatment. Cuba was a pioneer in the use of interferon on those testing HIV-positive. Cuba produces its own interferon, which prolongs the life expectancy of patients, and also reagents for AIDS testing. There are special sanitariums for AIDS patients in most of Cuba's 12 provinces. Cuban adults who test HIV-positive are required to enter the sanitarium in a policy reminiscent of the way tuberculosis patients were tested in the US earlier in this century. Officials said the isolation of patients in sanitariums has been somewhat relaxed over past years by introducing greater flexibility in allowing persons who are considered reliable to live at home or make prolonged visits. (full text)
China reports increase in AIDS cases.
The number of people in China testing positive for HIV grew by 369 in the first 3 months of 1997, reaching 6359, according to figures from the Ministry of Health. The ministry previously had reported that as of the end of October 1996, 5157 people in China were known to be infected with HIV. The government estimates, however, that the actual number of people infected with HIV is about 100,000. AIDS has spread rapidly in parts of China, and China is concerned about a threat from neighboring countries where the rate of infection is much higher, the China Daily quoted Vice Minister of Health Yin Dakui as saying at the opening of a conference on AIDS. China plans to set up a National Center for AIDS Control to provide guidance for AIDS research, Yin said. (full text)
IPPF urges end to violence against women.
Nearly every woman experiences some form of violence during her life, said Mrs. Ingar Brueggemann, Secretary General of the International Planned Parenthood Federation (IPPF), who called on people everywhere to use the occasion of International Women's Day as a catalyst for action to stop violence against women throughout the world. In a widely distributed statement released on that occasion, IPPF warned that violence against women was causing terrible human suffering and was a clear violation of women's basic human rights. Violence against women is gradually gaining the attention it deserves, and IPPF intends to keep up the momentum by raising awareness and pressing for policy and program changes that will allow women to enjoy their fundamental human rights, it was said in the statement. In its message, IPPF drew attention to two issues of particular importance: the harmful practice of female genital mutilation (FGM) and the tradition of forced and early marriage. It was stated that 85-114 million girls and women in the world today are estimated to have undergone FGM. Concerning the tradition of early marriage, it was stated that mothers under the age of 15 years had been found to be seven times more at risk of death during pregnancy and delivery than those who delay childbearing until they reach the age of 20 years. Children born to mothers aged 15-19 years face a 30% greater chance of dying than those born to mothers aged 20 years and older, the press release concluded. (full text modified)
Abortion must not be advocated as preventive solution to unwanted pregnancy [letter]
Jacqui Wise's coverage of the MORI survey on abortion was biased, mainly because of her misleading interpretation of the findings but also because the survey was commissioned by and commented on only by pro-abortion groups. The title and article gave the impression that the public supports all abortions carried out in Britain. The figures given show that the public does support legal abortion. The noteworthy findings, however, are that people have different views on abortion depending on the circumstances. Most people in this survey "disapproved" of "social abortions" (the categories of "when the woman cannot afford to have the child" and "when the woman does not wish to have the child for any reasons"). Since over 95% of abortions carried out in Britain are done for these reasons (according to Office for National Statistics data), a tightening of the law may well be supported by the public. One could also conclude from the survey that the current media attention given to the anti-abortion campaign is warranted and that more balanced coverage of the realities (rather than hyperbole) is needed. We have allowed abortion to become a form of contraception, which is unacceptable, whether you believe that it concerns potential or full life. This issue should be the domain not of extremists but of a responsible society. We must put more resources and emphasis on prevention, in schools and throughout society, so that unwanted children are not conceived in the first place. Those who oppose giving widespread contraceptive advice must regard it as the lesser of evils and look on education as an opportunity rather than a threat. No one can seriously advocate abortion over a preventive solution to unwanted pregnancy. It is this solution we should be working towards. (full text)
Legal abortions save women's lives [letter]
As doctors who saw the serious and sometimes fatal consequences of illegal abortion before 1967, we believe strongly that equating legal abortion with the inhumanity practiced by doctors in Nazi Germany is wrong. In all societies throughout history, women faced with an unwanted pregnancy have resorted to abortion, and millions have died in the attempt. While we all wish that we lived in a society in which women did not feel the need to deal with an unplanned pregnancy in this way, no country has yet reached that ideal state. The tragic experience in Romania in 1966, where the maternal death rate rose six-fold when access to legal abortion was restricted, is an example of the strength of women's resolve not to bear a child they do not want. In 1935 the BMA set up a committee to look at the question of changing the abortion law because of concerns about the high and static maternal mortality of 4-6/1000 deaths for almost a century. At that time it was estimated that the number of abortions performed illegally was anywhere between 50,000 and 150,000 per year. Doctors who perform abortions consider that the lives of women are saved by their performing abortions legally rather than leaving women to kill themselves in the attempt. Most doctors today in Britain have never seen a woman die from such an abortion, and we hope that they never will. Working to reduce the need for abortion is much more useful than suggesting that doctors are acting like Nazis. (full text)
Health official emphasizes increase in malaria, AIDS, and TB incidence. International (Zimbabwe).
Zimbabwe has recorded more than 255,000 cases of malaria since the rainy season began last November, 1996. Almost 500 infected people have died of the disease. The death toll from malaria during the same period a year ago was 200; in all, over 2000 people died of malaria in 1996. The increase in disease incidence is attributed to the especially wet rainy season Zimbabwe is experiencing this year. Conditions are favorable for the disease-carrying mosquitoes to breed. Timothy Stamps, Zimbabwe's Minister of Health and Child Welfare, announced these figures at the Medic Africa 1997 exhibition held in Harare on April 16, 1997. According to an article by Segun Adeyemi, a Panafrican News Agency correspondent, Stamps told "some of the continent's top scientists attending [the exhibition] that the health challenges facing African and other developing countries [remain] as daunting as ever." HIV/AIDS research updates also were presented at the exhibition, a 3-day international medical event which includes conferences and seminars presented primarily by research scientists. According to Adeyemi, Stamps told his audience that "the HIV/AIDS pandemic continues to decimate critical human resources and overwhelm the health care system with no respite in sight." "Coupled with that," Adeyemi wrote, "was the vengeful return of tuberculosis, which had since become more difficult to treat and cure. The disease had hitherto been brought under control through immunization and multi-drug therapy." (full text)
South Africa says 2.4 million people infected with HIV.
South Africa's Health Ministry said the HIV infection rate had risen to 6% of the population from about 4.6% a year ago. Rose Smuts, Health Ministry AIDS expert, said that the estimated number of people infected with HIV was up to 2.4 million at the end of 1996 from 1.8 million a year earlier. "In 1997, about 90,000 people will progress to [advanced], of whom about 20,000 will be children," she said. Health Minister Nkosazana Zuma released results at the same news conference of the 1996 antenatal HIV survey, which showed that the infection rate among pregnant women attending state clinics rose nearly 35%. Anonymous testing of more than 15,000 pregnant women showed the infection rate up from 10.44% at the end of 1995 to 14.07% in 1996. Infections have almost doubled from 7.5% in 1994. "The sharp increase of 34.8% over the previous year confirms that South Africa is still experiencing a fast growing HIV epidemic," the Health Ministry said in a report. The highest infection rate and a threefold increase were recorded in Northwest Province, near Johannesburg, where positive tests jumped from 8.3% in 1995 to 25.13% in 1996. KwaZulu-Natal, South Africa's most populous province and previously the worst affected, showed a modest increase from 18.23% to 19.9% in 1996. The Western Cape, which includes Cape Town, showed the lowest infection rate of 1.65%, which was unchanged from the previous year. Zuma said that the doubling rate of HIV infection had slowed from 12 months to about 24 months, but she said that the emphasis should remain on the spread of the epidemic, which hits the working population hardest. Smuts said results of the antenatal survey could be extrapolated to a national infection rate of 6%, an 11% infection rate among all adults, and a 10% infection level among men aged 15-45 years. (full text)
Data complement anti-STD activity of PRO 2000 gel. Contraceptives.
Procept, Cambridge, Massachusetts, announced preclinical results demonstrating the contraceptive efficacy of its PRO 2000 topical microbicide gel. In a program of late-breaking discoveries presented at the National Conference on Women and HIV, held in Pasadena, California, Procept scientists described the results of studies recently conducted with PRO 2000. The in vitro results showed that PRO 2000 was contraceptive when rabbits were dosed intravaginally with a gel containing a 4% concentration of PRO 2000. At a concentration about 10 times lower, PRO 2000 did not appear to affect the rabbit pregnancy rate. Results of preclinical tests have indicated that both concentrations prevent HIV infection, suggesting that contraceptive and noncontraceptive formulations of this drug may be developed. "The potential of this compound as an advancement in the area of women's health is significant," said Stanley C. Erck, Procept. "We believe that the contraceptive properties demonstrated by PRO 2000 Gel will complement the anti-HIV/STD activity we will be evaluating in clinical trials." "More than 70% of all HIV infections worldwide follow heterosexual intercourse. A major problem confounding efforts to prevent AIDS in women has been the lack of effective, female-controlled barrier methods. PRO 2000 Gel has been identified as a topical microbicide well suited for use by women to prevent HIV infection. In laboratory studies, PRO 2000 blocked infection by a wide variety of HIV strains and also was active against herpes simplex virus." Clinical studies currently are underway to assess the safety of PRO 2000 Gel in healthy female volunteers. Assuming the results of these studies are positive, additional studies will be conducted to demonstrate safety and efficacy in populations at high risk for HIV infection. (full text)
Recent large-scale field trials show that mosquito nets impregnated with insecticide can substantially reduce all-cause mortality in children in malaria-endemic areas in Africa. This paper considers the cost-effectiveness of impregnated nets, initially from the perspective of a government program which would distribute nets free of charge and organize and fund re-impregnation on an annual basis. The calculations show that with the reductions in all-cause mortality observed in the trials, complete government subsidy of nets through a vertical program would represent an efficient use a scarce resources for most combinations of assumptions. However, alternative ways of financing and organizing the use of impregnated nets are also possible and may be more cost-effective than vertical delivery. Distribution of nets and insecticide might be less costly than required for a vertical program by integrating delivery with other types of government health programs, with private sector delivery systems for other types of products, or with government systems developed for other sectors such as agriculture. Further, not all the costs need to be met by governments, as costs could be shared with donors, NGOs and the beneficiaries. The major conclusion is that impregnated nets would save a large number of lives in malaria endemic areas, they are an efficient use of scarce resources, and ways of encouraging their use need to be developed and tested. (author's)
Emergent migration policy in a democratic South Africa.
This article sets recent debates on migration policy in South Africa against broader historical realities that have shaped patterns of population movement on the subcontinent since the end of the nineteenth century. During the course of the last century, most forms of population movement were the result of disjointed regional economic development which can be traced to two epochal events at the end of the nineteenth century: the creation of the modern African state system and the discovery of mineral wealth in Southern Africa. Although regulation of migrant labor was a fundamental feature of the colonial period, it was only after 1950, when independent states began to define specific migration priorities, that states began to restrict significantly the flow of transnational labor. From this point notions such as internally displaced person, refugee and illegal immigrant become increasingly appropriate to the study of regional migration. Particular attention is given to current debate on the definition of refugee which forms part of a broader international debate. A number of South African writers have argued that, given the structural imbalances contained in the regional economy, the term "refugee" should be redefined to included economic migrants. This position is not shared by the South African Government, and an analysis of current policy and legislation demonstrates a growing tendency to restrict the influx of undocumented migrants. This is due, in part, to the recent political transition and the institutional compromises that it produced as well as the growth of negative sentiment towards illegal immigrants at both mass and elite levels, as demonstrated by two recent research findings. The article concludes with a summation of recent trends in South African migration policy and an evaluation of the ambiguous position that South Africa occupies within Southern Africa. (author's)
Population in context: a typology of environmental driving forces.
This paper presents a typology and qualitative model of causation for use in assessing the relative contributions of population growth to problems of pollution, lost biodiversity, and natural resource depletion. Population growth is placed "in context" as one of eight key driving forces that shape environmental quality today. It is treated primarily as an impact "amplifier", along with technology. Root causes are traced to paradigmatic beliefs--especially anthropocentrism and contempocentrism--which find expression in unsustainable consumption patterns and designs of political economy. (author's)
Successfully meeting population goals. Islamic Republic of Iran.
The Islamic Republic of Iran has achieved success in attaining several population goals noted H.E. A. Arabmazar, head of that country's delegation to the 53rd session of the Commission. During the last decade "the infant mortality rate declined from 44/1000 to 26/1000 live births. Life expectancy rose from 61 to 68 years and the literacy rate increased from 62.2% to 85%," he informed the Commission. Further, the population growth rate has declined from 3.2% to 1.7%, he added. Another Iranian representative at the Senior Officials segment of the meeting said that poverty alleviation measures implemented in recent years by the Government have dramatically reduced the incidence of poverty. The number of people living below the poverty line has fallen to 17% of the total population compared with 47% at the end of the decade of the 1970s. Among the measures implemented by the country is the provision of health care, including a very successful family planning program. Others are human resources development and creating productive employment opportunities. "Sustained employment is a major means of poverty alleviation," said the Iranian delegate. "It is essential that programs of human resources development aim at enabling the poor to become qualified for employment opportunities. Moreover, greater attention should be given to the expansion and improvement of social services and the empowerment and capability building of the poor." Currently, a poverty alleviation bill is being discussed by the Parliament and, if it is ratified, will be implemented from 1997. (full text)
Korean delegation focuses on women.
Among the opportunities and challenges facing the ESCAP region in the 21st century is the full and equal participation of women in all sectors of society, stated one of the representatives of the Republic of Korea at the Senior Officials segment of the 53rd session of the Commission. As a follow-up to the Fourth World Conference on Women, held at Beijing in 1995, her country passed the Women's Development Act, which entered into force in July 1996, she explained. It "provides a strong legal basis for adequate institutional and financial support towards the achievement of gender equality," which is also one of the goals of the Program of Action of the International Conference on Population and Development held at Cairo in 1994. In tandem with domestic efforts, enhancing cooperation at the regional and international levels is essential, she added. In a separate intervention, another member of the Korean delegation elaborated on the comments of his colleague. He pointed out that, "for the past 30 years, the Republic of Korea as a nation has done its best to alleviate the pressure of absolute poverty and has improved the quality of life through continued economic growth." He admitted, though, that rapid economic growth has brought about its own side effects -- "unsolved problems still remain such as residual absolute poverty and increasing relative poverty." Poverty alleviation policies aimed at creating equal opportunities must address four aspects, he noted: 1) maintenance and enhancement of health, 2) promotion of educational opportunities, 3) vocational training, and 4) employment promotion. (full text)
Survey of condom-related beliefs, behaviors, and perceived social norms in Mexican migrant laborers.
This study reports findings from a survey of condom-related beliefs, behaviors, and perceived social norms in Mexican migrant laborers that live and work in the US for extended periods of time. Snowball sampling was used to recruit 501 Mexican migrants from five "sending towns" in Jalisco, Mexico, with historically high rates of out-migration to the US. Results showed that subjects reported few negative beliefs about condom use and high efficacy to use condoms in challenging sexual situations, but social norms sanctioning condoms were limited. Results also revealed mixed knowledge of HIV transmission, poor knowledge of condom use, and higher condom use with occasional vs. regular sex partners. 44% of male migrants reported sex with prostitutes while in the US, with married men reporting less condom use with prostitutes than single men. It was concluded that condom promotion efforts with Mexican migrants should concentrate on men to encourage consistent use with occasional sex partners, including prostitutes. AIDS prevention education should be provided with sensitivity to the language needs, limited education, and extreme social and geographic marginality of this highly under-researched Latino population. (author's)
The purpose of this study was to document the effectiveness of small group condom motivation education in reducing new and reinfection rates of sexually transmitted diseases (STDs) among female teenagers. 205 female adolescents (age 13-20 years) with a current STD were studied at two sites of a Teen Health Clinic. There were 86 teens in the Study Group and 119 in the Comparison Group. Patients were sampled from December 1992 to July 1993. The patients in the Study Group received a condom motivation class given by the clinic STD educator in small groups of four or more adolescents. The Comparison Group, comparable in age and ethnicity, received treatment for their STDs but did not participate in condom motivation classes. All teens were given treatment and condoms. The sample was followed for 6 months. The total number of patients returning with new infections was 21 (14.7%). The total number of patients with reinfections was 14 (9.8%). There were no significant differences between the Study and Comparison Group on return rates, new and reinfection rates or on any sociodemographic variables. The comparison of these groups suggests that a specific condom motivation class has minimal effectiveness in urban teens. However, almost 70% of the teens returned to the clinic for their scheduled visits. It is suggested that adolescent clinics that combine family planning and STD treatment services maintain high client enrollment and therefore may be ideal locations to initiate new and continuous interventions for condom use, especially for high-risk teens. (author's)
Zimbabwean teenagers' knowledge of AIDS and other sexually transmitted diseases.
A cross-sectional anonymously administered questionnaire was used amongst 1689 secondary school girls and boys to determine their knowledge of AIDS and other sexually transmitted diseases (STDs). Their knowledge was found to be very low. While 80% could name an STD in an open question, only 16% could recognize the important symptoms of the common and treatable diseases, such as gonorrhea and syphilis. This finding is worrisome in view of the fact that these common STDs facilitate transmission of HIV/AIDS. The awareness of AIDS was high, but when it came to the mode of transmission of AIDS, the large majority were not aware of the risk of intercourse with an infected person. Furthermore, despite an intensive AIDS awareness campaign program mounted by the government of Zimbabwe, a large number of students thought that one can contract HIV/AIDS by shaking hands, sharing a toilet, and witchcraft. Misconceptions on transmission abound. The data show that there is a need to review strategies of disseminating information to teenagers regarding STDs, including AIDS, reproductive biology, sexuality, and contraception. The best strategy may be the introduction of a reproductive health education curriculum in all schools starting at an early age. (author's)
Characteristics and sexual behavior, knowledge of HIV and knowledge of attitudes to and use of the condom were assessed by a questionnaire survey of a sample of 734 patients attending a sexually transmitted diseases clinic at the Queen Elizabeth Central Hospital, Blantyre, Malawi. The male respondents had a mean age of 27.4 years compared with 24.5 for the women. Nearly two-thirds of either sex reported more than one sexual partner during the previous year. 31% of the females and 43% of the males admitted having ever exchanged money directly for sex. Knowledge about HIV transmission and prevention and the condom was generally good. Only 24% male and 45% female respondents reported having ever used the condom, with 27% and 43%, respectively, using it sometimes. No respondent used the condom always. The most common reported reason for not using the condom was partner refusal. Many of the respondents exhibited a high level of HIV risk behavior. (author's)
The research aim was to study outcome of pregnant adolescents and single young women who attended and those who chose not to attend a nonurban, developmentally appropriate, pilot antenatal clinic called the Young Moms' Clinic; furthermore, to study "perceived" outcome among the Young Moms' Clinic participants. A multidisciplinary clinic was established to provide education about pregnancy, childbirth, infant care, contraception, and healthy lifestyles to young mothers with similar backgrounds. Over a 2-year period, all adolescents and single young mothers aged 13-23 years were invited to attend the Young Moms' Clinic after the first trimester. The clinic group consisted of the first 101 young women who were invited and chose to attend. The nonclinic group consisted of the first 95 young women who were invited but declined to attend. Both groups had the same obstetric caregivers, had a similar number of prenatal visits (median number, 12), and delivered in the same hospital. Univariate and multivariate analyses were performed to determine whether participation in the clinic was an independent factor in outcome. Maternal weight gain and infant birth weight were significantly higher in the clinic group. Pregnancy complications (preterm labor, intrauterine growth retardation, anemia) were significantly higher in the nonclinic group. Participants in the nonclinic group were almost three times as likely to have cesarean section delivery as those in the clinic group. Neonatal intensive care unit transfer occurred only in infants of the control group. Participation of pregnant adolescent and young adult women from a nonurban community in a developmentally targeted pilot prenatal program resulted in fewer pregnancy complications and improved outcome in comparison with those who chose not to participate in the program. The results may be subject to bias because of self-selection among participants. (author's)
Pelvic inflammatory disease in patients with bilateral tubal ligation.
Classic teaching has stated that women who have undergone bilateral tubal ligation (BTL) are not susceptible to pelvic inflammatory disease (PID). The purpose of this study was to confirm the existence of PID in patients with BTL and to compare clinical parameters of these patients with PID patients who have not had BTL. A retrospective chart review of emergency department (ED) patients diagnosed with PID over a 1-year period at a large urban university hospital found 209 patients who fulfilled the criteria for a definition of PID. Of the 209 patients with PID, 24 (11.7%) had undergone BTL. Patients with and without BTL were compared with respect to age, white blood cell count (WBC), temperature, admission rate, length of hospitalization, prior history of PID, culture results, presence of bilateral abdominal pain, presence of rebound tenderness, and complications of tubo-ovarian abscess (TOA) and hydrosalpinx. Patients with BTL had lower WBCs (11,100/mcl vs. 14,700/mcl) and were 2.5 times less likely to be hospitalized compared to patients without BTL. These results show that PID in the setting of a prior BTL not only exists but occurs with surprising frequency and deserves further study. Patients with BTL and PID may have a clinically milder form of PID than patients without BTL. (author's)
The performance of condoms in actual use has been poorly researched in the past, especially in comparing condoms that met different quality control standards as indicated by laboratory testing. The present study used a double-blind crossover design to compare the performance of two types of condoms in actual use; one that met the Australian and International Organization for Standardization (ISO) standards for condom quality and one that met the more stringent Swiss Quality Seal requirements. 92 men recruited from Metropolitan Melbourne completed a self-report diary sheet after each condom was used, which assessed the performance of the condom and the conditions under which it was used. From a total of 1917 condom uses, there was an overall breakage risk of 2.7%. The breakage risk ratio (Australian/ISO:Swiss) for all types of use was 1.16 (95% confidence interval 0.68-1.99). When subanalyses by method of entry were performed, the condoms meeting the Swiss standard appeared to fare better than the Australian/ISO standards for anal sex (RR = 4.84, 95% CI 1.07-21.8, P = 0.022), while the opposite was the case for vaginal sex (RR = 0.74, 95% CI 0.35-1.53, P = 0.41). The result for anal use was statistically significant at the 5% level, despite being based on fewer condom trials than that for vaginal use, but this result needs to be replicated. Although the participants appeared representative of the general male population in Melbourne in the age bracket 18-46 years, there was a significant history of condom usage reported. This may have influenced the risk of breakage. (author's)
The aim of this study was to evaluate the potential causal relationship between alcohol and drug use and behavior that increases the risk of sexually transmitted diseases (STDs). The longitudinal study was conducted at an STD clinic and four community-based primary care clinics for adolescents. The participants were 82 female adolescents (age 16-19 years) who agreed to complete diaries recording each coital event. Subjects were participants in a larger study of prevention of reinfections by sexually transmitted organisms. The main outcome measure was condom use at each coital event. Predictor variables were usual pattern of condom use (when substances were not involved) and two event-specific measures: sex partner change and use of alcohol or drugs before intercourse. Average time span of the diaries was 9.2 weeks. Subjects recorded 1265 coital events. 93 substance-associated coital events were recorded by 22 subjects. Event-specific condom use was associated with usual pattern of condom use but not with event-specific variables of partner change or substance use before intercourse. These data do not support the hypothesis that substance use causes alteration of adolescent women's behavior in a manner that increases risk of STDs. (author's)
A microlaparoscopic technique for Pomeroy tubal ligation.
The aim of this study was to evaluate the efficacy of performing Pomeroy tubal ligation using microlaparoscopic techniques. 38 consecutive women desiring permanent sterilization underwent laparoscopic Pomeroy tubal ligation using small (2 or 5 mm) transumbilical laparoscopes and secondary midline sites (5 mm and 14 gauge). The procedures were performed under general anesthesia (n = 28) or local anesthesia with conscious sedation (n = 10). The mean operative time +or- standard deviation (SD) in minutes was 33.0 +or- 10.3. The mean recovery time +or- SD in minutes was 104.3 +or- 41.6. There were no operative complications, and no cases required conversion from the microlaparoscopic technique to a traditional method. The results of this study indicate that the Pomeroy tubal ligation may be performed using microlaparoscopic techniques. Furthermore, in selected cases, this technique can be performed under local anesthesia in an outpatient setting. (author's)
The aim of this study was to examine the consequences of having a physically abusive primary partner on the condom use and sexual negotiation practices of young African-American women. Interviews were conducted with 165 sexually active African-American women aged 18-29 years in San Francisco, California. Women in abusive relationships were less likely than others to use condoms and were more likely to experience verbal abuse, emotional abuse, or threats of physical abuse when they discussed condoms. They were more fearful of asking their partners to use condoms, worried more about acquiring the human immunodeficiency virus (HIV), and felt more isolated than did women not in abusive relationships. HIV prevention programs for women should address domestic violence prevention strategies. (author's)
[Act No. 18 of 9 July 1991 amending and repealing articles of Book I of the Civil Code]
Law 18 of Panama's legislative assembly dated July 9, 1991, modifies several articles of Book 1 of the Civil Code regulating marriage, divorce, and guardianship. The revised article 97 states that marriages in violation of the prohibitions of article 94 of the Civil Code are valid, but property agreements between the spouses are nullified and neither can receive property from the other. Minors under 18 who marry without parental permission are exempt from this ruling upon attainment of the majority. It is assumed that the property of widows or widowers who remarry without having a judicial inventory of the property of their legitimate minor children belongs to the children, unless proof is presented to the contrary. Guardians or their descendants are prohibited from marriage with an individual under their guardianship until the financial records are inspected. If the marriage occurs despite the prohibition, the guardian and descendant may not inherit from or administer the property of the individual. Article 98 of the Civil Code is revised to state that a widow remarrying within 300 days of the late husband's death must submit scientific proof of her pregnancy status. Article 118 is revised to require that a petition for divorce must, in cases of doubt about the possibility of pregnancy, include a medical or laboratory test for pregnancy. Article 119 is revised to state that a divorced wife may remarry once the divorce decree is recorded. A scientific test of pregnancy is required if the remarriage occurs within 300 days of the divorce. Article 120 is revised to consider the best interests of the child to be the criterion for awarding custody, rather than responsibility for the divorce. Article 248 is revised to remove several prescriptions about child custody after death of parents and to allow the juvenile court to designate a guardian in accordance with the child's best interests. Article 304 is revised to eliminate the preference for sons over daughters and for fathers over mothers in decisions about guardianship of handicapped persons.
[Act No. 45/91, the Divorce Act, Title 1, of 1 October 1991]
Paraguay's law 45/91 of October 1991 regulates divorce. No divorce without judicial sentence is recognized. Initiation of divorce proceedings also initiates liquidation of the marital property, which is overseen by the same judge. Grounds for divorce include attempted murder of the spouse, immoral behavior, mistreatment, habitual drunkenness, drug use, gambling threatening family ruin, judicially recognized permanent and serious mental illness, voluntary and malicious abandonment, adultery and de facto separation for more than one year. Minors emancipated by marriage may seek divorce only when both spouses have reached the age of majority. The judge will attempt to reconcile the parties before a divorce by mutual consent is granted. In divorces of persons with severe mental illness, the healthy spouse should assist for life with medical care and support if the ill spouse is otherwise without means. The presumed death of a missing person declared by a judge authorizes the surviving spouse to remarry. Reappearance of the missing spouse does not nullify the second marriage. Divorced persons must wait 300 days before remarrying. The judge of minors is responsible for questions of custody, support, and visitation of minor children of the couple. The spouse not declared at fault retains the right to alimony, unless a new marriage or consensual union is entered or the spouse receiving alimony does grave injury to the other. Divorced women are not to use their former husband's surnames.
[Amendments of 21 June 1991 to the Swiss Penal Code and the Military Penal Code (Sexual Offenses)]
Modifications to title 5 of the Swiss penal code dated June 21, 1991, concern infractions against sexual integrity. Article 187 states that persons committing sexual acts with children under age 16 or inducing them to have sex will be punished by reclusion for 5 years or more or by imprisonment. The act is not punishable if the age difference is under 3 years. The sanction may be different in some cases if the perpetrator is under 20. Persons taking advantage of relationships of dependence in education, work, or other nature to commit a sexual act on a minor at least 16 years old will be imprisoned. Persons using threats or violence to force another into a sexual act or rape will be punished by reclusion for 10 years or more or imprisonment. Use of a dangerous weapon will be punished by a sentence of at least 3 years. If the perpetrator is married to the victim, the matter will be pursued upon complaint. A person committing a sexual or analogous act on a person incapable of discernment or resistance will be punished by reclusion for 10 years or imprisonment, and one in a relationship of authority who takes advantage of a situation of hospitalization, detainment, or similar status to commit a sexual act will be imprisoned. In several of the crimes, if the victim contracts marriage with the perpetrator, the case may be dropped or the sanction otherwise modified. Those who force minors into prostitution or in other ways encourage prostitution are subject to 10 years' reclusion or imprisonment. Persons making pornography available to minors under age 16 are subject to imprisonment or fine. Persons fabricating, importing, selling, or otherwise making available pornography involving children, animals, or human excrement or involving violence will be imprisoned or fined, and the objects will be confiscated. Individuals violating canton regulations regarding places, hours, and modes of exercise of prostitution may be fined.
[Ordinance No. 1 on asylum procedures (Ordinance No. 1 on asylum) of 22 May 1991]
This document contains Switzerland's Ordinance 1 dated May 22, 1991, relative to procedures for granting asylum to refugees and an ordinance dated December 18, 1991, concerning the Swiss Commission for Appeals in Matters of Asylum. The ordinances for asylum carry out the mandate of Article 50 of the Law of Asylum of October 5, 1978, while the ordinances regarding appeals implement Article 11 of the same law. The 20 articles of Ordinance 1 all identify the article in the original law to which they refer. The ordinances cover such topics as second asylum, admission to a third country, family regrouping, refusal of authorization to enter, quotas for distribution of the refugees in the different cantons, procedures preceding a decision denying entry, complementary hearings, and other procedural matters. Section 1 of the ordinance concerning the Swiss Commission for Appeals in Matters of Asylum states that it is responsible for definitive decisions in appeals of actions by the Federal Office of Refugees. Section 2, on organization of the Commission, describes the composition of the commission, the nomination and requirements of the 29 judges, the officers of the commission, administrative structure, documentation, and public information services. Section 3 describes the procedures of the Commission.
This document contains the text of a 1991 UN resolution on the establishment of national, regional and international machinery to promote the advancement of women. After reviewing previous UN action on this issue, the resolution recommended that: 1) all countries establish appropriate machinery for the advancement of women by 1995; 2) governments provide adequate resources to ensure the effective functioning of national machinery; 3) the UN provide technical assistance; 4) countries exchange information on this topic; 5) the UN support such an exchange of information; 6) a UN interregional advisor assist in these and related efforts; 7) technical help be provided to facilitate the preparation of reports for the 1995 World Conference on Women; 8) the UN Secretary-General report on UN activities in this regard to the 36th session of the Commission on the Status of Women; 9) the Secretary-General invite governments to publish pertinent case studies; 10) appropriate sections of the Secretariat be strengthened; 11) governments make accurate information on their national machinery available; 12) governments ensure proper training of staff and include gender-analysis training and information; and 13) the UN report on the effectiveness of these efforts to the World Conference on Women.
[Resolution No.] 1991/18. Violence against women in all its forms [30 May 1991].
This document contains the text of a 1991 UN Resolution on violence against women. After reviewing previous UN action on this issue and noting that the Convention on the Elimination of All Forms of Discrimination against Women fails to explicitly address violence, the resolution recommends that member states 1) recognize that violence against women can be countered by a variety of measures, 2) remember that violence against women results from male-female power imbalances, 3) prohibit violence against women, and 4) protect women from all forms of mental or physical violence and that 1) an international instrument be developed to address this issue explicitly, 2) the UN Secretary-General convene a meeting of experts on this issue, 3) governments train criminal justice and health care personnel to ensure justice in equality issues, and 4) researchers investigate the causes of violence against women.
Act No. 443, of 30 May 1991, concerning equal opportunities.
This document contains the text of Sweden's 1991 Act on equal opportunity in employment for men and women as well as an analysis of the Act. The opening paragraph states that the purpose of the Act is to promote equality at work for women and men. The Act covers cooperation between employers and employees; affirmative action; working conditions; recruitment activities; the requirement of employers of 10 or more to prepare an annual equal opportunities plan; collective agreement; a definition of "sex discrimination" which includes direct and indirect discrimination; sex discrimination in recruitment, promotion, or training; conditions of employment; organization of work; termination or transfer; statement of qualifications in cases of alleged sex discrimination; prohibition of sexual harassment; compensation for damages; supervision of this Act; creation of an equal opportunities ombudsman and equal opportunities board; obligation of employers to supply information; functioning of the equal opportunities board; and proceedings in discrimination cases before the Labor Court. The analysis notes that this law remedies many of the faults and loopholes of the previous law and is extremely comprehensive in its definition of "unacceptable discrimination according to sex." While primarily concerned with improving the working conditions of women, the law can be applied to paternity leave and male child care issues.
[Resolution No.] 1991/23. Refugee and displaced women and children [30 May 1991].
This document contains the text of a 1991 UN resolution on refugee and displaced women and children. After reviewing previous UN action on this issue, the resolution recommends that: 1) member states cooperate with UN agencies and nongovernmental organizations to address the root cases of refugee migrations; 2) women and children be protected from violence and abuse; 3) the specific needs of refugee women and children be considered in planning; 4) refugee women be given sufficient information to make decisions on their own future; 5) women and, when possible, children, be given access to individual identification documents; 6) refugee women participate fully in the assessment of their needs and in the planning and implementation of programs; 7) the UN Secretary-General review the ability of its organizations to address the situation of refugee women and children; and 8) international organizations increase their capacity to respond to the needs of refugee women and children through greater coordination of efforts. The resolution commends member states which receive large numbers of refugees and asks the international community to share the resulting burden and further recommends that all pertinent organizations adopt an appropriate policy on refugee women and children, female field staff be recruited, staff be trained to increase awareness of the issues related to refugee of women and children and skills for planning appropriate actions, and the collection of refugee statistics be disaggregated by age and gender.
Preparatory draft of constitution. [Excerpts, 2 June 1991].
This document contains major provisions of the 1991 Constitution of Burkina Faso and a chronology of important political events in 1989-91 which preceded adoption of the constitution. Title 1 of the constitution sets forth the fundamental rights and duties of citizens. These provisions prohibit discrimination based on race, ethnic background, region, color, sex, language, religion, caste, political opinions, wealth, and birth. Slavery is forbidden as is mistreatment of children. Equal protection under the law is guaranteed as is the inviolability of family and household, religious freedom, freedom of the press, the right to information, the right of asylum, and free choice of residence. Citizens are required to defend the territory. Political participation is guaranteed, and the creation of anti-imperialist political parties is permitted. Natural resources are the property of the people, and the right to personal property is protected. The constitution recognizes social and cultural rights to education; employment; social security; housing; health; social protection of mothers, infants, the aged, and the handicapped; and to artistic and scientific creation. Discrimination in employment based on sex, color, social origin, ethnicity, or political opinion is forbidden. The freedom of association and the right to form unions are protected. The family is protected as the basic unit of society. Title 2 of the constitution is concerned with the organization of the state and the sovereignty of the people.
Planned Parenthood Ass'n v. Miller [17 June 1991].
This document reports on four US court cases. In Planned Parenthood Association vs. Miller, the plaintiffs challenged the constitutionality of Georgia's Parental Notification Act by claiming that 1) it does not allow a physician to notify a minor's parent through private uncertified mail carriers, by giving the minor a note to take to her parent, or by telephone; 2) it requires that a minor must wait 72 hours from the time that the notification is sent before obtaining an abortion; and 3) its judicial bypass provision is too burdensome. In rejecting the challenge, the Court ruled that 1) the legislature can impose notification requirements that will ensure that a parent or guardian is actually notified; 2) the waiting period does not unduly burden a minor's rights and ensures that a minor's decision is voluntary and informed; and 3) the judicial bypass proceedings provide a valid timetable for action, sufficiently protect a minor's anonymity, and are adequate in deeming that a minor's petition is granted if not acted upon in a certain amount of time. In Glick vs. Mackay, the US Court of Appeals, Ninth Circuit, held that the provisions of Nevada's abortion law relating to judicial bypass proceedings were unconstitutional because 1) they required a minor to show that parental notification would not be in her best interests rather than requiring the Court to determine this fact and 2) they placed no time limit on bypass proceedings. In Eubanks vs. Wilkerson, the US Court of Appeals, Sixth Circuit, held that a federal judge had erred in applying limiting language to modify a Kentucky statute to avoid "unconstitutionality" once it had ruled that the statute unduly burdened a woman's right to an abortion. In Planned Parenthood of Nashville vs. McWherter, the Supreme Court of Tennessee held that a statute requiring notice to be given to the parents or guardians of a minor before she obtains an abortion had the effect of repealing a previously enacted statute that required parental consent for a minor to obtain an abortion.
This document contains the text of a 1991 act of the state of Louisiana, enacted on June 18, 1991, over the governor's veto, which prohibited the performance of abortions except 1) to preserve the life or health of the unborn child or to remove a dead unborn child; 2) to save the life of the mother; or 3) to terminate a pregnancy resulting from rape or incest. On 7 August 1991, the US District Court, Eastern District of Louisiana, ruled this Act unconstitutional.
Migration Amendment Act 1991 [26 June 1991].
This document contains the text of Australia's 1991 Act which amends the Migration Act of 1958 to do the following, among other things: 1) limit the power to grant visas and entry permits to specific situations and hold that a travel-only visa does not entitle its bearer to enter Australia or be granted an entry permit; 2) narrow the circumstances under which a person holding an entry visa may enter Australia and prohibit an entry visa from being granted to a "statutory" visitor; 3) require persons applying for visas and entry permits to make a declaration about their character and/or conduct; 4) make the provision of a false or misleading statement in such a declaration grounds for being considered an illegal entrant; 5) provide that a permanent entry permit must not be granted to a non-citizen after entry into Australia unless the non-citizen is the holder of a valid temporary permit; 6) specify that a person subject to a deportation order who leaves Australia before the order is executed will be considered to have been deported; 7) increase the penalty for carriage of persons to Australia without documentation; and 8) limit the period in which an application can be made to review an immigration decision to a maximum of 28 days if the person is in Australia. In addition, the Act contains new provisions that allow authorized officers to designate as unprocessed persons those whom they reasonably suppose would be illegal immigrants if allowed to enter Australia. Such persons are to be taken to a processing area to wait until a decision is made on their request for an entry permit. If their request is refused, they are to be removed from Australia as soon as possible with the proprietor of the vessel on which they came to Australia liable for their removal and for their maintenance while in Australia.
[Resolution No.] 1991/93. International Conference on Population and Development [26 July 1991].
This document contains a 1991 UN resolution on the 1994 International Conference on Population and Development (ICPD). After reviewing previous UN action on this issue, the resolution 1) names the conference; 2) makes recommendations about preparatory activities; 3) identifies six broad objectives for the ICPD; 4) identifies population, sustained economic growth, and sustainable development as the overall theme of the conference and identifies six issues which require attention (population growth and structure; population policies and programs; the interrelationships between population policies, development, the environment, and related matters; changes in the distribution of population; linkages between the status of women and population dynamics; and family planning programs, health, and family well-being); 5) stresses the need to take the circumstances of developing countries into consideration; 6) authorizes the UN to convene expert meetings on each issue; 7) requests that appropriate UN agencies guide the preparatory activities and that UN resources be devoted to this task; 8) asks regional commissions to meet to review population policies and programs; 9) sets up a mechanisms to receive progress reports; 10) sets dates for the second and third sessions of the Preparatory Committee; and 11) makes funding recommendations.
[Resolution No.] 1991/92. Work programme in the field of population [26 July 1991].
This document contains the text of a 1991 UN resolution on the UN's work program in the field of population. After reviewing previous UN action on this issue and stressing the relationship between population and development, the resolution notes with satisfaction the progress made in implementing the population work program to date and makes the following specific requests of the Secretary-General: 1) to continue to give monitoring world population trends and policies high priority; 2) to continue working on specified issues; 3) to give priority to strengthening multilateral technical cooperation in specified areas; and 4) subject to the availability of funds, to study the needs of developing countries for skilled human resources in the field of population. In addition, the resolution reemphasizes the importance of maintaining the population program and strengthening coordination among various UN agencies and departments and among member states and appropriate intergovernmental, nongovernmental, and national organizations.
Refugees Act, 1991 [24 August 1991].
This document contains the text of Belize's 1991 Refugees Act which, among other things, gives the force of law to the Geneva Convention Relating to the Status of Refugees and the Protocol Relating to the Status of Refugees. Various sections of the act present its title and interpretation, provide force of law to the Convention and Protocol, define "refugee," establish a "Refugees Office" and Director of Refugees, establish and define the functions of a "Refugee Eligibility Committee," create the conditions under which a person can apply for refugee status, grant the right to petitioners to remain in Belize pending the outcome of their petition for refugee status, and deal with such issues as the residence in Belize of recognized refugees; the family of recognized refugees; the rights and duties of recognized refugees; the non-return of refugees, their families, and other persons; the withdrawal of recognition of refugees; the expulsion of recognized refugees and protected persons; and pertinent regulations.
Law No. 20 of 1991 on the Consolidation of Freedom [1 September 1991].
This document contains the text of Libya's 1991 Law on the Consolidation of Freedom. This law gives male and female citizens equal rights, including the right to defend the homeland. Freedom of expression is limited to exclude "covert calls for ideas or opinions." Citizens may form trade unions and other societies and to choose their mode of employment. The law protects private ownership and land tenure as well as domestic privacy and freedom of movement. Refugees are welcome, and extradition is forbidden. Citizens have the right to education, social protection, and establishment of a family based on marriage. Divorce requires mutual consent or a court ruling, and mothers have the right to rear children and to stay in the conjugal home while the children are growing. Women have the right to work, and children are protected from working in jobs which impede their growth or moral development.
This document contains the text of a 1991 Chinese amended law which seeks to punish criminals who abduct and sell women and children. The law assigns a prison sentence of 3-10 years and a fine for the abduction and sale of women and children. When circumstances are deemed especially serious, the penalty is increased to death and confiscation of property. Such circumstances include being the ringleader of a group which abducts and sells women and children, abducting and selling three or more women or children, raping abducted women, inducing or forcing women to prostitution, causing serious injury or death to abducted women and children or their relatives, and selling women and children outside of the territory. A 10-year sentence is to be imposed for the use of force, threats, or narcotics to kidnap women and children to sell them. Those who buy abducted women or children are also to be punished unless they fail to obstruct the women from returning to their home, fail to abuse the children, or fail to obstruct the children from saving themselves.
This document contains the text of a 1991 law detailing the legal status of foreigners in Lithuania. The law contains general statements which protect the rights of foreigners, allow Lithuania to impose retaliatory restrictions on the rights of foreigners who are citizens of countries which restrict the rights of Lithuanians within their borders, apply the Constitution and laws of Lithuania to foreigners, require foreigners to respect the customs and traditions of Lithuania, and detail the conditions under which a foreigner may apply for permanent residence. Part 2 of the law provides specifics about the fundamental rights, freedoms, and obligations of foreigners in Lithuania. The third part of the law deals with the arrival and departure of foreigners, and the fourth part covers deportation. The law concludes by exempting diplomatic staff and acceding supremacy to any statutes contained in any international treaty which Lithuania has signed.
Law for Protection of Minors [4 September 1991].
This document contains the text of China's 1992 law which seeks to protect minors under age 18 by guaranteeing their legitimate rights and interests, respecting their human dignity, fostering their mental and physical development, and combining education with protection. All adults and organizations are charged with the duty of protecting minors, and minors will receive the education they require to safeguard their own legitimate rights and interests. Families must not mistreat minors, discriminate against females or handicapped children, or drown or abandon infants. Parents must not force minors to discontinue compulsory education; must stop minors from smoking, drinking alcohol, gambling, taking drugs, or engaging in prostitution; and must not allow or force minors to get married. Schools also have specific duties towards minors, and the state will create organizations to develop the social and cultural lives of minors. Employment of minors under age 16 is forbidden except according to specific stipulations, and the state will regulate the employment of minors aged 16-18. Public health departments and schools must provide the necessary medical care for minors, including the prevention of disease. In criminal cases, minors will be protected from public scrutiny and, if sentenced to prison, will be housed separately from adults. The inheritance rights of minors are protected. The law also provides for punishment to be meted out in cases when a minor's rights are denied or when an adult contributes to the delinquency of a minor.
Lithuanian Republic Law on Immigration [4 September 1991].
This document contains the text of Lithuania's 1991 Law on Immigration. The law establishes the right of foreigners and their families to immigrate to Lithuania and the procedures under which they may do so. Foreigners may be denied permission to immigrate if they 1) have a dangerous infectious disease, 2) are mentally retarded or ill, 3) abuse drugs or other substances, 4) are homeless, 5) have committed a serious premeditated crime within the past five years, 6) have no legal source of income, 7) engage in activities directed against Lithuania, 8) have been deported from Lithuania within the past five years, 9) knowingly committed fraud when applying for residency, or 10) do not possess proof of identity. The Supreme Council will establish an annual immigration quota. Immigrants will be given the opportunity to learn Lithuanian and otherwise adapt to life in the country. The law also sets forth the procedures for consideration of immigration petitions, requires that immigration statistics be maintained, and accedes to any international treaty which Lithuania has signed.
This Act makes a number of modifications to Belgium's law relating to the access of foreigners to Belgium. In particular, it revises Article 52 of the Act of 15 December 1980 to authorize the government to turn away those claiming refugee status at the border a) if they are considered to be a threat to public order or national security; b) if their request is based on facts that do not qualify them for refugee status; c) if they have been expelled from Belgium within the last 10 years; d) if, after leaving their country of origin, they have resided in another country for at least 3 months without fear of persecution or in other countries for 3 months without fear of persecution in the last of these countries; e) if they have in possession a ticket for transport to another country as well as documents allowing them to enter that other country; or f) if the person comes from a country which, during the previous year, accounted for at least 5% of asylum applicants, but of whom less than 5% were granted refugee status, unless that person can establish a serious risk to life or liberty. In addition, the Act authorizes the government to refuse to grant refugee status to persons already in the country for many of the same reasons, in particular item f) above. Further provisions of the Act contain rules on determining the domicile of persons claiming refugee status; on appeals, including the provision that an appeal no longer automatically suspends deportation procedures; on the composition of the appeals commission; and on the detention of foreigners at the country border, among other things. Those detained at the border will not be considered to have entered the country. A Royal Order of 25 November 1991 (Moniteur belge, 5 December 1991) designates Ghana, India, Pakistan, and Poland as countries to which item f) above applies. A Royal Order of 25 September 1991 (Moniteur belge, 3 October 1991) sets forth new rules on the notification by the Ministry of Justice of its rejection of applications for refugee status. A Royal Order of 30 October 1991 (Moniteur belge, 17 December 1991) provides that the minister in charge of foreign affairs shall provide an identity card free of charge to diplomats, employees of international institutions, and their children under age 5. These persons are not subject to provisions limiting immigration or procedures for the registration of foreigners.
[Population and society in twentieth-century Venezuela]
This is an analysis of population dynamics in Venezuela over the course of the twentieth century, with emphasis on the period since World War II. The first chapter describes population trends over time using data from the censuses taken in the late nineteenth century and over the course of the twentieth century. The second chapter analyzes trends in mortality; the third, trends in fertility. The fourth chapter looks at the demography of the major cities, and the fifth and final chapter analyzes immigration trends. (ANNOTATION)
Report on the demographic situation in Canada 1996.
Translated from the original French, this is the 1996 edition of an annual review of the demographic situation in Canada. There are sections on Canada and the world, nuptiality, fertility, mortality, international migration, internal migration, and demographic aging. As in previous years, a particular subject is selected for an in-depth examination; this year, the topic is common-law unions. The authors "have studied its general evolution, the principal factors associated with its increasing numbers and certain of its consequences, as well as its differing rate of diffusion through Canada's sub-populations. The analysis is based mainly on the results of the General Social Survey carried out by Statistics Canada in 1995." (EXCERPT)
The Texas challenge: population change and the future of Texas.
The implications of current population trends in the state of Texas are examined in this study. Specifically, the authors "summarize our most recent and comprehensive attempt to examine systematically the impacts of change in four sets of demographic factors that are markedly altering Texas population and which we believe are likely to play a major role in determining the future of the state. We examine the implications of change in the rate of growth of the Texas population and of inmigration and immigration in that growth, of the increase in the size of the minority population, of the aging of the population, and of change in household composition. We analyze these as they are expected to affect the socio-economic resources of Texans and, through such resource change, the demand for a variety of public- and private-sector goods and services in Texas." (EXCERPT)
[Population and social policy in Japan and Mexico, 1870-1990]
This is a comparative analysis of demographic trends in Japan and Mexico from the end of the nineteenth century up to 1990. The first part examines demographic trends over time, first in Japan and then in Mexico, and describes how population policies in the two countries have changed in response to those trends. The focus is primarily on fertility, but some consideration is given to mortality. The second part discusses changes in the characteristics of the two populations over time, and considers the modifications in social policy that have been made in response to those changes. The focus is on education policy and on the development of the labor force. The author also examines how the Japanese are planning to deal with the problems posed by the aging of the population.
Demographic trends in Vietnam.
"Asia's four `little dragons' (South Korea, Hong Kong, Singapore and Taiwan) have in common not only an economic boom, but also the same rapid demographic transition. How does Vietnam, whose economy is poised for a take-off, stand in this respect? In an attempt to answer this question, [the authors] study the growing corpus of information which a number of ad hoc surveys have added to the 1979 and 1989 population censuses." (EXCERPT)
[Twenty-fifth report on the population situation in France]
This is one in a series of annual reports, mandated by French law, which review the current demographic situation in France. The first part contains a description of recent demographic trends, including fertility; abortion; marriage and divorce; mortality; and AIDS. The second part examines the resident population of foreign origin; trends in immigration and the impact of policies designed to affect immigration; and the realities of the assimilation of immigrants. (ANNOTATION)
The end of the demographic explosion in the Mediterranean?
"We...compare the UN projections made in 1994 to the previous set in 1992 and to the Blue Plan projections, for [Algeria, Egypt, Morocco, Syria, Tunisia, and Turkey, the] six most populated [developing countries in the Mediterranean region]....We shall also consider more briefly the lesser populated countries. This will enable us to appreciate the changes that have occurred in the UN's perception of population growth in this region." (EXCERPT)
[The demographic situation in the Sakha Republic (Yakutia)]
The authors analyze population dynamics over the period 1991-1995 in the Sakha Republic, formerly known as Yakutia and located in Siberia, Russia. The authors note that the positive balance resulting from natural increase is cancelled out by the level of out-migration from this region. (ANNOTATION)
[The socio-demographic situation of the region affected by the radiation catastrophe]
This is an analysis of the demographic and social impact of the Chernobyl nuclear disaster on the population living near the site of the accident. (ANNOTATION)
[Demographic trends in Sub-Saharan Africa: the ambiguity of "cultural" explanations]
"Although concerns have been expressed about how demographic knowledge is perverted for political and administrative ends--with detrimental social consequences--there seems to be less interest in the objects of demographers' work. By looking at research studies supporting the thesis of an `African system' controlling procreative and sexual behaviour, this article highlights the hybrid nature of demographic knowledge and the various issues involved in the hypothesis of a `distinct Africa'." (SUMMARY IN ENG AND SPA) (EXCERPT)
[Mediterranean Europe and population change. Are the countries of the South unique?]
In the context of European demographic trends as a whole, the author analyzes demographic trends in the European countries that border the Mediterranean. The demographic changes that are occurring are analyzed in the light of ongoing changes in economic activity and employment. The author examines whether there is a common pattern in the developments affecting these Mediterranean countries. The author also discusses whether current events in Southern Europe are due to a difference in the timing of the second demographic transition affecting fertility trends since World War II, or to cultural and institutional characteristics that are unique to the region.
[Dynamics of population in the USSR (1959-1989)]
Geographical differences in the rates of population growth and in the distribution of the rural and urban population are analyzed over the course of the last 30 years of the existence of the Soviet Union. (SUMMARY IN ENG) (ANNOTATION)
Swedish urban demography during industrialization.
"This anthology presents contributions to an international conference on urban demography in Sweden held in Umea, December 3-5, 1993, and organized by the Centre for Population Studies at the Demographic Data Base. Family reconstituted data from the DDB and the Stockholm Historical Database provide material for many of the studies. The authors discuss both general aspects of urbanisation and its relation to population growth, and more specific issues like the role played by migrants in population increase and structural changes. The articles cover different urban environments such as Stockholm, Kalmar, Linkoping, Uppsala, Vasteras and Sundsvall. Furthermore, developments in Sweden are compared with those in urban England. Previous theories are challenged and new, important knowledge is presented." (EXCERPT)
Population history of western U.S. cities and towns, 1850-1990.
Using data primarily taken from the U.S. census, population estimates are presented for the towns and cities of the western states for 10-year intervals from 1850 to 1990. (ANNOTATION)
Metropolis or region: on the development and structure of London.
"Drawing on a disparate range of sources and viewing the question from several perspectives, an attempt is made to trace the development of London over the period since 1800. An account of the physical expansion and population growth is outlined, with `London' defined at a number of distinct scales. Attention is first focused on London as a metropolis, and various modelling techniques are used to illustrate the nature of metropolitan expansion. Consideration is given to the possibility that the changing spatial distribution of population through migration may be likened to a well-known process in physics. This is followed by an analysis of London at the broader scale of a region, with similar modelling techniques being employed. Finally, the question is raised as to whether London can still be meaningfully viewed as a metropolitan entity or whether a regional perspective is now more appropriate." (SUMMARY IN FRE AND GER) (EXCERPT)
An urbanizing world: global report on human settlements, 1996.
This book examines "conditions and trends in cities and other settlements around the world and...the urbanization process through which more than half the world's population will soon live in urban centres. Prepared by Habitat (the United Nations Centre for Human Settlements) the book shows the positive and negative side of cities. Drawing from thirty specially commissioned papers from leading specialists in both North and South and on data from recent censuses, it shows how the growth in urban population has slowed in most parts of the world, while the scale of urban poverty has been underestimated. The book also describes what is being done to address the problems of poor housing and environmental degradation. The main conclusion...is the importance of good governance in cities. It describes how cities have great potential to combine healthy and safe living conditions, cultural riches, and environmental advantages. It also provides illustrative case-studies of cities where poverty, very poor housing conditions and lack of basic services have been tackled, environmental performance much improved and dependence on motor cars reduced." (EXCERPT)
Simulating urban population density with a gravity-based model.
"Theoretical justifications for the negative exponential urban density function were first proposed by urban economists, although some of their foundations have been criticized. From the geographer's perspective, the gravity-based model reported in this research uses a well-known concept (the `potential') to offer an alternative explanation. Using numerical analysis techniques, the model simulates various urban density patterns. By varying the model's parameters (the distance friction coefficient [beta] and the city size), the numerical simulations do confirm two important empirical findings: the flattening of density gradients over time owing to transportation improvements, and flatter gradients in larger cities. The observed relationship between the [beta] value and the urban density gradient, as established by this research, opens an avenue for empirical testing." (EXCERPT)
Population of South Africa: updated estimates, scenarios and projections 1990-2020.
The aim of this report "is to provide a quantitative exposition of the size, structure and distribution of the South African population, and it is directed at especially those persons requiring detailed information on the demography of this country....An in-depth analysis of demography is currently being made with the intention to supplement this quantitative presentation with a qualitative analysis." (EXCERPT)
[The working population should continue to rise for a decade]
Future trends in the size and characteristics of the population of working age in France are analyzed using data from official sources. "The future working population is expected to comprise even fewer young people and more women than today. This population should continue to grow and will probably have risen by one and a half million people by 2006, essentially for demographic reasons. The trend should subsequently reverse due to the first post-war generations reaching 60 years old. The working population should therefore start to decrease. Yet the effect of the turnaround should remain modest up to 2015." (SUMMARY IN ENG AND GER AND SPA) (EXCERPT)
New South Wales' aged population in 2011.
"The aim of the paper is to outline a picture of likely demographic developments in the State's elderly population by the end of the first decade of [the] next century....The picture presented in the paper is based on data from two main sources: (a) population projections from the New South Wales Department of Planning (DoP) published in 1994 and (b) 1991 Census and other population data from the Australian Bureau of Statistics (ABS)....For the purposes of the paper `the elderly' are defined as persons aged 65+." (EXCERPT)
[The future of humanity over the long term: after the transition?]
Some long-term aspects of global fertility trends are explored, starting from UN projections up to the year 2050. Three alternative hypotheses are suggested and their implications discussed: universal adoption of the one-child family norm; two-stage fertility behavior, in which women achieve replacement fertility by having most of their children at a young age, but have some more children between ages 50 and 59; and a fertility regime which guarantees replacement, but in which most children are born to women aged 45-54. Long-term population trends are considered based on two alternative assumptions: that life expectancy is limited to age 85, and that life expectancy increases to 150 years.
[Projections of the population of the Russian Federation up to the year 2010]
Population projections are presented for Russia up to the year 2010. Three alternative projections are considered, according to optimistic, neutral, and pessimistic assumptions concerning future trends in fertility and mortality. The projections are given separately for the rural and urban population, and for the different republics in the Russian Federation. (ANNOTATION)
Future population and education trends in the countries of North Africa.
This report reviews the available data on recent demographic trends in North Africa, and presents some projections of future population trends in the region, with particular emphasis on how these trends will affect education. It is noted that "the projection of education is...particularly suitable for the demographic cohort-component method because it is the past and present school enrollment of the young cohorts that largely determines the future educational composition of the population. It turns out that, due to the large educational fertility differentials and the great inter-cohort differences in education in the countries of North Africa, an explicit inclusion of education in projections makes the population projections more accurate." (EXCERPT)
[The use of years of life lost for measuring the level and change of mortality]
"The use of the new index of years of life lost allows us to relate mortality by age and causes of death to the change of the life expectancy, at birth or between any given ages. This index replaces the use of the multiple decrement life tables for analyzing the impact of the change in mortality by age and cause of death on the life expectancies....The article presents the theoretical derivation of the index, some examples of its use, and a detailed calculation." Examples provided include Mexico, Chile, and Argentina. (SUMMARY IN ENG) (EXCERPT)
"This paper presents a new, continuous, version of the index of years of life lost (YLL) in the population, distinguishing different causes of death. Also, it shows the mathematical relationship between the YLL and temporary life expectancies in the discrete and continuous cases....The model is applied to the analysis of mortality of the province of Cordoba, Argentina, during 1947-1991." (SUMMARY IN ENG) (EXCERPT)
What demographers can learn from fruit fly actuarial models and biology.
"Historically demographers have viewed the results of actuarial studies of nonhuman species, particularly those on invertebrates such as fruit flies, as largely irrelevant to investigations on human populations. In this paper I present life table data from large scale studies on the Mediterranean fruit fly, and show that they provide important insights into fundamental aspects of mortality relevant to human populations: the trajectory of mortality at older ages, sex mortality differentials, the concept of maximal life span, and demographic heterogeneity and selection. An overriding theme of the paper is the need for demographers to acquire a heightened awareness of new developments in biology including areas such as evolutionary ecology, experimental demography and molecular medicine." (EXCERPT)
Two approaches to making mortality forecasts are examined: the extrapolation method, based on past mortality trends, and the target method, whereby a threshold is fixed which the mortality indicator should reach at the end of the forecast period. "This chapter will look at these two approaches, indicating the hypotheses and methods most widely used in demography. The results will be given of a number of applications for ex post comparisons with data observed to assess each method's potential in interpreting the reality in question. Focus will then be given to the impact of the length of the data series on the forecasts' outcome, also taking into consideration for certain countries in Europe the estimates provided by some international and national bodies." The author stresses the importance of analyzing potential changes in individual causes of death. (EXCERPT)
Death and taxes: longer life, consumption, and social security.
"In this paper we focus on the influence of mortality decline on the long run finances of the [U.S.] Social Security system, excluding Medicare. The paper is divided into three parts. In the first part we develop an analytic approach for deriving comparative static effects of different mortality levels....In the second part...we consider the likely extent of mortality declines in the coming decades....In the third part, we combine the work of the first two parts in dynamic simulations to examine the implications of mortality decline and of alternative forecasts of mortality for the finances of the Social Security system. Also, we develop stochastic population forecasts as outlined by Lee and Tuljapurkar (1994) of the Social Security finances, which we compare to recent Social Security Administration forecasts, and use to assess the relative importance of uncertainty in mortality and fertility." (EXCERPT)
"In 1825 British actuary Benjamin Gompertz made a simple but important observation that a law of geometrical progression pervades large portions of different tables of mortality for humans. The simple formula he derived describing the exponential rise in death rates between sexual maturity and old age is commonly referred to as the Gompertz equation--a formula that remains a valuable tool in demography and in other scientific disciplines. Gompertz's observation of a mathematical regularity in the life table led him to believe in the presence of a law of mortality that explained why common age patterns of death exist....In this paper we review the literature on Gompertz's law of mortality and discuss the importance of his observations and insights in light of research on aging that has taken place since then." (EXCERPT)
Contributions of various major causes of death to life expectancy in Singapore, 1980-1990.
"This paper considers the contributions by age of the various major groups of deaths to the increase in life expectancy at birth between 1980 and 1990 for both sexes in Singapore. Sixteen cause groups were used in the study. The data were analysed using LIFETIME, a personal computer package with a wide variety of methods for mortality investigations. Respiratory diseases made the largest contribution to the increase in life expectancy for both sexes. In contrast, ischaemic heart disease made a negative contribution of 1% in the gain in female life expectancy but contributed 12% improvement for males. Life tables for Singaporean males and females in the year 2000 were projected by extrapolating the mortality trends observed in earlier periods. The calculations show the life expectancy at birth in the year 2000 to be 74.72 years for males and 79.48 years for females." (EXCERPT)
A method of estimating infant deaths in Korea.
"The goal of this project was to develop a new method for estimating infant deaths in [South] Korea. An attempt was made to collect information on real infant death cases by using...medical insurance benefit data and by conducting a medical facilities survey, which allows us to [trace] back the fate of the births from the delivery. Another strategy employed was the gathering of information on infant deaths from the various existing sources and integrating them into one set after adjusting for overlapping cases among the sources." (SUMMARY IN KOR) (EXCERPT)
A multilevel model of sudden infant death syndrome in England and Wales.
The relationship between migration and sudden infant death syndrome (SIDS) in England and Wales is analyzed using official data for the period 1979-1983. "In this paper, multilevel modelling is used to examine the variability in SIDS deaths at different geographical scales, namely district, county, and regional levels. Given the population-mixing hypothesis, it is possible that high levels of population mixing in one district will have an effect on the spread of infections in an adjacent district, and the rates for individual districts will not be spatially independent of each other. Factors such as climate varying at regional scale may also be important. A log-linear multilevel model is developed to examine these issues, and the discussion focuses on the methodological issues raised by the analysis such as appropriate multilevel structure, methods of estimation, dispersion of residuals, and significance of parameter estimates." (EXCERPT)
[Child and adolescent mortality in Uruguay]
"Uruguay can be ranked among the countries with fairly reliable vital statistics. The last population census included questions about ever-born and surviving children which allow [the derivation of] independent estimations relative to level and trends of infant and early childhood mortality. The purpose of this paper is to estimate such parameters based on 1985 Census information and compare them with those of 1975. Furthermore, particular interest is paid to the differentials which show that Uruguayan society is no longer the homogeneous society it seemed to be decades ago....The last chapter is devoted to examining infant mortality by causes of death. This section evaluates the amount of lives that could be saved, if deaths due to exogenous factors are avoided." (SUMMARY IN ENG) (EXCERPT)
Physical activity and mortality in postmenopausal women.
The association between physical activity and all-cause mortality in postmenopausal women is analyzed using data on 40,417 Iowa women aged 55-69 in 1986. The "results demonstrate a graded, inverse association between physical activity and all-cause mortality in postmenopausal women. These findings strengthen the confidence that...recommendations to engage in regular physical activity are applicable to postmenopausal women." (EXCERPT)
Rectangularization of the survival curve in the Netherlands, 1950-1992.
"In this article we determine whether rectangularization of the survival curve occurred in the Netherlands in the period 1950-1992. Rectangularization is defined as a trend toward a more rectangular shape of the survival curve due to increased survival and concentration of deaths around the mean age at death....Our results show that absolute and relative rectangularization of the entire survival curve occurred in both sexes and over the complete period (except for the years 1955-1959 and 1965-1969 in men). At older ages, results differ between sexes, periods, and an absolute versus a relative definition of rectangularization....The implications of the recent rectangularization at older ages for achieving compression of morbidity are discussed." (EXCERPT)
"This publication comprises life tables for [Finland] by type of municipality and province compiled for the period 1991-1995 and probability of death rates by marital status." (SUMMARY IN ENG AND SWE) (EXCERPT)
Mortality trends in Mexico for the period 1900-1980 are first described. Next, the author assesses the impact on mortality of the economic and social crises that occurred in 1990. Following a description of the methodology used, abbreviated life tables are presented for the whole country and its major administrative divisions. (ANNOTATION)
Abbreviated life tables by sex are presented for Panama for five-year periods from 1990 to 2010. (ANNOTATION)
Mortality and causes of death of Moroccans in France, 1979-91.
"The results of a study by Michele Tribalat showed that the death rates of immigrants in France were surprisingly low: they were not only better than the national average, but far better than the rates specific to the socio-occupational categories the immigrants belonged to. Was this due to observation errors, to selection of the fittest applicants for immigration, or to the fact that immigrants adapted positively, that is, by taking the best (health services, living conditions...) and leaving the worst (overnutrition, road accidents...)? [The authors] investigate these questions here with respect to Moroccans living in France, first by a general analysis, then by a study of the causes of death. They confirm the surprisingly low mortality of Moroccan immigrants. But incidentally, in the case of mobility within France, adult mortality was shown to be roughly 11% lower among men who had changed regions at least once than among those who had not." (EXCERPT)
[Socioeconomic inequalities in mortality in Portugal in the period 1980/1982-1990/1992]
Using data from the censuses of 1981 and 1991, this article provides an analysis of mortality differentials by occupation in Portugal. The focus is on differences in the causes of death by sex for seven categories of occupations ranging from the professional and technical level to industrial workers. The study is part of a wider study on mortality differences in developed countries that is being carried out under the auspices of the European Union. (SUMMARY IN ENG AND FRE) (ANNOTATION)
Postmenopausal acceleration of age-related mortality increase.
"The force of natural selection to eliminate deleterious genes is attenuated with advancing age, allowing senescence to evolve. This suggests that a distinctly marked end of the reproduction period is likely to be followed by an acceleration of senescence. It is thus expected that menopause should trigger an acceleration of age-related mortality increase in human females. Such an abrupt initiation of mortality acceleration is not predicted for human males at the same ages, whose fecundity declines more gradually. Life table aging rate patterns for selected industrialized countries generally support this hypothesis. A cause-of-death decomposition analysis indicates that the sex differential in mortality acceleration is mainly due to cardiovascular diseases, which is consistent with the prevalent view that postmenopausal changes in the sex hormone status may affect lipoprotein metabolism, and in turn, raise the risk of arteriosclerosis." (EXCERPT)
"We studied physical fitness and physical activity in relation to all-cause and cancer mortality in a cohort of 7,080 women and 25,341 men examined at the Cooper Clinic in Dallas, Texas, during 1970 to 1989....After adjustment for baseline differences in age, examination year, cigarette habit, chronic illnesses, and electrocardiogram abnormalities, we found a strong inverse association between risk of all-cause mortality and level of physical fitness in both men and women....Among women...self-reported physical activity was not significantly related to risk of death from all causes. The risk of mortality from cancer declined sharply across increasing levels of fitness among men...whereas among women the gradient was suggestive but not significant....Physically active men also were at lower risk of death from cancer than were sedentary men...but among women physical activity was unrelated to cancer mortality." (EXCERPT)
Marital status and mortality: an epidemiological viewpoint.
"This study examined the available marital status patterns of all-cause mortality in England, Wales and Scotland throughout the twentieth century. It also assessed bias in the mortality rates by considering the consistency of marital status information available from samples of records of people who died shortly after they were enumerated in a census. It is concluded that bias is present, but consistent over time and that the married still have lower death rates than the others after adjustment for this. Marriage also appears to be associated with greater protection for men than women. However there are difficulties with making more detailed comparisons by type of marital status because of bias. The implications of these true differences in mortality by legal marital status are discussed given the social and demographic changes taking place." (SUMMARY IN FRE AND GER) (EXCERPT)
"The present study compared all-cause mortality of non-Hispanic whites with that of United States-born and foreign-born (i.e., born in Mexico) Mexican Americans. Subjects were 3,735 residents of San Antonio, TX, who were followed-up for 7-8 years. The sex-age adjusted death rates per 1,000 person-years were higher for United States-born Mexican Americans (5.7) than for non-Hispanic whites (3.8) or for foreign-born Mexican Americans (3.6). Foreign-born Mexican Americans had the lowest socioeconomic status (SES), and non-Hispanic whites had the highest SES....[The] data suggest that lower SES is strongly associated with increased mortality. After adjustment for SES, mortality rates were similar for United States-born Mexican Americans and non-Hispanic whites. Foreign-born Mexican Americans had the lowest mortality rates of the three groups." (EXCERPT)
Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92.
Mortality differences in England and Wales among selected groups of immigrants, including migrants from Scotland and Ireland, are analyzed using data from the censuses of 1971 and 1991. The results suggest that "widening differences in mortality ratios for migrants compared with the general population were not simply due to socioeconomic inequalities. The low mortality from all causes for Caribbean immigrants could largely be attributed to low mortality from ischaemic heart disease, which is unexplained. The excess mortality from cerebrovascular and hypertensive diseases in migrants from both west Africa and the Caribbean suggests that genetic factors underlie the susceptibility to hypertension in people of black African descent." (EXCERPT)
Follow up study of moderate alcohol intake and mortality among middle aged men in Shanghai, China.
The risk of death associated with various patterns of alcohol intake in China are examined using data on 18,244 men aged 45-64 enrolled in a prospective study on diet and cancer carried out in Shanghai from 1986 to 1989. The results show that "regular consumption of small amounts of alcohol is associated with lower overall mortality including death from ischaemic heart disease in middle aged Chinese men. The type of alcoholic drink does not affect this association." (EXCERPT)
"A new approach to measuring maternal mortality indicates that there are some 585,000 maternal deaths [per year], 99% of them in developing countries. This is around 80,000 deaths more than earlier estimates have suggested and indicates a substantial underestimation of maternal mortality in the past. There is a greater disparity in levels of maternal mortality between industrialized and developing countries than in any other public health indicator. While significant progress has been made in reducing infant mortality, the same is not true for maternal mortality. Although the actions needed to reduce maternal mortality have long been known, 1 woman in 50 is still dying as a result of pregnancy-related complications and the figure rises to 1 in 10 in many parts of Africa. By contrast, the figure for developed countries can be as low as 1 in 8,000." (SUMMARY IN FRE) (EXCERPT)
Women and smoking: a global issue.
"Smoking kills over half a million women each year and is the single most important preventable cause of female premature death in several developed countries. However in many countries smoking is still regarded as a mainly male problem. This paper explores the reasons why more attention needs to be paid to smoking and women, even in countries with low levels of female smoking. Included is an overview of the patterns and trends of smoking among women, the factors which influence smoking uptake and cessation in women, and some of the key challenges facing developed and developing countries. It is argued that to be successful in addressing the tobacco epidemic among women, tobacco control policies need to encompass both gender-specific and gender-sensitive approaches." (SUMMARY IN FRE) (EXCERPT)
Regression analysis of recent changes in cardiovascular morbidity and mortality in the Netherlands.
Official data for the period 1969-1993 are used to examine whether recent declines in mortality from coronary heart disease in the Netherlands are associated with increased mortality from other cardiovascular diseases. The results suggest that "improved management of coronary heart disease seems to have reduced mortality, but some of the gains are lost to deaths from stroke and other cardiovascular diseases. The increasing numbers of patients with coronary heart disease who survive will increase demands on health services for long term care." (EXCERPT)
Declining cancer mortality in the United States.
"For as long as such statistics have been kept in the United States, the overall age-adjusted cancer mortality rate had been increasing. However, from 1990 to 1995, there occurred for the first time a continuous and sustainable decline in cancer mortality in the U.S. This article describes the decline and suggests major reasons for it." Results indicate that "both cancer prevention activities, especially those directed against smoking, and improvements in medical care have produced an appreciable reduction in cancer mortality in the United States." (EXCERPT)
[Mortality from malignant pleural neoplasms in Italy in the years 1988 to 1992]
An analysis of mortality from malignant pleural neoplasms in Italy is presented using official data. The results show higher mortality from this cause in areas with shipyards, areas of asbestos-cement industrial production, and areas of general major industrial production. The relationship between mortality from this cause and exposure to asbestos is identified as a topic for future study. (SUMMARY IN ENG) (ANNOTATION)
Age patterns of the life table aging rate for major causes of death in Japan, 1951-1990.
"It has been widely supposed that human mortality from all causes increases with age nearly exponentially (at a constant rate) through adult ages except for very old ages, and that this exponential increase also holds fairly well for most major causes of death (CODs). However, the present analysis of death registration data from Japan, 1951-1990, reveals that the rate of age-related relative increase in mortality (the life table aging rate) changes with age significantly and systematically for many CODs. Above age 75, the mortality increase decelerates for most CODs; under age 75, it remains at a relatively stable pace for ischemic heart disease, decelerates for most major cancers, and accelerates for diseases related to a declining ability to maintain homeostasis (pneumonia, bronchitis, influenza, gastroenteritis, and heart failure). These results seem to suggest that significantly different types of senescent processes may underlie atherogenesis, oncogenesis, and immunosenescence." (EXCERPT)
Maternal mortality in England and Wales 1970-1985: an analysis by country of birth.
The author assesses "the risk of maternal mortality in immigrants to England and Wales [using] death registrations, 1970-1985, by country of birth....Women born in West Africa...and the Caribbean...were at very elevated risk of maternal death and of the main causes of death. Women from Southern Asia...and `Europe and the USSR'...were at moderate risk. Adjustment for year of death increased the estimates of risk and women born in the `Rest of the World' and Scotland were at significantly elevated risk....An increased incidence of obstetric conditions in immigrant groups may account for the elevated risk but it is also possible that differences in care may account for some of the additional risk. The pattern of increased risk does not appear to be explicable by the parity or social class distribution of immigrants as far as data are available on these." (EXCERPT)
Changes in the age dependence of mortality and disability: cohort and other determinants.
"It is important to understand the ebbs and flows of cause-specific mortality rates because general life expectancy trends are the product of interactions of multiple dynamic period and cohort factors. Consequently, we first review factors potentially affecting cohort health [in the United States] back to 1880 and explore how that history might affect the current and future cohort mortality risks of major chronic diseases. We then examine how those factors affect the age-specific linkage of disability and mortality in three sets of birth cohorts assessed using the 1982, 1984, and 1989 National Long Term Care Surveys and Medicare mortality data collected from 1982 to 1991. We find large changes in both mortality and disability in those cohorts, providing insights into what changes might have occurred and into what future changes might be expected." (EXCERPT)
Health crisis in Russia. I. Recent trends in life expectancy and causes of death from 1970 to 1993.
The authors analyze trends in life expectancy and causes of death in Russia from 1970 to 1993, with a focus on reasons for the recent declines in life expectancy. "Before discussing the trends themselves, we shall...look at the possible distortions that changes in data quality may have produced. However, even if it has been exaggerated to some degree, nobody contests the reality of the Soviet health crisis, and we shall attempt to derive some explanation by analysing the age and cause-of-death structures of mortality in Russia." (EXCERPT)
"Trends in Russian mortality appear all the more negative in comparison with the very favourable trends in most Western countries, especially during the last two decades. To highlight the most damaging causes, we compare Russian cause-specific mortality trends with those observed in France and England and Wales, two countries for which we have reconstructed continuous time series of deaths by cause....It was within the framework of...30 categories [of causes] that we calculated death rates by age group and standardized mortality rates by cause...." (EXCERPT)