Male contraceptive shows promise.
The combination of an oral gestagen with depot testosterone "looks to be the most promising approach to male contraception", says Richard Anderson of Edinburgh University, UK. Anderson is principal investigator of a study, which, he explains, was a "proof of concept to demonstrate the benefit of a long-acting testosterone, which is what we will ultimately be looking for". 31 normal men were given a single dose of 300 mg testosterone as a pellet, implanted into the lower abdominal wall under local anesthetic; they also received varying oral doses of desogesterol daily for 8 weeks. Sperm concentrations fell in a dose-dependent fashion; 7 of 10 men in the 300 mcg desogesterol group had severe oligozoospermia, and 3 experienced azoospermia. "Male contraception is now becoming a reality instead of a "cloud cuckoo land" where it has been for a long time", asserts Anderson. A recently completed 6-month study using the same combination was "extremely effective, with sperm counts down to zero", he adds. "In a few years, with the pharmaceutical industry taking an interest, we are looking at a major change in people's attitudes toward this approach". "This is an important development", comments Carlos Huezo-Toledo of the International Planned Parenthood Federation in London, UK. "For a method to be acceptable, it has to be reasonably effective, safe, and reversible--all of which this method seems to be. If it has to be an injection, it will be acceptable as long as the injection is not that often. "The method will give more options to couples who need long-term contraception", he predicts. "Even though we see protection against infection (from sexually transmitted diseases) as an important priority, there is still a big role for other contraceptive methods, because not all acts of sexual intercourse carries the risk of infection". (full text)
Taliban relents stance on female aid workers.
On July 12, the Taliban government revoked its controversial edict that barred Afghan women from working for international relief agencies in war-ravaged Afghanistan. "Quietly things will return to normal. Afghan women can return to work", commented UN coordinator for Afghanistan, Erick de Mul after talks with Taliban officials in Qandahar. The announcement, which indicates a sharp shift in the Taliban's policy, is considered a great step forward to improving women's rights in the country. The Taliban also freed Mary MacMakin, a US relief worker who, along with seven female employees, was arrested on July 9 on charges of spying and attempting to convert Muslims to Christianity. MacMakin was arrested after the Taliban's Minister for Vice and Virtue, Mullah Mohammed Turabi, warned international aid groups, including the UN, against employing Afghan women. As a result, hundreds of women who worked for aid agencies, including health workers, stayed at home for fear of being publicly beaten. Health experts believe that getting the edict rescinded has saved dozens of health and nutrition projects. But although some concessions have been made by the Taliban in the areas of health and emergency social services, women are still forbidden to work. Hundreds of women health workers effectively remain prisoners in their homes. (full text)
Swaziland debates sterilisation of HIV patients.
In Swaziland, a legislation was proposed by some members of the parliament that calls for mandatory sterilization of the country's HIV-infected citizens. The bill tabled by Sikakadza Matsebula and Timothy Buthelezi, calls on the Ministry of Health and Social Welfare to introduce urgently the legislation to control the spread of HIV. To this effect, the country's parliament will hold a debate over the implementation of such a legislation. Opposition argues that instead of controlling the spread of the virus, such a program will further increase its spread because people would not get tested for HIV. Arthur Caplan of the Center of Bioethics, University of Pennsylvania warns that such a policy would violate the human right to reproduce, and may actually increase the risk of HIV transmission if the consequences of sexual intercourse are removed. In addition, Pamela Sankar also from the Center for Bioethics, says the proposal is medically and ethically unsound and urges people to speak out against it.
DDT house spraying and re-emerging malaria.
This article discusses the role of DDT in the re-emerging cases of malaria worldwide. It is noted that malaria is reappearing in urban areas and in countries that previously eradicated the disease, including the Amazon Basin, South and North Korea, Armenia, Azerbaijan, and Tajikistan. In addition, the frequency of imported malaria has also increased in industrial countries. Although many factors contribute to such a phenomenon, the strongest correlation is with decreasing numbers of houses sprayed with DDT. Early studies of DDT showed repellent, irritant, and toxic actions that worked against malaria vector mosquitoes. Sprayed on house walls, DDT exerted powerful control over indoor transmission of malaria. However, since the ban of DDT in the 1970s and the implementation of alternative malaria-control programs there has been a global outburst of malaria epidemics. In view of this, it is recommended that the global response to burgeoning malaria rates allow for DDT residual house spraying where it is known to be effective and necessary. Regulations and policies of industrialized countries and international agencies that block financial assistance to countries that use DDT for malaria control should be eliminated.
Anti-malarial drugs for Africa [letter]
In Africa, there is an imminent loss of cheap and effective antimalarial drugs, such as chloroquine and Fansidar. It has been reported that the countries of Tanzania, Malawi, Kenya, and South Africa have all switched from chloroquine to Fansidar as first-line treatment for malaria. However, resistance to chloroquine and Fansidar are reported, thus requiring alternative strategies in the treatment of malaria. One of the suggested alternatives is the use of artemisinin derivatives in combination with conventional antimalarial agents such as chloroquine or Fansidar. Theoretically, artemisinin derivatives seem to be the obvious choice for inclusion in such combination therapy because they are the most potent and rapidly acting antimalarial agents available. However, drawbacks to the combination have been noted. Another suggested alternative is to combine chloroquine with Fansidar rather than switching directly from one to the other. Although this combination is cheap and includes drugs that are widely available and very popular, an obvious disadvantage is the lack of data concerning its efficacy.
Anti-malarial drugs for Africa [letter]
In the article by R. Shretta and colleagues, important issues on the equity and sustainability of a national drug policy that incorporates expensive antimalarials donated by drug companies were raised. Specifically, the article raised the issues of drug security and sustainability of the Malarone Donation Programme once it is implemented at the national level. It is noted that although Malarone is registered in Kenya with no restrictions, Glaxo Wellcome did not initially make Malarone available except through the Donation Programme. However, in response to requests from private sectors, the Malarone Donation Programme Advisory Committee recommended that the company make the drug available in a controlled manner through selected private-sector pharmacies for dispensing against prescriptions. Such an approach offers an opportunity to explore means of preserving the utility of new safe and effective antimalarials. An operational research will find out how best to achieve this goal in compliance with existing national malaria control strategies. Moreover, the approach of the Programme is to assist the health authorities to make policies on the basis of sound empirical data.
Anti-malarial drugs for Africa [letter]
The article of R. Shretta and colleagues stresses that the difficulties involving drug-donation programs in developing countries are not adequately addressed by WHO guidelines. In addition, there has been a failure to appreciate the context within which public-private health partnerships are set up and the implications of an altered landscape of international health cooperation. In an overview of partnerships by Walt and Buse, it has been found that they tend to divert attention from other health priorities, while failing to provide adequate support to health system strengthening upon which public health programs rest. Moreover, partnership institutions were indicated to rarely conform to principles of good governance and rarely provide for a balanced representation in their decision-making and technical bodies. However, it is believed that some of the private resources available for partnership activities should be harnessed as a sustainable source of finance with which to strengthen the WHO.
Vitamin D deficiency and tuberculosis [letter]
This paper comments on the case-control study of Robert Wilkinson and colleagues on the association of vitamin D deficiency and vitamin D receptor polymorphisms with the susceptibility of tuberculosis. Lars C. Stene questions whether the data presented in the study really supported the conclusion that polymorphisms of vitamin D receptor gene contribute to the susceptibility of tuberculosis when combined with 25-hydroxycholecalciferol deficiency. On the basis of evidence presented by Wilkinson and colleagues showing that the odds ratio of having both a "non-tt" genotype and 25-hydroxycholecalciferol deficiency was nearly equal to that for deficiency, irrespective of genotype, then the association between 25-hydroxycholecalciferol deficiency and tuberculosis is independent of vitamin D receptor polymorphisms. In other words, the effect of having both a "non-tt" genotype and 25-hydroxycholecalciferol deficiency could be attributed to 25-hydroxycholecalciferol deficiency alone. The author emphasizes that careful attention should be paid by anyone who wants to undertake a study such as that of Wilkinson and colleagues for a proper analysis and interpretation of the joint effect of two putative risk factors of the disease.
Vitamin D deficiency and tuberculosis [letter]
Robert Wilkinson and colleagues simply describe an association between serum concentrations of 25-hydroxyvitamin D in Gujarati patients with tuberculosis and they conclude that vitamin D deficiency "may account for a proportion of the acquired susceptibility of Gujarati immigrants to tuberculosis". They conclude with the suggestion that vitamin D supplementation may have a role in tuberculosis prevention. This study is potentially confounded by the striking dependence of serum 25-hydroxyvitamin D levels on sunlight exposure and by the near certainty that individuals requiring admission to hospital with tuberculosis will have had less sunlight exposure in previous months than the noninfected control subjects studied. Several publications have documented hypovitaminosis D in patients with a variety of conditions requiring admission to hospital, and in individuals who are seldom outdoors because of frailty. It should also be noted that lower concentrations of serum 25-hydroxyvitamin D, are frequently found in individuals from the Indian subcontinent than in Europeans. On the basis of the evidence presented by Wilkinson and colleagues, there is no reason to conclude that tuberculosis is associated with any greater degree of vitamin D deficiency than other illnesses producing comparable debility. The laboratory data cited in their paper provide the basis for an interesting hypothesis, but since these changes in serum vitamin D concentrations would be predicted on the basis of the basic principles of vitamin D metabolism, they cannot be interpreted as providing support for the hypothesis. (full text)
Vitamin D deficiency and tuberculosis [letter]
According to Richard Bellamy in his commentary, Robert Wilkinson and colleagues showed an interaction between vitamin D deficiency and both of the vitamin D receptor polymorphisms under investigation. Although in table 3 they showed a significantly increased risk of tuberculosis in several small subgroups (e.g., in participants with the “non-tt” genotype and vitamin D deficiency, compared with all other participants) this itself is not a test for interaction. Evidence for an interaction between an environmental exposure (such as vitamin D deficiency) and a genotype would require that the association between the exposure of interest and disease risk in those with a certain genotype was significantly different from the exposure-disease association in those with another genotype. A simple method of presenting the data to look for evidence of a gene-environment interaction in the study by Wilkinson and colleagues is shown in the table. The participants are split according to their genotype, and the odds ratio (OR) for the association between vitamin D deficiency and the risk of tuberculosis calculated separately for each genotype (OR“non-tt” and OR“tt”). Evidence for interaction would require, at the very least, that these two odds ratios were significantly different from each other. Unfortunately, Wilkinson and colleagues did not present their data in a way that permits the appropriate calculations to be carried out. (full text, modified)
Vitamin D deficiency and tuberculosis. Authors' reply [letter]
This paper presents the arguments of Robert Wilkinson and colleagues in reply to the critiques of several authors concerning the case-control study they conducted. It is noted that, in general, the comments conclude that the overall finding of the study, which states that polymorphisms in the vitamin D receptor gene contribute to the susceptibility of tuberculosis when considered in combination with 25-hydroxycholecalciferol deficiency, is erroneous. In terms of the comment that an analysis of complex traits necessitates statistical modeling, Wilkinson reasoned that the procedure was not done because the preliminary nature of the study meant that it was of insufficient power to confirm a moderate protective effect of the “t” allele. Moreover, in response to the issue raised regarding causality posed by any association study, Wilkinson states that a dose effect has been shown and that vitamin-D receptor genotypes associated with less receptor activity show the same trend. Considerable data from other laboratories, which support the findings of the study, were also presented.
Creating safety with the social model of birth [letter]
Since 1987 the Safe Motherhood Initiative has been the central theme of international work on maternal care. When taken up by the WHO, it was hoped that maternal mortality rates would be halved by the year 2000. In view of this, many strategies at national levels worldwide relied on the medical model of birth, highlighting hospital-based care for pregnant women. However, it is noted that this model had unfortunate consequences. In several settings it has led to the exclusion of the skills of the traditional midwife and of birth technologies that work with the women to ensure a better birth outcome. Hence, it is argued that the social model of birth in its many locally diverse forms can lead to far more effective support for women at critical moments in pregnancy and labor and thus fully support women's overall well-being. Use of evidence-based care in documentations supports this logic by underlining the importance of the social model of birth. Thus, it is believed that there is a need for a close examination of workable, carefully assessed strategies that are used in nonmedical settings by community-based caregivers, and a reintegration of these strategies into Safe Motherhood approaches.
How reliable is a vasectomy? Longterm follow-up of vasectomised men.
Vasectomy is a well-recognized and widely used method of family planning worldwide. However, this contraceptive method has been noted to fail at any stage of use. Often this failure is attributed to the spontaneous recanalization of the vas deferens after vasectomy. To assess the rate of recanalization, a prospective study was conducted in Oxford (UK) to look for reappearance of semen at 1, 2, and 3 years after initial clearance and to determine any correlation with pregnancy rate. Findings suggest that men with low counts of motile sperm are no more likely than persistently azoospermic patients to cause pregnancy. Reappearance of nonmotile sperm was noted in 0.8% of men post-vasectomy, but no pregnancies were reported after 22 months of follow-up. This study confirms that vasectomy is an extremely reliable form of contraception, but all patients should be warned that there is no guarantee that it will not fail at some point in the future.
Northern Ireland resists extending abortion act.
Politicians from the unionist and nationalist parties in Northern Ireland joined forces to block any extension of the 1867 British Abortion Act to the North where terminations are allowed on a restricted basis. It is noted that terminations in the North are allowed in limited cases; these include cases in which the pregnancy could jeopardized the life of the woman, the mother is mentally handicapped, there is proven contact with rubella, or there is a substantial genetic risk of the child being born mentally handicapped. Consequently, more than 2000 women from the North go to Britain for abortion services every year. Along with debates concerning the non-legalization of abortion in the North, there is the issue on banning the morning-after pill for emergency contraception. Inconsistencies in the application of emergency contraception by physicians and the need to address the issue are pointed out.
Breaking the silence: setting realistic priorities for AIDS control in less-developed countries.
The AIDS pandemic is a human tragedy that is threatening development in the poorest countries. There is no cure or vaccine, but the tools to control the epidemic already exist. Nevertheless, there are few examples of national AIDS control programs that have had an impact on the epidemic. The authors (an economist and a planner) attribute this to the reluctance of governments to confront AIDS and a failure to prioritize activities in the face of severe financial and administrative constraints. When implementation capacity is weak, expanding the number of activities may not improve program effectiveness. Rather, by implementing a smaller, core set of the most cost-effective activities on a national scale, policymakers could have a huge effect on the overall epidemic in a sustained way and provide a foundation for expansion. The authors propose three core priorities for AIDS control in poor countries for prevention, treatment, and mitigation of the impact. (author's)
Prevalence of intimate partner violence and injuries --Washington, 1998.
This paper reports on the prevalence of intimate partner violence (IPV) and injuries in Washington State (US) in 1998. Data on the prevalence of IPV were obtained by adding questions from the Conflict Tactics Scale and the Revised Conflict Tactics Scale to the 1998 Behavioral Risk Factor Surveillance System (BRFSS) of the State Department of Health. Results showed that among the approximately 2,113,000 women aged 18 and older, about 499,000 (23.6%) experienced IPV during their lives and 456,000 (21.6%) sustained a physical injury from IPV. For the 2,049,000 men, approximately 336,000 (16.4%) experienced IPV and about 154,000 (7.5%) sustained injury from it. These findings indicate that IPV in Washington is more prevalent among women than men. In addition, divorced or separated status and low education are shown to be associated with an increased risk for reported IPV. Implications for interventions and usefulness of BRFSS for collecting data on IPV are discussed.
Noncontraceptive benefits of oral contraceptive use: an evidence-based approach.
Numerous noncontraceptive benefits of oral contraceptive (OC) use have been identified. These include a reduction in ovarian and endometrial cancers, functional ovarian cysts, pelvic inflammatory disease, benign breast disease, iron deficiency, menstrual disorders, dysmenorrhea, bone loss, and acne. The best "evidence" is in the area of cancer prevention, maintenance of bone mineral density (BMD) and the treatment of acne vulgaris. Based on the body of evidence available today, several evidence-based clinical recommendations can be made regarding BMD. In young, reproductive-age women with hypoestrogenic condition, there is a protective effect on BMD with OC use. In older reproductive-age women with declining ovarian function, there is also a protective effect on BMD with OC use. With long-term use of OCs (>5 years) protection increases with increasing duration of use. There is a high degree of biologic plausibility for the beneficial effect of OC use on states associated with androgen excess, such as acne. Two randomized, placebo-controlled, multicenter clinical trials of a triphasic norgestimate-containing OC were published. Using evidenced-based criteria, there is strong evidence that this OC effectively treats acne vulgaris. As further experimental and observational studies are completed, they should substantiate many of the other known benefits; thus, further evidence-based recommendations will be possible. (author's)
First vaccine designed for Africa cleared for testing in humans.
During the International AIDS Conference in Durban, South Africa, the International AIDS Vaccine Initiative (IAVI) announced that a DNA vaccine based on HIV subtype A has been approved for testing in humans. This vaccine, designed specifically for Africa, has been noted to have a very good chance of stimulating cellular immune responses to HIV. Extensive studies on sex workers in Nairobi found that, despite frequent exposure to HIV, a small minority of these women has resisted infection over many years. In addition, research has also suggested that white blood cells activated by the DNA vaccine can destroy virus-infected cells. Coinciding with the news was the release of the Scientific Blueprint 2000, a global strategic research and development agenda from IAVI. This report concluded that developing an effective AIDS vaccine in the shortest possible time will require a widening of the vaccine pipeline, compressed timeliness for clinical trials, greater focus on the needs of developing countries and more funding. To this effect, the report calls for the implementation of several initiatives for the realization of the scientific program of IAVI.
AIDS vaccines. IAVI issues blueprint to assure global access.
During the 13th International AIDS Conference, the International AIDS Vaccine Initiative (IAVI) issued a detailed working agenda, “AIDS Vaccines for World: Preparing Now to Assure Access.” The report provides an overview of vaccine economics and concludes that the existing 15-year delay in introducing vaccines to developing countries constitutes a colossal public health failure. Hence, it calls for specific changes in the way vaccines are produced, licensed, priced, purchased, and distributed, and includes a five-point action plan for immediate implementation. To this effect, IAVI proposes a program of unprecedented global collaboration in order to assure global access. This collaboration is a firm commitment from richer nations to purchase vaccines for use in hard-hit developing countries. The Initiative also calls for the tiered pricing of new vaccines so that poorer countries can sharply lower prices than industrialized countries. Moreover, IAVI proposes the creation of an international panel of experts to monitor HIV vaccine trials.
Savings can be achieved if Ugandan company provides HIV drugs to employees.
At the 13th International AIDS Conference in Durban, South Africa, it was reported that researchers have found that it may be cost-effective for Ugandan companies to provide HIV drugs to infected employees. The study team developed an economic model that considers the HIV-related costs to operating the business and then compares these costs with the costs of a more intensive preventive care program, accounting for anticipated savings in HIV treatment costs. Focusing on the costs and benefits of providing highly active antiretroviral treatment (HAART) and the preventive drug cotrimoxazole (PCTMX) to employees with HIV once they become symptomatic, the model reflects reductions in the costs of antiretrovirals for developing countries. Overall, the study concludes that it would save Ugandan companies money to fund the prophylactic PCTMX alone or along with HAART for skilled workers.
Is global warming harmful to health?
Projections from computer models predict that global warming will expand the incidence and distribution of many serious medical disorders. Global warming, aside from indirectly causing death by drowning or starvation, promotes by various means the emergence, resurgence, and spread of infectious diseases. This article addresses the health effects of global warming and disrupted climate patterns in detail. Among the greatest health concerns are diseases transmitted by mosquitoes, such as malaria, dengue fever, yellow fever, and several kinds of encephalitis. Such disorders are projected to become increasingly prevalent because their insect carriers are very sensitive to meteorological conditions. In addition, floods and droughts resulting from global warming can each help trigger outbreaks by creating breeding grounds for insects whose desiccated eggs remain viable and hatch in still water. Other effects of global warming on health include the growth of opportunist populations and the increase of the incidence of waterborne diseases because of lack of clean water. In view of this, several steps are cited in order to facilitate the successful management of the dangers of global warming.
The aim of this study was to evaluate possible changes in predisposing factors in sexual preventive behaviors that could result from the availability of an efficient new antiretroviral therapy. A total of 136 young adults were randomly assigned to read a vignette describing AIDS as a lethal or chronic disease. After reading the vignette, the participants completed a self-administered questionnaire assessing the psychosocial determinants of intention to use a condom with a new sexual partner. The variables were measured according to Ajzen's theory of planned behavior and Triandis's theory of interpersonal behavior. The experimental manipulation was more successful when the disease was described as lethal (66 of the 68 subjects) rather than chronic (30 of the 68 subjects). For the 96 participants who correctly identified the expected outcome of the disease presented in the vignette, a significant difference in intention was found between the two experimental situations (p < 0.05). Regression of intention to use condoms on the psychosocial variables yielded an adjusted R squared of 0.62. Perceived behavioral control, social norms, personal normative belief and anticipated affective reaction were the significant variables explaining this intention. The results suggest that intention to use condoms with a new sexual partner is likely to be modified by the expected outcome of the disease, that is, whether lethal or chronic. Thus, it is suggested that interventions aimed at young adults take into account the impacts the new antiretroviral treatments are likely to have on preventive behaviors. (author's)
AIDS in South Africa takes center stage.
AIDS in South Africa takes center stage at the 13th International AIDS Conference in Durban, South Africa. An estimated 3.5 million South Africans and about 13% of all adults aged 20-64 years are HIV-infected, and as many as 6-10 million could die of AIDS in the next 10-15 years. By 2010, as many as 6 million people could be living with HIV/AIDS, unless major behavioral changes alter the course of the epidemic. In addition, AIDS-related deaths are expected to increase from 120,000 in 2000 to as many as 635,000 in 2010, and an estimated 1.5 million children younger than 15 years will be orphaned. Despite the alarming statistics, the prevention message has not yet been embraced by many South Africans, and denial about the epidemic still persists. With no HIV vaccine in the horizon, fighting the epidemic requires new, targeted prevention programs to reach those who are not yet infected, particularly the youth. Strategies should be targeted at attitudinal and behavioral change related to HIV risk and prevention. A 5-year prevention plan has been launched by the government promoting safer sex, voluntary HIV testing, improving access to treatment and support services for people with HIV/AIDS and other sexually transmitted disease, and increasing facilities for infected children and for AIDS orphans.
Emerging-market indicators. AIDS and youth.
Within the context of AIDS among young people, statistics revealed that people aged 15-24 comprise roughly 30% of the world's 34 million HIV-infected people, with 7.9 million infected youths living in sub-Saharan Africa. Girls are usually infected by older men and at an earlier age than boys, bearing the brunt of the disease. The UN Children's Fund believes that better education about AIDS at an earlier age is crucial to stemming the spread of AIDS.
This paper describes the use of a participatory approach to community assessment and planning in Ethiopia. The purpose of the assessment was for government health staff and community members to jointly identify and prioritize maternal and child health problems and develop a plan to solve them. Activities were conducted in five “woredas” (districts) in the Southern Nations and Nationalities People’s Region of Ethiopia. Some of the key features of the approach were: 1) use of a limited number of maternal and child health behaviors as a “menu” to guide planning; 2) use of an integrated household survey that measures indicators of caretaker behaviors which must be changed to reduce the most important causes of childhood morbidity and mortality; 3) implementation by a team of community volunteers and health staff; 4) collection of data that can be used at the community level for planning and at district, zonal, and regional levels for project monitoring and evaluation; and 5) an emphasis on immediate use of information by community members and health staff to produce joint action plans. The community planning process resulted in: 1) community action plans for the communities in five districts; 2) baseline data on key behaviors for monitoring and evaluation; and 3) trained staff at regional, zonal, and district levels. Community action plans included activities at both the facility and community levels, such as training of health workers, integration of health facility services, health education, and involvement of community organizations. The quantitative data were aggregated to provide baseline indicators for monitoring and evaluation. Follow-up data show changes in key child health behaviors. (author's)
Is biology destiny? Birth weight and life chances.
Two key questions are addressed regarding the intersection of socioeconomic status, biology, and low birth weight over the life course. First, do the income and other socioeconomic conditions of a mother during her pregnancy affect her chances of having a low-birth-weight infant net of her own birth weight, that of the father, and other family-related, unobserved factors? Second, does an individual's birth weight status affect his or her adult life chances net of socioeconomic status? These questions have implications for the way the authors conceive of the relationship between socioeconomic status and health over the life course, specifically in sorting out causal directionality. The authors use intergenerational data from the Panel Study of Income Dynamics, for the years 1968 through 1992. Results of sibling comparisons (family-fixed-effects models) demonstrate that maternal income does not appear to have a significant impact on birth weight. However, low birth weight results in lower educational attainment net of other factors. These findings suggest that, when considered across generations, causality may not be as straightforward as implied by cross-sectional or unigenerational longitudinal studies. (author's)
Demographic transition in ecological focus.
Demographic transition theory posits that modernization, particularly in the form of urban industrialism, fundamentally alters the environmental context surrounding fertility decision-making, thereby reducing the advantages of having children. While fertility research has either questioned the link between modernization and fertility or attempted to provide the intervening links between the two, there has been little theoretical or empirical refinement of the macrosocial/contextual principles of the theory. The authors argue that human ecology and evolutionary theory can help respecify and revitalize demographic transition theory. The authors' respecification produces a more logical account of fertility decline that emphasizes the influences of service economies and the social adaptations attendant on ethnic heterogeneity and preindustrial social complexity. Analyses of changes in total fertility rates in approximately 60 less developed countries suggest: 1) general (if partially ambiguous) support for demographic transition theory, 2) confirmation of a robust effect of service-sector dominance on fertility, and 3) the importance of ethnic homogeneity and preindustrial social complexity to demographic transition. (author's)
Childhood sexual abuse linked with adult substance use, victimization, and AIDS-risk.
College women who report childhood sexual abuse were compared with women who do not report abuse on a number of variables concerned with problems in living. Multivariate Analysis of Variance revealed that, compared with nonabused women, sexually abused women reported significantly more negative attitudes about sexuality, less sexual assertiveness about birth control or refusing unwanted sex, less efficacy concerning HIV prevention, more anticipation of a negative response from a partner concerning safer sex, more hard substance use, and more sexual victimization in adulthood. These results support and extend previous work in this area and argue for greater attention to relational issues for interventions with sexually abused women. Limitations to the study and future directions for research are discussed. (author's)
This cross-sectional study determined the prevalence of domestic violence among female patients presenting to four community-based primary care internal medicine practices in Baltimore, Maryland, between February and July, 1993. Furthermore, it identified clinical characteristics associated with domestic violence. A total of 1952 female patients of diverse socioeconomic backgrounds participated in a self-administered, anonymous survey that solicited data on physical and sexual abuse, alcohol abuse, emotional status, demographic characteristics, physical symptoms, use of street drugs and prescribed medications, and medical and psychiatric history. Of the 1952 respondents, 108 (5.5%) had experienced domestic violence in the previous year, 418 (21.4%) had experienced violence sometime in their adult lives, 429 (22%) before age 18 years, and 639 (32.7%) as either an adult or a child. Current violence status is associated with single or separated status, substance abuse, specific psychological symptoms, specific physical symptoms, and the total number of physical symptoms. In a logistic regression model, the likelihood of current abuse increased with the number of risk factors. The magnitude of these associations supports the idea that domestic violence is a significant medical public health problem. Detection of domestic violence by physicians or other health care professionals might alter both the diagnostic and treatment plans for these women.
Prevalence of sexual assault history among women with common gynecologic symptoms.
The purpose of this study was to evaluate the prevalence of sexual assault history among women with and without 3 common gynecologic complaints: dysmenorrhea, menorrhagia, and sexual dysfunction. Data came from 3 surveys of women randomly selected from general populations: 2 US regional samples (n = 1428 and n = 1703) and 1 national sample (n = 963). Prevalence rates and adjusted odds ratios were calculated and combined across the 3 samples with a meta-analysis. The prevalence of an assault history ranged from 6-26% among women with 1 symptom to 13-40% among women with 3 symptoms. Symptoms were associated with increased odds of an assault history for women 18-34 years old (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.56-2.32), 35-44 years old (OR 1.99, 95% CI 1.57-2.53), and >54 years old (OR 1.37, 95% CI 1.04-1.80). Symptoms were unrelated to sexual assault history for women in the perimenopausal (45-54 years) age group (OR 0.94, 95% CI 0.71-1.24). Symptom level was unrelated to having disclosed assaults to a physician (OR 1.17, 95% CI 0.85-1.62). Women in the general population with common gynecologic complaints are at a substantially increased risk of having a history of sexual assault. (author's)
Chronic pelvic pain as a somatoform disorder.
The purpose of this study was to determine whether psychiatric disturbances, particularly somatization, and an increased number of traumatic and critical life events, which have been found in women with idiopathic chronic pelvic pain (ICPP), can also be observed in women with chronic pelvic pain and abdominal adhesions (ACPP). 40 women who underwent diagnostic laparoscopy were subdivided into three groups according to blind rated somatic pathologies: ICPP patients (n = 16), ACPP patients (n = 10), infertile controls without pain (n = 14). Besides the standardized assessment of Diagnostic Statistical Manual for Mental Disorders III-R diagnosis, questionnaires and semi-standardized interviews were used to estimate depression, somatization, pain, the prevalence of sexual and physical abuse, and the number of critical life events. Diagnostic criteria for somatoform pain disorder were fulfilled in 73.3% of the ICPP patients, 60% of the ACPP patients and none of the controls. With respect to the somatization symptom checklist the two pain groups scored significantly higher than the controls (p < 0.05). Referring to perceived pain, ACPP patients differed from the ICPP patients by 1 out of 7 subscales (higher persistence of pain; p < 0.05). No correlation was found between the intensity of pain and the severity of classified adhesions. The two groups of pain patients significantly differed from controls by a higher prevalence of sexual abuse (p < 0.05). Depression was found neither in the pain groups nor in the controls. Because high somatization and high prevalence rates of abuse were not only found in patients suffering from ICPP but also in ACPP patients, it seems to be doubtful that the somatic pathology may fully explain the psychopathology in patients with ACPP. (author's)
Violence, rape, and sexual coercion: everyday love in a South African township.
This paper presents findings of an anthropological study among pregnant adolescents in Cape Town, South Africa. The inquiry focuses on the sexual dynamics within adolescent relationships. The study reveals widespread male coercion and violence within sexual relationships. Informants describe assault as a regular feature of their relationships. In South Africa, power relations between men and women are commonly manifested as and imposed through sexual violence and assault. Men use physical assault to force sexual contact, beating their female partners if they refuse to have sex, are suspected of sexual infidelity, or are found to be using contraceptives. Moreover, women experience abuse such as gang rape. Yet, health promotion interventions fail to acknowledge sexual encounters as instances in which unequal power relations between men and women are expressed. It is these power relations which determine women's ability or inability to protect themselves against sexually transmitted disease, pregnancy, and unwelcome sexual acts. This study underlines the need to consider gender power issues in the design and impact assessment of HIV/AIDS and reproductive health interventions and in challenging male violence.
Childhood sexual abuse and women's substance abuse: national survey findings.
Clinical studies have found elevated rates of childhood sexual abuse (CSA) in women seeking treatment for alcohol or drug abuse, and elevated rates of alcohol and drug disorders among female psychiatric patients with histories of CSA. The present study examines the relationship of CSA to women's use of alcohol and other drugs in a large, nationally representative sample of US women. As part of a national survey of women's drinking, 1099 women were asked about sexual experiences occurring before age 18. Women who reported sexual experiences classified as abusive were compared to women without histories of CSA on nine measures of substance use, self-perception of anxiousness, the occurrence of one or more lifetime depressive episodes, five measures of sexual dysfunction, and early onset of masturbation and consensual sexual intercourse. Results of logit analyses, controlling for age, ethnicity and parental education, indicated that women with histories of CSA were significantly more likely than women without CSA histories to report recent alcohol use, intoxication, drinking-related problems and alcohol dependence symptoms; lifetime use of prescribed psychoactive drugs and illicit drugs; depression and anxiety; pain that prevented intercourse; and consensual sexual intercourse before age 15. Findings from this US national sample support those of previous clinical studies and suggest that women's experience of sexual abuse in childhood may be an important risk factor for later substance abuse, psychopathology and sexual dysfunction. Implications of these findings for future research, treatment and prevention are discussed. (author's)
Prevalence of childhood sexual abuse in a community sample of Australian women.
This retrospective study determined the prevalence of childhood sexual abuse (CSA) in a community sample of women in Australia. Conducted in 1994, the study was part of a larger two-stage case-control study of the possible relationship between CSA and alcohol abuse in women. The sample consisted of 710 women randomly selected from the Australian federal electoral rolls. Of the total sample population, 144 women (20%) had experienced CSA; 14 of these 144 women (10%) had experienced either vaginal or anal intercourse. The mean age at the first episode of CSA was 10 years, and most (71%) of the women were under 12 years of age at that time. Perpetrators of the abuse were usually males (98%) and were usually known to the child; 41% were relatives. Of the CSA experiences, only 10% were ever reported to the police, a doctor, or an agency. The high CSA rates (estimated to be 20% of all women) and the low reporting rates (10%) indicate the need for general practitioners and other health professionals to be aware that a history of such abuse may be common in women in the general population.
Child sexual and physical abuse and alcoholism: a review.
The aim of this study was to examine possible relations between child sexual or physical abuse and adult alcoholism. Studies reviewed included prospective studies, retrospective studies on the prevalence of child sexual or physical abuse in alcoholics and nonalcoholics, and retrospective studies on mental health clients and on population samples comparing the prevalence of alcohol use disorders in abused and nonabused subjects. Prospective studies do not indicate a significant association between child sexual or physical abuse and alcoholism. In contrast, studies among alcoholic women do suggest a relationship. Also, a significantly higher prevalence of alcohol problems in abused women than in nonabused women is found in population samples. The results of studies among mental health clients are inconclusive. In addition, several methodological limitations should be taken into consideration when evaluating results of the available studies. Current evidence is insufficient to draw conclusions about relationships between child sexual or physical abuse and alcoholism among men. Among females however, there is a higher likelihood of alcohol problems if they were sexually or physically abused as children. (author's)
Prevalence of sexual abuse of children in Germany.
A survey of the prevalence of sexual abuse of children in two different areas of Germany (Wurzburg--former West Germany, and Leipzig--former East Germany) was conducted using a multiple screen questionnaire. The sample consisted of 1841 students from different institutions in Wurzburg and 310 students from vocational schools in Leipzig (n = 2151). Data on a similar number of males and females were recorded. Problems of definition, sample characteristics and methodology are discussed. Sexual abuse was reported by 16.1% of the women and 5.8% of the men in the Wurzburg sample and by 9.6% and 5.8%, respectively, in the Leipzig sample. More comparable subsamples showed less discrepancy in the prevalence rates for women in the two cities. (author's)
The effect of child sexual abuse on social, interpersonal and sexual function in adult life.
The association between reporting child sexual abuse (CSA) and a range of social, interpersonal and sexual difficulties in adult life was examined. A random sample of 2250 women was posted a questionnaire exploring a range of abuse experiences. All 248 reporting CSA were invited for interview, together with an equal number of controls. At interview a detailed inquiry was made into the CSA and into current interpersonal, social and sexual function. Significant associations emerged between reporting CSA and a decline in socioeconomic status, increased sexual problems, and the disruption of intimate relationships by difficulties with trust as well as propensity to perceive their partners as uncaring and overcontrolling. CSA was more common in those from disturbed and disrupted families and in those who also reported physical and emotional abuse. This explained part, but not all, of the apparent association between CSA and negative outcomes. Those reporting CSA are more likely to suffer social, interpersonal and sexual difficulties in adult life. (author's)
The long-term impact of the physical, emotional, and sexual abuse of children: a community study.
The associations between giving a history of physical, emotional, and sexual abuse in children and a range of mental health, interpersonal, and sexual problems in adult life were examined in a community sample of women. Abuse was defined to establish groups giving histories of unequivocal victimization. A history of any form of abuse was associated with increased rates of psychopathology, sexual difficulties, decreased self-esteem, and interpersonal problems. The similarities between the three forms of abuse in terms of their association with negative adult outcomes was more apparent than any differences, though there was a trend for sexual abuse to be particularly associated to sexual problems, emotional abuse to low self-esteem, and physical abuse to marital breakdown. Abuse of all types was more frequent in those from disturbed and disrupted family backgrounds. The background factors associated with reports of abuse were themselves often associated with the same range of negative adult outcomes as for abuse. Logistic regressions indicated that some, though not all, of the apparent associations between abuse and adult problems was accounted for by this matrix of childhood disadvantage from which abuse so often emerged. (author's)
Childhood sexual abuse and adolescent pregnancy are two of the most publicized social problems in the US. To elucidate the relationship between childhood sexual abuse and adolescent pregnancy, the English literature pertaining to the sequelae of childhood sexual abuse or the antecedents of adolescent pregnancy was reviewed. In general, studies suggest that former victims of childhood sexual abuse may be at increased risk for conception during adolescence. Moreover, adolescent childbearing that is antedated by childhood sexual abuse is often the manifestation of socially deviant behavior. Experiences associated with childhood sexual abuse may affect the incidence and the outcome of adolescent childbearing. Identification and treatment of previously abused adolescent prenatal patients may break this vicious intergenerational cycle of violence.
This study sought to determine the risk of low birth weight from intimate partner abuse. The case-control design was used in a purposively ethnically stratified multi-site sample of 1004 women interviewed during the 72 hours after delivery between 1991 and 1996. Abuse was determined by the Index of Spouse Abuse and a modification of the Abuse Assessment Screen. Separate analyses were conducted for 252 full-term and 326 pre-term infants. The final multiple logistic regression models were constructed to determine relative risk for low birth weight after controlling for other complications of pregnancy. Physical and nonphysical abuse as determined by the Index of Spouse Abuse were both significant risk factors for low birth weight for the full-term infants but not the pre-term infants on a bivariate level. However, the risk estimates decreased in significance in the adjusted models. Although short delivery stays make it difficult to assess for abuse, it is necessary to screen for domestic violence at delivery, especially for women who may not have obtained prenatal care. The unadjusted significant risk for low birth weight that becomes nonsignificant when adjusted suggests that other abuse-related maternal health problems (notably low weight gain and poor obstetric history) are confounders (or mediators) that help to explain the relation between abuse and low birth weight in full-term infants. (author's)
Sexual abuse history and problems in adolescence: exploring the effects of moderating variables.
This study explores the relationship between sexual abuse and two problem outcomes, binge drinking and suicidal ideation, in a sample of 42,568 adolescents. The effects of current and prior sexual abuse on these outcomes were examined for females and males separately. Of particular interest were factors related to the likelihood of problem behaviors among adolescents who had been sexually abused. Adolescents who had been both physically abused and sexually abused exhibited more problems than those who experienced only one type of abuse. High levels of parental monitoring and high levels of support from at least one parent decreased the risk of problem outcomes among sexually abused adolescents. School success also reduced the risk of problem outcomes for some of the groups studied. (author's)
Sexual assault history and women's reproductive and sexual health.
Associations of sexual assault history with reproductive and sexual symptoms were evaluated in 3419 women randomly selected from two communities. Sexual assault was associated with excessive menstrual bleeding, genital burning, and painful intercourse (whether or not attributable to disease or injury), medically explained missing two menstrual periods, and medically unexplained dysmenorrhea, menstrual irregularity, and lack of sexual pleasure. Physically violent assaults and those committed by strangers were most strongly related to reproductive symptoms. Multiple assaults, assaults accomplished by persuasion, spouse assault, and completed intercourse were most strongly related to sexual symptoms. Assault was occasionally associated more strongly with reproductive symptoms among women with lower income or less education, possibly because of economic stress or differences in assault circumstances. Associations with unexplained menstrual irregularity were strongest among African American women; ethnic differences in reported circumstances of assault appeared to account for these differences. Assault was associated with sexual indifference only among Latinas. (author's)
This article discusses the reasons why Curitiba, Brazil, is considered the greenest city in the world. Accomplished by Jaime Lerner, former mayor of Curitiba, this city has been called by some planners the most environmentally advanced urban area on Earth. Several initiatives have contributed to Curitiba's environmental success. Most important of these initiatives is the bus system, which offers faster, cheaper and more comfortable transportation. Created in the 1970s, the system is a winning mix of fast express arteries, local feeder buses, and special routes for circulating in the downtown area. From this bus system a series of other initiatives were facilitated, including the creation of a 42 sq. km "Industrial City". This Industrial City is restricted to low-polluting industries, which generates about 33,000 jobs directly and another 150,000 indirectly. Moreover, Curitiba launched a series of programs aimed not only at preserving the city's existing trees and green space, but adding to them. Other programs include trading garbage for food, recycling rates, and free health care.
Global climate depends on compounding factors interacting in subtle and complex ways that have not been fully understood. In 1995, a study by the Intergovernmental Panel on Climate Change (IPCC) concluded that there is a discernible human influence on global climate. Although specific consequences of human activity are ambiguous, such an ability to alter the atmosphere is incontestable. In view of such, it is noted that studies on climate patterns are helping scientists make projections on future climate changes in the world. In the case of the greenhouse effect, it has been projected that in the next 100 years global average temperatures will rise by 1-3.5 degrees. This warming of the magnitude anticipated by the IPCC could prompt widespread calamity. A most probable effect is that the average amount of precipitation in any given event will be greater. In turn, an increased precipitation may cause dry regions to become more arid and many wet areas to experience increased rainfall. However, it is noted that these projections have been made with the use of general circulation models, which have been known to provide only a range of projected temperature change, resulting in uncertainty of the projections.
The resources available for agriculture.
The physical resources of earth, fire, and water, although they are very large, are ultimately fixed. However, the biological and social resources are far from being pressed to the limit. According to Thomas Malthus, the human population will always increase until it reaches the limit set by the food supply. This limit is determined by the physical resources available for agriculture. He recognized that farm production increases with improved technology; however, the rates of increase would always be lower than the potential capacity of human beings to multiply. This paper considers the inverse of Malthus's proposition--whether the effective utilization of resources for food production can be made to increase the limits set by human population size. A more important inquiry is whether rates of growth of agricultural production can be made to exceed rates of population growth. It is noted that the amount of cultivated land per person could be increased in every part of the world by the year 2000. However, large capital investments would be needed for a major increase in crop yield in favorable regions. One way to accomplish this is to increase scientific knowledge of plant and animal biology and of the environment and to transform scientific advances into practical knowledge farmers can use. In addition, many resources other than arable land and water must be utilized to increase world food production.
Air pollution in all its forms, including sulfur dioxide, ozone, fine particles, carbon monoxide and nitrogen oxides, has resulted in human deaths and diseases worldwide. This article reports on the human suffering caused by air pollution in terms of mortality and morbidity. Based on interviews with scientists, health experts and victims, it is noted that the cities of Thailand, Mexico, Japan, Poland, the Czech Republic, Romania, and the US have the highest levels of air pollution. In these areas people suffer from respiratory illnesses such as pharyngitis, sinusitis, laryngitis, tonsillitis, bronchitis, asthma, flu, and loss of lung function. A most alarming finding indicates that residents of Los Angeles exposed to ozone pollution have double the risk of cancer compared to residents of cleaner cities. Aggravating this situation is the fact that governments often opt to sacrifice human health and lives when forced to choose between protecting the public and shielding industry from pollution regulations.
Violence against women: an integrated, ecological framework.
This article encourages the widespread adoption of an integrated, ecological framework for understanding the origins of gender-based violence. An ecological approach to abuse conceptualizes violence as a multifaceted phenomenon grounded in an interplay among personal, situational, and sociocultural factors. Although drawing on the conceptual advances of earlier theorists, this article goes beyond their work in three significant ways. First, it uses the ecological framework as a heuristic tool to organize the existing research base into an intelligible whole. Whereas other theorists present the framework as a way to think about violence, few have attempted to establish what factors emerge as predictive of abuse at each level of the social ecology. Second, this article integrates results from international and cross-cultural research together with findings from North American social science. And finally, the framework draws from findings related to all types of physical and sexual abuse of women to encourage a more integrated approach to theory building regarding gender-based abuse. (author's)
Addressing battering during pregnancy: reducing low birth weight and ongoing abuse.
Battering during pregnancy is a frequently occurring and significantly deleterious phenomenon and has received increasing attention in the areas of both research and practice. This article reviews the research conducted in the US related to battering during pregnancy, along with implications for interventions. In particular, the paper outlines the results of these studies concerning the prevalence of battering, its dynamics, health-related correlates, outcomes, and cultural influences. Although tested interventions for abuse during pregnancy are limited, there are clear indications from research with other battered women for directions to be taken. Addressing abuse during pregnancy is both a significant health enhancement and an important aspect of confronting other serious threats to maternal and infant health.
Advances in segmentation modeling for health communication and social marketing campaigns.
Large-scale communication campaigns for health promotion and disease prevention involve analysis of audience demographic and psychographic factors for effective message targeting. A variety of segmentation modeling techniques, including tree-based methods such as Chi-squared Automatic Interaction Detection and logistic regression, are used to identify meaningful target groups within a large sample or population (N = 750-1000+). Such groups are based on statistically significant combinations of factors (e.g., gender, marital status, and personality predispositions). The identification of groups or clusters facilitates message design in order to address the particular needs, attention patterns, and concerns of audience members within each group. The authors review current segmentation techniques, their contributions to conceptual development, and cost-effective decision-making. Examples from a major study in which these strategies were used are provided from the Texas Women, Infants and Children Program's Comprehensive Social Marketing Program. (author's)
Toward a restatement of demographic transition theory.
Interpretations of past population movements and expectations about future trends rest primarily on the "demographic transition theory". However, over the years, there has been a failure to update the theory. Subsequently, researchers have tended to obscure the important distinction between the origins of fertility decline and the demographic history of societies experiencing such decline. This paper argues that an inadequate understanding of how birth levels first begin to fall has led to a premature gloom about the success of family planning programs and unnecessary hysteria about the likely long-term size of the human population, and to antagonisms between countries at different stages of demographic transition. It is the contention of this paper that there are only two fertility regimes: one in which there is no economic gain to individuals from restricting fertility and one in which there is economic gain from such transition. Furthermore, the author posits that the transition of a society from one with economically unrestricted fertility to one with economically restricted fertility is a product of social change. The forces sustaining economically unrestricted fertility are strengthened by economic modernization accompanied by specific types of social change. Three types of societies are discussed: primitive, traditional, and transitional societies. Lastly, the author maintains that unlimited fertility eventually crumbles in transitional societies, and such crumbling, as well as its preconditions, is unrelated to reductions in family size subsequently occurring in transitional societies.
Given improvements in human papillomavirus (HPV) testing that have revealed a strong link between sexual activity history and cervical HPV infection, the authors conducted a large case-control study of HPV and cervical intraepithelial neoplasia (CIN) to evaluate whether sexual behavior and the other established risk factors for CIN influence risk primarily via HPV infection. The authors studied 500 women with CIN and 500 control subjects receiving cytologic screening at Kaiser Permanente, a large prepaid health plan, in Portland, Oregon. The established epidemiologic risk factors for CIN were assessed by telephone interview. The authors performed HPV testing of cervicovaginal lavage specimens by gene amplification using polymerase chain reaction with a consensus primer to target the L1 gene region of HPV. Unconditional logistic regression analysis was used to estimate relative risk of CIN and to adjust the epidemiologic associations for HPV test results to demonstrate whether the associations were mediated by HPV. The case subjects demonstrated the typical epidemiologic profile of CIN: they had more sex partners, more cigarette smoking, earlier ages at first sexual intercourse, and lower socioeconomic status. Statistical adjustment for HPV infection substantially reduced the size of each of these case-control differences. 76% of cases could be attributed to HPV infection; the results of cytologic review suggested that the true percentage was even higher. Once HPV infection was taken into account, an association of parity with risk of CIN was observed in both HPV-negative and HPV-positive women. The data show that the great majority of all grades of CIN can be attributed to HPV infection, particularly with the cancer-associated types of HPV. In light of this conclusion, the investigation of the natural history of HPV has preventive as well as etiologic importance. (author's)
Possible prognostic significance of human papillomavirus type in cervical cancer.
While several different human papillomaviruses (HPVs) have been associated with cancer of the cervix, it is yet to be determined if specific HPV types have clinical or prognostic significance. To address this question, 30 cases of invasive carcinoma (squamous carcinoma, adenosquamous carcinoma, and adenocarcinoma) with HPV DNA sequences detectable in the tissue were analyzed. HPV type was determined by Southern blot DNA hybridization. Clinical information was obtained by chart review, and all biopsy and surgical specimens were reviewed microscopically without knowledge of HPV type. HPV 16 was detected in 14 cases, HPV 18 in 6, and HPV 31 in 2. In 8 samples there were distinctly different, but as yet uncharacterized, HPV DNAs. Of the factors evaluated, tumor grade was found to have a statistically significant relationship to HPV type. 83% of HPV 18-associated tumors were grade 3 tumors (5 of 6) as compared to only 7% of HPV 16-associated tumors (1 of 14) (P = 0.002). Age at diagnosis and nodal status in relation to HPV type exhibited a trend but were not statistically significant. The mean age of the HPV 18 group was 37 years, compared to 49 years for the HPV 16 group. Similarly, among Stage IB cancers, nodal involvement was associated with 60% of HPV 18 cases (3 of 5) as compared with 36% of HPV 16 cases (4 of 11). These observations suggest that HPV 18 may be associated with a more aggressive form of cervical cancer than other HPV types. (author’s)
Previous research suggests that the female sex hormones may moderate cardiovascular and mood responses to cigarette smoking and abstinence. To test this possibility, acute effects of cigarette smoking on cardiovascular reactivity and mood were examined in 12 oral contraceptive (OC) users and 12 nonusers across two menstrual phases (early and late cycle). After overnight deprivation, each participant attended two sessions in which they first sham-smoked and then smoked two standard cigarettes, via a quantified smoke delivery system. OC users exhibited larger cigarette smoking-induced increases in heart rate compared with nonusers. In addition, cigarette smoking-induced cardiovascular changes varied with both the phase of the menstrual cycle and OC use. No menstrual phase-dependent effects were observed for tobacco withdrawal symptoms, premenstrual symptoms, or moods prior to smoking. Cardiovascular hyper-reactivity to cigarette smoke in OC users may help explain the mechanisms by which smoking and OC use contribute to an elevated risk for coronary heart disease. (author's)
South African leader declines to join the chorus on HIV and AIDS. AIDS meeting.
This article reports the address of South African President, Thabo Mbeki during the XIII International AIDS Conference. In his address, Mbeki convened to help his government develop policies to tackle the growing AIDS crisis. He also included the so-called “dissidents” insisting that HIV does not cause disease and questioned whether AIDS is a new disease or old diseases collectively given a new name. Much of his speech was quoted from a 1995 WHO report which documented that extreme poverty is the greatest cause of ill health and suffering across the globe. Such a failure to acknowledge directly that HIV causes AIDS has angered the country's AIDS researchers. On the positive side, Mbeki did note that his government would continue to intensify its anti-AIDS campaign by encouraging the use of condoms, supporting research on an AIDS vaccine and anti-HIV drugs, and responding humanely to people living with AIDS and HIV.
The role of gynaecologists in women's health care -- women's views.
Reproductive matters are common reasons to use health services, and both primary care providers (general practitioners and public health nurses) and specialists (gynecologists) can be consulted. The purpose of this study was to find out how Finnish women think about and use specialist care in reproductive matters; gynecological health checks, contraception, and prenatal care served as examples. The data came from a questionnaire survey sent in 1994 to a representative sample (74% response rate) of 18-44 year old Finnish women (n = 2189). Most (87%) women considered regular health checks by a gynecologist important, and 55% had visited a gynecologist regularly in the past 5 years. Healthier women and women having more education were more likely to visit gynecologists regularly. Most women (86%) preferred a gynecologist to a general practitioner for contraceptive matters, and 54% reported visiting one for their last contraceptive visit. Maternity centers with their public health nurses and general practitioners were the main source of prenatal care. The results suggest the need to study the benefits of regular gynecological health checks, and to define the best provider in common reproductive matters. Evaluation should include organizational impacts, such as those of the division of work between primary and secondary health care and small area population responsibility. (author's)
Intermittent employment among married women: a comparative study of Buenos Aires and Mexico City.
This comparative study examines how individual, family, gender relations and job characteristics affect women's patterns of participation in the labor force and how the effect of these characteristics differ in Buenos Aires and Mexico City. Using panel data and retrospective life histories, the analysis emphasizes the determinants of short-term movements into and out of the labor force. It is noted that intermittent employment is very common among married women and is not necessarily determined by changes in the life cycle. Nevertheless, intermittent employment arises from the conflict in combining paid and domestic work and from the nature of the labor opportunities available to women. In both cities, labor force stability appeared to be positively associated with women's level of education, the employment stability of husbands, the presence of another woman in the household who can help with domestic chores, the types of jobs women have access to, and to a lesser extent having young children at home. The study suggests that women's welfare would improve with the enforcement of the existing labor legislation.
This study was designed to explore the level of knowledge and risk of contracting HIV/AIDS among a sample of 60 young adults with mild/moderate intellectual disability. In comparison to a sample of undergraduate students, they showed greater deficits in their general knowledge of the disease and in methods to minimize risk of infection. They also had less adaptive attitudes regarding AIDS in general and specifically with regard to condom use, and they had lower confidence in their capacity to accomplish safe-sex practices. Furthermore, when presented with hypothetical risk situations they were more likely to present unsafe sexual solutions to the interpersonal dilemmas. These indications of potential risk were compounded by the finding that the majority were either sexually active or had strong intentions to become so, and that poor performance on the range of measures was associated with greater behavioral risk as assessed by actual or anticipated sexual activities. The implications of these results are discussed in relation to the need for urgent implementation and ongoing evaluation of multifaceted educational programs. (author's)
Abortion, birth control, and public policy.
This article examines the public policy issue of abortion using percent program to analyze the existing alternatives and formulate a Super-Optimum Solution (SOS) to address issues concerning abortion. In order to include a more representative cross section of opinions for the issue, the alternatives considered for the analysis include an ultra conservative, conservative, neutral, liberal, and an ultra liberal alternative. Meanwhile, the SOS package developed consists of three main parts: education, availability, and effectiveness. Overall, it is observed that the SOS package, created with the help of the percent program, seems to be superior to the other available policy alternatives in the controversy. Using different weightings, the SOS consistently scored higher than the other alternatives, and the threshold analysis showed that it would be impossible for any of the other alternatives to equal the SOS in this framework of analysis.
Vigorous abortion rights and anti-abortion rights movements developed differently in the US and Canada. In the US, abortion has long been a national political issue as activists on each side pursued a wide range of tactics. In Canada, abortion has never been a significant issue in national party politics, and advocates used a narrower range of tactics until the 1980s. As the two nations share the essential “political opportunity” characteristics used in most comparative studies (“weak” and federal states), the authors need a more nuanced theory to explain these differences in abortion politics. The authors argue that volatility in particular state institutions produces distinct political opportunities for opposing movements. Openings in particular institutions, in conjunction with political culture, affect the claims, tactics and frames of advocates on each side. The authors stress the importance of opposing movements in creating and responding to political opportunities. (author's)
[Nutrition and psychomotor development during the first six months of life]
The aim of this study was to study the psychomotor development of young infants from a poor and underfed rural community and to correlate this with the nutritional conditions of the mother during pregnancy and the child itself. The authors studied 82 mother-child pairs from the 5th month of pregnancy to the 6th month of life of the child as to anthropometry and food consumption. The neonatal Brazelton test and the Bayley test at 3 and 6 months were applied to the child. Several of the neonatal psychomotor tests applied to the child correlate positively with the mother's weight and skin folds, as well as with the child's own previous weight and size. This was also true for maternal consumption of animal foods and fruits during pregnancy. A negative correlation was observed with the consumption of corn tortillas and beans. The correlation of several tests applied to the child at 6 months was positive with its complementary consumption, total energy and several foods, specially egg, milk and fruit around 3 months of age. Small variations in nutrition of the mother-child pairs from the poor rural community studied had consequences on the psychomotor development of the infant. These findings point to the need for more applied nutrition programs. (author's)
[Weight and length at birth: the role of maternal nutrition]
To identify determinants of weight (BW) and length at birth (BL), the authors studied 481 mother-newborn pairs in three Mexico City hospitals. Multiple regression models were developed to identify statistically significant predictors of BW and BL with respect to a predetermined biological model. Independent variables included were: maternal anthropometry, age, smoking habits, and civil status, parental education, obstetric history, hypertension, and neonatal characteristics. In the group with calf circumference (CC), height, and head circumference below the median, BW was 133, 92, and 96 g lower (+or- 35 standard error [SE], p < 0.01) than the group above the median, adjusting for socioeconomic, obstetric history, and neonatal characteristics (NC). In the group below the median CC or height, BL was 5.8 or 6.2 mm (+or- 1.9 mm SE, p < 0.01), respectively, adjusting for obstetric history and NC. Results suggest that maternal anthropometry is the most important predictor of birth size and that predictors for BW and BL differ. (author's)
Data were collected on the drinking behavior of 415 pregnant adolescents from 1990-94. The relationships between knowledge and attitudes about drinking and drinking behavior were examined. Knowledge about drinking was not related to average daily volume of alcohol before or during pregnancy. Those with specific knowledge about fetal alcohol effects drank less before pregnancy, and in the first trimester, and were also less likely to drink to intoxication. Among drinkers, general knowledge about drinking was significantly related to a decrease in drinking between pre-pregnancy and first trimester, as well as between first and third trimesters. Those with more intolerant attitudes about drinking drank less before and during pregnancy. They had fewer episodes of binge drinking, intoxication, negative consequences, and problem drinking during pregnancy. They were more likely to decrease drinking from the first to third trimesters. These relationships are relevant to developing effective education programs for the high-risk group of pregnant teenagers who drink. (author's)
This essay explores the reactions of the French physicians and social commentators in the 18th century to the health experiences of the European and African slave populations in the French West Indies. Specifically, it seeks to delineate the extent to which physicians utilized categories of race and class, and concepts of pollution and purity, to explain the incidence of diseases among Europeans and Africans within the Caribbean tropics. It is noted that towards the close of the 18th century, physicians and school commentators drew upon health and hygiene to reinforce specific social agendas in Europe. These two factors encouraged the active separation and segregation between social classes. In contrast, such a discourse reflected both the powerful class and racial boundaries within the Antilles colonies. With regard to the Caribbean slave population, physicians speculated that their predisposition towards the plethora of pathogenic entities indicated that either the African body was innately predisposed to sickness or that institutions and the tropical surroundings facilitated the occurrence of disease. However, on the eve of the French Revolution, abolitionist writers believed that the disciplinary functions of dietary and hygienic regimen remained the major tenets for assimilating the potentially liberated African slave.
When good intentions are not enough: modeling postdecisional cognitive correlates of condom use.
Measures of intention usually leave substantial proportions of the variance in behavior unexplained. It has been suggested that improved behavioral prediction could be achieved by identifying postdecisional cognitive processes capable of distinguishing between intenders who do act and those who do not act. Condom-related self-report measures of postdecisional cognitive processes were developed and tested in a cross-sectional questionnaire study involving 447 heterosexual students. A discriminant function composed of postdecisional measures was found to significantly distinguish between intenders who reported use and non-use and to correctly classify 80% of intenders. The results indicate that measures of the relative importance of competing intentions, prior planning of specific preparatory actions, and action-specific self-efficacy may enhance the prediction of condom use among intenders. (author's)
The media can have more than an impersonal impact: the case of AIDS risk perceptions and behavior.
Two field survey studies concerning AIDS tested Tyler and Cook's (1984) impersonal- and differential-impact models of the effects of exposure to communication channels on perceptions of personal and social risk. Contrary to the impersonal-impact hypothesis, when media exposure was decomposed into news and entertainment, there was no impact on personal risk. Exposure to entertainment programs (e.g., movies and sitcoms) that dealt with AIDS was related to increased judgments of personal risk. The data suggest (but not conclusively) that exposure to news programs covering AIDS may have decreased personal risk perceptions. Perceived personal risk and, in study 2, conversations with peers, elders, and health professionals, were related to people changing their behavior in an appropriate manner. The results have implications for media-effects studies, risk analysis, and communication campaigns. (author's)
A study of the ethics of induced abortion in Korea.
The purposes of this study were to investigate the ethical aspects of induced abortion from the viewpoint of Korean women, and to compare and contrast their ethical considerations and values with the views of western ethical scholars. The two extremes of ethical arguments about induced abortion are pro-life and pro-choice. However, the Korean women who participated in this study showed that conflicting ethical values were raised between the principle of caring and the sanctity of life or the principle of respect for the person, not between the right of self-determination and the sanctity of life. The results of the study suggest that it would be better to include the viewpoints of women in any ethical discussion on abortion in order for ethicists and health professionals to understand more fully the dimensions of moral clinical problems and be in a better position to discuss them in a practical manner. (author's)
20 first-born infants from low socioeconomic status (SES) families and 20 first-born infants from middle SES families in Costa Rica were observed for 12 hours when they were 14 weeks old. The goals of this study were the following: 1) to study the impact of length of observation and context on the authors measures of interactional engagement; 2) to compare the interactional experiences of the infants in the two groups in various functional (e.g. feeding, object play) and social (e.g. with mother, with mother and others) contexts. Attuned and disharmonious interactions, as well as the frequency of positive affect, soothing, and vocalization, varied considerably across the functional contexts. In addition, disharmonious interactions increased and interactional engagement decreased when mothers and infants were joined by others. Highly unstable measures of individual differences were obtained when observations were limited to 45-minute blocks, but stability increased considerably as the duration of the observations expanded. The groups did not differ with respect to amounts of time spent in various functional and social contexts, in attuned or disharmonious states, or in high levels of interactional engagement. Within some of the functional contexts, however, significant group differences in levels of attuned interactions, infant vocalization, and maternal response vocalization were found. Overall, functional and social contexts clearly moderated interactional experiences. SES effects on verbal and other interactional measures were limited to some contexts and may thus represent the infants' overall experiences quite poorly. Consequently, comparisons based on a single context may be inadequate for studies of subjects from differing socioeconomic backgrounds. (author's)
China's openness to the world and the increasing individualization of its population have resulted in a resurgence of prostitution, trafficking in women, and related sexual offenses. The Chinese government has continuously passed laws and escalated its efforts to control illicit sexual activity, in particular against prostitution and pandering, to the point of “whore wars”. Coincident with state-sanctions and containment efforts has been a rise in aggressive, and not uncommonly, violent, punitive behavior against those who traffick in women and against prostitution as an organized activity. This paper reviews official reports, news, and case histories in an effort to ascertain legitimization of aggressive behavior by the State, and show how the State constructs such legal rationales in light of China's socialist moral stance. (author's)
Fertility and a mate's signals of continued presence.
This paper presents evidence that female fertility is higher in the presence of a man, with possible mechanisms involving either repeated copulation, or pheromones, or both. It is noted that a well designed human female would have one or more devices for detecting committed males, and increasing her fertility in his presence. Such devices show that the menstrual cycle is more often of a fertile type when there is regular sexual contact with a man and that copulation promotes the success of the gamete intra-fallopian transfer procedure. In addition, it shows the ability of an extract from males to affect the female cycle in a way that appears to promote fertility and that exposure to men influences the occurrence of ovulation in women. In addition, the existence of such devices explain several observations including the influence of exposure to males on ovulation, the large amount of non-reproductive sexual activity, the presence of what may be a functional vomeronasal organ, and the apparent design of the axilla for emitting odors or pheromones.
Fertility and marital rates in first-onset schizophrenia.
Many studies have demonstrated that in schizophrenia there are decreased rates of marriage, fertility and marital fertility. However, it is not clear whether this finding occurs as a social consequence of having the illness or is an inherent part of the illness. One would expect it to vary across cultures if it were being mediated by social and cultural factors. The authors investigated this by reviewing the marital and fertility data from a multi-ethnic first-contact group of patients in London with CATEGO broadly defined schizophrenia, and comparing this with similar data from a group of controls who were matched for age, gender and ethnicity. The authors' sample comprised 38 White British, 38 Caribbean and 24 Asian subjects. The Asian group were significantly older (mean age 38, P < 0.003) and had a greater percentage of females (50%). When compared to controls, the White and Caribbean patients, but not the Asians, had decreased marital and stable relationship rates. There was also decreased fertility and marital fertility as evidenced by number of children among the Whites and Caribbeans, but again significantly not among the Asians. Marital status did not predict fertility rates, particularly among the Caribbeans. Regression analysis demonstrated an effect for age on the number of children but not on marital status. These findings suggest that marital and reproductive behaviors are reduced in schizophrenia, but this effect may be mediated by social and cultural factors and therefore not apply consistently across ethnicity. Further research is needed to prospectively investigate populations to determine whether impairments of this nature are inherent or consequential to the illness. (author's)
There is some evidence that women are less likely to be raped during the mid-portion of the menstrual cycle. In order to determine if women might be behaving in ways to decrease their chances of sexual assault when they are most likely to conceive, female college students were asked to complete a questionnaire about their activities during the past 24 hours and indicate the first day of their last menstruation. A statistically significant decrease in risk taking behavior during the ovulatory phase of the menstrual cycle was obtained for respondents who were not taking birth control pills. (author's)
In the present study, the persuasive communication of HIV test counselors as cues to action in clients' decisions to practice safer sex was examined. Results indicated that contrary to expectations, hypothesized relationships inherent in the Health Belief Model (HBM) were not supported for the pre-HIV test survey. However, clients' perceptions of the severity of HIV/AIDS, their susceptibility to HIV/AIDS, the benefits of and barriers to practicing safer sex, and self-efficacy were correlated with compliance with safer-sex recommendations reported on the post-HIV test survey. Intriguing results revolved around communication cues to action. HIV test counseling session transcripts were content analyzed to determine the persuasive messages used by HIV test counselors that may have cued clients' health beliefs and safer-sex behaviors. The inductively-derived coding scheme emphasized the complexity of the interpersonal interaction taking place during counseling sessions. Results indicated that in some cases, use of certain persuasive strategies was related to short-term adoption of safer-sex recommendations. These findings bolstered the argument for a move toward reconceptualizing the HBM by centralizing communication cues to action. (author's)
Subject content analysis of AIDS literature, as produced in Latin America and the Caribbean.
The purpose of this paper is to present the preliminary results of a research in progress regarding the subject content analysis of AIDS literature, as produced in or about the Latin American and Caribbean (LAC) region. An AIDSLINE/OVID literature search was conducted to obtain only the Medical Subject Headings (MeSH) geographic terms related to the LAC region. The period of study was from 1982 to June 1998. Indicators regarding the distribution of records throughout the years of study, as well as the subject, check tags, and subject/subheadings distribution patterns were analyzed. This was done through the application of a modular bibliometric information system, as well as the applications of Biblio-Link for Windows, version 1.2, 1994-97, Research Information Systems; Pro-Cite for Windows, version 4.0.1, 1995-98, Research Information Systems; and Microsoft EXCEL 97, 1985-98, Microsoft Corporation. A total of 4124 records were obtained and analyzed. In descending order, Brazil, Mexico, Haiti, Argentina and Puerto Rico, generated the highest number of citations. Highly ranked MeSH subject headings were Risk Factors; AIDS; Sex Behavior; Support, Non US Government; HIV Infections; and Developing Countries. Results demonstrate that major research concerns centered on the epidemiological aspects and transmission of AIDS; and more recently, on the prevention and control of the disease. A switch of the studies from male to female, and from middle age to adolescence was also observed. The authors provide further lines of research. (author's)
College students' reasons for nonuse of condoms within dating relationships.
210 heterosexual undergraduates in dating relationships were surveyed about reasons for not using condoms every time for vaginal and anal sex and for increasing or decreasing condom use during their relationships. Half of the respondents reported consistent condom use in the first month of their relationships, while only 34% reported consistent condom use in the past month. Subjective assessments of partner safety and the belief that sufficient measures were being taken to avoid pregnancy were important reasons for condom nonuse. Study results suggest that interventions should emphasize the importance of objectively assessing HIV/sexually transmitted disease risk before reducing condom use within relationships. Interventions also need to provide additional information on the riskiness of heterosexual anal sex. (author's)
This article examines epidemiological repercussions and social determinants of adolescent sexual problems in order to effect developmentally sound intervention strategies. It is noted that the proportion of American teens with sexual experience has increased compared with that found in 1970. Adolescents are engaging in sexual activity and with a greater number of partners. Studies indicate that nonsexual dynamics can help explain the reasons behind such an increase in adolescent sexual activity despite self-reported lack of sexual interest. Based on the observations of the authors, exploring attitudes, knowledge, and behavior regarding HIV and contraception can help in designing appropriate health-promoting and preventive measures. Such interventions must focus on postponing sexual activity, but not excluding information and availability of contraceptives for teens choosing to engage in sexual intercourse. These interventions require a neutral location, with trained counselors who present a balanced message regarding sex and discuss with teenagers their motivations and concerns. Moreover, it is important to teach adolescent girls concerning their control over intimacy, sex, and contraception, in turn reduces their risky sexual behavior with their peers.
Fertility policy in Ceausescu's Romania.
This study tests a model for the impact that Ceausescu's pronatalist policies had on the Romanian fertility rate between 1967 and 1989. Using time-series analysis, the authors' findings show that the Ceausescu regime continually struggled with the Romanian population to increase the national birthrate. As a result of the regime's policies, there was a significant increase in overall fertility between 1967 and 1989, when the Ceausescu regime was overthrown. Reasons are offered as to why Romania pursued such policies and was able to make them work, while other Eastern and Central European regimes proved to be less able to sustain drives to increase national fertility. This article also presents a model of what happened to the Romanian fertility rate since 1989, showing that there has been a significant decline in fertility in the post-Communist period. (author's)
Child fostering and fertility: some evidence from Ghana.
This study analyzed demographic data on the relationship between fostering and fertility, and the social factors associated with fostering. Data were collected from Ghana Demographic and Health Survey 1993, in which a total of 4562 women were interviewed regarding fertility, mortality, contraception, and maternal and child health indicators. Overall, the data have shown a positive association between education and fostering. Women with higher education tend to transfer their children to live with surrogate parents, usually their own relatives, within the extended family system. This practice allows them the flexibility to engage in other activities such as further studies or labor force participation. It was also shown that women's occupation was related with fostering, in which the reason for the variation may be the nature and demands of professional and skilled jobs that were incompatible with childrearing and childcaring. However, data further indicated that the practice has no reproductive implications.
Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma.
The study estimates the relative importance of specific types of traumas experienced in the community in terms of their prevalence and risk of leading to post-traumatic stress disorder (PTSD). A representative sample of 2181 persons in the Detroit area aged 18-45 years were interviewed by telephone to assess the lifetime history of traumatic events and PTSD, according to the Diagnostic and Statistical Manual of Mental Disorders-IV. PTSD was assessed with respect to a randomly selected trauma from the list of traumas reported by each respondent, using a modified version of the Diagnostic Interview Schedule, Version IV, and the WHO Composite International Diagnostic Interview. The conditional risk of PTSD following exposure to trauma was 9.2%. The highest risk of PTSD was associated with assaultive violence (20.9%). The trauma most often reported as the precipitating event among persons with PTSD (31% of all PTSD cases) was sudden unexpected death of a loved one, an event experienced by 60% of the sample, and with a moderate risk of PTSD (14.3%). Women were at higher risk of PTSD than men, controlling for type of trauma. The risk of PTSD associated with a representative sample of traumas is less than previously estimated. Previous studies have overestimated the conditional risk of PTSD by focusing on the worst events the respondents had ever experienced. Although recent research has focused on combat, rape, and other assaultive violence as causes of PTSD, sudden unexpected death of a loved one is a far more important cause of PTSD in the community, accounting for nearly one-third of PTSD cases. (author's)
Sexual abuse of boys: definition, prevalence, correlates, sequelae, and management.
This study clarifies the definition of sexual abuse among boys, updates estimates of its prevalence, and explores its reported correlates, sequelae, and management. Using studies conducted during the period 1985-97, 166 cases representing 149 sexual abuse samples were analyzed. Studies were methodologically limited and definitions of sexual abuse varied widely. Variation of prevalence estimates ranged from 4% to 76%. Boys younger than 13 years, non-White and of low socioeconomic status were found to be at highest risk. Perpetrators, on the other hand, tend to be known but unrelated males. Abuse frequently occurred outside the home, involved penetration and occurred more than once. Sequelae included psychological distress, substance abuse, and sexually related problems. Evaluation of management strategies was limited. Sexual abuse of boys appears to be common, under-reported, under-recognized and undertreated. Thus, future study requires clearer definitions of abuse, improved sampling, more rigorous data collection, more sophisticated data analyses, and better assessment of management and treatment strategies. As such, health care professionals must be more aware of and sensitive to the possibility of sexual abuse in their male patients.
Women's disclosure of HIV status: experiences of mistreatment and violence in an urban setting.
Women represent an increasing proportion of AIDS cases and anecdotal reports suggest some face substantial risks when others learn they are HIV-positive. The purpose of this paper is to describe women's fears and experiences regarding disclosure of their HIV status. 50 HIV-positive women, ages 16-45 from urban teaching hospital outpatient clinics, were interviewed using an in-depth, qualitative interview. 86% of the women were African-American and 56% were current or former intravenous drug users. At the time of the interview, 88% of the women had known their HIV status for a year or more. All but one woman had disclosed her HIV status to at least one person and 82% had disclosed to multiple people. Although two-thirds of the women had been afraid to disclose to others because of concerns about rejection, discrimination or violence, three-quarters of the sample reported only supportive and understanding responses to their disclosure. One-quarter of the sample reported negative consequences of disclosure, including rejection, abandonment, verbal abuse and physical assault. Disclosure-related violence was discussed by nine women (18%): two who feared violence were relieved to find a supportive response; four chose not to disclose their status because they feared violence; and three women were verbally or physically assaulted. Fear of mistreatment figured prominently in decisions about disclosure among this sample. That many women found supportive and understanding responses is encouraging. However, there were sufficient examples of negative consequences, including violence, to suggest individualized approaches to post-test counseling, enhanced support services for HIV-positive women, and public education to destigmatize HIV-disease. (author's)
Violence, pregnancy and birth outcome in Appalachia.
Few studies have followed pregnant women prospectively to examine the impact of violence on birth outcome. The authors included such an assessment in a prospective study of pregnancy among low-income women. Nurses and social workers interviewed pregnant women (n = 364) and asked if they had been the object of violence since they became pregnant. These prenatal interviews were linked with information from perinatal records and with birth and death information. In total, 15.9% of women in the study indicated they had been abused since they became pregnant. Abused women were more likely to be teenagers and to have partners who were teenagers. Abused women were more likely to be primiparous, to smoke during pregnancy, and to have physical problems related to stress. Women battered during pregnancy were more likely to suffer fetal distress or fetal death [odds ratio (OR): 3.68; 95% confidence interval (CI): 1.36, 9.94], even after adjusting for maternal age and smoking status. Finally, the infants of abused women were more likely to remain in the hospital after their mother's discharge (OR: 3.75; 95% CI: 1.38, 10.23). The findings suggest that fetuses may be compromised in utero, as shown by higher rates of fetal distress and fetal death found among women physically abused during pregnancy. (author's)
This study describes the demographics of all pregnant trauma patients at a tertiary care center and a large community hospital. Variables predictive of fetal outcome including an examination of Kleihauer-Betke and nonstress testing were identified, and an evaluation and management protocol after trauma based on empirical data was recommended. 476 medical records of pregnancies complicated by trauma from July 1987 through October 1993 were retrospectively reviewed. The most common trauma cases include motor vehicle accidents (54.6%), domestic abuse and assaults (22.3%), associated with falls (21.8%), and due to burns, punctured wounds or animal bites (1.3%). Uterine contraception occurred in 39.8% of patients, preterm labor occurred in 11.4%, preterm delivery in 25%, and abruptions 1.58%. Abnormal monitoring and positive Kleihauer-Betke tests were not predictive of adverse pregnancy outcomes. Findings underscore that initial external fetal monitoring be performed for 4 hours. Likewise, the authors recommend an Rh-immunoglobulin work-up. Lastly, incorporating trauma prevention into routine prenatal care would be beneficial given the frequency of trauma effects in pregnancy and the difficulties encountered in identifying variables predictive of pregnancy outcomes.
Physical violence during pregnancy: maternal complications and birth outcomes.
The aim of this study was to assess the association between physical violence during the 12 months before delivery and maternal complications and birth outcomes. The authors used population-based data from 6143 women who delivered live-born infants between 1993 and 1995 in South Carolina. Data on women's physical violence during pregnancy were based on self-reports of “partner-inflicted physical hurt and being involved in a physical fight.” Outcome data included maternal antenatal hospitalizations, labor and delivery complications, low birth weights, and preterm births. Odds ratios and 95% confidence intervals were calculated to measure the associations between physical violence, maternal morbidity, and birth outcomes. The prevalence of physical violence was 11.1%. Among women who experienced physical violence, 54% reported having been involved in physical fights only and 46% had been hurt by husbands or partners. In the latter group, 70% also reported having been involved in fighting. Compared with those not reporting physical violence, women who did were more likely to deliver by cesarean and be hospitalized before delivery for maternal complications such as kidney infection, premature labor, and trauma due to falls or blows to the abdomen. Physical violence during the 12 months before delivery is common and is associated with adverse maternal conditions. The findings support the need for research on how to screen for physical violence early in pregnancy and to prevent its consequences. (author's)
Correlates of battering during pregnancy.
Battering during pregnancy affects the health of both pregnant women and their unborn children. The purpose of this retrospective study of 488 primarily Medicaid-eligible postpartum women was to identify the constellation of factors associated with violence. The prevalence of battering during pregnancy was 7%, similar to that found in other studies. Significant correlates of battering included anxiety, depression, housing problems, inadequate prenatal care, and drug and alcohol use. Woman battering by a partner during pregnancy was associated with a greater severity of this constellation of patterns than those experiencing abuse before pregnancy only, or those experiencing physical attack by someone other than their partner. These factors are important to recognize in nursing assessments of pregnant women. (author's)
The impact of sexual abuse: implications for drug treatment.
Previous research has shown a high incidence of sexual abuse histories among chemically dependent women. This paper reports on the associations among sexual abuse, past traumatic experiences, and current drug-associated behaviors in a study of chemically dependent pregnant and parenting women in New York City in order to examine the implications for drug treatment. Interviews were conducted with 146 indigent New York City women. Subjects were eligible for the study if they met the following criteria: were current users of crack/cocaine or had used crack/cocaine within the past 3 years, were currently pregnant, and/or were the mother of a preschool-age child. Subjects were recruited and interviewed from drug treatment programs (n = 72) and nontreatment sites (n = 74). 133 (91%) of the 146 women interviewed were African-American or Latina. Study participants had a mean age of 29.4 years, with an average of 11.5 years of education. 74 (51%) of the women interviewed reported having been victims of at least one forced sexual encounter. Sexual abuse was associated with both past experiences and current drug-associated behaviors. The age of abuse had a significant impact on outcome. Given the frequency with which sexual abuse has been found in the histories of chemically dependent women, and the linkages of sexual abuse to indicators of drug problem severity, it appears important to integrate therapy for sexual abuse into treatment for chemically dependent women. (author's)
Urban violence and health -- South Africa 1995.
Many cities all over the world are the loci of various forms of violence. Violence is a complex phenomenon, its causes are multidimensional and its consequences have ramifications far beyond the immediate perpetrators and victims. The aim of this paper is to review various forms of urban violence and their health consequences, locating them in the wider South African context. Owing to the lack of centralized data, the information presented in this paper is based on the best available data derived from numerous sources. Using the socioenvironmental model of health and disease as a framework, violence and its impact on health is discussed. The brief review of political violence, violent crimes, violence against women and domestic violence in South Africa, highlights the fact that South Africa is a particularly violent society. The data presented suggest a link between the social context of violence and its health consequences, dealing with the impact of urban violence in the form of physical trauma as well as emotional trauma associated with it. Consequently, adopting a comprehensive approach that violence needs to be understood in the wider societal context and has to be dealt with in the broadest terms possible, as advocated by the “New Public Health” approach, a way forward to reduce levels of violence and cope with its health consequences is suggested. An emphasis is placed on the three levels of prevention and the vital collaboration between the judicial system, police, the health sector as well as the community. (author's)
Domestic violence (DV) against women often goes unrecognized by health care providers due to multiple barriers. In an effort to increase screening, identification, and referral for services, the RADAR Training project was created for the health care staff of 12 federally qualified community health centers (CHCs). A two-phase evaluation was conducted to assess the intervention. Phase one evaluated the health care providers' perceived knowledge and comfort pre-training, post-training, and at 3 months follow-up. The second phase included a medical chart review of four CHCs to assess the rates of screening, documentation of abuse, assessment of safety, and referrals for help at baseline (6 months pre-training) as compared to the intervention period (6 months post-training). The health care providers' perceived level of knowledge and comfort increased significantly post-training and then later decreased at 3 months follow-up. The rate of screening for DV (25% vs. 5%), suspicion of DV (6% vs. 2%), completion of safety assessments (17% vs. 5%), and referrals (4% vs. 0%) increased significantly between the intervention and baseline periods. However, the rates of documentation of abuse did not change. This intervention was successful in increasing provider perceived knowledge and comfort, however, comfort decreased at follow-up. Additionally, the rates of screening and referrals increased 6 months post-training. Health care provider training and support and integrated quality assurance mechanisms may be necessary to increase the overall rate of these activities, and to sustain this effort over time. Further study is needed to identify effective methods to increase provider comfort regarding DV screening. (author's)
Effects of abuse on maternal complications and birth weight in adult and adolescent women.
The aim of this study was to estimate the incidence of physical and sexual abuse in a sample of adult and adolescent pregnant women and to determine the relationship between abuse and maternal complications and infant birth weight. 1897 women were screened for abuse during pregnancy. Maternal complications and infant birth weight were obtained by record review. Physical abuse in the past year and/or during pregnancy was reported by 37.6% of the adolescent and 22.6% of the adult women (P < 0.001). Abused adult women were more likely to have unplanned pregnancies (P < 0.001) and to begin care after 20 weeks (P < 0.01) than nonabused women. For the aggregate sample of 1597 for whom birth weights were available, abuse was a significant risk factor for low birth weight (LBW) (P < 0.05) as was poor obstetric history (P < 0.05). Using Institute of Medicine risk factors for LBW, abused adults were more likely to have poorer past obstetric histories and to use tobacco, alcohol, and drugs (P < 0.05). Abused adolescents were at greater risk for smoking and first- or second-trimester bleeding (P < 0.05). For the aggregate, abused women were at greater risk for poor obstetric history, vaginal/cervical infection during pregnancy, smoking, and alcohol and drug use. More than one-third of the adolescent and nearly one-fourth of the adult women reported abuse in the past year and/or during pregnancy. Abuse is related to poor obstetric history, substance use, and LBW. The short abuse assessment screen detects potential abuse in order that interventions can be implemented. (author's)
The global burden of mental disorders.
Recent data on the burden of mental disorders worldwide demonstrates a major public health problem that affects patients, society, and nations as a whole. Research must be done to find effective ways to deal with the increasing burden of mental disorders. Given the growing evidence that mental disorders are disorders of the brain and that they can be treated effectively with both psychosocial counseling and psychotropic medications, intervention packages could be developed to deal with the increasing burden. Such packages should be tested for real-world effectiveness and their cost-effectiveness should be demonstrated to guide policymakers to choose from among many other non-mental health interventions. The transportability and sustainability of intervention packages should be studied in public health research and a link between efficacy, effectiveness, cost-effectiveness, generalizability, and sustainability should be demonstrated. The WHO initiative on the World Mental Health 2000 Survey will provide the first basic epidemiologic data. Together with other data, the initiative will provide solid evidence for including mental disorders into essential treatment packages. In this way, parity can be achieved for mental disorders and mental health can be mainstreamed into health and public health practice. (author's)
Factors that influence clinicians' assessment and management of family violence.
Using a mail survey, this study investigates the factors that influence clinicians' assessment and management of family violence. Of the 2100 questionnaires mailed to health care professionals, 1588 were completed (78% overall response rate). Extent of subjects' formal education on domestic violence showed that 33% had no education in the three types of abuse (child abuse, spouse abuse, and elder abuse). Subjects suspecting abuse cases depend on their education, with 19.0% and 20.6% commonly suspecting physical and sexual child abuse, respectively. Based on the results, several trends were found: 1) similarities within and wide differences among three groups of subjects; 2) high numbers of practicing clinicians without education on the assessment and management of family violence; 3) the belief that abuse is infrequent among their patients. Lastly, the trends in the data are indicative of the need for expanded curricula on family violence and re-examination of mandatory reporting laws relative to available protective services.
Primary care physicians' response to domestic violence: opening Pandora's box.
This qualitative research study using open-ended, semistructured interviews explored primary care physicians' experiences with domestic violence to determine the factors that hinder problem recognition and intervention in primary care settings. Study participants comprised 38 physicians from an urban health maintenance organization. 89% of these physicians were family practitioners serving a predominantly White, middle-income population. Analysis of the interviews revealed that exploration of domestic violence in the clinical setting is analogous to “opening Pandora's box.” This metaphor suggests that there is a fear of a myriad of potential problems, including lack of comfort, fear of offending, powerlessness, loss of control, and time constraints. The findings provide information on the dilemmas confronting physicians from within the physicians' frame of reference and in the physicians' language. Likewise, this paper underscores the need to address these issues in training programs. Further studies must be conducted to assess the generalizability of these findings to other groups of physicians.
The purpose of this study was to report the prevalence, risk, and implications of comorbidity between partner violence and psychiatric disorders. Data were obtained from a representative birth cohort of 941 young adults through use of the Conflict Tactics Scales and Diagnostic Interview Schedule. Half of those involved in partner violence had a psychiatric disorder; one-third of those with a psychiatric disorder were involved in partner violence. Individuals involved in severe partner violence had elevated rates of a wide spectrum of disorders. The findings support the importance of mental health clinicians screening for partner violence and treating victims and perpetrators before injury occurs. (author's)
Characteristics of sexual abuse associated with greater psychological impairment among children.
The psychiatric histories and projective test responses of 102 sexually abused girls (ages 5-16) were examined to determine if some particular characteristics of sexual abuse were reliably associated with more serious impairment. Characteristics of abuse significantly associated with greater psychological disturbance were: more than one perpetrator, an early age of abuse onset (before age 7 or 8), and periods of intense and frequent abuse episodes (more than 3 or 4 times per month). What enhanced the child's capacity to recover was the presence of a relatively stable two-parent household. Implications for prognosis and treatment are discussed. (author's)
Adolescent pregnancy and sexual risk-taking among sexually abused girls.
Data on 3128 girls in grades 8, 10, and 12 who participated in the 1992 Washington State Survey of Adolescent Health Behaviors were used to analyze the association of a self-reported history of sexual abuse with teenage pregnancy and with sexual behavior that increases the risk of adolescent pregnancy. In analyses adjusting for grade level, respondents who had been sexually abused were 3.1 times as likely as those who had not been abused to say they had ever been pregnant; in multivariate analyses, respondents who had experienced abuse were 2.3 times as likely as others to have had intercourse but were not more likely than other sexually active respondents to have been pregnant. However, those with a history of sexual abuse were more likely to report having had intercourse by age 15 (odds ratio, 2.1), not using birth control at last intercourse (2.0) and having had more than one sexual partner (1.4). Thus, an association between sexual abuse and teenage pregnancy appears to be the result of high-risk behavior exhibited by adolescent girls who have been abused. (author's)
[The Day of Six Billion celebrated. Merida children sensitize adults to the care of the Earth]
A workday for school children in observance of the attainment of a world population of 6 billion was held in Merida, Venezuela, on October 12, 1999, the estimated day of arrival at 6 billion. A community development organization associated with the Cultural Office of the University of the Andes sponsored the workday in accordance with Manifesto 2000 for the International Year of the Culture of Peace and Nonviolence, which signaled that care of the earth is a necessary aspect of the culture of peace. All societal sectors must become aware of the urgent need for public policies to improve quality of life for the 6 billion inhabitants of the planet. School children in the state of Merida will carry out various activities including an art festival in which they will express their views on the size of the world population. The activity will demonstrate to children and adults alike the need to care for the planet through prevention and control of population growth at the world level.
[Knowledge, attitudes and practices of the Caranavi community with regard to pulmonary tuberculosis]
683 school teachers, parents, and students participated in a survey of knowledge and practices regarding pulmonary tuberculosis (TB) conducted by SERVIR in the municipio of Caranavi, Bolivia, between August 1998 and January 1999. Caranavi’s TB rate of 450/100,000 inhabitants is nearly 5 times the national average. The study was a baseline survey for development of prevention and control measures in the region. Respondents were judged to have adequate knowledge of pulmonary TB if they could identify the mechanism of transmission, knew TB was curable and where to obtain treatment, and were aware that treatment is free. Over half of the 282 household heads interviewed had no knowledge of TB prevention, control, or treatment. 17.2% of the remaining respondents were adequately informed. The majority with knowledge of TB cited talks by health personnel as their major source of knowledge. Around 20% of households surveyed contained at least one TB patient. The majority of patients began treatment but nearly one-third abandoned it due to negligence, lack of economic resources, or lack of knowledge. Only half concluded the treatment and were cured. 57.1% of the teachers interviewed were well informed, 42.8% had partial knowledge, and 4.5% were completely uninformed about TB. 75% of the 278 students aged 12-16 who were interviewed had no knowledge of TB. 6.1% were well informed and 22.5% were partially informed. 41.3% of the students were vaccinated with BCG. Only 13.9% of the 683 persons in the total sample had adequate information about TB. 33% knew where treatment could be obtained, and 18% knew that treatment is free.
The First International Course for Pediatric Onco-Hematologists from Latin American countries with limited resources was held in Milan in September 1996, reflecting recognition in the “Declaration of Montevideo” of the value of collaboration with specialists for improving diagnosis, treatment, and integral care of children with leukemia and other cancers. The International School of Pediatric Oncology-Hematology of Monza (MISPHO) was created to facilitate collaboration between participating institutions. The MISPHO school is organized and directed by Italian experts, and brings together participants from the Latin American countries and internationally recognized specialists. Various documents and declarations have been prepared in conjunction with the MISPHO program for health professionals and parents of children with cancer to identify treatment priorities and research needs, reaffirm the right to health, and channel requests for support from the international community. The four scientific courses held by MISPHO have examined leukemia and its variants, Hodgkin’s and Non-Hodgkin’s lymphoma, hemophilia, histiocytosis, psychosocial aspects of cancer, specialized training for nurses, aplastic anemia, soft tissue sarcomas, hepatitis, and medical education. The course methodology combines dialogue with interchanges of experience and open discussion and group work. The MISPHO courses recognize the importance of parents’ groups for assistance with diagnosis and treatment and mutual support. The parents’ association in Bolivia seeks to develop educational strategies and encourage solidarity with low-income parents.
[Multicenter study on attitudes and cultural norms on violence (ACTIVA project): methodology]
The study design, development of research instruments, sample selection, data collection, and conceptual basis of the multicenter ACTIVA study are described. The ACTIVA project is a transversal study utilizing a common questionnaire administered in face-to-face interviews with residents of private households aged 18-70 in 8 Latin American and Spanish cities: San Salvador, San Jose, Cali, Caracas, Salvador, Rio de Janeiro, Santiago, and Madrid. The study sought to analyze and compare the prevalence of verbal and physical aggression toward children, spouses, and non-family members, and to identify personal, environmental, and socioeconomic factors associated with violent behavior as a contribution to policy development and program formulation. The final sample consisted of 10,821 persons. The initial model was based on social cognition theory. The questionnaire was intended to quantify norms, attitudes, skills and other psychosocial variables associated with aggression and victimization. Sociodemographic attributes, socioeconomic conditions, family characteristics, confidence in institutions, exposure to television, drunkenness, possession of firearms, and other variables intervening between psychosocial components and violence were identified. The questionnaire was validated in three pilot studies. Data collection began in July 1996 in Cali and concluded in March 1997 in Santiago. The methods employed allowed construction of various scales and indicators for use in other investigations. The rigorous instrument design, sampling, and data collection, and the use of a standard method in different cities facilitate comparisons. The study design has certain vulnerabilities, however, including possible sample bias, nonrepresentativeness, and inability to support assumptions of causality.
[A model of simultaneous determination of the number and quality of children]
A 1996 survey of 1200 families in the principality of Asturias, Spain, provided data for development of a model simultaneously determining the number and quality of children within the framework of the New Home Economics. The model emphasized interaction between the quality and quantity of children, female labor force participation, and family leisure activities. A system of simultaneous equations was estimated to contrast empirically the main linkages between the endogenous variables and those characterizing the economic and social position of the family: male and female wage rates, non-labor income, age and education of the spouses, rural or urban residence, and others. The model was estimated using a two-stage least squares method. The estimates obtained were consistent with the study hypotheses, reflecting satisfactorily the effects of the demographic and economic variables studied on the number and quality of children, labor force participation of women, and leisure activities, as well as interrelations among the endogenous variables.
[Population dynamics of Cuenca. Analysis for the period, 1950-1982]
The last four Ecuadorian censuses provide data for a descriptive analysis of population growth and structure in the province of Azuay and especially the canton of Cuenca in the three intercensal periods. The canton of Cuenca had a higher annual growth rate over the entire period than did the province of Azuay or the other cantons. During the intercensal periods 1950-62, 1962-74, and 1974-82, respectively, the rates of growth were 0.75, 2.52, and 2.19% for Azuay province and 1.30, 3.45, and 3.02% for Cuenca. Urban population growth rates exceeded rural in Cuenca in all three periods. Fertility and mortality rates declined in all areas studied over the 32-year span. Between 1950-62 and 1974-82, the crude birth and death rates, respectively, declined from 44.0 and 20.2 to 35.7 and 10.3 in Azuay province, and from 44.1 and 20.5 to 32.0 and 9.4 in Cuenca. Net migration resulted in population loss in all periods and at all levels of analysis except in Cuenca in 1962-74 (5.6/1000) and 1974-82 (7.4/1000). In 1962, 1974, and 1982, respectively, the general fertility rates were estimated at 196.5, 161.2, and 149.6 per 1000 in Azuay province and 192.4, 148.2, and 109.0 per 1000 in Cuenca. The proportions under age 15 in Azuay province and Cuenca, respectively, were 40.9 and 40.3% in 1950, 43.9% and 42.6% in 1974, and 41.5% and 39.5% in 1982. The proportion of the Azuay population that lived in Cuenca increased from 48.8% in 1950 to 62.2% in 1982. The proportion urban increased from 19.6% in 1950 to 38.3% in 1982 in Azuay, and from 32.7% to 55.4% in Cuenca.
[The concentration of the population in Azuay]
Trends in population distribution in Azuay province are closely related to the socioeconomic development of the area and of Ecuador. A capitalist organization of labor encourages population concentration, while precapitalist forms of production are associated with greater dispersion. Data from the censuses of 1962, 1974, and 1982 are the basis for a preliminary analysis of changes in the spatial distribution of Azuay province. The population is increasingly concentrated in lower altitude slopes and valleys where soil and climate are favorable for large-scale agroindustry. The higher altitudes are populated by impoverished subsistence farmers who cope with poor soil and erosion through progressive fragmentation of their lands or out-migration. The canton of Cuenca contained 27.2% of the provincial population in 1962, 30.2% in 1974, and 35.5% in 1982. The population of the city of Cuenca increased from 60,000 in 1962 to 152,000 in 1982. Parishes near the city have become dormitory communities for Cuenca’s workers, while more distant parishes have lost population through out-migration. In 1962 and 1982, respectively, 3.65% and 15.9% of the provincial population lived in political and administrative localities of 10,000-19,999 inhabitants near the city of Cuenca. The proportion living in localities of 2000-9999 inhabitants declined from 61.6% in 1962 to 43% in 1982. Localities of under 2000 inhabitants, located in the higher altitudes, contained 7.6% of the total population in 1962 and 3.2% in 1982. The province lacks intermediate sized cities. Application of the Lorenz curve and Gini’s coefficient of concentration confirm the trend toward concentration in the province of Azuay.
A brief discussion of the crisis in Ecuadorian universities and a survey of the development and activities of the Population Center (CEPD) at the University of Cuenca Institute of Social Investigation are the basis for an assessment of the role of population studies in the social science programs of Ecuadorian universities. Ecuadorian universities were late in incorporating research into their normal activities, and finally did so in response to production needs. General problems of Ecuadorian society were reflected in the university system in absence of medium or long term academic policy and planning, competition from private institutions, deteriorating quality of instruction and saturated labor market for professionals, lack of government financial support, and lack of interest in academic reform. The few existing population studies were concerned with measurement and quantification rather than analysis of population as a social phenomenon. The CEPD was formed in 1983 as part of the Institute of Social Investigation (IDIS) through a convention between the UN Population Fund and the University of Cuenca for purposes of providing population training and research in the region. As in other IDIS programs, empirical studies, multidisciplinary research, and a regional focus are stressed. Theory and methodology of demographic research were emphasized in the first phase of CEPD program development. The priority research interests of the Center were defined in the second phase as labor force, spatial distribution, and measurement techniques. The third and current phase emphasizes assuring availability of trained personnel for population analysis, generating information on the regional population, and developing capacity to provide population information and documentation.
[Reproductive strategies of the campesino families of Cuenca: an exploratory study]
A brief synthesis is provided of results of a study carried out by the Population Center of the University of Cuenca on reproductive strategies of peasant families in rural areas within 10-15 km of the city of Cuenca, Ecuador. The first section provides theoretical and methodological background for the analysis, defining terms such as “survival strategies”, “forms of production”, and “spatial mobility”, and assessing use of the family as a unit of analysis. Information on the study area is then presented. Three large zones with different predominant crops and economic activities were distinguished. The size, composition, and type of households studied in each of the three areas are described, including information on deaths of children, contraceptive usage, and type of attendance at delivery. Patterns of land tenure, crops grown, livestock owned, and other productive activities and sources of labor in the three zones are described. The division of labor and occupations of the household members in the three zones are also described. Results of a household consumption survey are briefly summarized. The social conditions of reproduction in the three zones are discussed in the areas of education, health, housing, and basic services, and the main features of social organization are identified. The reproductive strategies of the labor force were found to embody a strong monetary component, related to activities requiring spatial mobility between the countryside and the city of Cuenca. A considerable differentiation was observed in most aspects studied between the three areas.
[Results of a baseline study on adolescent sexual and reproductive health]
138 female and 128 male adolescents in the city of Oruro, Bolivia, were surveyed in October 1999 for a baseline study of sexual and reproductive health. 24% were aged 14-15, 33% were aged 16-17, and 42% were aged 18-19. 5% were married and 2.3% were in consensual unions. 140 attended school and 126 did not. In a study of stereotypes, 13 female and 10 male respondents stated that child care is the responsibility solely of the mother, while 14 females and 35 males believed that supporting the family economically is the responsibility solely of the father. 100 females and 87 males believed that women should be virgins at marriage, while 83 female and 62 male respondents believed that men should also be virgins. 59 females and 34 males did not believe that pleasure should be a goal of sexual relations. 32.7% of the adolescents interviewed stated they had had sexual relations. 16.4% of those attending school and 51% not attending had had intercourse. The median age at first intercourse was calculated at 15.5 years. 122 of the female and 118 of the male respondents did not think there was any benefit to adolescent child bearing. 87% of female and 91% of male respondents knew about the existence of contraception. 45% of female and 32% of male respondents used contraception at the last intercourse. 12% of the adolescents currently used a method, most frequently condoms. 85% of the females and 82% of the males had heard of sexually transmitted diseases. 56% knew they could be avoided by using condoms; 40%, by abstaining from sex. 4 of the 266 respondents were pregnant.
Socioeconomic and cultural determinants of abortion among Jewish women in Israel.
This study uses data from the 1974-75 Israel Fertility Survey and the 1987-88 Study of Fertility and Family Formation to examine the changing determinants of abortion among Jewish women in Israel. Over the course of socioeconomic development, some economic and cultural variables (e.g., education, employment, and ethnicity) lose their explanatory power whereas others become increasingly important for understanding variation in the practice of abortion. This article argues that the relationship between these variables and abortion is mediated by a variety of external and macro-level factors including social norms, the availability of contraceptive technology, and laws governing access to abortion. (author's)
The fertility impact of temporary migration in China: a detachment hypothesis.
This paper expands the migration-fertility linkage literature by examining the fertility impact of temporary migration in Hubei, China. The central hypothesis is that temporary migration affects migrants' fertility through a detachment process: The separation of temporary migrants' actual residence from their de jure residence creates a loophole in family planning administration, weakening the social control over their fertility. The analysis of annual order-specific births since 1979 suggests that temporary migrants exhibit significantly higher probabilities of having a second birth than permanent migrants and nonmigrants once type of residence is controlled for: rural-rural temporary migrants have the highest fertility among all groups examined. The results lend support to the detachment hypothesis while indicating a strong antinatal impact of urban residence. Rural-urban temporary migrants are not the ones to blame for increases in outplanning births in contemporary China, but their fertility would have been lower if there had been no detachment. Rural-rural temporary migrants are actually the escapees of the one-child-per-family policy. (author's)
Religiosity and contraceptive method choice: the Jewish population of Israel.
The primary purpose of this paper is to explore the relationship between religiosity and contraceptive method choice among users of contraception. The authors analyze a representative sample of 1751 married urban Israeli Jewish women interviewed in 1987-88. The authors' findings indicate that the contraceptive choices of religious women are determined largely by considerations unrelated to religious doctrine. A combination of factors, including the suitability of specific methods to fertility control needs, peer influences, and other cultural effects, appear to modify the acceptance and application of a particular religious theology. (author's)
Data from a 1989 Brazilian survey were analyzed to determine the impact of breast-feeding on child health and the demand for medical assistance. Health production functions for illness among infants aged 0-5 months and 0-20 months and for height of infants aged 0-23 months were estimated. Estimated health outcome production functions testify to the substantial health benefits of breast-feeding. Exclusive breast-feeding reduces the probability of illness by about 15% among infants aged 0-5 months. Moreover, the benefits of breast-feeding did not decline but were virtually constant among infants over the age range of 0-20 months. Those who were currently breast-fed were in significantly better health. In the context of medical care, a child's predicted health does not have a significant impact on the demand for medical care. Findings of this study underscore the need to have further research on the relationship between child health and the demand for medical care.
Structural change in the impact of income on food consumption in China, 1989-1993.
China is undergoing a marked transition in its diet and nutritional status patterns. This study determines the structural change in the impact of income on food consumption in China during 1989-93. Utilizing data from a longitudinal study of 3800 households in China, evidence points to a shift in the relationship between income, dietary structure, and total nutrient intake at the macrolevel. Overall, it is noted that the increase in income over time in the country coincided with a shift in the demand for inferior and normal food groups. In addition, there was a pronounced increase in the income elasticity for more luxury foods during the specified period, while less superior goods became more inferior over this 4-year span. Such an increase in income elasticities for total energy and for energy from fat suggest a worsening of the composition of the diet in ways that are linked to obesity and obesity-related diseases as incomes continue to rise. In view of this, several implications for the formulation of future nutrition policies in China are cited.
Adolescents' sexual media diets.
A model of how adolescents choose, interpret, and interact with the mass media is discussed in the context of sexual development. The Media Practice Model suggests that adolescents select and react to sexual media diets that speak to an emerging sense of themselves as sexual human beings. Relatively little is known about how the sexual content adolescents attend to in the media is interpreted or incorporated into their lives. Entertainment-education and media literacy are two strategies for increasing the possibility of healthy outcomes from adolescents' use of sexual media. (author's)
Media matters for youth health.
According to the authors of this paper, we live in a media world and the mass media offer educational and entertainment opportunities for adults and children. However, pediatricians and parents are increasingly aware of the potential health risks that media exposure presents to children and adolescents. For many years, the American Academy of Pediatrics (AAP) has made media education a key goal for member pediatricians: six policy statements about the impact of mass media have been published (and revised) over the past decade. In 1997, the AAP launched a 5-year, nationwide media education campaign called Media Matters. Although education about media is the cornerstone of Media Matters, pediatricians have other important roles. In offices and clinics, the AAP suggests that pediatricians take a media history from patients and discuss connections between a child's health and behavior and media use habits. Pediatricians can also provide anticipatory guidance to families about media in the home, including limiting media use, making wise media choices, encouraging co-viewing and critical thinking, and making the home a positive media environment. Many gaps in our knowledge about the effects of media images and messages on young people still exist; pediatricians call for ongoing, targeted research about media. In this way, the authors can all enjoy the benefits offered by media, while minimizing the risks. (author's, modified)
Ischemic stroke risk with oral contraceptives. A meta-analysis.
The aim was to review available literature to determine whether oral contraceptive (OC) use is associated with increased stroke risk. Studies published from January 1960 through November 1999 were identified from electronic databases (MEDLINE, BIOSIS, and Dissertation Abstracts Online), Index Medicus, bibliographies of pertinent review articles and pertinent original articles, textbooks, and expert consultation. From 804 potentially relevant references retrieved, 73 were studies investigating risk of ischemic stroke with OC use. Two reviewers independently applied the following inclusion criteria: more than 10 stroke cases sampled, clear stroke subtype differentiation, concurrent controls included, adequate data included to determine relative risks (RRs) and confidence intervals (CIs), analysis controlled for age, and no later publication of identical data. A third investigator adjudicated disagreements. 16 studies met all inclusion criteria and were included in the meta-analysis. Two investigators independently extracted data, with disagreements resolved through discussion. The 16 studies were analyzed using random effects modeling. Current OC use was associated with increased risk of ischemic stroke (RR, 2.75; 95% CI, 2.24-3.38). Smaller estrogen dosages were associated with lower risk (P = 0.01 for trend), but risk was significantly elevated for all dosages. Studies that did not control for smoking (P = 0.01) and those using hospital-based controls (P < 0.001) found higher RRs, but no other patient characteristics or elements of study design were important. The summary RR was 1.93 (95% CI, 1.35-2.74) for low-estrogen preparations in population-based studies that controlled for smoking and hypertension. This translates into an additional 4.1 ischemic strokes per 100,000 nonsmoking, normotensive women using low-estrogen OCs, or 1 additional ischemic stroke per year per 24,000 such women. The RR of stroke due to OC use was not different in women who smoked, had migraines, or had hypertension. Summary results indicate that risk of ischemic stroke is increased in current OC users, even with newer low-estrogen preparations. However, the absolute increase in stroke risk is expected to be small since incidence is very low in this population. (author's)
The relevant population dynamics to land degradation in the northeast region.
This paper reviews the possible linkage between population factors such as population size/growth, in-migration/out-migration, and age/sex structures and land degradation in northeastern Thailand. Using both qualitative and quantitative methods, the feasible relationship between population factors and land degradation are analyzed. In addition, a review of the existing reforestation and population policy of the Thai government is presented. Analysis within sample units demonstrated a significant relationship between land degradation and population dynamics and economic factors. The sample analyses showed that the rate of change was influenced by environmental conditions, which play an important role in the man-forest interaction. Based on the findings, four concluding remarks are drawn. These include: 1) population growth usually appears as the major cause for land degradation; 2) overgrazing, and especially cassava growing in the northeast, have destroyed vegetation which led to the loss of topsoil; 3) the promotion of mono-cash crops by the government increased land clearing for cultivation in the northeast both for the domestic market and for export; and 4) population factors are viewed as an intermediate variable; social variables such as agricultural technology, fertilizer, irrigation, economic factors are influenced by population growth which exacerbates the effect of these processes.
This paper examined the effects of alternative service-delivery strategies with regard to dropouts among the current pill and condom users who, before the intervention, were supplied with the methods by the fieldworkers at their homes in an operations research conducted by the Centre for Health and Population Research in urban Bangladesh. Moreover, the effects of the selective home visitation approach on acceptance of modern family planning methods among current nonusers were assessed. Two program areas of the Concerned Women for Family Planning in Dhaka City, one each at Wari and Siddiquebazar, served as the comparison areas. Data for the analyses came from the service records of the fieldworkers and community-based surveys. Results showed that the contraceptive prevalence rate (CPR) considerably increased in both the intervention areas: from the pre-intervention level of 63% to 68% at the Hazaribag primary health care clinic (PHCC) intervention area and from 55% to 57% at the Gandaria community service points (CSPs) intervention area. The corresponding increases at the two comparison areas were from 61% to 63% at Wari and from 60% to 63% at Siddiquebazar. The quantitative growth in the CPR in the PHCC-based strategy clearly indicated the comparative advantage of the clinic-based strategy in terms of sustainable program performance over conventional doorstep CBD- and CSP-based strategies.
Breast cancer in Iran: a review of 903 case records.
A retrospective study was carried out in five main General District and Teaching Hospitals in Tehran (18 general surgical wards) to investigate breast cancer in Tehran, Iran. All patients who have had breast pathology during 1985-95 were reviewed. For each patient the following data were extracted from case records sex, age, type of disease (based on ICD-10 and ICD-O), breast cancer pathology, tumor size, lymph node involvement, pathological staging (based on TNM system), type of surgery, mass location, and the affected side of breast. In all 3085 records were reviewed. Of these, in 903 cases the final diagnosis was breast cancer. The mean age of breast cancer patients was 47.1 (SD = 12.3 years) and the age-adjusted analysis showed that the observed number of breast cancer cases in the age group 40-49 was higher than expected (P < 0.001). The majority of patients (71%) were patients with infiltrating ductal carcinoma. 70% had advanced disease (Stage III), and in 51% of cases the tumor was more than 5 cm in size. Finally it was found that two-third of patients (76%) underwent modified radical mastectomy. Although this study does not address true incidence, but rather frequency, the findings suggest that the Iranian breast cancer patients are relatively younger than their western counterparts and mostly have locally advanced disease. In terms of breast cancer screening programs, these findings have some implications for public health professionals in Iran. (author's)
The urban health project, Karachi [letter]
This paper presents a reply to the article of Tollman and Zwi on health system reform and the role of field sites. The author supports their intention to document all existing demographic and health surveillance field sites in Africa, Asia and Latin America and correlates it with the Urban Health Project (UHP) of the Aga Khan University in Karachi, Pakistan. The UHP falls into a category of projects that has contributed to the development of national programs of primary health care and family planning and provincial health systems development at the district level, including the implementation of health information systems. The author affirms that field sites can support investigations for efficacy and effectiveness as well as action research. This article emphasizes the need for open, objective and ongoing scientific debate on how to obtain the full benefit of field sites and their potential contribution to new knowledge and policy applications.
The screening of women of childbearing age for hematuria, leukocyturia, and proteinuria to detect urinary schistosomiasis can be confounded by several factors such as menstruation, pregnancy, and genitourinary infections. The authors therefore undertook a study in an area endemic for Schistosoma haematobium in the United Republic of Tanzania to carry out the following: assess the sensitivity, specificity, and predictive values--in women of childbearing age--of indirect indicators of urinary schistosomiasis, as measured by urine reagent strip readings; assess the predictive values of self-reported symptoms; and finally to estimate the morbidity attributable to S. haematobium. A total of 303 women (128 and 175, respectively, living in high- and low-risk sites) participated in the study. Hematuria was more frequent among women excreting S. haematobium eggs than among those who did not (65% vs. 32%). The predictive potential of all indirect disease markers was poor in the highly endemic site, while in the sites with low endemicity the negative predictive values were high. Among infected women, 54% of hematuria could be attributed to S. haematobium, but for patients with more than 10 eggs/10 ml the attributable fraction rose to 70%. Symptoms of "bloody urine" and "pain while urinating" were recalled significantly more often by women living in the highly endemic site. On a population level, one-third of the self-reported cases with bloody urine could be attributed to urinary schistosomiasis. Screening of women of childbearing age for urinary schistosomiasis using urine reagent strips can be biased in two directions. The prevalence of S. haematobium will be overestimated if other causes of hematuria, such as reproductive tract infections, are highly endemic. On the other hand, women with light or very light infections will be missed and will not be treated. This is of concern because genital schistosomiasis, a possible risk factor for the transmission of HIV, occurs among women even with light infections. (author's)
Cross-sectional data for breastfed infants in rural Zambia were used to evaluate the effect of applying two different data sets as a reference, i.e. the WHO 12-month breastfed pooled data set and the National Center for Health Statistics (NCHS) growth reference in terms of prevalence of malnutrition (stunting, underweight, and wasting). A total of 518 infants who were attending mother-and-child health clinics were included. Age, weight and length were recorded. Anthropometric Z-scores were calculated in two ways: by applying the NCHS growth reference and by using the WHO breastfed data set. Anthropometric Z-scores calculated using the breastfed data set were lower during the first 6-7 months of life compared with those calculated by applying the NCHS growth reference. This resulted in a higher proportion of children aged 0-6 months being classified as stunted and underweight using the breastfed data set versus the NCHS growth reference. After the age of 7 months, similar prevalences of stunting or underweight were observed. Relatively few infants were classified as wasted. In order to adequately assess the prevalence of stunting and underweight in breastfed infants, it is recommended that a new growth reference be developed, as has been initiated by the WHO. (author's)
To assess liver function and prevalence of co-infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in AIDS patients, 100 consecutive patients admitted to Chris Hani Baragwanath Hospital were studied. There were 52 males and 48 females aged 16-54 years (mean + SD: 34.6 + 7.5 years). The results of laboratory test were as follows: liver function tests: bilirubin 11.8 (+15.6) mcmol/l; aspartate aminotransferase: 79.6 (+or- 116.6) IU/l; alkaline phosphatase: 204.3 (+or- 237.4) IU/l; albumin: 23.9 (+or- 6.2) g/l; CD4+ lymphocytes: 141.5 (+or- 168.6) mcl; CD8+: 666.9 (+or- 618.3) mcl; HBV-hemoglobin surface antigen (HbsAg): 6 (6%); HbsAg + eAg: 3 (3%); previous disease (anti-HBV surface antibody and/or anti-HBV core antibody): 35%, HCV: 1 (1%). Liver function tests were impaired in the majority of patients with AIDS (93%) in the authors' setting. Evidence of previous and present HBV infection was present in 41%. This is different from what is observed in western countries (90-95%). The results also suggest that patients here acquired HBV infection while still immunocompetent. HCV infection was rare. (author's)
To evaluate the Christie, Atkins, Munch-Peterson (CAMP) and hippurate hydrolysis reactions as diagnostic tools for Streptococcus agalactiae carriage in pregnancy, observational, analytical, case-control study was conducted in a primary and a tertiary health care institution. 106 pregnant and 56 nonpregnant (controls) women were included in the study. The participants were of different socioeconomic status. A volunteer sample was used. About 800 subjects were contacted and 162 participated in the study. The sensitivity of the screening test varied from 25% for the CAMP test to 77.78% for the hippurate hydrolysis reaction. The specificity was the same for both tests at (50%). A significant difference in positivity between the CAMP and hippurate hydrolysis reactions (95% confidence limit, P < 0.05) was observed. The predictive values of the positive test were 66.6% (CAMP) and 87.55% (hippurate hydrolysis) while the negative test were 14.29% (CAMP) and 33.30% (hippurate hydrolysis). Pregnant women had 0.33 chances of being Group B Streptococcus (GBS) carriers with the CAMP compared to 3.5 with the hippurate hydrolysis. The hippurate hydrolysis test is highly recommended since the reagents are easily available and the organism was easily isolated using this method. The presence of GBS in the anorectum and endocervix is likely to induce systemic and local immunity in the female genital tract. This can contribute to the development of a mucosal vaccine for GBS diseases. (author's)
The aim was to estimate the effect of improved stoves on the prevalence of acute respiratory infections (ARI) and conjunctivitis among children aged below 5 years and women aged between 15 and 60 years. A field trial or intervention study design, in which cluster and random sampling were used to recruit households with improved stoves. Nearest households with traditional three-stone stoves were recruited as controls. Prevalence of ARI and conjunctivitis among the study subjects was estimated by clinical evaluation and physical observation, and by history (including clinical and socioeconomic information), and compared between the two study groups. The prevalence of ARI among children aged below 5 years and among women aged between 15 and 60 years was significantly higher in households with traditional three-stone stoves than in those with improved stoves (chi-square (X2) = 31.45, rho = 0.00000, RR = 2.6, CI: 1.86-3.63 and X2 = 30.13, rho = 0.00000, RR = 2.8, CI: 1.93-4.06, respectively). Similarly the prevalence of conjunctivitis among children aged below 5 years and among women aged between 15 and 60 years were significantly higher in households with traditional three-stone stoves than in those with improved stoves (X2 = 24.18, rho = 0.00000, RR = 3.3, CI: 2.05-5.32 and X2 = 7.6, rho = 0.0057, RR = 3, CI: 1.38-6.54, respectively). Prevalence of ARI and conjunctivitis among children aged below 5 years and also among women aged between 15 and 60 years in households with traditional three-stone stoves was significantly higher than that in households with improved stoves. (author's)
Factors affecting condom use among South African university students.
To investigate factors affecting condom use among South African university students, a cross-sectional survey was conducted among students in the Department of Psychology, University of the North, South Africa. 146 female and 60 male first-year students, mean age 20.9 years (SD = 3.4), with a range of 17-34 years, were surveyed. Almost one-third (29.2%) of the sample reported never using condoms, 35.4% always using them, 19.8% regularly using them, and 8.5% using them irregularly in the past 3 months. Perceived barriers were associated with increasing age and reduced condom use intentions. In addition, perceived susceptibility was associated with past condom use. The total AIDS Health Belief was not related with age, gender, past condom use, and condom use intentions. Self-efficacy of condom use was associated with decreasing age, past condom use and condom use intentions but not with gender. Findings have relevant implications and are discussed in the context of developing an educational or intervention program. (author's, modified)
Even though effective chemotherapeutic regimens are available for treatment of tuberculosis (TB), disseminated tuberculosis (DT) continues to be a challenge to physicians. DT represents the unchecked hematogenous dissemination of Mycobacterium tuberculosis. It has been reported that 1.3% of all TB cases are classified as DT. Patients with DT present with a febrile illness of 2-4 months' duration. Organomegaly affecting liver, spleen, and lymph nodes can be seen in DT. The radiological findings of DT associated with HIV infection are similar to those seen in HIV-seronegative patients. The value of high resolution computed tomography in DT is to demonstrate miliary pattern when chest radiographic findings are atypical or even normal. DT patients may have a mild normochromic anemia with a normal white blood cell count. Leukemoid reaction can occur in DT, but pancytopenia is rare. Pulmonary function studies show a mild restrictive ventilatory defect with diffusion defect in cases of pulmonary miliary tuberculosis. Treatment of DT is same as that for pulmonary tuberculosis. Replacement treatment with corticosteroids should be given in tuberculosis patients with adrenal insufficiency. The overall mortality from DT is nearly 20%. (author's)
Menstrual disorders in genital tuberculosis.
This study included 120 cases of genital tuberculosis proved by histopathology. Analysis of their menstrual history showed that the common menstrual disorder was oligohypomenorrhea found in 54.0% cases, menorrhagia in 19.0% cases, and postmenopausal bleeding in 1.6% cases. History of amenorrhea was present in 14.3% cases. There were 8 cases of secondary amenorrhea and 1 case was of primary amenorrhea. The pelvic examination showed cervical involvement in 43.1% cases. A tubo-ovarian mass was present in 19.8% cases. Genital tract tuberculosis is a disease of varied symptomatology. A high degree of suspicion and efficient investigation are important for diagnosis. (author's)
Tuberculosis: the global epidemic.
The modern era of tuberculosis (TB) began in the mid-1980s. In 1993, WHO took the unique step of declaring TB to be a world emergency. Despite this intervention it is estimated that deaths from TB will increase from 3 million a year currently to 5 million by the year 2050. There are four principal reasons: world population's increase, co-infection with HIV/AIDS, poverty and program decline. Other causes contributing to the global epidemic are multidrug-resistant TB, immigration, and indifference. The practical solution must concentrate on the completed correct treatment of the disease particularly in those who are sputum smear positive. For this reason WHO is vigorously promoting the Direct Observed Therapy Short course (DOTS) campaign. Doctors treating TB should ideally be part of the public health system. They should have access to first class bacteriological services, good quality of drugs, and should make sure that the patient receives the drugs under supervision. Though the reasons for increasing TB are multifactorial it is within the capability of the world to re-exert control providing that the political will is present. (author's)
Tuberculosis -- triumphs and tragedies.
This editorial by Dhiman Ganguly, guest editor of the Journal of the Indian Medical Association (JIMA), March 2000 special issue, focuses on the achievements and failures in the treatment and prevention of tuberculosis (TB). It is noted that with the advent of anti-TB drugs in the 1950s, expectations were high. However, during the 1960s the realization that TB can be treated at home and that sanatoria are not really necessary became popular. This is probably the root cause of the TB epidemic of the present. The author emphasizes the failure of physicians to fight the spread of TB despite their knowledge about its treatment. He also introduces the articles of this JIMA issue written by well-known experts in the field of TB and with the sole purpose of promoting TB awareness that will improve the current scenario of TB in India.
HIV / AIDS and the young: three studies in Southern Africa.
This article synthesizes three independent studies on children and youth, including orphans, conducted in Zimbabwe, Zambia and Malawi. The Zimbabwe study focuses on the impact of HIV/AIDS on children living in a commercial farm worker community; the Zambia study examines the psychological and physical needs of families living with HIV/AIDS with an emphasis on the needs of children; and the Malawi study focuses on AIDS knowledge and its impact on adolescents, with implications for interventions. Together, the studies provide valuable insights into the impact of the AIDS epidemic on children and youth. The Zambia study utilized a children's behavioral questionnaire to elicit information on children's behavior from adults; the Malawi study used a combination of a survey questionnaire and personal observation of 229 students between the ages of 12 and 20 years; and the Zimbabwe study used a qualitative operational and participatory method. Overall, the studies found a similar impact of AIDS on children from impoverished backgrounds indicating that poverty intensifies the impacts and further predisposes children to the risk of infection. These three studies, through findings from diverse methodologies, endorses the central importance of engaging young people actively and effectively in the response to the epidemic and highlights the urgency of taking seriously young people's immediate and long term needs to help them be active participants in shaping their future.
Sexual health education: lower risk.
This article outlines the findings of the updated Joint Programmes on HIV/AIDS WHO review programs around the world with the goal of promoting sexual health education to young people. Contrary to what many parents feared, the review found that sex education does not lead to earlier or increased sexual activity. Moreover, the review found that effective programs share certain features: they have as specific aims of both delayed first intercourse and protected intercourse; encourages the learning of life skills; discusses clearly the results of unprotected sex and the ways to avoid it; they help young people personalize the risk through role-playing; and reinforces group values against unsafe behavior, both at school and in the community. This paper emphasizes the need for international cooperation among world organizations to develop appropriate and effective programs.
Young people: force for change.
This paper discusses different issues regarding the impact of AIDS on young people's lives, as well as implications for policies and programs to support them. It is noted that of the 30 million people that are HIV/AIDS infected, young people aged 10-24 years account for at least one-third. Reasons for this include inaccessibility to youth-friendly health services where they can discuss questions related to sexual health; susceptibility of young women; and sexual abuse and exploitation such as prostitution. Compounding these challenges, in the name of morality, culture or religion, young people are often denied their right to education regarding the health risks of sexual and other risk behavior, and the important tools and services for protection. In response, the Force for Change: World AIDS Campaign, culminating in World AIDS Day, promotes young people's genuine participation regarding the impact of the epidemic and promotes policies for health and development using human rights framework. Moreover, the Commonwealth Youth Forum of 1997 endorsed sexual and reproductive rights for all young people worldwide.
Benchmarks of fairness for health care reform: a policy tool for developing countries.
Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adopted a policy tool originally developed for evaluating health insurance reforms in the US into "benchmarks of fairness" for assessing health system reform in developing countries. The authors describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation (i.e., on a scale of -5 to 5, with zero representing the status quo). The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and the authors describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political, and cultural differences. (author's)
Benchmarks for health expenditures, services and outcomes in Africa during the 1990s.
There is limited information on national health expenditures, services, and outcomes in African countries during the 1990s. The authors intend to make statistical information available for national level comparisons. National level data were collected from numerous international databases, and supplemented by national household surveys and World Bank expenditure reviews. The results were tabulated and analyzed in an exploratory fashion to provide benchmarks for groupings of African countries and individual country comparison. There is wide variation in scale and outcome of health care spending between African countries, with poorer countries tending to do worse than wealthier ones. During 1990-96 the median annual per capita government expenditure on health was nearly US$6, but averaged US$3 in the lowest-income countries, compared to US$72 in middle-income countries. Similar trends were found for health services and outcomes. Results from individual countries (particularly Ethiopia, Ghana, Cote d'lvoire, and Gabon) are used to indicate how the data can be used to identify areas of improvement in health system performance. Serious gaps in data, particularly concerning private sector delivery and financing, health service utilization, equity and efficiency measures, hinder more effective health management. Nonetheless, the data are useful for providing benchmarks for performance and for crudely identifying problem areas in health systems for individual countries. (author's)
New resolution on HIV / AIDS announced at the 53rd World Health Assembly.
This article focuses on the different health issues tackled at the 53rd World Health Assembly in Geneva, Switzerland. One of the highlights of the assembly was a far-reaching resolution on HIV/AIDS. The resolution asks WHO member states to increase access to treatments for HIV-related illnesses and urges for renewal of efforts to make drugs more available and affordable to developing countries. Grants to support the Polio Eradication Initiative are detailed here as well as the monetary contribution from the Bill and Melinda Gates Foundation to support the collaborative efforts of WHO to eradicate dracunculiasis. The ethical problems of genetics and biotechnology and related issues and their impact on public health were also considered at the Health Assembly. In view of this, this paper also addresses the need for WHO to identify and form an external bioethics advisory group to provide advice on the complex issues of biotechnology.
Companies reduce prices for HIV drugs in developing countries.
This article reports the decision of pharmaceutical companies to reduce the prices of anti-HIV drugs in developing countries. It is stated that some of the companies have pledged to sell the pharmaceuticals at prices just above the manufacturing costs, at a discount of up to 90%. This strategy is part of an unprecedented effort to combat AIDS in sub-Saharan Africa. Participating companies include Glaxo Wellcome, Boehringer Ingelheim, Bristol-Myers Squibb, Hoffman-La Roche and Merck & Co. Experts say that lowering the price of medicines is not the sole solution to the problem, but new efforts also must be introduced to improve prevention, medical infrastructure, international funding, and political involvement. On the other hand, President Bill Clinton issued an executive order regarding the actions of the US Trade Representative's office against nations who seek access to cheap drugs. The ruling provides that the office can no longer threaten trade sanctions against developing nations that use the intellectual property rules of the World Trade Organization to gain access to cheaper drugs.
Politics and fertility: a new approach to population policy analysis.
This paper aims to explain why divergent population policies and programs arise in otherwise similar countries and to clarify how such policies relate to fertility decline. An analysis was undertaken of demographic and policy change over a 30-year period in four pairs of developing countries: Algeria and Tunisia; Bangladesh and Pakistan; the Philippines and Thailand; and Zambia and Zimbabwe. In some countries, popular demand for family planning facilitated changing policy. In others, independent factors, such as economic crisis or international pressure, pushed policy makers into action on population policy, often in the absence of popular demand. In these countries, governments that identified a coherent rationale, usually economic, for reducing population growth, tended to develop more successful policies. Strong and financially secure coalitions of policy elites were important in sharing the political risk associated with such policies. Analysis of these processes has lessons for policy makers and researchers interested in expediting implementation of new approaches to population and reproductive health. (author's)
Spousal communication and contraceptive use among the Yoruba of Nigeria.
The present study examines the level of spousal communication and its impact on contraceptive use among Yoruba couples in southwest Nigeria. Data for the study are obtained from a survey on the Role of Men in Family Planning conducted in one of the states inhabited by the Yoruba of Nigeria--Ondo. The sample for this study consists of 381 monogamously married couples. Multivariate analyses were used to determine the impact of background variables on dependent variables. The study shows that fairly high percentages of men and women perceive that decisions on reproductive issues are taken jointly by both partners. The significantly high proportion of women who perceived that they participate in decision making is particularly worth noting and is an indication that women's voices are heard in the study society. Although the impact decreases on controlling for other variables, spousal communication was found to affect contraceptive use: contraceptive is higher among marital partners who discuss and take joint decisions on contraception. The study also reveals that family planning counseling has a significant impact on contraceptive use. (author's)
Are there crisis-led fertility declines? Evidence from central Cameroon.
Past demographic transitions have been observed with and without economic progress, but there is little empirical record of crisis-driven fertility transitions. In recent years, several authors have argued that conditions for such transitions are met in African countries under economic crisis and structural adjustment. Using retrospective family histories, this study examines fertility responses to crisis in Cameroon, a country with a particularly abrupt economic reversal. The thesis of a crisis-led decline is tested on the basis of five criteria including timing of the decline, statistical and substantive significance, rural-urban response differentials and social salience. Findings are consistent with a crisis-led effect. (author's)
The dynamics of single mothers' living arrangements.
Using a four-way definition of living arrangements (independent, live with parents, cohabit, share with others) and data from the 1990 Survey of Income and Program Participation, the author find that single mothers have a 26% probability of switching living arrangements at least once during a 32-month period. Mothers living independently are at least likely to change arrangements, and those sharing housing with individuals other than a boyfriend or parents are the most likely to switch. Having lived for a longer period of time in any of the four arrangements decreases the probability of switching. Among those who change living arrangements, there appear to be some patterns of transition. Mothers living with their parents tend to move into either independent households or those that they share with individuals other than an unrelated man. If they leave, mothers who lived with their parents tend not to move back into their parents' household, at least within the time period examined. Women who share with others or cohabit tend to cycle between their current living arrangement and living independently. Among those who switch living arrangements, mothers who do not live independently tend to have transitions into independence or other arrangements which increase the probability they will choose independence in the future. (author's)
A study of 258 truck drivers and 467 itinerant female hawkers in Ibadan, Nigeria, reveals that occupational demands have resulted in a network of multiple sex partners that may spread AIDS to and through Nigeria. Although 78% of the truck drivers are currently married, only 5% report having no regular sex partners besides their wife. The drivers say they have an average of six regular sex partners, about one woman at each of their overnight stops. During the year prior to the 1991 interview, the drivers report having an average of 12 partners besides their wife, and the lifetime number of partners is 25. 44% of the drivers have been treated for a sexually transmitted disease (STD). Nearly all drivers have heard of AIDS, but only 15% use condoms regularly. The female hawkers, who sell a wide variety of goods at truck stops, average 20 years of age and report their median age at onset of sexual activity to be 14. Most of the women are single, 95% are sexually experienced, and half acknowledge supplementing their income from hawking goods by providing sex for money. More than 20% report having had an STD. (author's)
The great debate on population policy: an instructive entertainment.
This paper presents a debate on population policy among three positions intended as prototypic. The debate utilizes actual statements from recent literature. The discussion concentrates on the following topics: population in the context of development, the merit of family planning programs, and the strategies of intervention. In summary, debaters FamPlan, DevDev, and AcCrit argued about the demographic facts, the absence of any panaceas, population as only a means, the need for both direct and indirect efforts, and the empirical results of family planning programs including the existence of a problem. The most consequential differences in the debate were in the formulation of issues. DevDev and AcCrit talk about theoretical analysis and basic causes and fundamental solutions, whereas FamPlan deals with the practical next steps and allocation of resources and incremental advances. The author underscored an important point, that the debate seems to be least joined but most needed, the importance of proper policy issues. As a whole, the author concluded that the debate did not lead to an optimistic conclusion, rather it adds up to an overwhelming impression of negativism. Indeed, the debate is too schematic, it assumes clear-cut and clearly formulated alternatives that do not exist.
The challenge of contraceptive implant removals in East Nusa Tenggara, Indonesia.
Indonesia has the largest contraceptive implant program in the world. The rapid increase in insertions resulting from the promotion of mass acceptance of the method created strains on the systems for training staff, providing client information and monitoring users. Moreover, the economic crisis experienced by the country raises questions about the capacity of the health and family planning systems to guarantee the quality and efficiency of implant services. A study conducted by the Australian National University and the Indonesian Institute of Science in the province of Nusa Tengarra, Indonesia, gathered information on implant use and problems associated with timely removal recounted during interviews with providers, users and other community members. Three salient points emerged from the investigation. First, implants were very popular despite some serious concerns about side effects and services. Second, providers and users alike lacked a full or clear understanding of how the method works and why it expires in 5 years. Third, many women do not obtain timely implant removals, but there is not enough information available to correctly assess the nature and magnitude of any problems these delays may produce. The future direction of the method is discussed. Ultimately, the difficulties with implants in the future will be more related to field service organization and client and provider education than to matters of technology.
There is an increasing amount of literature pointing to a relationship between sexual and/or physical abuse history and poor health status, although few studies provide evidence concerning which aspects of abuse may impact on health. In female patients with gastrointestinal (GI) disorders, the present study examined the effects on health status of: 1) history of sexual abuse and physical abuse, 2) invasiveness or seriousness of sexual abuse and physical abuse, and 3) age at first sexual and physical abuse. The sample included 239 female patients from a referral gastroenterology clinic who were interviewed to assess sexual and physical abuse history. The authors found the following: 1) 66.5% of patients experienced some type of sexual and/or physical abuse; 2) women with sexual abuse history had more pain, non-GI somatic symptoms, bed disability days, lifetime surgeries, psychological distress, and functional disability compared to those without sexual abuse; 3) women with physical abuse also had worse health outcome on most health status indicators; 4) rape (intercourse) and life-threatening physical abuse seem to have worse health effects than less serious physical violence, and sexual abuse involving attempts and touch; and 5) those with first abuse in childhood did not appear to differ on health from those whose first abuse was as adults. The authors conclude that asking about abuse should be integrated into history taking within referral-based gastroenterology practices. (author's)
Although domestic violence (DV) is recognized as a serious crime, only recently has it been acknowledged as a critical public health problem. To develop appropriate medical intervention methods to stop abuse, the authors interviewed 406 female patients in the ambulatory clinics at the Miami Veterans Affairs Medical Center, using a standardized questionnaire. The authors assessed their experiences with DV and their expectations of physicians in treating victims. Of the 406 women, 40% have had emotional/physical abuse by a partner, 7% were currently in abusive relationships, and 3% had forced sex within the past year. Although 68% of the women could tell their doctors they were abuse victims, only 12% have been asked about abuse. Even when told of abuse, the doctors did nothing for 20% of the patients. The majority of the respondents believe that doctors should routinely screen for abuse. As part of treatment, all women strongly recommended that doctors provide information on community and legal resources and assistance in seeking protective services. Domestic violence is a significant problem for female patients in the ambulatory care setting. Women expect physicians to act as their advocates and, in partnership with other community professionals, to assist abuse victims and stop the violence. (author's)
Health care utilization and history of trauma among women in a primary care setting.
Participants in this study were 150 women seen consecutively by a female family physician in a health maintenance organization setting for nonemergent medical care. Each participant completed a questionnaire that explored three areas of trauma. 12 months after the administration of the questionnaire, medical records of each participant were reviewed for several measures of health care utilization (i.e., number of telephone contacts, physician visits, ongoing prescriptions, acute prescriptions, and specialist referrals). Age, education, and current marital status were unrelated to medical utilization. Participants' acknowledged history of physical and emotional abuse significantly correlated with most measures of health care utilization, whereas sexual abuse generally did not. The implications of these findings are discussed. (author's)
Breaking the silence. Battered women's perspectives on medical care.
Battered women make up a large proportion of patients in a variety of clinical settings. To examine issues common to women of different ethnic groups that influence identification and management of domestic violence, a qualitative research was conducted in urban and suburban community-based organizations in San Francisco Bay, California. Participants included 51 women with histories of domestic violence, which comprised 8 focus groups. These focus groups were divided as follows: 2 groups of Latino (n = 14), 2 groups of White (n = 14), and 2 groups of African-American (n = 9) women. Findings revealed that many battered women experience social, institutional, and provider barriers in obtaining help from the health care system. Such barriers include threats of violence from the partner, embarrassment, and adherence to gender roles, concerns about police involvement, and lack of trust in the health care provider. However, these barriers can be overcome if providers as well as institutions would understand the social context of domestic violence and the victim's needs. Identification may be improved through a trusting patient-provider relationship and by direct questioning about domestic violence.
Little is known about the acute effects of sexual assault on pregnant victims and the outcome of their gestations. A retrospective review of sexual assault victims in Dallas County from 1983 to 1988 revealed that 114 of 5734 (2%) were pregnant. There were 0.55 and 0.75 gravid sexual assault victims per 1000 deliveries for Dallas County and Parkland Memorial Hospital, respectively. The purpose of this study were to examine patient demographics, forensic evidence, and patterns of injury in pregnant victims compared with 114 matched nonpregnant sexual assault victims, and to compare pregnancy outcome with that of the Parkland Memorial Hospital obstetric population. The typical victim was a black, parous gravida in her 20s at a mean gestational age of 15 weeks, without previous prenatal care. Vulvar (95%), oral (27%), and anal (6%) penetration were reported with similar frequency in both groups. The detection of whole and motile sperm from the vaginal specimens was similar in pregnant and nonpregnant women. Physical trauma was more common in nonpregnant victims (63 vs. 43%; P < 0.004), especially genital trauma (21 vs. 5%; P < 0.001). Injury was more common to the head and neck or extremities than to the abdomen, chest, or back in both groups. There was no difference in the pattern of trauma by gestational age, but there were no truncal injuries in women at 20 weeks' gestation or greater. There were no spontaneous abortions or deliveries within 4 weeks of the assault, but low birth weight delivery (24%) and preterm delivery (16%) were common. Sexual assault during pregnancy is accompanied by less physical trauma than in nonpregnancy and has little immediate effect on pregnancy outcome. (author's)
History of trauma and attempted suicide among women in a primary care setting.
The results of past research have demonstrated apparent links between suicidality and a history of sexual abuse or physical abuse. However, the relative predictive power of such abuse histories in explaining suicidality remains unknown, as does the potential relationship between suicidality and emotional abuse, physical neglect, and witnessing violence. In the current study, 151 women who presented for nonemergent medical care indicated whether they had experienced each of five types of abuse and whether they had ever attempted suicide. Similar to past research, increased rates of having attempted suicide were evident among women who had been sexually or physically abused. Rates of past suicide attempts were also higher among those who had experienced emotional abuse or had witnessed violence. However, many women indicated having experienced multiple forms of trauma. In a multivariate analysis, only sexual abuse and physical abuse were uniquely predictive of having attempted suicide. Results are discussed with regard to the potential importance of bodily intrusiveness during abuse as most predictive of subsequent suicidality. (author's)
Suicidal behaviour: an epidemiological and genetic study.
Psychiatric history, familial history of suicide attempts, and certain traumatic life events are important predictors of suicidal thoughts and behavior. The authors examined the epidemiology and genetics of suicidality (i.e. reporting persistent suicidal thoughts or a plan or suicide attempt) in a large community-based sample of monozygotic (MZ) and dizygotic (D1) twin pairs. Diagnostic telephone interviews were conducted in 1992-93 with twins from an Australian twin panel first surveyed in 1980-82 (N = 5995 respondents). Data were analyzed using logistic regression models, taking into account twin pair zygosity and the history of suicidality in the respondent's co-twin. Lifetime prevalence of suicidal thoughts and attempts was remarkably constant across birth cohorts 1930-64, and across gender. Major psychiatric correlates were history of major depression, panic disorder, social phobia in women, alcohol dependence, and childhood conduct problems. Traumatic events involving assault (childhood sexual abuse, rape or physical assault) or status-loss (job loss, loss of property or home, divorce), and the personality trait neuroticism, were also significantly associated with suicide measures. Prevalence of serious suicide attempts varied as a function of religious affiliation. After controlling for these variables, however, history of suicide attempts or persistent thoughts in the respondents' co-twin remained a powerful predictor in MZ pairs (odds ratio, 3.9), but was not consistently predictive in D1 pairs. Overall, genetic factors accounted for approximately 45% of the variance in suicidal thoughts and behavior (95% confidence interval, 33-51%). Risk of persistent suicidal thoughts and suicide attempts is determined by a complex interplay of psychiatric history, neuroticism, traumatic life experiences, genetic vulnerability specific for suicidal behavior and sociocultural risk of protective factors. (author's)
Risk factors for violent death of women in the home.
Two population-based, case-control studies of violent death in the home were reanalyzed to determine the relationship between domestic violence, gun ownership, and a woman's risk of violent death. Specifically, it assessed the degree of increased risk for homicide attributable to a history of domestic violence, particularly when the suspect was a spouse, an intimate acquaintance, or a close relative of the homicide victim. Incident information for suicides and homicides that took place in the home of victims living in Shelby County (Tennessee), King County (Washington), and Cuyahoga County (Ohio) were analyzed. A total of 143 homicides and 123 suicides were identified in the three counties during a 5-year period, as well as 266 matching controls. Firearms were involved in 46% of the homicides and 42% of the suicides. Independent factors associated with homicide included living alone (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.0-13.2); illicit drug use by any member of the household (OR, 4.9; 95% CI, 1.3-15.9); prior domestic violence (OR, 4.0; 95% CI, 1.5-10.5); 1 or more guns in the home (OR, 3.4; 95% CI, 1.6-7.1); and previous arrest of any member of the household (OR, 3.0; 95% CI, 1.3-6.6). On the other hand, factors for suicide include a history of mental illness (OR, 258.8; 95% CI, 18.2-3679.8), living alone (OR, 13.4; 95% CI, 2.0-87.8), and having 1 or more guns in the home (OR, 4.6; 95% CI, 1.2-17.5).
Findings from a study comparing partner abuse in African-American women suicide attempters (n = 148) and nonattempters (n = 137) revealed higher rates of physical and nonphysical partner abuse among attempters than their demographically similar nonsuicidal counterparts. The partner abuse--suicidal behavior link was mediated by psychological distress, hopelessness, and drug use and moderated by social support. Results also revealed that nonphysical partner abuse accounted for unique variance in the prediction of suicide attempt status beyond that attributable to childhood maltreatment. Implications of the findings for assessing both suicidal and abused women are discussed, and recommendations for preventive interventions for women at risk for suicidal behavior are provided. (author's)
Impact of sexual abuse on children: a review and synthesis of recent empirical studies.
A review of 45 studies clearly demonstrated that sexually abused children had more symptoms than nonabused children, with abuse accounting for 15-45% of the variance. Fears, posttraumatic stress disorder, behavior problems, sexualized behaviors, and poor self-esteem occurred most frequently among a long list of symptoms noted, but no one symptom characterized a majority of sexually abused children. Some symptoms were specific to certain ages, and approximately one-third of victims had no symptoms. Penetration, the duration and frequency of the abuse, force, the relationship of the perpetrator to the child, and maternal support affected the degree of symptomatology. About two-thirds of the victimized children showed recovery during the first 12-18 months. The findings suggest the absence of any specific syndrome in children who have been sexually abused and no single traumatizing process. (author's)
This study compared symptoms of post-traumatic stress disorder (PTSD) in a group of 45 adult women in outpatient treatment for childhood sexual abuse (CSA) and a group of 31 women who reported no CSA. The comparison group consisted of women in outpatient treatment for problems in their committed relationships with male living partners. This research also investigated the traumatic impact of dual abuse (both childhood sexual and physical abuse). Standardized assessment instruments were used to measure PTSD, CSA, and childhood physical abuse (CPA). Results indicated that 86.7% of the CSA group met criteria for current PTSD in accordance with the Diagnostic and Statistical Manual of Mental Disorders, compared with 19.4% of the relationship distress group, providing support for CSA as an etiological agent for PTSD. In addition, 89% of the CSA survivors reported CPA. Multivariate analysis revealed that both CSA and CPA exposure variables for a significant portion of the variance in PTSD symptoms in the CSA group. (author's)
The role of familial, demographic, developmental, and treatment-mediating factors on treatment outcome of sexually abused preschool children was evaluated 6 and 12 months after treatment. 43 sexually abused preschool children and their parents who were evaluated shortly after disclosure of sexual abuse and then were provided with one of two treatment interventions were reevaluated at the completion of treatment and 6 and 12 months after treatment. Parents completed the Child Behavior Checklist, the Child Sexual Behavior Inventory, and the Weekly Behavior Report to measure a variety of emotional and behavioral symptoms in children. Parents also completed the Beck Depression Inventory, the Family Adaptability and Cohesion Evaluation Scales-III, the Parent Emotional Reaction Questionnaire, the Parental Support Questionnaire, and the Maternal Social Support Index. Children completed the Battelle Developmental Inventory and the Peabody Picture Vocabulary Test at pretreatment to assess developmental levels. Correlational and stepwise multiple regression analyses were conducted to analyze the role of the hypothesized mediating variables in predicting scores on outcome measures across the two treatment groups. While the Parent Emotional Reaction Questionnaire was the strongest familial predictor of treatment outcome at post-treatment, parental support became a stronger predictor of outcome at the 6- and 12-month follow-up points. Treatment group was the strongest overall predictor of outcome at post-treatment and at 12-month follow-up. Demographic and developmental factors did not strongly predict outcome. Findings indicate the strong impact of parental support on treatment outcome in sexually abused preschool children over the course of a 12-month follow-up and emphasize the importance of including parental interventions in treating sexually abused preschool children. They also support the superior effectiveness of cognitive-behavioral therapy over supportive counseling for this population. (author's)
Health-related quality of life and symptom profiles of female survivors of sexual abuse.
This study determined the association between severity of sexual abuse and psychiatric or medical problems and assessed its correlation with health-related quality of life before and after controlling for the effects of a psychiatric or medical diagnosis. Structured interview and self-report questionnaire were administered to 252 women selected by somatization status using a screen for unexplained physical symptoms. Findings revealed that women with a history of severe sexual trauma, as a child or as an adult, have substantial impairment in health-related quality of life and a greater number of somatized symptoms, psychiatric symptoms and diagnosis. In regression analyses, sexual abuse severity was a significant predictor of high scores on the subscales mental health (P < 0.05), social functioning (P < 0.05), and quality of life (P < 0.05), even after adjusting for the presence of several common psychiatric diagnoses. These findings underscore the need to better understand the long-term effects of the various types of violence and abuse on mental and physical health for improving the quality of life of abuse victims.
The effects of systemic family violence on children's mental health.
This study examines the link between different forms of family aggression and children's symptoms of psychopathology. The goal of the study was to understand what forms children's problems might take in violent homes and whether close ties within the family (to the mother or a sibling) buffered children. Interviews with 365 mothers and 1 of their children between the ages of 6 and 12 about abuse in the home, support and closeness within the nuclear family, and mother's and children's mental health formed the basis of this study. Families were recruited from battered women's shelters and the community. The authors found that different forms of abuse in the home were highly interrelated and that children of battered women were at risk for child abuse. Domestic violence predicted children's general psychopathology, but the authors uncovered little evidence for the presence of specific sorts of disorders as a result of family dysfunction. Although mothers experiencing conjugal violence were more likely to have mental health problems, their mental health did not mediate the children's response to family conflict. Finally, there was less sibling and parental warmth in families marked by aggression, although when it was present, family social support failed to buffer children. Although the general pattern of results was consistent across respondents (mother and child), there was low agreement on symptoms of child psychopathology. (author's)
An ethnically and economically heterogenous (majority well educated, African-American, and poor) urban community sample of women, self-identified as having a serious problem in an intimate relationship, were interviewed 3 times over 2.5 years. The inclusion criteria of battering was repeated physical and/or sexual assault within a context of coercive control. Feminist action research was used, combining interview and measurement instruments. Thematic analysis (coding, clustering, “subsuming particulars into the general”, and confirming) was used for a random subset of 31 women's in-depth interviews. The patterns of response identified were complicated and iterative, demonstrating resistance and resourcefulness. A process of achieving nonviolence was identified for most of the participants, although relationship status did not necessarily correspond to abuse status and there was continued violence after leaving the relationship. Identifiable themes included 1) active problem-solving, including conscious decisions to “make do” in a relationship and/or subordinate the self; 2) responding to identifiable pivotal events; and 3) a negotiating process first with the self and then, directly and/or indirectly, with the male partner. (author's)
Medicolegal response to violence against women in India.
This article examines women's experiences in India with health and legal interventions that address domestic violence, dowry-related violence, and rape. By examining the experiences of survivors of abuse with the medicolegal system in New Delhi, it considers the extent to which women are able to access their legal rights within the special protection system constructed specifically for them. The use of primary data highlights the impact of state procedures on women, and it demonstrates how procedures designed to enhance women's access to the law actually inhibit it. Using semistructured interviews with female survivors of abuse, police officers, case workers, nongovernmental organization leaders, lawyers, physicians, and government officials in a 4-year period, this article examines women's access to state services designed to address violence against women, and raises questions about state tolerance of domestic and sexual violence. (author's)
This study aimed to measure the prevalence of emotional distress among women in Leon, Nicaragua, and to identify risk factors for emotional distress, with special reference to wife abuse. A survey was performed among a representative sample of women aged 15-49. Among ever-married women, 20% were classified as experiencing emotional distress at the time of the interview, and 52% reported physical partner abuse at some point in their lives. Women reporting abuse were six times more likely to experience emotional distress. An estimated 70% of all cases of emotional distress found among ever-married women were attributable to wife abuse. The study underscores the need to improve screening and care for battered women within mental health services in Nicaragua. (author's)
Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization.
The aims of this study were to examine the extent to which exposure to childhood sexual abuse (CSA) was associated with increased rates of sexual risk taking behaviors and sexual revictimization during adolescence. A birth cohort of 520 New Zealand born young women was studied at regular intervals from birth to the age of 18 years. At age 18 retrospective reports of CSA were obtained from sample members. Over the course of the 18-year study, information was gathered on 1) childhood, family, and related circumstances, and 2) the young women's history of sexual experiences from 14 to 18 years. Young women reporting CSA, and particularly severe CSA involving intercourse, had significantly higher rates of early onset consensual sexual activity, teenage pregnancy, multiple sexual partners, unprotected intercourse, sexually transmitted disease, and sexual assault after the age of 16. Logistic regression analyses suggested that the associations between CSA and sexual outcomes in adolescence arose by two routes. First, exposure to CSA was associated with a series of childhood and family factors including social disadvantage, family instability, impaired parent-child relationships, and parental adjustment difficulties that were also associated with increased sexual vulnerability in adolescence. Second, there appeared to be a causal chain relationship between CSA and sexual experiences in which CSA was associated with early onset sexual activity which, in turn, led to heightened risks of other adverse outcomes in adolescence. The findings of this study suggest that those exposed to CSA have greater sexual vulnerability during adolescence. This appears to arise because: 1) the childhood and family factors that are associated with CSA are also associated with increased sexual risks during adolescence, and 2) exposure to CSA may encourage early onset sexual activity which places those exposed to CSA at greater sexual risk over the period of adolescence. (author's)
Despite the fact that needle exchange was introduced in Vancouver as early as 1988, needle sharing remains common. An analysis was conducted to identify determinants of borrowing used needles among subjects participating in a case-control study. Injection drug users (IDUs) had a documented HIV seroconversion after 1 January, 1994 (n = 89), or repeatedly tested HIV-seronegative after this date (n = 192). Interviewer-administered questionnaires focused on drug use, sexual behaviors, source of needles and depression. Subjects were asked if they had “ever been forced to have sex” as a child, youth, or adult. Logistic regression identified determinants of borrowing needles. After controlling HIV serostatus, factors independently associated with borrowing were injecting >4 times/day, polydrug use, and ever experiencing nonconsensual sex (adjusted odds ratio = 3.4, 95% confidence interval: 1.8, 6.5). Depression was associated with borrowing, although not independently so. Homosexual activity was independently associated with borrowing among males, whereas living with a sexual partner was an independent predictor for females. Access or barriers to clean needle use were not associated with borrowing. Social determinants, particularly a history of sexual abuse, are among the most significant predictors of needle borrowing among Vancouver's IDUs. Early identification of these factors should be a component of HIV prevention programs. (author's)
Women experience alarming levels of physical and sexual assault, which may lead to escalation of substance use. Reciprocally, evidence from cross-sectional studies indicates that substance use may increase risk of assault. To date, directionality of this relationship remains unclear. This issue is addressed by the present 3-wave longitudinal study in which a national probability sample of 3006 women were followed for 2 years. Dependent measures were obtained at each wave of the study and included questions about lifetime and new assault status, alcohol abuse, and drug use. Wave 1 use of drugs, but not abuse of alcohol, increased odds of new assault in the subsequent 2 years. Reciprocally, after a new assault, odds of both alcohol abuse and drug use were significantly increased, even among women with no previous use or assault history. For illicit drug use, findings support a vicious cycle relationship in which substance use increases risk of future assault and assault increases risk of subsequent substance abuse. (author's)
Clinical characteristics of women with a history of childhood abuse: unhealed wounds.
This cross-sectional, self-administered, anonymous survey determined the prevalence of childhood physical or sexual abuse in women seen in primary care practices in the US, identified physical and psychological problems associated with that abuse, and compared the effects of childhood physical versus sexual abuse, and childhood versus adult abuse. 1931 women were examined from February through July 1993. The main outcome measures were the prevalence of physical and sexual abuse, physical symptoms, psychological symptoms, alcohol abuse, and street drug use. Of the total respondents, 424 (22%) experienced childhood physical or sexual abuse. Women who reported having been abused as children were less likely to be married even when age were controlled; were more likely to have attempted suicide, were more likely to be abusing drugs, and had higher scores for depression, anxiety, somatization, and interpersonal sensitivity. This study confirms that childhood abuse, independent of adult abuse, is associated with a wide variety of physical symptoms and psychosocial problems. Women abused only as children did not differ from women who reported current, but not childhood, abuse in a number of these health problems. In conclusion, childhood physical or sexual abuse is associated with adult health problems; this association is just as strong in-patients experiencing current abuse.
The aim of this study was to report on rates of sexual abuse among a normative sample of adolescents and identify psychosocial correlates associated with sexual abuse. An anonymous self-report survey examining an array of psychosocial items to which 3448 grade 8 and 10 students from rural and metropolitan school districts in a southern state responded. There was a 105 rate of sexual abuse among this normative sample. Victims of forced sex were disproportionately female and African-American, and were more likely to reside in single-parent households. These sexually abused girls reported significantly higher levels of risky health behaviors and risky attitudes on 11 (P < 0.001) of the 12 comparisons. Sexually abused boys showed a similar pattern on 8 (P < 0.001) comparisons. Indications are that forced sex experiences are associated strongly with risky health behaviors in some adolescents, which should alert clinicians to the possibility of sexual abuse. (author's)
Women's responses to battering: a test of the model.
A volunteer community sample of 141 well-educated, economically heterogeneous, primarily African American (80%), urban battered women was used to test a model of women's responses to battering. The model, based on Orem's theory, was developed previously with an independent sample. The major independent variables were physical and nonphysical abuse, and self-care agency. The outcomes were physical and emotional health. Using structural equation modeling techniques, there was sufficient support for the model structure to conclude preliminary support for the overall model. There was both a direct effect of abuse on health, and an indirect effect mediated through self-care agency as a protective factor. (author's)
Deaths from injuries and induced abortion among rural Bangladeshi women.
Information about injuries and violence as causes of death of women is scarce and often incomplete, and particularly so regarding women in the rural areas of South Asia. This report provides detailed specific information collected in Matlab, a sub-district of rural Bangladesh. Of 1139 women (aged 15-44 years) who died there during the 11-year period of 1976-86, 207 (18%) were victims of unintentional injuries or violence. In this study, unintentional injuries include domestic and traffic accidents, drowning and snake-bites, while violent deaths are defined as due to intentional injury and include homicide, suicide and lethal complications of induced abortion. Injuries and violence accounted for 31% of all deaths among women aged 15-19 years. This proportion dropped significantly with age to 10% among women aged 35-44 years. Unmarried women suffered a higher proportion of such deaths (36%) than married women (15%). Violent deaths during pregnancy and complications of induced abortion among young unmarried women deserve special attention. In the male-dominated society under study, suicide and homicide are observed to be two frequent consequences of illegitimate pregnancy. Although this study suffers from the absence of data on non-fatal injuries and attempted violence, it may serve as a basis for recommending preventive measures. (author's)
This descriptive study compared the education, attitudes, and practices related to domestic violence of perinatal nurses from three types of practice sites in North Carolina. A total of 275 nurses in perinatal practice (87 public health, 71 hospital, and 117 private office) completed a questionnaire about their educational preparation, screening and referral behavior, attitudes, and personal experience related to abuse/domestic violence. Nurses from different practice sites differed in their attitudes and beliefs, but more differences were found in their behavior. Only 54% of the total sample reported having education about domestic violence, received in formal or continuing education programs. Public health nurses were most likely to have such education. Education affected both attitudes and behavior. In the total sample, 31% of nurses reported abuse of themselves or family members. From the findings, many nurses lacked education about domestic violence; thus nursing care for women who have experienced domestic violence should include assessment and appropriate counseling.
Is adverse pregnancy outcome predictable after blunt abdominal trauma?
The aim of the study was to evaluate the following: 1) pregnancy outcome after blunt abdominal trauma and 2) factors that may predict preterm birth and adverse peripartum outcomes. All women who had noncatastrophic abdominal trauma and came to the labor and delivery suite during July 1994 to August 1997 were prospectively evaluated and admitted for continuous uterine and fetal monitoring. A complete blood cell count, coagulation profile, and Kleihauer-Betke stain were performed. Ultrasonographic examination was performed to rule out hematoma. Tocolytic agents were administered in cases with persistent contractions. Pregnancy outcomes and risk factors were compared between those with preterm birth before 37 weeks' gestation and those who were delivered after 37 weeks' gestation. Delivery information was available for 85 women with blunt abdominal trauma from motor vehicle accident (28), falls (27), and direct assault (30, which included 17 cases of domestic abuse). 4 women, 3 of whom were exposed to domestic abuse, were hospitalized twice. 13 patients had preterm birth and 72 patients were delivered at term. In all cases the results of Kleihauer-Betke stains, maternal vital signs, blood cell count, coagulation profile, and placental ultrasonographic examinations were normal. The differences between the 2 groups with respect to gestational age at the time of trauma, length of hospital stay, subjective reports of abdominal pain, objective findings of abdominal tenderness, patterns of uterine contractions, interval between trauma and delivery, and Apgar scores were not statistically significant. However, the preterm birth group received magnesium sulfate tocolysis more frequently (31% vs. 7%) and had a significantly greater rate of peripartum complications, such as rupture of membranes and abruptio placentae, than the group of patients who delivered at term (46.2% vs. 12.5%, P < 0.05). Women with domestic abuse had increased uterine contractions at the time of abdominal trauma (52.9% vs. 19.1%, P = 0.01) but did not require increased use of tocolysis. Women with domestic abuse had more peripartum complications (41.8% vs. 11.8%, P < 0.01). Women with noncatastrophic blunt abdominal trauma in pregnancy tend to have favorable neonatal outcomes. Findings or reports of abdominal tenderness and uterine contractions are not predictive of preterm birth. Preterm birth was associated with increased peripartum complications. However, domestic abuse was associated with repeated trauma in the index pregnancy and increased peripartum complications. (author's)
From May 1989 through April 1990, 1001 adult homosexual and bisexual men attending urban sexually transmitted disease (STD) clinics were interviewed regarding abusive sexual contacts during childhood and adolescence. Sexual abuse was found to be significantly associated with mental health counseling and hospitalization, psychoactive substance use, depression, suicidal thought or actions, social support, sexual identity development, HIV risk behavior including unprotected anal intercourse and injecting drug use, and risk of STDs including HIV infection. Data suggest that sexual abuse may have a wide-ranging influence on the quality of life and health risk behavior of homosexual men. Increased awareness as to the potential outcomes of male sexual abuse is critically important to the design and implementation of medical and psychological services for sexually abused men. (author's)
Wife-beating in rural India: a husband's right? Evidence from survey data.
Drawing from the data collected in the course of a study on women's autonomy in two culturally distinct sites, Uttar Pradesh and Tamil Nadu, this paper sheds light on the prevalence and patterns of a specified aspect of domestic violence, wife-beating and intimidation, and the ways in which women interpret this violence. It attempts to provide a backdrop against which the government can be held accountable for failure in respect of its obligation to take appropriate steps to prevent such abuse of women. (author's)
Sexual abuse of children and adolescents.
Increasingly, clinicians are being asked to help determine whether a child or adolescent has been a victim of sexual abuse. Since the late 1970s numerous articles about sexual abuse have appeared in the literature. This review article will acquaint the clinician with the definition and incidence of sexual abuse and the characteristics of the abused and the abuser. Practical guidelines are included for interviewing the victim, performing the physical examination, appropriate laboratory testing, treatment, reporting to appropriate authorities, and court testimony. (author's)
A prospective, hospital-based sampling procedure conducted between June 8th, 1989, and August 24th, 1990, identified 1592 victims of interpersonal violence in six state and five private hospitals serving the Johannesburg magisterial district (which includes Soweto). For the 1282 victims resident in the areas, this corresponded to crude annualized incidence rates per 100,000 population of 3821 for Coloreds, 1527 for Blacks, 467 for Whites, 433 for Asians, and 1380 for all residents. Males, most of whom were aged 20-24 years, constituted 83.9% of all victims and were most often attacked on the streets. The majority of females were attacked at home by a spouse or lover, and most incidents occurred between dusk and midnight on weekends. Sharp violence was the most frequent type, involving 52.2% of the male and 51.4% of the female victims. Analysis by racial classification of the overall findings for mechanism of injury and relationship to aggressor showed dramatic differences. Limitations of the findings are discussed. After comparison with similar data for two US cities and Copenhagen, Denmark, it is hypothesized that the racial differences in the present findings reflect the interplay of universal structural determinants and a specific colonial factor rooted in the sociology and psychology of oppression. Some implications of these findings and hypothesized determinants for violence prevention initiatives are mentioned. (author's)
Sexual assault history and health perceptions: seven general population studies.
This article uses data from seven population surveys to evaluate the association of sexual assault history with health perceptions. It estimates the extent of generalizability across gender, ethnic groups, and studies; the extent to which depression accounts for or mediates the association; and whether some circumstances of assault are more strongly related to poor subjective health. Data from each of 18 subsamples of the surveys were analyzed (pooled N = 10,001; 7550 women and 2451 men), and results were combined by using meta-analysis. Assault was associated with poor subjective health (odds ratio [OR] = 1.63, 95% confidence interval [CI] = 1.36, 1.95) and this result was consistent regardless of gender, ethnicity, or sample. Controlling depression did not markedly change this result (OR = 1.46, 95% CI = 1.21, 1.77), indicating that depression did not account for or mediate the assault-health perceptions association. Multiple assaults and assaults by strangers or spouse were most strongly associated with poor subjective health. (author's)
The study objective was to evaluate the associations between selected socioeconomic risk factors and acute injury from domestic violence against women. The authors conducted a preliminary matched case-control study to measure the association of selected predictor variables with acute injury from domestic violence against women. Patients identified as cases were Hispanic or White female emergency department (ED) patients, 16-65 years of age, with acute injury sustained from physical assault by an intimate male partner. Cases were selected for inclusion in the study if they reported or admitted acute physical assault by their male partners. Controls were selected from non-case female ED patients so as to represent the base population of the cases and enhance comparability. Two controls were matched to each case. The socioeconomic predictor variables examined were the education level, employment status, history of alcohol abuse, and history of drug abuse of the male partner, and the education level and cohabitation status of the female partner. 46 cases were identified and included in the study. The age range was 16-51 years (mean, 33 years). There were 26 (57%) Hispanic and 20 (43%) White cases. The strongest predictor for acute injury from domestic violence in these patients was a history of alcohol abuse by the male partner, as reported by the female partner (odds ratio, 12.9). The remaining predictor variables were weakly associated or not associated with domestic violence. One-half of the cases stated that their male partners were intoxicated with alcohol at the time of assault. Of the socioeconomic variables examined in this preliminary study, a history of alcohol abuse by the male partner, as reported by the female partner, was the strongest predictor for acute injury from domestic violence. A large-scale, multicenter, ED-based study is needed to clarify the relation between alcohol abuse, other socioeconomic factors, and acute physical assaults against women by their intimate male partners. (author's)
Somatic consequences of violence against women.
This article reviews the rapidly growing literature on the somatic, nonpsychiatric effects of violence on women's health, including rape, battery and the adult consequences of child sexual abuse. The sequelae of these victimizations are summarized with consideration of their acute effects (genital and nongenital injuries, sexually transmitted disease, and pregnancy), late consequences (chronic pelvic pain and other forms of chronic pain, gastrointestinal symptoms, premenstrual symptoms, and negative health behaviors), and long-term increases in the use of medical services. A recurrent theme across the literature is that the medical treatment of all types of victimized women can be improved by providing attention to the underlying cause of their symptoms. To achieve this goal, physicians need to identify victimization history and provide access to appropriate services. It is noted that all forms of violence against women are prevalent among primary care populations, and victimization is clearly linked to health, health care providers cannot afford to miss this relevant history. The paper concludes with suggestions for fostering and responding to disclosures of victimization.
Long-term medical consequences of incest, rape, and molestation.
131 patients who gave a history of childhood sexual abuse were seen in a general medical practice decades after the event and were compared with a control group. The subject patients were found to be distinct for chronic depression, morbid obesity, marital instability, high utilization of medical care, and certain psychosomatic symptoms, particularly chronic gastrointestinal distress and recurrent headaches. It is clear that these remote events can underlie difficult chronic medical problems. Questions about childhood sexual abuse must become part of the practitioner's review of systems in these difficult cases, if not routinely. (author's)
The long-term effects of battering on women's health.
The authors examined the effects of intimate violence on the physical and psychological health of women over time. Changes in levels of physical and psychological abuse, injuries, physical health symptoms, anxiety, and depression were assessed 3 times immediately after exit from a domestic violence program and at 8.5- and 14.5-month follow-ups. Analyses showed a significant decline in abuse, physical health symptoms, anxiety, and depression over time. Longitudinal structural equation modeling demonstrated that ongoing abuse was significantly related to increased physical and psychological health problems from one time period to the next, even when prior levels of physical and psychological health were controlled. Within each time interval, the effects of abuse on physical symptoms appeared to be mediated through anxiety and depression; although this relationship was replicated at several time points, the mediation was not verified across time, probably because measurement intervals were too long to reflect the underlying causal sequence. Although injuries were the direct result of abuse, injuries showed no significant effect on physical symptoms, anxiety, or depression. Implications for intervention and future research are discussed. (author's)
Sexual assault history and limitations in physical functioning in two general population samples.
The purpose of this study was to evaluate the functional impact of sexual assault history in two general population surveys (pooled N = 6024). Sexual assault was associated with functional impairment regardless of gender, ethnicity, and study site. Repeated assaults, spousal assaults, physically threatening assaults, and those resulting in intercourse or sexual disturbances were most strongly related to impairment. The greater numbers of severe physical symptoms experienced by sexually assaulted persons accounted for their poorer functioning. Depression did not account for this association despite its mediating role. Physical symptoms and depression had similar relationships to functioning for assaulted and nonassaulted persons. (author's)
Violence against women by their partners is now recognized as a major international public health problem, in both developed and developing countries. For example, it is estimated that each year in the US, 4 million women experience a serious assault by their partner and that the victim-related economic cost of partner violence is about US$67 billion. Traditional domestic violence campaigns focus on legal threats and sanctions in an attempt to stop men from being violent. While incarcerating violent men and issuing protection orders are necessary components of domestic violence prevention interventions, they do not--and cannot--remove women's fear of the man reappearing at some future time or place, often with tragic consequences. Furthermore, many women do not want to leave the relationship, nor do they want the man incarcerated; they simply want the violence to stop. The Western Australian “Freedom From Fear” campaign is an innovative social marketing initiative that acknowledges these factors and aims to reduce the fears of women (and children) by motivating perpetrators and potential perpetrators to voluntarily attend counseling programs. (author's)
Married women's labor supply behavior in the 1990s: differences by life-cycle stage.
The purpose of this research is to examine how various factors influence the labor supply of married women at different stages of the life cycle. Using data from the 1992-94 National Survey of Families and Households, multinomial logit models of full-time employment, part-time employment, and nonparticipation in the labor force are estimated separately for various stages, depending on the presence and ages of children. The effects of the husband's earnings and the wife's own wage on her employment decisions vary considerably across the life cycle stages and are highly nonlinear. Significantly, among women who have preschoolers, an increase in the wage rate raises the odds of part-time employment as opposed to either of the two extremes, full-time work or nonparticipation. Two variables that have received little attention in previous research are found to be important and worthy of further investigation: religion and the presence of stepchildren in the household. The determinants of married women's labor supply behavior vary across the life cycle stages and include factors beyond those considered in conventional models of female employment. (author's)
Violence in the lives of pregnant teenage women: associations with multiple substance use.
Using data from a consecutive sample of approximately 700 prenatal patients aged 12-19, the extent of violence and substance use in the lives of these women was examined, as were associations between violence and substance use. The findings show that 29% of the study participants had been victims of violence, with 15% experiencing physical violence only, 5% sexual violence only, and 9% both physical and sexual violence. Adjusted odds ratios and 95% confidence intervals from logistic regression analyses showed that, after controlling for confounding factors, victims were more likely than nonvictims to use cigarettes, alcohol, and illicit drugs, with victims of both physical and sexual violence being the most likely to use each type of substance. Ordinal logistic regression analysis found that, compared to nonvictims, violence victims were more likely to have more severe patterns of substance use (use multiple types of substances), with victims of both physical and sexual violence being the most likely to be multiple substance users. These findings underline the importance of both violence and substance use as health concerns among our youth. (author's)
Increasing use of the female condom through video instruction.
The female condom is effective in preventing sexually transmitted diseases and when used properly reduces risk of HIV infection among women. This field experiment evaluated the effect of a video presentation on reported use of and satisfaction with the female condom. Participants were 100 women tested for HIV infection in a community agency. Ages ranged from 17 to 62 years, and one-fifth of the sample were African American or Hispanic. The 23 women who viewed an instructional video were significantly more likely than 13 of the control group of 50 to try the condom and report to the researcher. Video viewing was unrelated to liking the product and future intent to use. Almost three-quarters of those who used the condoms reported they liked and would use them. (author's)
Historical perspectives on health. Semmelweis: a lesson to relearn?
This paper focuses on the historical perspective on health based on Ignaz Phillipp Semmelweis's beliefs, which indicated that most hospital infections are spread manually by staff. A considerable body of circumstantial evidence supported this notion when Semmelweis, known as the "Father of Infection Control," studied the incidence of "puerperal fever", an acute febrile illness that attacked lying-in women. His study showed that the cause of puerperal fever was transmitted not only by way of cadaveric material but also by way of living organisms. The findings of the study led to his insistence that the procedure of handwashing with chlorinated lime should be routinely performed between examining different patients, thus preventing transfer of transient microorganisms to other patients. However, Semmmelweis's beliefs were largely ignored by many clinicians until recent work evidenced that the simple exercise of handwashing is not "practices de rigor" and demonstrated that hands could become contaminated from objects which have themselves been contaminated. This paper also presents the life, times, and family history of Semmelweis.
Recent medical news. Oral contraceptives and health.
The combined pill, containing estrogen and progestogen, is 99% effective against pregnancy. This oral contraceptive (OC) is probably the most widely researched drug in modern medicine. Medicine is an uncertain discipline and no guarantee can ever be given for certainty of a diagnosis or safety of any drug. Therefore, OCs are under constant review by scientists throughout the world. A recent research paper published in the British Journal of General Practice reassures women who use OCs. Writing an article to follow up the OC study, carried out by the Royal College of General Practitioners' Research Unit, Drs. Hannaford and Kay have clarified: 1) Women who have used the combined pill with 50 mcg of estrogen, in the past, can be reassured that the small increased risk of serious disease, associated with that dosage of estrogen in the pill, does not persist after stopping the pill. Moreover, latent effects do not appear later in life. 2) Currently, available OCs, containing less than 50 mcg of estrogen (which is accompanied by the progestogen, levonorgestrel, or norethisterone acetate) do not appear to be associated with an increased net risk of serious disease which can be life-threatening and/or associated with long-term disability. Although the debate and research continues, it should be remembered that no child should be conceived that could become an unwanted child. However, a wanted child is a great asset for parents and society. Therefore, there is a greater need for understanding and promotion of family planning services throughout the world. However, there are benefits and risks attached to all contraceptive methods. Every woman who chooses to use contraception should consult a trained health professional before, during, and after using any contraceptive method. Finally, it is noteworthy that the risk of an unwanted pregnancy is far greater than being on the combined pill for 1 year. Nevertheless, a doctor or a family planning nurse can help a woman to choose an appropriate contraceptive method. (full text)
Family planning and family doctors in Estonia [letter]
A random survey of primary care/family doctors in Estonia was conducted to assess the availability of family planning (FP) information and modern methods and the involvement of these doctors in family planning services. With a response rate of 67%, the study revealed that 82% of family doctors and 16% of district doctors possessed the necessary equipment to carry out gynecological work. Moreover, Estonian primary care/family doctors consider their involvement in FP to be essential, especially in a society with high abortion rates, insufficient use of modern contraceptive methods, and insufficient coverage of the population by FP services. This study underscores the need to additionally train and retrain family doctors to further lower abortion rates in Estonia.
The aim was to identify predictors of subsequent infection among a sample of 15-19 year old African-American males attending an urban sexually transmitted disease (STD) clinic in the Midwest. During a 14-month period, 562 youth participated in a brief STD prevention intervention designed to promote condom use. They completed self-administered questionnaires (baseline, posttest, 30-day and 6-month) on their sexual and condom use behavior in the past month. Infection data (baseline, 5 years before, and 12 months after baseline) were obtained from clinic and state surveillance records. Logistic regression was used to predict infection within 6 and 12 months of the baseline visit. Within 12 months of the baseline, 31.3% were treated for an infection, of whom 1.4% returned within 30 days, an additional 17.1% within 6 months, and the remaining 12.8% within the last 6 months. The 12-month rate was 1.6-1.7 times higher than the rates reported for older STD clinic attendees. Subsequent infection was positively associated with age at first intercourse, number of children fathered, infection prior to and at the index visit, exchange of sex for drugs in the past year, and perceived risk of infection within the year; it was negatively associated with frequency of condom use with one's steady partner. STD clinic staff routinely obtains information from young African-American males that can be used to identify individuals who are most likely to become reinfected. Because repeaters account for a disproportionate number of infections, prevention efforts tailored to their needs would have a corresponding impact on STD rates. (author's)
Stratified partial likelihood estimation.
When multiple durations are generated by a single unit, they may be related in a way that is not fully captured by the regressors. The omitted unit-specific variables might vary over the durations. They might also be correlated with the variables in the regression component. The authors propose an estimator that responds to these concerns and develop a specification test for detecting unobserved unit-specific effects. Data from Malaysia reveal that concentration of child mortality in some families is imperfectly explained by observed explanatory variables, and that failure to control for unobserved heterogeneity seriously biases the parameter estimates. (author's)
What leads to sex? Adolescent preferred partners and reasons for sex.
83 African-American and White male and female adolescents, ages 16-20 years old, were asked to list preferred partner qualities and reasons to have or not have sex as measures of their perceptions of antecedents of sex. High frequency items were placed on cards and sorted separately by an additional four gender and racial subsamples (n = 79). Data were analyzed using multidimensional scaling and cluster analysis. Health-related antecedents to sex were not predominant in responses. Both African-American female and male adolescents mentioned "nice body" as criteria for evaluating partner attractiveness and associated this with good looks, whereas White adolescents did not mention "nice body". African-American male adolescents associated love relationships with marriage and parenthood whereas others did not. African-American and White male adolescents indicated sexual arousal as a reason for sex, whereas African-American and White female adolescents did not, with African-American male adolescents associating sexual arousal with an attractive partner and White male adolescents associating sexual arousal with drinking. Implications for sexually transmitted disease prevention are considered. (author's)
The supply of infants relinquished for adoption: did access to abortion make a difference?
Motivated by a theory of desired fertility the author uses 3 years of aggregate state level data to examine the impact of abortion access on the supply of infants relinquished for adoption. The author shows evidence that abortion access affected the supply of infants relinquished during the 1980s in two different ways. First, the availability of abortion providers has the expected effect of reducing the supply of infants relinquished, particularly relative to the demand for abortion. Second, abortion law has an unexpected negative effect. This suggests that as abortion laws become more restrictive the total number of unwanted births may decrease. (author's)
Outcomes of social and environmental change in the Kalahari of Botswana: the role of migration.
This paper assesses the contemporary significance of migration in the Kalahari of Botswana as populations are affected by the dual impacts of natural environmental variability and structural land use change. The study focuses on the mobility outcomes of the Tribal Grazing Lands Policy of 1975, which states that preexisting populations were to be resettled in specially designated Service Centers that were expected to improve livelihood opportunities and household food security. Overall, the study revealed that the policy was accompanied by extensive population displacement rather than migration per se as ranch owners exercised their exclusive rights to the land. While some ranch populations moved to Service Centers, lack of infrastructure and alternative livelihood opportunities forced many of them back into the ranch areas where many now live as squatters dependent on the goodwill of ranch owners. Based from the findings, the policy has not created a population of settlers, as intended, but a population of transients involved in some highly localized moves.
Gender differences in the epidemiology and treatment of anxiety disorders.
Women are more likely than men to develop anxiety disorders. Yet, relatively few studies have investigated whether women with anxiety disorders have characteristics that are distinct from those of men with the same disorders. The cause of the enhanced vulnerability to anxiety for women remains largely undetermined. Recent data suggest that female reproductive hormones and related cycles may play an important role. In addition to etiologic functions, reproductive hormones may substantially influence the clinical course of preexisting anxiety conditions in women. Psychotropic medications are more likely to be prescribed to women, and gender differences have been identified in the pharmacokinetics of psychotropic medication. Yet, relatively few systematic data are available concerning the potential clinical relevance or possible treatment implications of gender differences in the treatment of women with anxiety disorders. This article reviews the unique characteristics of primary anxiety disorders in women, summarizes the neurobiological effects associated with estrogen and progesterone, discusses gender differences in medication metabolism and the potential relevance of these differences in the pharmacologic management of women with anxiety disorders, and reviews issues specific to women (e.g., hormone therapy, oral contraceptives, menstrual cycle, pregnancy, lactation) that may impact treatment with psychotropic medication. (author's)
Abortion as stigma: cognitive and emotional implications of concealment.
The study examined the stigma of abortion and psychological implications of concealment among 442 women followed for 2 years from the day of their abortion. As predicted, women who felt stigmatized by abortion were more likely to feel a need to keep it a secret from family and friends. Secrecy was related positively to suppressing thoughts of the abortion and negatively to disclosing abortion-related emotions to others. Greater thought suppression was associated with experiencing more intrusive thoughts of the abortion. Both suppression and intrusive thoughts, in turn, were positively related to increases in psychological distress over time. Emotional disclosure moderated the association between intrusive thoughts and distress. Disclosure was associated with decreases in distress among women experiencing intrusive thoughts of their abortion, but was unrelated to distress among women not experiencing intrusive thoughts. (author's)
Parenting of young children by fathers in Mexico and the United States.
In the present study, the parenting practices and development expectations were examined in a sample of 96 fathers from Mexico and the US, all with children from 1 to 5 years of age. The selection of fathers from both countries was controlled for the family's socioeconomic status (SES) and for the age and gender of their children. The Parent Behavior Checklist, a 100-item rating scale was used to measure parents' developmental expectations and their discipline and nurturing practices. According to the results, Mexican and US fathers did not differ significantly in their developmental expectations or parenting practices. In both countries, fathers from lower-SES families were less nurturing and used discipline more frequently than fathers from higher-SES families. (author's)
Abstinence and safer sex among adolescents [letter]
This editorial by Dr. DiClemente criticizes the US$50 million per year allocated by Congress for abstinence education as a triumph of ideology over science. There are reasons to believe that the editorialist has made a hasty judgment. The National Longitudinal Survey of Adolescent Health found that teens whose parents made it clear that they expected them not to have sex and expected their teens not to use birth control were much less likely to have had sex than other teens. In addition, teens who had made a pledge of abstinence were 3 times less likely to have had sex. Perhaps failure of the randomized controlled trial by Dr. Jemmott and colleagues to include parents in the promotion of abstinence was one reason the effects were not long lasting. Also, since the educators were assigned randomly it is possible that those chosen to teach about abstinence had no more commitment to, or confidence in, abstinence than to the safe sex message. Teen sexual activity, with or without protection, is correlated with high-risk, self-destructive behaviors. Orr reported that teenagers who are sexually active are substantially more likely to be suspended from school, run away from home, use marijuana, be arrested by police, and for girls, to attempt suicide. Teen sex may reflect "acting out" behavior for deeper problems related to sexual abuse, low self-esteem, poor relationships, and a lack of vision and goals. These are problems that endorsing safer sex cannot solve. For instance, condom use does not protect from infection with human papillomavirus and herpes, which are spread by skin-to-skin contact throughout the entire genital region, not just in the parts covered by a condom. Other studies show that condom use provides little to no protection for chlamydia, the most widely sexually transmitted infection in the US. Students should also be exposed to deeper issues, such as the ethics of love and the positive value of children being raised by two parents who love and are committed to each other. Young people have many questions, but are responsible trusted adults ready to give them real answers? Or shall adults just continue to push latex "Band-Aids" to hide the issues they do not feel comfortable talking about? (full text)
Case reports: 1. Maternal mortality following the use of misoprostol.
Three cases of maternal death following the use of misoprostol are presented. In two of the cases the drug was used to procure illegal abortion, and in the third case maternal death occurred following uterine rupture, after misoprostol was used clinically for induction of labor. A brief review of the usage of misoprostol is presented, including recommendations for its safe use. (author's)
Although AIDS is spreading rapidly in minority communities, little is known about attitudes, knowledge, and behavior related to AIDS and HIV in the Asian community. The purpose of this study was to examine these variables in a sample of gay Asian males, as well as to investigate the relationship between knowledge, sources of information, culturally influenced attitudes and high-risk behaviors in this population. Results from a sample of 60 young Asian men who self-identified as "having sex with other men" indicated they were generally knowledgeable about methods of transmission and prevention, and appeared linked to a large information network that included informal sources such as peers and formal sources. However, significant percentages held culturally biased views of AIDS, such as believing race of partner or one's own gender role in the sexual encounter determined level of risk; and one-third of the sample did not use condoms regularly. Having been tested for HIV was associated with holding less traditional cultural beliefs and a higher sexual activity level. Open communication about safer sexual practices was associated with monogamous as opposed to multiple relationships and with decreased tendency to engage in alcohol-related unprotected sex. Variance in overall risk was predicted by demographic variables such as education, age, and level of sexual activity, rather than by the attitudinal factors measured. Limitations of this exploratory study include a time-limited subject recruitment period and consequent small sample size, a homogeneous sample weighted toward young, well-educated, and middle-class respondents, and the exclusion of non-English speaking individuals. Nevertheless, study findings suggest that educational outreach targeting Asians who have sex with other men needs to address inaccurate cultural beliefs about HIV/AIDS, emphasize consistent condom use, and encourage models of open communication with partners about safer sexual practices. (author's)
Epidemiology of pediatric AIDS in Puerto Rico: 1981-1998.
The objective of this study was to describe the AIDS-defining conditions (ADC) and survival experience of pediatric AIDS cases (<13 years age) reported in Puerto Rico. A descriptive analysis of the data gathered by the Puerto Rico AIDS Surveillance System was performed. Data for the 377 pediatric AIDS cases reported from January 1981 through June 1998 were reviewed. Survival curves following AIDS diagnosis were estimated using the Kaplan-Meier method and differences between curves were assessed by the Wilcoxon test. The majority (61%) of the cases were diagnosed before 2 years of age, and nearly 94% of them acquired the infection through perinatal transmission. The most common ADC were Pneumocystis carinii pneumonia (PCP) (23%), wasting syndrome (19.4%), and esophageal candidiasis (19.1%). The overall median survival time during the study period was 53.5 (95% confidence interval: 38.0-106.2) months. Children <1 year of age had a significantly shorter median survival time compared with older ages (p < 0.05). The survival experience in children diagnosed with PCP, pulmonary candidiasis, cytomegalovirus, and lymphocytic interstitial pneumonia was significantly different (p < 0.05) to those children not diagnosed with these conditions. Although patients diagnosed after 1990 showed a median survival time longer than those diagnosed prior to 1990, the difference did not reach statistical significance (p > 0.05). The frequency of several ADC and median survival time of Puerto Rican children differed from those reported in the US. This may reflect differences in diagnostic procedures or reporting practices. (author's)
I was interested to read the report by Dr. Mahe and his colleagues, describing a woman who suffered from five episodes of puerperal mania and two of postabortion psychosis, one after a therapeutic abortion and one after a spontaneous abortion. This clinical observation is a valuable contribution to the literature. The association of acute psychosis with abortion in women susceptible to puerperal psychosis has previously been noted in nine reports, starting with Esquirol in 1819. Some of the terminations were carried out in order to prevent a puerperal psychosis. This literature is summarized in my book Motherhood and Mental Health, pages 91-93. There is evidence, especially from Denmark, that abortion is a greater risk factor than a full-term pregnancy. (full text)
This study examined the relationship between native-language retention, social/psychological insecurity, and fertility among Asian Indians living in the US. A national representative sample of 3408 Asian Indian women in their childbearing years (ages 15-44) currently married to and living with Asian Indian spouses was obtained. Overall, regression analysis showed no evidence of either a native-language retention of English-proficiency effect on fertility. However, among older women, native-language retention had a profound, negative, and statistically significant impact on fertility. In addition, although it is possible to hypothesize that native-language retention had a negative impact on fertility in this sample of Asian Indian women, there is no support for the minority group status hypothesis. Based on these results, it is suggested that domain assumptions about assimilation, the insecurities associated with upward mobility, and minority group fertility behavior be reexamined.
Third World debt puts AIDS drugs beyond reach.
Nurse leaders should campaign to cancel Third World debt, a leading Zambian nurse told the ICN Centennial Conference (student conference) in London, June 1999. Genevieve Tororo Mwale, a nurse consultant and lecturer at the University of Zambia, told students that the poverty of her country--where a fifth of the population is infected with HIV--meant that drug therapy was beyond the reach of AIDS patients. Instead, they had to rely on traditional and untested treatments, including aloe plant pulp and banana bark. Most patients die within a year of developing AIDS, and by 2005 it is estimated that 43% of hospital bed occupancy will be AIDS-related. Ms. Mwale pointed out that the link between debt servicing and the strain on health services in Zambia, where often one nurse will be looking after a ward of 80 seriously ill patients. Zambia spends three times as much on debt servicing as it does on health care. (full text)
A trivariate model of participation, fertility and wages: the Italian case.
Italy has unusually low fertility by Organization of Economic Cooperation and Development standards, accompanied by unusually low female participation in paid work. This paper addresses the issue of the empirical relationship between fertility, female participation in the labor market and wages with these Italian "peculiarities" as a backcloth. A trivariate model of participation, fertility and wages has been constructed and estimated using three pooled cross-sections of Italian micro data, allowing for the identification of cohort effects. This model follows a "purist" approach: the participation and fertility decisions, as well as the wage equation, are modeled as completely joint. The cohort effects turn out to be significant: the point estimates do not appear to confirm actual trends, which are negative for fertility and positive for participation. The female wage is the most important variable influencing the propensity to have children and the propensity to participate in the labor market, casting doubt on suggestions that observed trends are the products of shifts in women's "tastes". (author's)
Predictors of risk for sexually transmitted diseases in ninth grade urban high school students.
This study examined risk factors associated with acquisition of sexually transmitted diseases (STDs) including HIV in adolescents, using the AIDS Risk Reduction Model. The study participants were 985 students who were 54% female, ethnically/racially diverse, had a mean age of 14.7 years, and were mostly 9th graders (74%). Logistic regression was used to predict sexual experience. Linear regression was used to predict risky sexual behaviors and condom use within the previous month. The results indicate that demographic factors are associated with being sexually experienced, but few demographics are associated with specific STD-related risk behaviors. STD and AIDS knowledge are not associated with any risk behaviors. Use of alcohol and drugs is associated significantly with being sexually experienced and sexual risk. The results also indicate that peer affiliation, perceptions of peer norms, perceptions of risk, perceptions of self-efficacy, and social support are associated with STD-related risk among sexually experienced youth. (author's)
Reproductive health: the young have a right to know --Dr. Brundtland.
Annually, 333 million of curable sexually transmitted diseases (STDs) are reported, and 1 in 20 adolescents are affected. The HIV virus infects more than 5.2 million people each year, over half of them being young people of 24 years or under. This article reports the speech made by Dr. Brundtland, Director General of the WHO during a follow-up session to the International Conference on Population and Development, held in New York. In her speech, Dr. Brundtland emphasized the need to inform the public, particularly the youth, about reproductive health so as to reduce STDs, avoid early or unwanted pregnancy, and control population growth. The most effective means to prevent these problems as stated by Dr. Brundtland is to address the needs of young people in a comprehensive way. Furthermore, she emphasized the key challenges to stabilize population growth, which include the need to combat poverty and prevent maternal morbidity and mortality. Lastly, the key indicator is to provide the most important single intervention--the assistance of a skilled health worker during labor and delivery.