Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections.
Objective: To draw up evidence-based guidelines to make injections safer. Methods: A development group summarized evidence-based best practices for preventing injection-associated infections in resource-limited settings. The development process included a breakdown of the WHO reference definition of a safe injection into a list of potentially critical steps, a review of the literature for each of these steps, the formulation of best practices, and the submission of the draft document to peer review. Findings: Eliminating unnecessary injections is the highest priority in preventing injection-associated infections. However, when intradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterile injection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries to the provider, and the prevention of access to used needles. Conclusion: The availability of best infection control practices for intradermal, subcutaneous, and intramuscular injections will provide a reference for global efforts to achieve the goal of safe and appropriate use of injections. WHO will revise the best practices five years after initial development, i.e. in 2005. (author's)
Understanding women's attitudes towards wife beating in Zimbabwe.
Objective: To investigate the factors associated with attitudes towards wife beating among women in partnerships in Zimbabwe in order to assist public health practitioners in preventing intimate partner violence (IPV). Methods: A nationally representative survey of 5907 women of reproductive age (15–49 years) was conducted in Zimbabwe. Women were asked about their attitudes towards wife beating in five situations. The survey included sociodemographic characteristics, partnership characteristics, and household decision-making. Findings: Over half of all women in Zimbabwe (53%) believed that wife beating was justified in at least one of the five situations. Respondents were most likely to find wife beating justified if a wife argued with her spouse (36%), neglected her children (33%), or went out without telling her spouse (30%). Among women in partnerships (n = 3077), younger age, living in rural areas, lower household wealth, schooling at a lower level than secondary, and lower occupational status were associated with women reporting that wife beating is justified. Women who reported that they make household decisions jointly with their partners were less likely to say that wife beating is justified. Conclusions: Zimbabwe has a long way to go in preventing IPV, particularly because the younger generation of women is significantly more likely to believe that wife beating is justified compared with older women. Given the current social and political climate in Zimbabwe, finding means to negotiate rather than settle conflict through violence is essential from the household level to the national level. (author's)
Objectives: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub- Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. Methods: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3–5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. Findings: We studied 7195 children aged 2–59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. Conclusion: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children. (author's)
Objective: To gauge the effects of operating the Bamako Initiative in Kongoussi district, Burkina Faso. Methods: Qualitative and quasi-experimental quantitative methodologies were used. Findings: Following the introduction of fees-for-services in July 1997, the number of consultations for curative care fell over a period of three years by an average of 15.4% at ‘‘case’’ health centres but increased by 30.5% at ‘‘control’’ health centres. Moreover, although the operational results for essential drugs depots were not known, expenditure increased on average 2.7 times more than income and did not keep pace with the decline in the utilization of services. Persons in charge of the management committees had difficulties in releasing funds to ensure access to care for the poor. Conclusion: The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay. (author's)
Poverty, equity, human rights and health.
Those concerned with poverty and health have sometimes viewed equity and human rights as abstract concepts with little practical application, and links between health, equity and human rights have not been examined systematically. Examination of the concepts of poverty, equity, and human rights in relation to health and to each other demonstrates that they are closely linked conceptually and operationally and that each provides valuable, unique guidance for health institutions’ work. Equity and human rights perspectives can contribute concretely to health institutions’ efforts to tackle poverty and health, and focusing on poverty is essential to operationalizing those commitments. Both equity and human rights principles dictate the necessity to strive for equal opportunity for health for groups of people who have suffered marginalization or discrimination. Health institutions can deal with poverty and health within a framework encompassing equity and human rights concerns in five general ways: (1) institutionalizing the systematic and routine application of equity and human rights perspectives to all health sector actions; (2) strengthening and extending the public health functions, other than health care, that create the conditions necessary for health; (3) implementing equitable health care financing, which should help reduce poverty while increasing access for the poor; (4) ensuring that health services respond effectively to the major causes of preventable ill-health among the poor and disadvantaged; and (5) monitoring, advocating and taking action to address the potential health equity and human rights implications of policies in all sectors affecting health, not only the health sector. (author's)
Mixed reaction to US pledge of US$ 15 billion to fight AIDS.
While welcoming the increased commitment to spending on AIDS in Africa, activists are upset that Bush has set aside only US$ 200 million a year for the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund was set up two years ago to coordinate and deliver resources to projects around the world quickly and with a minimum of bureaucratic red tape. Next year the Fund faces a US$ 4 billion shortfall. (excerpt)
Long-chain polyunsaturated fatty acids, pregnancy, and pregnancy outcome.
During pregnancy, essential long-chain polyunsaturated fatty acids (LCPUFAs) play important roles as precursors of prostaglandins and as structural elements of cell membranes. Throughout gestation, accretion of maternal, placental, and fetal tissue occurs and consequently the LCPUFA requirements of pregnant women and their developing fetuses are high. This is particularly true for docosahexaenoic acid (DHA; 22:6n23). The ratio of DHA to its status marker, docosapentaenoic acid (22:5n26), in maternal plasma phospholipids decreases significantly during pregnancy. This suggests that pregnancy is associated with maternal difficulty in coping with the high demand for DHA. The DHA status of newborn multiplets is significantly lower than that of singletons; the same is true for infants of multigravidas as compared with those of primigravidas and for preterm compared with term neonates. Because the LCPUFA status at birth seems to have a long-term effect, the fetus should receive an adequate supply of LCPUFAs. Data from an international comparative study indicated that, especially for n23 LCPUFAs, the fetus is dependent on maternal fatty acid intake; maternal supplementation with LCPUFAs, their precursors, or both increased LCPUFA concentrations in maternal and umbilical plasma phospholipids. However, significant competition between the 2 LCPUFA families was observed, which implies that effective supplementation requires a mixture of n26 and n23 fatty acids. Further research is needed to determine whether higher LCPUFA concentrations in plasma phospholipid will have functional benefits for mothers and children. (author's)
An Ebola epidemic simmers in Africa. In remote region, outbreak shows staying power.
An epidemic of Ebola hemorrhagic fever has sputtered along unabated since October 2001 in the dense jungles that span the northern border between Gabon and Congo, raising questions about how health officials respond to outbreaks of the deadly infection. (excerpt)
This was a prospective study conducted at the Moi Teaching and Referral Hospital, Eldoret, Kenya. Twenty-three children admitted to the hospital with cerebral (CM) and 10 children with noncerebral malaria (NCM) were studied. The aim of the study was to establish and compare levels of tumour necrosis factor (TNF-a) and transforming growth factor (TGF-b1) in these children. Serum and cerebrospinal fluid (CSF) cytokine levels were assayed using ELISA kits. In serum, TGF-b1 and TNF-a decreased over 5 days after admission to the hospital in both groups of patients with CM and NCM. In the CSF of cerebral cases the levels of TNF-a and TGF-b1 were low and inversely related. Children in deeper coma had lower levels in serum of TGF-b and higher levels of TNF-a than those in lighter levels of coma. The serum TNF-a levels in CM children were the same irrespective of the duration of illness before admission, but children with NCM who had been sick for a shorter duration before admission tended to have higher serum levels of TNF-a and higher levels of TGF-b than those with a longer duration of illness before admission. In conclusion, this study shows that TNF-a and TGF-b1 may not be useful in predicting the outcome for CM. They may, however, be useful in detecting children at risk of developing deep coma. TNF-a and TGF-b levels were inversely related both in serum and CSF. (author's)
In January, Bush called for the USA to fund a 5-year, US$15 billion initiative, called the Emergency Plan for AIDS Relief, to support efforts to combat HIV/AIDS in the hardest hit countries in Africa and the Caribbean. The stated goals of the plan are to reduce by 60% of the projected new infections (roughly 7 million new infections), provide antiretroviral drug treatment for 2 million HIV-infected people, and provide care for 10 million HIV-infected individuals and AIDS orphans. The US Congress, however, has authorised only $2 billion for the project instead of the $3 billion Bush originally asked for, and so far none of the money has been dispensed. (excerpt)
Six countries of the Africa Great Lakes sub-region have signed an agreement to cooperate on the prevention and control of epidemics and diseases that can be prevented by vaccination. Their health ministers signed the protocol of cooperation in the Ugandan capital, Kampala, on June 27. According to a 14-page document the six ministers released jointly, the countries would share epidemic information across borders, harmonise treatment policies and protocols, and standardise laboratory procedures and techniques. They also agreed to coordinate mass vaccination activities, implement joint activities aimed at eliminating measles, vitamin A deficiencies, and maternal and neonatal tetanus. c(excerpt)
Trachoma is the most common infectious cause of blindness. It is caused by ocular serovars of Chlamydia trachomatis. Transmission is favoured in poor communities, where crowding is common and access to water and sanitation inadequate. Repeated reinfection over many years causes dense scarring of the upper eyelid. The resultant inversion of the lashes abrades the eyeball, and the abrasion leads to corneal opacification and visual impairment. The host immune response is probably at least partly the cause of this process. The “SAFE” strategy is used for the control of trachoma: surgery for inturned lashes, antibiotics for active disease, facial cleanliness, and environmental improvement. The demonstration that a single oral dose of the antibiotic azithromycin is as effective as 6 weeks of topical tetracycline was an important advance in trachoma control. By means of the SAFE strategy, WHO and its partners aim to eliminate trachoma as a public-health problem by the year 2020. (author's)
Applying an equity lens to child health and mortality: more of the same is not enough.
Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidised health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed. (author's)
Pharmaceutical interests versus AIDS in Africa [editorial]
As retired chairman and chief executive officer of Eli Lilly & Company, and as ex-vice chairman of AT & T, Tobias clearly has top-level management experience. He is also a substantial donor to the Republican Party. However, critics have already questioned his knowledge of AIDS and Africa. Rapid appointment of a team behind him with proven African public-health and HIV experience would help him gain credibility in his new role, as would announcement of a detailed plan of how the Bush AIDS initiative will work with the Global Fund to Fight AIDS, Tuberculosis and Malaria. His connections with the pharmaceutical industry have led to concerns about whether Tobias is committed to providing access to low-cost generic AIDS drugs, or whether he will purchase patented versions so protecting the interests of US drug companies. Tobias needs quickly, and publicly, to support purchasing of low-cost generics to provide ammunition against those who charge that he is no more than a stooge of the drug industry. He could even go as far as to counter current US opposition to full implemention of the Doha Declaration of 2001. (excerpt)
The need to update the classification of acute malnutrition [letter]
These positive results from the new community-based therapeutic care (CTC) model of intervention call for a change in the way that we classify acute malnutrition. The WHO classification consists of moderate and severe categories, defined according to anthropometry and the presence of bilateral pitting oedema. This classification was appropriate and operationally relevant when the modes of treatment involved inpatient therapeutic feeding centres for severe acute malnutrition, and outpatient supplementary feeding for moderate acute malnutrition. This new era of community-based care, however, has three treatment modes. To be operationally relevant, a new system of classification must, therefore, include complicated malnutrition as well as severe and moderate malnutrition. (excerpt)
In Report Number 107-663, Congress requested the State Department to provide a report on support for microbicide and vaccine research. This report is divided into two parts. The first part of this report describes U.S. Agency for International Development-funded microbicide research efforts, and complements the National Institutes for Health Office of AIDS Research’s report on federally funded microbicide research as requested by Congress in the FY03 Appropriations bill for the Department of Health and Human Services and National Institutes for Health. The second part is an update to last year’s report to Congress related to USAID’s support of the vaccine research efforts by the International AIDS Vaccine Initiative. (excerpt)
Multisectoral responses to HIV / AIDS: a compendium of promising practices from Africa.
HIV/AIDS is among the greatest challenges to sustainable economic, social, and civil society development today; it is a global crisis that undermines all aspects and all sectors of entire societies. An effective response demands committed, urgent, and sustained action by alliances of individuals, organizations and governments. Furthermore, an epidemic as complex and as destructive as HIV/AIDS requires innovative and multisectoral responses beyond standard public health measures. The implementation of multisectoral HIV/AIDS programs warrants total national commitment and reduction in stigma associated with the disease. Thus all governmental and nongovernmental agencies and private organizations engaged in development efforts need to have necessary information to respond to HIV/AIDS as a major development issue. Private voluntary organizations (PVOs) are key players in development efforts. In January 2000, as the new administration was settling in, 40 leaders of private voluntary organizations met with USAID, Bureau for Africa officials and identified the onslaught of HIV/ AIDS as a priority continuing challenge facing sub-Saharan Africa. HIV/AIDS was identified as a key challenge requiring interventions in multiple sectors and by multiple actors in the development assistance community. In response, a PVO/USAID Steering Committee on Multisectoral Approaches to HIV/AIDS was formed and met regularly to discuss these issues and catalyze action. This compendium of promising practices was proposed as a way for the PVOs to share multisectoral HIV/AIDS promising practices and innovations. This promising practice compendium, a direct outcome from this conference, features 22 practices submitted by 13 organizations working in Africa. To ease the submission process and the comparability of practices, organizations followed a format adapted from other promising practice compendia and limited their entries to five pages. A background piece introduces the practice. This is a collection of promising practices. Most practices in this compendium are very young practices. Therefore, they do not have measurable results without which they cannot be termed best practices. (excerpt)
The report describes some of the many ‘champions’ of the profession—individuals who, with singular commitment and resourcefulness, are delivering good-quality care to people with HIV/AIDS, or who are otherwise helping families and communities to understand the epidemic, to come to terms with their own fears and prejudices, and to protect themselves from infection. However, this is not some kind of league of heroines and heroes of the epidemic. The champions featured here are just a few of the ordinary nurses and midwives who are simply doing their job well, under difficult circumstances. There are, without doubt, very many more of them. In describing the work of a few, the intention is to pay tribute to all who are doing a caring, committed job in the face of great odds, and to share as widely as possible the valuable lessons they have learned from experience. The report was commissioned by the SADC AIDS Network of Nurses and Midwives (SANNAM) in collaboration with UNAIDS. It involved original investigation in the field by a consultant who, over the course of one month, visited five countries in Southern Africa—namely, Botswana, Lesotho, Namibia, South Africa and Zambia—to link up with the national nursing associations and speak to a wide range of people. In addition to nurses and midwives, these included some of the people they work with in communities, such as volunteer caregivers, members of youth groups, and PLWHA and their families, as well as people working within ministries of health, and relevant United Nations agencies and nongovernmental organiza-tions. Besides being aimed at nurses and midwives themselves, the report is addressed at all those with an interest in improving the quality of care and support of people living with HIV/AIDS (PLWHA), especially those responsible for training, managing and supervising nursing and midwifery staff, and policy-makers within the health services. (excerpt)
HIV-infected women and their families: psychosocial support and related issues. A literature review.
This review is divided into three sections. Section one provides a synthesis of the reviewed literature on prevention of mother-to-child transmission (PMTCT) of HIV, voluntary HIV testing and counselling (VCT), and other issues that impact on the care, psychosocial support and counselling needs of HIV-infected women and their families in the perinatal period. Section two provides examples from around the world of projects that focus on the care and support of women and families, with a focus on MTCT. The fi nal section contains recommendations on psychosocial support and counselling for HIV-infected women and families. (excerpt)
Dangerous liaisons. People in cross-generational relationships underestimate risk.
A PSI study of Kenyan women’s and men’s motivations for entering into cross-generational relationships1 and their risk perceptions of such relationships has found that most participants underestimate the risk of sexually-transmitted infections (STIs) and HIV. HIV/AIDS disproportionately affects young African women as compared to older men. Studies have found that HIV infection in women 15-24 is significantly higher than for men in the same age group. Researchers believe that both young women’s physiological susceptibility and sexual relationships with older partners contribute to their increased risk of infection. Cross-generational relationships are reportedly quite common. A comprehensive literature review of quantitative studies in sub-Saharan Africa revealed that 12% to among men over the age of 30 who reported non-marital partners, 25% had a partner at least 10 years younger. Data were collected in June 2000 as part of a behavior change communication strategy for young women in Kenya that addressed crossgenerational relationships and their risk for STIs and HIV/AIDS. Eight focus groups were conducted with women aged 15-19 and 28 in-depth interviews were carried out with men aged 30 years and older in Nairobi, Mombassa, Kisumu and Meru. Participants discussed motivations for entering into cross-generational relationships, perceived risks and relationship dynamics. (author's)
Chapter 1 crystallizes my thoughts, commitments and ideas on this vital issue. We have a rich historic mandate that calls us to the challenge of fighting poverty. Our experience on the ground is bringing that mandate to life throughout the world. And we face common challenges as we join with others to provide women and men with the tools and support to work out of poverty. Chapter 1 is my personal exploration of these key issues. The subsequent chapters are more technical in nature, providing an in-depth and detailed account of the various dimensions of ILO efforts to eradicate poverty. Chapter 2 focuses on the complexity of poverty and the cycle of disadvantage that it creates. Chapter 3 describes ILO action on the ground and tools in the fight against poverty. Chapter 4 examines how rights at work and the institutional structure of the informal and formal labour market relate to employment creation, poverty reduction and competitiveness in a global economy. Finally, Chapter 5 discusses the need for a coordination of policies that focus on different dimensions of the life of people living in poverty. (excerpt)
Effective counseling for adolescents is critical, since they generally have less knowledge about contraceptive methods, higher rates of contraceptive noncompliance, higher risk for unintended pregnancy, and have rapidly rising STD and HIV infection rates as compared to the adult population. Many teenagers use hormonal methods of contraception. Health care providers need to take the time to ensure that adolescents fully understand their options in relation to pregnancy and STD prevention, as well as the use and potential side effects of the contraceptive method they choose. (excerpt)
Key Points to Emphasize with Patients: Correct condom use is critical. Most failures are the result of not using the condom correctly. Store condoms in a cool, dry, and dark place. Condoms stored in wallets may be safe for up to one month. Most condoms, if stored properly, can be used up to five years past the indicated manufacture date. Respect the expiration date. Make sure the condom is on the penis before it enters the vagina, anus or mouth. (excerpt)
Federal, state, and local laws and regulations frequently impose restrictions on the medical procedure of induced abortion to a greater extent than on any other medical procedure, even those far more dangerous. Providers need to be aware of the legal restrictions affecting provision of reproductive health services in their locality. Examples of these restrictions include: biased counseling laws; government-mandated delays before abortion parental involvement; laws for minors funding restrictions for abortion; “partial-birth” abortion bans; targeted regulation of abortion providers (TRAP laws; physician-only laws. (excerpt)
Fertility rates across Europe are now so low that the continent's population is likely to drop markedly over the next 50 years. The UN, whose past population predictions have been fairly accurate, predicts that the world's population will increase from just over 6 billion in 2000 to 8.9 billion by 2050. During the same period, however, the population of the 27 countries that should be members of the EU by 2007 is predicted to fall by 6%, from 482m to 454m. For countries with particularly low fertility rates, the decline is dramatic. By 2050 the number of Italians may have fallen from 57.5m in 2000 to around 45m; Spain's population may droop from 40m to 37m. Germany, which currently has a population of around 80m, could find itself with just 25m inhabitants by the end of this century, according to recent projections by Deutsche Bank, which adds: “Even assuming (no doubt unrealistically high) annual immigration of 250,000, Germany's population would decline to about 50m by 2100.” (excerpt)
Assessing human resources for health: what can be learned from labour force surveys?
Background: Human resources are an essential element of a health system’s inputs, and yet there is a huge disparity among countries in how human resource policies and strategies are developed and implemented. The analysis of the impacts of services on population health and well-being attracts more interest than analysis of the situation of the workforce in this area. This article presents an international comparison of the health workforce in terms of skill mix, sociodemographics and other labour force characteristics, in order to establish an evidence base for monitoring and evaluation of human resources for health. Methods: Profiles of the health workforce are drawn for 18 countries with developed market and transitional economies, using data from labour force and income surveys compiled by the Luxembourg Income Study between 1989 and 1997. Further descriptive analyses of the health workforce are conducted for selected countries for which more detailed occupational information was available. Results: Considerable cross-national variations were observed in terms of the share of the health workforce in the total labour market, with little discernible pattern by geographical region or type of economy. Increases in the share were found among most countries for which time-trend data were available. Large gender imbalances were often seen in terms of occupational distribution and earnings. In some cases, health professionals, especially physicians, were overrepresented among the foreign-born compared to the total labour force. Conclusions: While differences across countries in the profile of the health workforce can be linked to the history and role of the health sector, at the same time some common patterns emerge, notably a growing trend of health occupations in the labour market. The evidence also suggests that gender inequity in the workforce remains an important shortcoming of many health systems. Certain unexpected patterns of occupational distribution and educational attainment were found that may be attributable to differences in health care delivery and education systems; however, definitional inconsistencies in the classification of health occupations across surveys were also apparent. (author's)
Misprostol use during the third stage of labor.
Objectives: To systematically review the efficacy of misoprostol compared with placebo or other uterotonics in preventing maternal morbidity associated with the third stage of labor. Methods: We identified, retrieved, evaluated, abstracted data, and assessed the quality of all published studies (from January 1996 to May 2002) which assessed misoprostol’s efficacy in minimizing uterine blood loss during the third stage of labor. Seventeen studies included 28 170 subjects; of these, approximately one-half received misoprostol with the remainder receiving either a placebo or another uterotonic agent. An estimate of the odds ratio (OR) and risk difference for dichotomous outcomes was calculated using a random- and fixed-effects model. Continuous outcomes were pooled using a variance-weighted average of within-study difference in means. Results: In assessing studies comparing misoprostol with placebo, those who received oral misoprostol had a decreased risk of needing additional uterotonics (OR 0.64, 95% confidence interval 0.46, 0.90). Compared with placebo, use of misoprostol was associated with an increased risk for shivering and pyrexia. In contrast, in studies comparing misoprostol with oxytocin, oxytocin was associated with significantly lower rates of postpartum hemorrhage, maternal shivering and pyrexia. In studies comparing misoprostol with Syntometrine, misoprostol was associated with higher rates of the need for additional uterotonic agent as well as shivering. Conclusions: Misoprostol was inferior to oxytocin and other uterotonics with regard to any of the third stage of labor outcomes assessed. However, when compared to placebo, misoprostol had a decreased risk of needing additional uterotonics. Thus, in less-developed countries where administration of parenteral uterotonic drugs may be problematic, misoprostol represents a reasonable agent for the management of the third stage of labor. Additional randomized clinical trials examining objective outcome measures (i.e. need for blood transfusion or 10% hemoglobin change) may further define benefits and risks of misoprostol use during the third stage of labor. (author's)
Objectives: To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. Methods: A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at G28 weeks of gestation from June 1994 through December 2000 at a tertiary care center. Results: Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (ns38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41women who had received anticoagulants had any congenital malformation. Conclusions: Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well. (author's)
Preterm premature rupture of membranes and neonatal outcome prior to 34 weeks of gestation.
Objectives: To investigate the impact of preterm premature rupture of membranes on neonatal outcome. Methods: A retrospective study was conducted among singleton pregnancies with or without intact amniochorional membranes. The impact of maternal age, gestational age at birth, 1- and 5-min Apgar scores, birthweight, presence of meconium, use of tocolytics, corticosteroids and antibiotics, mode of delivery, umbilical artery pH, histologic presence of chorioamnionitis, and state of the membranes were analyzed in relation to neonatal outcome. Neonatal outcomes were categorized into: none, presence of respiratory distress syndrome, early neonatal sepsis, neonatal death, and days at neonatal intensive care unit. Results: A total of 180 preterm deliveries with ruptured (n=80) and intact membranes (n=s100) constituted the study group (group 1) and the control group (group 2), respectively. Compared with group 2, there were more cases in group 1 of maternal antibiotic use (P<0.001), short-term tocolysis (P=0.03), and histologic chorioamnionitis (P<0.001). Multiple logistic regression analysis showed that gestational age at delivery (P=0.009), 1-min Apgar score (P=0.013), and umbilical artery pH (P=0.05) were the independent factors affecting neonatal outcome. Conclusions: Neonatal outcome was mainly affected by prematurity rather than by preterm premature rupture of membranes. (author's)
PGE2 induction of labor for consistent decreased perception of fetal movements at term.
Objectives: To determine the effects of labor induction with vaginal prostaglandin E2 (PGE2) on mode of delivery and immediate neonatal outcome in women with consistent decreased perception of fetal movements at term. Methods: The study group consisted of 115 women with consistent perception of decreased fetal movements admitted for induction of labor at term. Findings were compared with those of 510 women with normal spontaneous onset of labor. Women with previous cesarean section (CS) were excluded from both the study and control groups. Results: The rate of CS was higher in the study group (14.8%) than in the control group (9%) (not significant). The rates of low 5-min Apgar score (F7) and CS performed for non-reassuring fetal heart rate were two-fold higher in the study group than in the control group (2.6% vs. 1.2%, and 6.1% vs. 3.1%, respectively, not significant in both). Conclusion: Induction of labor with PGE2 is successful in approximately 85% of the patients with decreased perception of fetal movements at term and apparently with no serious maternal or fetal complications. However, these pregnancies might be at higher risk of perinatal complications. We suggest that active labor induction may be currently considered as the preferred strategy in these pregnancies. Large prospective randomized studies on maternal and neonatal outcome are needed to clarify this issue. (author's)
Objectives: The immediate results of interferon gamma (IFN-t) treatment in the management of cervical intraepithelial neoplasia (CIN) have been described. However, little is known of the long-term results of this conservative treatment and we aimed to assess them. Methods: We conducted a 5-year follow-up of 13 women with either complete response to intracervical administration of 6 000 000 IU of IFN-t (remission from human papilloma virus-induced CIN occurred in nine cases) or partial response (a lower grade of CIN and/or HPV clearance was achieved in four cases). Results: We performed Papanicolaou smears and colposcopic examinations every 3 months for the first 2 years and every 6 months for the next 3 years. We found three cases of relapse of stage 1 CIN (CIN I), for a recurrence rate of 33.3%, and three cases of complete remission in four subjects with initial diagnosis of partial response. This allowed us to assess the overall lesion-free rate at 53% for the entire group of patients who had CIN I and CIN II treated with IFN-t. Conclusions: Immunomodulation therapy with IFN-t has a high long-term efficacy; however, it is inferior to that of surgery. (author's)
A global health opportunity with effective leadership [editorial]
The new WHO should work to foster benefits to health. Health promotion, disease prevention, health literacy, quality service delivery, supportive policy environments, and other areas that help develop a health-competent society can serve as cornerstones with economic development and sustainable institutions. (excerpt)
Rapid increase in HIV rates -- Orel Oblast, Russian Federation, 1999-2001.
During 1999--2001, the estimated number of cases of human immunodeficiency virus (HIV) reported officially in the Russian Federation increased approximately 16-fold, from 11,000 to 177,000. In 2001, of 49,434 HIV-infected persons for whom a risk factor was identified, 46,274 (94%) were injection-drug users (IDUs). However, the actual number of HIV-infected persons in Russia is estimated to be four to 10 times higher than reported. Rapid increases in HIV have been reported in urban areas (e.g., Kaliningrad, Moscow, and St. Petersburg) and also might be occurring in rural areas. During 1997--2000, HIV seroprevalence reportedly increased 33-fold in Orel Oblast, a predominantly rural, agricultural province (1999 population: 900,000) in central European Russia. To confirm and describe this increase and evaluate the risk for continued rapid increase of HIV, CDC collaborated with the Orel Oblast AIDS and Infectious Diseases Prevention Center (AIDS Center) to assess recent HIV trends and the prevalence of risk behaviors among IDUs in Orel Oblast. This report summarizes the results of that assessment, which indicate continued increases in HIV rates and underscore the need for interventions directed at IDUs and their sex partners to limit further spread of HIV. (excerpt)
Intravaginal and intracervical misoprostol for cervical ripening of labor in primiparas.
In conclusion, a single dose of 50 mg misoprostol intravaginally is an efficient and safe method for induction of labor at term in primipara with unfavorable cervix. There were no gains from administering misoprostol intracervically as compared with intravaginally. On the contrary, there are significantly more cesarean section and tachysystoles with misoprostol administered by the intracervical route. The optimal dosage has yet not been established. Further clinical trials are necessary to establish the optimal dosing regimen for misoprostol. Furthermore, the patients undergoing labor induction with misoprostol should be treated with caution and must receive continuous monitoring of fetal heart rate and uterine activity in a hospital setting. (excerpt)
The outcome of diabetic pregnancies in Malta.
Diabetes in pregnancy is associated with a higher mortality–morbidity for both the mother and child. The 1989 St. Vincent’s Declaration had set the goal of achieving ‘‘a pregnancy outcome in the diabetic woman that approximates that of the non-diabetic woman’’. The study aimed to assess outcome indicators of Maltese pregnant women suffering from diabetes and compare these with the remaining obstetric population. (excerpt)
Women's knowledge and opinions of emergency contraception.
In conclusion, we can draw some practical advice for family planning providers from our survey: (a) the term—still frequently used—‘morning after pill’ should be avoided, and more publicity should concentrate on the timing of its use; (b) counseling on emergency contraception (EC) should state that the method is not 100% effective; (c) the family planning services and other providers of EC may consider producing and providing short information leaflets on EC. (excerpt)
An evaluation of a community-based approach to safe motherhood in northwestern Tanzania.
Objectives: We present an evaluation of the Community Capacity Building and Empowerment initiative, undertaken by the Community-Based Reproductive Health Project (CBRHP), designed to address high maternal morbidity and mortality. Methods: Qualitative data from group interviews and program data from CBRHP were used to assess progress in development and use of community level transport systems and support for the village health workers (VHWs). Results: Project activities increased community participation in maternal health. An increase was seen in knowledge of danger signs, birth planning, timely referrals, and transport of pregnant women to hospitals, as well as in support and retention of VHWs. More women with obstetrical problems are using the community-based transport system to get to hospitals. Conclusions: Community participation and support for VHW activities and the transport systems have led to better care for pregnant women and sustained links between the communities and health facilities, which may reduce maternal and infant morbidity and mortality. (author's)
Handwashing with soap -- a new way to prevent ARIs? [editorial]
Does handwashing reduce the risk of acute respiratory infections (ARI) in developing countries? That is now a major question for public health research. In the face of such significant grounds for hope, the recent decision by the UK Medical Research Council (MRC) not to fund a randomized controlled trial to answer which had passed its initial selection procedures, seems bizarre. As the trial funds are ring-fenced, it cannot be explained by the MRC’s current cash crisis. Fortunately, another trial is under way. Unfortunately, it is funded by a soap manufacturer, but the preliminary results are promising. If, as is to be hoped, that trial confirms that the promotion of handwashing in poor communities can significantly reduce the risk of ARIs, then we may at last have an explanation for the Mills–Reinicke phenomenon: that water supplies improve hand hygiene and reduce child mortality not only from diarrhoea but also from respiratory infections. We may also have in our hands an intervention which allows us to reach the millennium development goal of reducing child mortality by 2015. (excerpt)
Pentoxifylline adjunct improves prognosis of human cerebral malaria in adults.
Fifty-two adult patients with cerebral malaria were randomly categorized into two groups to receive either quinine dihydrochloride (Qn) alone or a combination of Qn and pentoxifylline (Px). Thirty-two of them received intravenous (i.v.) Qn (group I), and 20 patients (group II) received i.v. Qn along with parenteral Px support (10 mg/kg/day) for the initial 3 days. There was significant improvement in coma resolution time in group II (21.6 ± 13.9 h) in comparison with group I (63.5 ± 19.7 h) (P < 0.001), and mortality was 25% of patients in group I against 10% patients receiving Px adjunct (P > 0.05). Three days post-therapy, serum tumour necrosis factor-a (TNF-a) levels decreased significantly in patients on Px support (day 0 TNF = 415.62 ± 477.80 pg/ml; day 3 TNF = 47.92 ± 27.9 pg/ml; P = 0.0029). There was no significant change in TNF levels in those on quinine alone (day 0 TNF = 477.08 ± 933.90 pg/ml; day 3 TNF = 589 ± 602.3 pg/ml; P > 0.05). There were no serious side-effects necessitating withdrawal of patients receiving Px therapy. (author's)
Objectives: To assess malaria-related knowledge, attitude and practices (KAP) among primary caregivers, to identify associations between primary caregivers’ characteristics and positive KAP towards malaria, and to identify independent predictors of childhood malaria incidence in an urban setting. Methods: Children aged 6 months to 5 years living in Kampala, Uganda were enrolled as part of a longitudinal study on antimalarial therapy. Primary caregivers of 307 children were interviewed and information was collected on demographics, malaria-related KAP, environmental and household factors. Malaria incidence was measured prospectively using passive surveillance. Results: A total of 90% of respondents reported mosquitoes and/or malaria as the cause of fever. Caregivers reported that if their child had fever, 63% would go to a clinic or hospital as their first action and 97% as their first or second action. Only 38% knew that chloroquine was the recommended firstline treatment for malaria and 29% knew the correct dose. Preventive measures for malaria were reported in 45% of households but only 25% reported using bednets. Higher levels of education for the caregiver were associated with positive malaria-related KAP. Malaria incidence varied widely. The following were independent predictors of malaria incidence: (1) Children aged 24–41 months at enrolment had a higher incidence of malaria. (2) Reported bednet or chemoprophylaxis use reduced the incidence of malaria. (3) A child’s place of residence was associated with incidence. (4) Children from households using open water sources had a higher incidence than those using closed sources. Conclusion: Primary caregivers were knowledgeable about malaria and used modern health care facilities but knew less about the proper administration of antimalarials and had limited use of preventive measures. Malaria incidence was associated with child’s age at enrolment, geography, source of water and the use of preventive measures. (author's)
This document recommends that health care providers treating immigrants or refugees should consider the patient’s cultural identity including: assessment of ethnicity, language, migration history, degree of acculturation, premigration history, degree of loss, work and financial history, and support systems.
It is important to note that there may be many reasons that it may be difficult for patients to talk about sexuality. Most people are not raised to discuss sexual matters openly. Children are often taught that it is not permissible to talk about sexuality or discuss sexual body parts. When sexuality is taught, it is frequently taught in negative terms. Even when patients are clearly sexually active, sexual health issues are frequently not discussed. Research suggests that communication between health care providers and patients can improve sexual health, and has been correlated with increased condom use, while lack of communication about sex is a risk factor for HIV and STDs. “Sexual health is a legitimate and significant component of medical practice. Providers should assess the sexual health status and sexual health needs of patients as an essential part of routine care.” (excerpt)
There are many barriers to abortion provision with respect to both obtaining abortion care and providing abortion services. Health care providers should be aware of the barriers women may face when seeking comprehensive reproductive health services. (excerpt)
Social marketing is used to promote a range of health products, services and messages. These include insecticide-treated bed-nets for malaria control, water treatment for the prevention of water-borne diseases, oral rehydration solution for the treatment of diarrhoea, child immunisation services and micronutrients to help prevent childhood diseases, iodised salt to help prevent mental retardation, safe birthing kits, promotion of proper breast feeding and nutrition practices in maternal and child health education, sexually transmitted infection treatment kits, and voluntary HIV counselling and testing. The focus of this review is on the social marketing of modern methods of contraception for family planning, and condoms for STI/HIV prevention and control. (excerpt)
Indigenous South East Asian herbal remedies: symptomatic relief for people with HIV / AIDS.
By tapping into local knowledge of South East Asian indigenous plants with medicinal value, herbal remedies have been incorporated in the treatment of common symptoms and minor opportunistic infections among PWHAs. Modern medicines are often expensive, thus not accessible to many people, and sometimes associated with undesirable side effects. Besides providing symptomatic relief with fewer side effects than many modern medicines, indigenous plants are also effective nutritional supplements. Simple preparations and self-production by PWHAs, or in cooperation with a pharmacist or health care provider, enables self-reliance and avoidance of deceitful commercial sales or other misuses. This option has been applied to AIDS affected people at Mae Chan hospital, in Mae Chan district, Chiang Rai province, Thailand. The Thai Ministry of Health has promoted the use of Thai herbs in hospitals for common symptoms, such as cough and constipation, since 1978. In 1985, Mae Chan hospital produced and utilized Thai herbs in a clinical setting, and in 1996, the day care center supported PWHA groups in the production of Thai herbs for self-care, income generation and group activity. The plants described in the following pages have been used successfully in the treatment of opportunistic infections at Mae Chan hospital. Many of the plants have been internationally recognized for their medicinal properties and are undergoing further research into their application in modern medicine. However, the information provided here aims to promote self-care and treatment, not to provide cures. (excerpt)
Transfer of learning: a guide for strengthening the performance of health care workers.
The goal of a health care delivery site is to provide quality services to a community. The clinical knowledge and skills of a site’s staff are a critical factor in establishing and sustaining quality services. However, there are many other factors in the work environment that can directly or indirectly affect the quality of services and influence the ability of providers to apply their knowledge and skills in the services they offer. The primary purpose of this guide is to share strategies and techniques that can be used before, during, and after training interventions to ensure support for the transfer of knowledge and skills to improved performance on the job. The strategies and techniques for transferring learning are presented in an easy-to-use matrix that serves as a table of contents for the rest of the document. We have also included a brief introduction to the many performance factors that can play important roles in the transfer of learning. Users of this guide are encouraged to examine their work environments carefully in order to fully understand all the factors that may be affecting worker performance. A case story on page 7 illustrates several of the performance factors and demonstrates how to implement some of the ideas shared in the matrix. The information in this guide enables all of the stakeholders involved in a training intervention to play their respective roles in ensuring that transfer of learning occurs. Stakeholders in the training and learning process may include policy makers and officials at national, regional and local levels, program planners, supervisors, trainers, learners and their co-workers. For learning interventions to be successful, stakeholders must work together as partners with a common goal. While this guide outlines specific actions for supervisors, trainers, learners and their co-workers, other stakeholders can also use this information to gain an appreciation of the process and an understanding of the support and resources needed to ensure transfer of learning. (excerpt)
Objective: To identify the palliative care needs of terminally ill people in Uganda. Design: Descriptive cross sectional study. Setting Home care programmes in and around Kampala that look after terminally ill people in their homes. Participants: 173 terminally ill patients registered with the home care programmes. Results: Most of the participants had either HIV/AIDS or cancer or both; 145 were aged under 50 years, and 107 were women. Three main needs were identified: the control or relief of pain and other symptoms; counselling; and financial assistance for basic needs such as food, shelter, and school fees for their children. The preferred site of care was the home, though all these people lived in urban areas with access to healthcare services within 5 km of their homes. Conclusion: A “good death” in a developing country occurs when the dying person is being cared for at home, is free from pain or other distressing symptoms, feels no stigma, is at peace, and has their basic needs met without feeling dependent on others. (author's)
Quality care at the end of life in Africa.
Each year about 0.5% of the total population in Botswana, Ethiopia, Tanzania, Uganda, and Zimbabwe die from HIV/AIDS or cancer. The members of a WHO project to improve palliative care in these countries discuss their work. The greatest needs of terminally ill patients were for adequate pain relief, accessible and affordable drugs, and financial support to counter the loss of income of both patient and family caregiver. Special emphasis should be given to home based palliative care provided by trained family and community caregivers to counteract the severe shortage of professional healthcare workers. (author's)
TRIPS: whose interests are being served?
Developing countries are facing a health crisis on a massive scale. Improving access to effective and affordable medicines is a necessary element in a wider strategy that could reverse the rising trend of high mortality and morbidity from infectious and non-communicable diseases. However, the implementation of the World Trade Organisation’s agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) threatens to undermine access to effective new medicines. TRIPS extends patent protection on new products, and on the processes by which drugs are made, for a minimum of 20 years. Patent rules will no longer be adaptable to national circumstances, but will apply globally. This measure will delay the availability of cheaper generic alternatives to recently developed products, and thus undermine price competition, a vital mechanism for lowering prices sustainably. (excerpt)
With a pledge to give greater priority to HIV/AIDS and achieving results in poor countries, South Korea’s Jong-wook Lee took office as the new Director-General of WHO on July 21. “We must scale up an integrated global HIV/AIDS strategy linking prevention, care, and treatment, prioritising poor and underserved areas”, said Lee in his inaugural address to about 500 WHO staff at the organisation’s Geneva headquarters. (excerpt)
Europe refuses to match US cash for ailing Global Fund.
The international meeting to support the Global Fund to Fight AIDS, Tuberculosis, and Malaria—held on July 16 in Paris—ended without firm commitment from the European Commission (EC) to provide new money to the Fund. The letdown by the Europeans was compounded by the Fund’s announcement that it had a significant funding shortfall, estimated to be at least US$350 million for this year alone. (excerpt)
Resistance to antiretrovirals is a growing concern.
In the largest study of its kind to date, the 17-country CATCH study—combined analysis of resistance transmission over time of chronically and acute infected HIV patients in Europe—examined the prevalence of drug resistance mutations among 1633 patients. The team found that 9·6% of treatment-naive patients were resistant to any antiretroviral; 7·1% of isolates were resistant to nucleoside reverse transcriptase inhibitors; 2·7% of cases were resistant to non-nucleoside reverse transcriptase inhibitors; and resistance to protease inhibitors was seen in 2·3% of patients; and 1·8% were multidrug resistance. (author's)
Feeding risk cut for HIV-infected women.
Short courses of antiretrovirals given to pregnant HIV-1 positive women and their infants during breastfeeding, reduced the risk of vertical transmission, said Ugandan researchers at the AIDS society conference on treatment and pathogenesis in Paris, on July 13–16. Joseph Vyankandondera, principal investigator from the Centre Hospitalier de Kigali, Rwanda, told delegates that the study showed a drastic reduction of postnatal transmission from 15% to 1% in the first 6 months of life. “These are the first data to show that you can safely breastfeed children, even if they are HIV positive”, he said. (excerpt)
Knowledge into action for child survival.
The child survival revolution of the 1980s contributed to steady decreases in child mortality in some populations, but much remains to be done. More than 10 million children will die this year, almost all of whom are poor. Two-thirds of these deaths could have been prevented if effective child survival interventions had reached all children and mothers who needed them. Translation of current knowledge into effective action for child survival will require leadership, strong health systems, targeted human and financial resources, and modified health system to ensure that poor children and mothers benefit. A group of concerned scientists and policy-makers issues a call to action to leaders, governments, and citizens to translate knowledge into action for child survival. (author's)
Can health programmes lead to mistreatment of sex workers? [letter]
I fully admire the Network of Sex Work Projects (NSWP) for trying to protect the rights of sex workers. However, I ask that they direct their efforts accordingly—to mistreatment of sex workers, which is not a component of the 100% Condom Use Programme (CUP). The Network should promote the 100% CUP in such a way that the sex workers are more involved. (excerpt)
Can health programmes lead to mistreatment of sex workers? [letter]
Bebe Loff rightly draws attention to the importance of regarding sex work as an occupation rather than as a type of behaviour. This approach is essential in our projects that promote health among sex workers in Antwerp, Brussels, and Ghent, in Belgium. We consider the sex worker as someone who is occupationally exposed to certain diseases, just as a doctor or a nurse could be regarded as at risk of exposure to hepatitis B virus, HIV-infection, or other blood-borne infections. (excerpt)
Asia-Pacific and the millennium health targets [letter]
Despite well documented and successful HIV-prevention programmes in a few countries, the HIV/AIDS epidemic continues to spread in Asia and the Pacific. Moreover, without wishing to detract from the achievements of Cambodia and Thailand, recent developments show that success might be relative. Despite well funded, comprehensive programmes, one in every 100 people in Thailand is infected with HIV, and AIDS has become the leading cause of death in that country. Now is hardly the time to divert much-needed political commitment for confronting the major microbial killers. The diluted sense of urgency about tackling these diseases in the UN report’s sections on policy discussion can be attributed to flawed assumptions underlying the progress analysis. HIV/AIDS and tuberculosis pose clear and present danger to development in the Asia-Pacific region. The UN’s high-profile report is making its way toward the desks of the policy makers in the region. The public-health community has the duty to set the record straight and protect public-health interests. (excerpt)
Free retroviral drugs could save up to 1.7 million South Africans.
By offering free antiretroviral drugs to the six million people with HIV/AIDS who can’t afford them the South African government could save or prolong the lives of about 1.7 million people, a new study says. The study was commissioned by the ministers of health and finance in the South African government, but its results were leaked this week by the Treatment Action Campaign, frustrated by the government’s lack of action. (excerpt)
At the United Nations Special Session on Children in May 2002, nations committed themselves to a visionary and concrete action plan to build “a world fit for children”. With more than 100 million children, the 27 countries of Central and Eastern Europe and the Commonwealth of Independent States have a vital role to play in achieving this global goal. This year’s Innocenti Social Monitor looks at the CEE/CIS region with this global goal in mind. It tracks some key dimensions of child welfare and includes a special feature article on infant mortality. The research finds that, in several countries, the number of infant deaths is considerably higher than official figures suggest, that methods used to count births and deaths are inconsistent with best international practice, and that standards of care for pregnant women and infant children are often poor. Reducing infant deaths dramatically is an urgent priority not only in the region, but worldwide. A healthy start for mother and baby is essential to the responsible care and protection of the child. Overall, political stability has been regained in the region, and economic reform is advancing. Armed conflict has been greatly reduced, and living standards are rising. However, the residue of the damaging trends remains. It is evident in the faces of the large numbers of children in the region living in poverty, in institutions because they lack parental care, or as refugees and displaced persons. Improving conditions for these children is a pressing concern. States need to act decisively and firmly on their responsibilities for upholding the human rights of each and every child. There already exists a comprehensive and coherent set of international agreements to guide our collective action. Standing as a major outcome of the Special Session on Children, A World Fit for Children sets a global agenda for the current decade. It provides a contribution to the broader United Nations Millennium Development Goals, the targets of which embrace the reduction of poverty, HIV/AIDS and child mortality. It is incumbent upon States to live up to these commitments. Above all, it is critical that they steadily pursue the effective implementation of the Convention on the Rights of the Child, if we are to build the safe and nurturing world children need and have a right to claim. The Innocenti Social Monitor offers valuable data, analyses and insights on social trends, policy directions and practices in the CEE/CIS region. At UNICEF, we trust that this year’s report will further help decision makers and children’s advocates find the best route forward in building “a region fit for children”. (excerpt)
HIV and infant feeding counselling: a training course. Trainer's guide.
There is now an urgent need to train health workers in MCH and primary care settings to counsel women about infant feeding according to these guidelines. Infant feeding counsellors are needed, who have the skills to enable HIV-positive mothers to make a fully informed decision of infant feeding method; to support them in their decisions; and to counsel mothers who are HIV negative or of unknown HIV status about breastfeeding. HIV and Infant Feeding Counselling: A training course (HIVC) has been developed in response to this need. The materials are designed to make it possible for trainers with limited experience of teaching the subject to conduct up-to-date and effective courses. (excerpt)
Women for Conflict Prevention and Peace Building in the Southern Caucasus has five core objectives: Mobilizing and building the capacity of women and civil society to contribute to peace and prevent conflict. Strengthening the capacity of local NGOs to assist refugees and internally displaced persons. Building a popular culture of peace through public education Campaigns. Developing and strengthening mechanisms for dialogue between parties in actual or potential conflict. Encouraging change in current attitudes, rules of law and norms of diplomacy and international cooperation. (excerpt)
This paper provides a brief discussion of the current approaches in treating international migration as an emerging social development issue that merits attention in the post-Copenhagen Declaration years, with special emphasis on changing demographic dynamics and their implications for social development in the ESCAP region. An analysis is made of the key trends, including: (a) push factors that propel migrants away from their home countries; (b) pull factors that attract migrants to receiving countries; (c) social/ economic barriers that hinder or factors that facilitate migration in the region; and (d) the socio-economic consequences of migration for countries of origin, destination and transit. The paper highlights the consequences of irregular migration and its effects on trafficking in women and children. The paper also provides some policy options to develop effective national migration policies and suggests a regional framework for further cooperation on migration. (excerpt)
Population growth leveling off.
The growth of India's billion-plus population is slowing and southern parts of the country are approaching fertility rates close to those of European nations, according to a top official of the United Nations. However, this contrasts sharply with vast areas in the northern state of Uttar Pradesh and the eastern state of Bihar, where population growth is soaring and driving up the national average. (excerpt)
Peru moves away from birth control.
Women's advocates say Health Minister Fernando Carbone and Prime Minister Luis Solari are pushing their conservative Roman Catholic philosophy by promoting motherhood and cutting off free contraceptives and birth-control information to the poor. The government denies the accusations — and points to its efforts to make pregnancy safer — but the critics are not convinced. (excerpt)
Evidence for the ten steps to successful breastfeeding.
The “Ten Steps to Successful Breastfeeding” are the foundation of the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI). They summarize the maternity practices necessary to support breastfeeding. The purpose of this document is to review the evidence for the efficacy of the ‘Ten Steps’, and to provide a tool for both advocacy and education. It is hoped that policies and practices in future will be based on research rather than on conjecture and custom. (excerpt)
HIV and infant feeding counselling: a training course. Director's guide.
HIV infection among children is increasing, and in some countries is now one of the main causes of childhood death. In 90% of cases, children acquire the infection from their mothers, before or during, or after delivery through breastfeeding. This is called mother-to-child transmission (MTCT), or vertical transmission. Avoiding breastfeeding is one of the ways to reduce the risk of MTCT or HIV. Recent research has shown more precisely the time at which HIV is passed from a mother to her infant. However, there are still many uncertainties, one of the most important being the extent to which the quality of breastfeeding, whether exclusive or mixed, and the condition of the breasts, affects the risk of transmission. Great efforts have been made in recent years to promote breastfeeding by all mothers. There are considerable risks associated with not breastfeeding, particularly in resource poor settings. This has resulted in both policy makers and health workers being reluctant to suggest that a woman feed her infant in any other way. Accordingly, it has been difficult for health workers to advise HIV-positive women how best to feed their infants. It is perhaps even more difficult for a mother and her family to decide what is best, and women need accurate information and counselling to enable them to decide. In 1997, WHO, UNICEF and UNAIDS issued a joint policy statement, indicating that HIV-positive women should be enabled to make a fully informed decision about feeding their infants, and supported to employ the method of their choice. By 1998, it was known that the use of anti-retroviral drugs could substantially reduce the risk of mother-to-child transmission before and during delivery, and it became more urgent to find ways to reduce the risk of post-natal transmission through breastfeeding. Guidelines developed in 1998 set out several feeding options to suggest to HIV-positive women, including breastfeeding in the usual way, breastfeeding exclusively and stopping early, and the use of replacement feeds such as commercial or home prepared formula. The guidelines also emphasised the need to protect, promote and support breastfeeding for those who are HIV-negative or untested, and to prevent any spillover of artificial feeding to infants of uninfected mothers. There is now an urgent need to train health workers in MCH and primary care settings to counsel women about infant feeding according to these guidelines. Infant feeding counsellors are needed, who have the skills to enable HIV-positive mothers to make a fully informed decision of infant feeding method; to support them in their decisions; and to counsel mothers who are HIV negative or of unknown HIV status about breastfeeding. HIV and Infant Feeding Counselling: A training course (HIVC) has been developed in response to this need. The materials are designed to make it possible for trainers with limited experience of teaching the subject to conduct up-to-date and effective courses. (excerpt)
In his report to the Global Alliance for Vaccines and Immunization (GAVI) Board meeting being held at the World Bank, Executive Secretary Dr. Tore Godal reported that well over 30 million children have benefited already from the nearly $250 million in new vaccines and funding for infrastructure disbursed so far from GAVI and The Vaccine Fund. Approximately 30 million more of the world's children are now protected against hepatitis B, 4.3 million children are now protected against Haemophilus influenzae type b (Hib) and 1.6 million children are now protected against yellow fever. (excerpt)
Applying social franchising techniques to youth reproductive health / HIV services.
This Youth Issues Paper examines what role social franchising might have in expanding reproductive health and HIV services for youth. Steve LaVake, who coordinates private-sector programming for YouthNet, developed this paper based on a review of the literature on social franchising, visits to five programs that involve some aspect of social franchising for youth, and conversations with experts in the field. Chapter 1 addresses how social franchising techniques might be applied to meeting the needs of youth. Chapter 2 summarizes the research available in the still-new field of social franchising. Chapters 3 through 6 describe four types of social franchising models for youth: joint venture, community, private provider, and governmental. The models overlap and are not mutually exclusive. Case studies of the five programs visited by the author illustrate how these models have been put into practice. Chapter 7 offers observations and suggestions for next steps in the field of social franchising and youth. (excerpt)
Learning from each other. HIV and disability.
Anyone - disabled or not - can become infected with HIV if he or she is exposed to the virus. However, although there are no figures for how many disabled people have HIV, they may be much more vulnerable to infection because of their circumstances. For example, it is often assumed that disabled people do not have sexual feelings or cannot be sexually active, and therefore do not need to know about safer sex. (excerpt)
Disability and impairment. HIV and disability.
HIV-related illnesses can lead to temporary impairment, such as being unable to walk. They can also lead to permanent impairment, such as difficulty in seeing because of eye conditions. People with HIV, even when they are healthy, are also discriminated against which makes it more difficult to find jobs or feel accepted by their community. This treatment by others can 'disable' them. (excerpt)
Do you know how to say "safer sex" in sign?
Maybe the search for an effective HIV/AIDS education campaign for the Deaf is the task that everybody has been waiting for. I would like to see it used as a door for educators, scientists and social researchers to immerse themselves in the Deaf world and to see how wonderfully unique this place is. More than that, it would be an opportunity to assure the Deaf although they are a minority, this is as much their world as it the hearing. (excerpt)
Talking about sex and disability.
Carers, families and health workers often focus on disabled people's physical needs and ignore sexual and emotional health. It can be especially difficult for a person with impaired speech or a learning difficulty to talk about their concerns. A good listener and counsellor is someone who can make people feel relaxed and 'safe', use clear, simple language, avoid being judgmental, and have a good basic knowledge of sex, contraception, HIV and sexually transmitted diseases (STDs). Disabled people themselves, and also health workers, teachers and carers, have an important role to play in discussing these issues. (excerpt)
Keeping safe, feeling healthy. Life skills education.
All too often young disabled people are treated with pity or misplaced sympathy, or, even worse, their needs are ignored altogether. This is especially true for people with learning difficulties. Adults normally make the decisions which affect these young people's relationships, sexuality and bodies. (excerpt)
Learning disability, sexuality and HIV / AIDS.
In many Asian cultures, sexuality is not openly discussed. The sexuality of persons with disability, whether physical or intellectual, is an even greater taboo. In reality, people with disability are also sexual beings. More disturbing is that they are more vulnerable to sexual exploitation due to power imbalances in their sexual relationships, the non-disabled over the disabled, the men over the women. This also increases their risk of contracting HIV. (excerpt)
Check your attitudes. Training activity.
It is often difficult to talk about sexuality and relationships. We have our own beliefs about what is 'right' and 'wrong' and may feel awkward discussing this in public. This activity uses pictures of different people to encourage discussion about common assumptions and to explore whether these are true or not. It allows us to discuss our beliefs without having to disclose personal experiences. (excerpt)
Health workers and educators need to understand what influences people's attitudes to sex. They may need to improve their skills in discussing sensitive issues. People's attitudes to sex and their existing knowledge may be very different from yours. It is important to find out about these and avoid making assumptions. (excerpt)
Reproductive tract infections (RTIS) fall into three groups: sexually transmitted infections (STIs), such as HIV, gonorrhoea, syphilis, chancroid, chlamydia, pelvic inflammatory disease (PID), genital herpes and genital warts, which are spread by bacteriaor viruses during vaginal or anal sex. Gonorrhoea, syphilis and genital herpes can also be spread by oral sex. There is some evidence that HIV can also be spread by oral sex. Bacterial infections that result from changes in the body during menstruation, illnesses such as diabetes, pregnancy, or use of medicines such as antibiotics. These include candida (thrush) and bacterial vaginosis (trichomoniasis or trich). Bacterial infections that result from medical interventions such as insertion of IUDs, internal examinations, or during birth. (excerpt)
Preventing unwanted pregnancy and infection.
People wishing to prevent unwanted pregnancy and HIV/STIs need: information about what contraceptive methods are available, including traditional methods, how they work and possible side effects; information about HIV and STIs, so that they can assess their risk and decide how to protect themselves; information on how and why to use condoms and possibly another contraceptive method also, and support to continue using them; a regular supply of contraceptives, including condoms; the opportunity to change contraceptive methods if they wish; and counselling and medical attention if contraceptives fail or produce side effects. (excerpt)
Uganda: establishing adolescent-friendly services.
Sarah—a teenager in Uganda’s Jinja District—watched three of her friends drop out of school in 1998 when they became pregnant. As a “disco kid” she was at risk of finding herself in a similar predicament, yet her mother had told her very little about sexuality or contraception and she had received only a stern lecture from the provider on her one attempt to seek information at the local health center. When she returned to the clinic the next year she was surprised by what she found—a non-judgmental provider eager to help and advise her on family planning methods and reproductive health issues. Thanks to this change, Sarah’s mother, Florence, has become an advocate for offering these health services to adolescents and has joined the health center’s management committee. (excerpt)
Senegal. Breakthrough conference on postabortion care in Francophone Africa.
Over the four days of the conference, speaker after speaker rose to emphasize the urgency of the risk to the lives of women who are endangered by the lack of access to quality PAC services. They also highlighted the importance of linking PAC with family planning to prevent repeat unwanted pregnancies, and with other reproductive health services. The key roles of primary providers and communities were also singled out in proposed interventions. (excerpt)
Rwanda. Keeping newborns HIV-free.
Already in labor when she arrived at the hospital in Kibuye, a village on Lake Kivu in western Rwanda, Athanasie became the first client served by the maternity ward’s new program for the Prevention of Mother-to-Child Transmission (PMTCT) of HIV. The program offered her voluntary counseling and testing for HIV/AIDS from a specially trained nurse; after she learned that she was HIV-positive, Athanasie accepted nevirapine treatment for herself and her baby. The PRIME II Project has launched the PMTCT program to help stem Rwanda’s estimated 11% rate of HIV infection. IMPACT/Family Health International (FHI) and the Treatment and Research AIDS Center (TRAC) collaborate with PRIME on the initiative, which is being implemented at Kibuye and Byumba Hospitals. In addition to training nurses in counseling skills and teaching them how to administer nevirapine to mother and baby, the program trains lab workers to perform the HIV tests. PRIME works to enhance supportive supervision for these primary providers, proposes organizational changes at the hospitals to improve prenatal and obstetric care, and develops postpartum care including psychosocial support and nutrition for seropositive mothers. (excerpt)
Kenya. Linking family planning with postabortion care.
For Milka Mathea, a nurse-midwife at the Jamii Medical Clinic in Namanga, Kenya, offering family planning counseling and methods to the women she treats for complications of unsafe or incomplete abortion has become a normal part of interacting with her clients. By providing family planning services she can help women prevent future unwanted pregnancies, practice birth spacing, and reduce the risk of maternal mortality and morbidity. Mathea is one of 230 private-sector nurse-midwives trained in postabortion care (PAC) by the PRIME II Project since 1999. Working in primary-level clinics, health centers and dispensaries in three of Kenya’s seven provinces, these nurse-midwives reach underserved Kenyan women from rural marketplaces to the densely populated outskirts of Nairobi. Sponsored by Kenya’s Ministry of Health, the program is funded by USAID and supported by the Nursing Council of Kenya, which licenses the nurse-midwives, and the National Nursing Association of Kenya, a professional organization. (excerpt)
India. Supportive supervision for auxiliary nurse-midwives.
Rajabeti, an Auxiliary Nurse-Midwife in the Firozabad district of Uttar Pradesh, India, was nervous and couldn’t pass her first follow-up examination after IUD insertion training as part of the Innovations in Family Planning Services (IFPS) Project. Her supervisor, Kusma Devi, a Lady Health Visitor, promptly invited her to the Usaini Primary Health Center and provided additional guided practice. When the follow-up team returned again to Firozabad, Rajabeti met them with confidence and inserted two IUDs without hesitation, scoring 85% on her skills test. Rajabeti and Kusma Devi illustrate the role that supportive supervision plays in ensuring transfer of new skills to the work site. This transfer is an integral element of the IFPS Project, which has been implemented by the State Innovations in Family Planning Agency, an autonomous organization formed by the Government of Uttar Pradesh and funded by USAID. PRIME II provides technical assistance to IFPS, including design of interventions that improve supportive supervision. (excerpt)
El Salvador. Young mothers' clubs promote reproductive health.
As part of an effort to develop an adolescent-friendly approach to reproductive health care, the PRIME II Project has helped maternity hospitals in three rural districts of El Salvador to form young mothers’ clubs in which pregnant adolescents learn how to knit. Enabling young women to make clothes for their babies, the clubs also provide a forum where nurses and doctors can discuss reproductive health issues with the adolescents and answer their questions. The goals of the clubs—in addition to healthy deliveries and well-swaddled infants—include the prevention of future unplanned pregnancies and sexually transmitted infections and the promotion of birth spacing. For the majority of participants, the clubs provide the first education in sexual and reproductive health they have ever received. (excerpt)
El Salvador. Community health promoters provide family planning.
Lichita, a health promoter in rural El Salvador, reaches out to women with advice on family planning as part of her commitment to provide basic health services and referrals. The people she visits are those with the fewest resources and most limited access to physicians and hospitals in the country. One of 1,755 promoters working for El Salvador’s Ministry of Health, Lichita is responsible for 2,500 residents of the canton of Borbollon, El Taurito in the department of San Miguel. Along with a focus on family planning counseling and methods, promoters provide immunizations and offer advice on maternal health, prevention and management of acute respiratory infections and diarrhea, and water and waste management. They also coordinate the work of parteras, traditional birth attendants whose services are vital in a country where 57.3% of rural births occur in the home. The frontline role of promoters and parteras is more critical than ever as El Salvador rebuilds its infrastructure and health care system in the aftermath of devastating earthquakes that struck early in 2001. (excerpt)
Ghana. Self-directed learning strengthens bonds between midwives and adolescents.
For this 17-year-old Ghanaian adolescent, a midwife’s ability to provide both emergency postabortion care and non-judgmental counseling about sexuality and family planning provided key information and encouragement to avoid risky behavior and unplanned pregnancy in the future. The midwife who treated the young woman participates in a PRIME II pilot program to improve the quality and accessibility of adolescent reproductive health services by strengthening the relationships between private-sector nurse-midwives and their adolescent clients. Launched in 1999, the program is a joint effort of the Ghana Registered Midwives Association (GRMA) and PRIME II. The program relies on PRIME’s innovative self-directed learning course, which combines self-paced individual instruction, peer support, and periodic facilitated group learning sessions that allow nurse-midwives to gain new skills without leaving their clinics for extended periods of time. Sixty midwives from the regions of Brong Ahafo, Eastern and Ashanti participated in the course in 1999; then the program—with an additional module on HIV counseling and testing—was extended to another 60 midwives in 2001. (excerpt)
Dominican Republic. Community mapping in Bateyes.
Altagracia Feliciano, a health promoter in Batey Esperanza, Dominican Republic, recently participated in a community mapping exercise conducted by the PRIME II Project as part of a new reproductive health program in the country’s bateyes. Home to former sugar cane workers displaced when the industry was privatized, the bateyes are characterized by substandard living conditions. Mapping the houses in the seven bateyes where PRIME II will work was an integral component of baseline activities for the future evaluation of the program. The maps will also be used to designate which households will be served by each of the health promoters who will be trained through the intervention. But for Ms. Feliciano and the other promoters, who drew the first versions of the maps with technical assistance from PRIME, the maps quickly assumed broader significance. Provincial agencies involved in delivering a variety of services are interested in using the maps, and mayors and community officials have requested copies. (excerpt)
India. Supervising and training the village dais.
The PRIME II Project, under the direction of USAID/New Delhi, provides technical assistance to the State Innovations in Family Planning Services Agency by training master trainers from carefully selected nodal agencies in each district, and then following up with them as they conduct skills-based training sessions for the Auxiliary Nurse-Midwifes (ANMs). The ANMs, in turn, supervise and train the dais in their district. PRIME facilitates this unique private-public sector collaboration, builds institutional capacity, and supports the cooperative efforts of the local agencies, district health administration, ANMs and dais. Striving to improve prenatal care, delivery skills and postpartum family planning in ten districts of Uttar Pradesh, PRIME brings assistance in developing curricula, strategies and proposals; offers technical input for training and mentoring; and strengthens the process through all stages of program implementation. (excerpt)
Birth-rate policies whip-saw women in Peru.
After forced sterilizations under Fujimori, Peruvian women now face coercive Toledo programs to increase the birth rate. Such extremes are dangerous for women, who deserve control over their health and reproductive destiny. (excerpt)
Lack of consensus characterizes Philippine population policy.
A review of policies shows that there had been a lack of stable consensus on the Philippine government’s policy on population growth and fertility reduction that continues to this day. The national family planning program has been characterized by shifting objectives of fertility reduction, upholding of reproductive rights, and promotion of maternal health. This lack of policy consensus had slowed down Philippine fertility transition as evidenced in the fact that the country’s fertility decline has been the slowest compared to neighboring countries such as South Korea and Thailand. As a result, the Philippines did not have the advantage of a more favorable age distribution (the so-called demographic bonus) that these countries had which contributed to their sustained economic growth and higher standards of living. Given the controversial nature of the issue of population growth, there is a need for clear statements of policy. There are several views that could be taken with respect to fertility and population growth reduction, and several possible objectives for the family planning program. The government must state clearly what its position is with respect to these alternatives and then forge a stable consensus on the path to be taken. (excerpt)
HIV / AIDS and STI prevention and care in Rwandan refugee camps in the United Republic of Tanzania.
Until recently, relatively little attention had been paid to HIV/AIDS care and prevention in the context of a humanitarian response. Traditional priorities in emergencies included the provision of food, water, sanitation, shelter and basic health services. Because of the long incubation period of HIV, the disease was not considered an immediate threat to life and was therefore not thought of as a ‘relief issue’. Factors (such as poverty, social instability and powerlessness), typically associated with conflicts and the forced displacement of people, were already known to exacerbate HIV transmission. Until the catastrophic Rwandan refugee crisis of 1994, however, there was little appreciation of how very significant these factors were. Before that date, no major specific interventions for HIV infection or for other sexually transmitted infections (STIs) had been designed for refugees. This monograph documents the first large-scale AIDS and STI intervention programme to be implemented during a refugee crisis. It describes the operational aspects of the intervention, the observed impact and the effect this experience had on policies and practices in other refugee situations, among both international and nongovernmental organizations. It provides insights into the elements and approaches for STI services that will be useful for reproductive health programme managers from government and international organizations as well as nongovernmental organizations involved in relief operations. It will also be useful for district or regional health managers in identifying needed support systems for STI service delivery. (excerpt)
Maternal care in India reveals gaps between urban and rural, rich and poor.
In West Bengal state (Calcutta is the capital), it is common to see women in labor traveling on the backs of open, three-wheel "cycle vans" over pot-holed roads to distant rural health centers. Many other women opt for home delivery, often under dangerously unhygienic conditions. By contrast, upper- and middle-class women in metropolitan areas spend thousands of rupees for delivery at private nursing homes. These women would not venture to the government hospitals in the city, where, at times, two mothers with newborns must share a single bed. These and other scenarios illustrate the lopsided nature of maternal care in India, where maternity-related complications are leading causes of death and disability among women of reproductive age. In this country of roughly 1 billion people, where women have, on average, about three children, some 440 women die of maternity-related complications for every 100,000 live births. The United Nations estimates that at current levels of fertility and mortality, one out of every 55 women in India faces the risk of maternal death, compared with one in 80 in Pakistan and one in 610 in Sri Lanka. (excerpt)
Conflict imperils Liberia's reproductive and child health programs.
War and conflict also place reproductive health programs at risk. These programs are critical in a country with high fertility and huge risks associated with childbearing. The maternal mortality ratio — 1,000 deaths for every 100,000 live births — is one of the highest in the world. The country is also one of the region's leaders in fertility, with the average number of children per woman close to seven. At current levels of fertility and mortality, one out of every 12 women in Liberia risks dying of complications of pregnancy or delivery, compared with one in 70 in South Africa, according to UN estimates. By contrast, in the developed world, a woman's lifetime risk of dying from maternal causes is one in more than 4,000. (excerpt)
Rwanda. Mutuelles increase access to improved services.
For many residents of Bungwe, Rwanda, family planning and reproductive health care has improved through participation in a community prepayment health insurance scheme, or mutuelle. By pooling their resources, all mutuelle members receive services at their designated health center. Encouraged by Rwanda’s Ministry of Health, mutuelles are designed to enhance the performance of primary health care providers while reversing the low usage of services, especially family planning and reproductive health care, a trend due in large part to widespread poverty. (excerpt)
Armenia: expanding the role of nurses and midwives.
PRIME II and the Ministry of Health are now using the national policy framework and national forum recommendations to plan interventions based on the Performance Improvement (PI) approach. A program blending self-directed learning and supervised clinical practica for nurses and midwives at 60 facilities in Lori Marz is designed to enable these primary providers to monitor healthy pregnant women, educate communities on the danger signs associated with pregnancy, and counsel postpartum women on the benefits of exclusive breastfeeding and the importance of family planning to avoid unwanted or mistimed pregnancies. A subset of midwives will undergo comprehensive training in normal labor and delivery. (excerpt)
With every passing year, prospects for population growth in the more developed and less developed countries grow more dissimilar. On this year’s Data Sheet, the total fertility rate (TFR) for the more developed countries is a mere 1.5, compared with 3.1 in the less developed countries—3.5 if outlier China’s large statistical effect is removed. But the passage of time, as well as the difference in fertility rates, is ensuring that the two types of countries can expect to continue to have different population sizes in the future. The decline in Europe’s fertility rates is not a recent phenomenon; those rates have been low for quite some time. As a result, there have been long-term changes to age distributions in Europe, and this “youth dearth” is now taking on a more significant role in the near certainty of population decline. (excerpt)
Afghanistan: women and reconstruction.
The establishment of an Interim Administration for Afghanistan during the Bonn talks in December 2001 was heralded as offering Afghan women a chance to claim their place in public life and participate in the country’s development after systemic exclusion under the Taliban. Creation of a Ministry of Women’s Affairs, the commitment of substantial donor assistance to programs targeting women, and, most critically, the return of women to universities, schools, and government offices all portended a new day. Lost in the initial euphoria, however, was attention to the critical factors that had made past reform on women’s rights unsustainable and to the task of identifying strategies for mainstreaming gender issues in the development process as a whole. Without a coherent policy regarding gender and development on the part of both the international community and the Karzai government, donor assistance is being channelled to projects likely to prove at most symbolic. The Ministry of Women’s Affairs is the logical vehicle for developing strategies to embed gender in the planning activities of the line ministries. It has, however, been hobbled by lack of professional capacity and a hierarchical structure that impedes collaboration between its departments. This stems in part from its absorption of a communist-era women’s association, whose vocational training mission is ill suited to current challenges. In the words of a gender specialist in Kabul, the ministry is “functioning as a relatively large NGO”. The steps needed to make it more effective include re-staffing to develop research, program development, and budgeting capabilities; creation of links between its departments; and establishment of health, education, and gender advocacy and training departments. (excerpt)
Needle sharing among southern Thai drug injectors.
Aim: To examine factors associated with needle sharing among injecting drug users (IDU) in southern Thailand. Design: Using a cross-sectional survey, 272 active IDU were interviewed about their socio-economic background, needle sharing and drug use patterns at six drug-treatment clinics in southern Thailand. Findings: Ninety-one per cent of IDU gave a past history of ever sharing injecting equipment: of these, 23% currently injected but did not share and 68% still shared. Only 5% of participants knew that bleaching needles could reduce HIV transmission risks. Recent needle sharing was correlated with number of IDU friends (OR 12.23; CI, 5.24–28.51), engaging in illegal jobs (OR 2.74; CI, 1.13– 6.67), being unable to use new needles at all times (OR 2.89; CI, 1.17–7.14) and believing that cleaning contaminated shared needles with at least plain water could reduce HIV transmission (OR 3.32; CI, 1.16–6.68). Conclusions: Our data suggest that AIDS prevention efforts should focus on approaches to reduce needle sharing. Needle exchange programs, HIV counseling and testing and bleach distribution may reduce levels of needle-sharing risks. (author's)
Indigenous peoples and poverty: the cases of Bolivia, Guatemala, Honduras and Nicaragua.
This paper addresses some of the most pressing issues for indigenous peoples in Latin America. It looks at the poverty situation of indigenous peoples in four poor countries in Latin America – Bolivia, Guatemala, Honduras and Nicaragua. Despite there being little or no disaggregated data for indigenous women and men in Latin America, it can easily be concluded that indigenous peoples are disproportionately represented among the poor. Governments and donors, however, have judged indigenous peoples to be poor without asking indigenous peoples themselves how they see their situation. It may be that measured within the economic parameters of mainstream society, indigenous peoples are among the poorest but the official Poverty Maps do not necessarily reflect the real poverty situation as perceived by indigenous peoples. In some cases, poverty indicators may even reflect a discriminatory disregard for indigenous values as such, whereby expressions of indigenous identity become an indicator of poverty. Due to the current political marginalization, indigenous peoples are largely absent from the planning, design and implementation of development policies and programmes that directly affect their lives and territories. This study explains some of the impacts of this marginalization and offers a path towards an inclusive system of development. This inclusivity is sorely needed – arguably more now than ever – given that international development cooperation is working closer and closer with recipient governments, based on a globalized mainstreaming of tools and methodologies. Development processes are based on national poverty reduction strategies that are oblivious to indigenous peoples’ perception of wealth and poverty, and of the steps that indigenous peoples would like to take to reduce their poverty. Indigenous peoples’ own notions of poverty go far beyond a simplistic understanding of poverty as lack of income; their rights and identities as distinct peoples are at the centre of their concepts of wellbeing and quality of life. Indigenous peoples’ views have been sought in the writing of this study. Studies have been made for the four countries and several themes have emerged as common to indigenous peoples across the region with regards to poverty and poverty alleviation. Following these, a series of recommendations have been designed to ensure that policies and programmes are drawn up with indigenous peoples’ full participation and consent. (author's)
U.N. will back entrepreneurs in bid to lift poor nations.
Nearly a decade after microfinancing took hold as a method of stimulating the growth of grass-roots private sectors in developing countries, the United Nations is beginning a new effort to support entrepreneurial efforts that could help lift countries out of poverty. Secretary General Kofi Annan said today that a new commission would work to eliminate the institutional, legal and cultural roadblocks that could inhibit the development of small and medium-size businesses in poor countries. (excerpt)
A fast-dimming bright spot on the AIDS map of Africa.
A year or so later, Angola has become a petri dish for new strategies to combat the disease, according to "AIDS Warriors," a no-frills documentary that focuses on the role of the Angolan military in both spreading and fighting the epidemic. The film, to be shown tonight on PBS stations as part of the "Wide Angle" series of programs on international issues, begins by noting that the army is the one functioning institution that survived the civil war. As a result, it is a crucial force in stabilizing and rebuilding the nation — and in educating Angolans about the threat posed by AIDS. Yet the military — in Angola as elsewhere in Africa — is also a dangerous carrier of the AIDS virus, along with truck drivers and others who contract the disease from prostitutes while away from home. As the soldiers return to their cities and villages after fighting in border areas for long stretches, many spread the disease to their wives and girlfriends. (excerpt)
A desperate global scavenger hunt to keep AIDS patients alive.
Aid for AIDS in Manhattan — a nonprofit group with branches in Italy, Spain and Switzerland — collects secondhand drugs after people with H.I.V. switch prescriptions, take a break from medications or die. Expanding on the informal hand-me-down approach employed by Dr. Annel and other doctors, the group passes these antiretrovirals to more than 500 people with H.I.V. throughout Africa, the Caribbean and Latin America. (excerpt)
National Health Accounts (NHA) is a tool designed to inform the health policy process. It aims to do so by providing policymakers with valuable information on the distribution of health funds within the system. NHA was introduced and implemented in a number of middle - and low-income countries in the mid- to late 1990s. As sufficient time has passed for NHA findings to penetrate the policy processes in these countries, this study sets out to determine if NHA has actually met its principal goal of contributing to evidence-based policymaking. The paper examines the policy impact of NHA in 21 developing countries from the Latin America and the Caribbean region, East and Southern Africa, the Middle East and North Africa, and the Asia Pacific region. The study describes how policymakers have used NHA and assesses the various factors and influences that determine the extent to which NHA impacts the policy process. It is hoped that lessons learned from this study can help other countries as they move forward with efforts to inform health policymaking using health expenditure information. (author's)
Objective: To determine the extent and causes of iodine deficiency among women during pregnancy and lactation in the southeastern plains of Nepal. Design, Setting and Subjects: Urinary iodine (UI) was assessed as an indicator of iodine status in spot urine samples of women participating in a field trial in three rural communities in the plains of southeastern Nepal. Samples were collected during pregnancy (n=1021) and during lactation at 3–4 months postpartum (n=1028) at a central clinic; 613 women were assessed at both times. Salt iodine (SI) content was assessed semiquantitatively at 6–7 months postpartum in households (n=1572). Results: During pregnancy and lactation, median UI concentrations were 0.756 and 0.483 mmol/l, respectively, indicating mild iodine deficiency. UI and SI concentrations covaried markedly by season and were highest during hot, dry, premonsoon months and lowest during and following the humid monsoon season. Within women who contributed urine samples during both pregnancy and the postpartum period, iodine status determined by UI was not correlated. The percentage of households with adequately iodized salt (30 ppm) ranged from 85 to 44% from the hot, dry to the humid seasons, respectively. Conclusions: In the rural southern plains of Nepal, iodine deficiency remains a mild-to-moderate public health problem among pregnant and lactating women despite the availability of iodized salt. Marked seasonality in SI content may account for the lack of intraindividual correlation between maternal iodine status during pregnancy and postpartum periods and contribute to periodicity in the risk of iodine deficiency. (author's)
Honduras. Epidemiological fact sheet on HIV / AIDS and sexually transmitted infections. 2000 update.
This document presents HIV/AIDS and sexually transmitted infection statistics from Honduras in these areas: general country information; estimated number of people living with HIV/AIDS; assessment of epidemiological situation; HIV sentinel surveillance; maps of HIV sentinel sites; reported AIDS cases; curable sexually transmitted infections (STIs); health service indicators; and knowledge and behaviour.
Physical activity and self-esteem in girls: the teen years.
This article reports on the second phase of a study on the relationship between physical activity and self-esteem in girls that Melpomene has undertaken over the past two years. Our goal is to answer the question "Does the positive relationship between physical activity and positive self-esteem that exists for women exist for girls as well?" Additionally, through our conversations with the girls in this study, we hope to gain insight into some of the factors that are associated with diminished self-esteem in girls and the reasons they choose to drop out of sports. The second phase of this study involves girls between the ages of 12 and 17. In our research on younger girls aged nine to 12, we found a strong relationship between physical activity and self-esteem, as reported in the Fall 1992 issue of the Melpomene journal. (excerpt)
In Indonesia, from year to year since the last three decades, we try to address the problem through the comprehensive and integrated approach in our national development programme. All related health activities, including those for the protection and the increased welfare of the children, are carried out in line with our approach to population management through Family Planning programme, as well as linked to the other programmes such as women empowerment, small and medium enterprises promotion and nine-year compulsory study. All programmes have been underway though they are not free from problem in their implementation. Although we have been able to reduce the death-rate during birth as well as of children under five years old, we have to admit that we still have to meet great challenges like the high death-rate of children caused by acute respiratory tract infection, diarrhea, poor nutrition and prenatal disorders. And all are not easy to settle. (excerpt)
Athletic participation and risk for adolescent pregnancy: Is there a connection?
The current lack of research in this area makes conclusions about links between athletic participation and risk for teenage pregnancy unwarranted. However, there are some sound arguments and observations that suggest that sport may reduce girls' risk for pregnancy. We have informally discussed the question of whether or not athletic participation reduces girls' risk for pregnancy with researchers, coaches, athletic administrators, and athletes. Their views are summarized below in the form of 16 hypotheses. (excerpt)
Communications programming for HIV / AIDS: an annotated bibliography.
The first section of this annotated bibliography contains references related to the different theoretical concepts widely utilized in HIV/AIDS communication, and examples of their application in different settings. The theories considered are the diffusion of innovations, the health belief model, the theory of reasoned action, the AIDS risk-reduction and management model, the sense-making approach, and social learning and cognitive theories. The second section of this bibliography covers examples and reports of HIV/AIDS communication campaigns. In doing so, it provides references dealing with traditional mass media campaigns, multimedia campaigns, and the role of interpersonal and small-group communication in media campaigns; as well as more recent approaches to health and HIV/AIDS communication such as media advocacy and entertainment-education. The third section of this document contains references on community response to HIV/AIDS. Culture and context occupy the fourth section, which includes citations that might help users identify key references associated with some of the issues identified as highly relevant to future HIV/AIDS communication, such as language and different ways of knowing and communicating in varied contexts. (excerpt)
Bangladesh: contraceptive logistics system. Review of accomplishments and lessons learned.
This report documents the status of technical assistance provided by the USAID-funded Family Planning Logistics Management project to the Bangladesh Family Planning Program in developing a countrywide contraceptive logistics system. A study conducted in November 1999 to evaluate the impact of technical assistance on logistics management and contraceptive security is detailed. The report concludes with findings from the study, lessons learned, and recommendations to continue improvements in the system. (author's)
The interval between pregnancies and the risk of preeclampsia.
Background: The risk of preeclampsia is generally lower in second pregnancies than in first pregnancies, but not if the mother has a new partner for the second pregnancy. One explanation is that the risk is reduced with repeated maternal exposure and adaptation to specific antigens from the same partner. However, the difference in risk might instead be explained by the interval between births. A longer interbirth interval maybe associated with both a change of partner and a higher risk of preeclampsia. Methods: We used data from the Medical Birth Registry of Norway, a population-based registry that includes births that occurred between 1967 and 1998. We studied 551,478 women who had two or more singleton deliveries and 209,423 women who had three or more singleton deliveries. Results: Preeclampsia occurred during 3.9 percent of first pregnancies, 1.7 percent of second pregnancies, and 1.8 percent of third pregnancies when the woman had the same partner. The risk in a second or third pregnancy was directly related to the time that had elapsed since the preceding, delivery, and when the interbirth interval was 10 years or more, the risk approximated that among nulliparous women. After adjustment for the presence or absence of a change of partner, maternal age, and year of delivery, the odds ratio for preeclampsia for each one-year increase in the interbirth interval was 1.12 (95 percent confidence interval, 1.11 to 1.13). In unadjusted analyses, a pregnancy involving a new partner was associated with higher risk of preeclampsia, but after adjustment for the interbirth interval, the risk of preeclampsia was reduced (odds ratio for preeclampsia with a change of partner, 0.73; 95 percent confidence interval, 0.66 to 0.81). Conclusions: The protective effect of previous pregnancy against preeclampsia is transient. After adjustment for the interval between births, a change of partner is not associated with an increased risk of preeclampsia. (author's)
Objective: The objective of this study was to investigate the relation of short interpregnancy interval and cerebral palsy (CP) in a low birth weight population in whom neonatal brain injury was systematically ascertained in the newborn period. Study design: We used data from a prospective cohort study of 1105 infants bornInterpregnancy interval and the risk of premature infants.
Objective: Interpregnancy intervals are associated with the risk of low birth weight (LBW) infants, but the association between interpregnancy interval and prematurity is unknown. Our objective was to determine whether interpregnancy intervals were associated with the risk of premature infants and to define the degree of risk according to interpregnancy interval. Methods: We analyzed 289,842 singleton infants born to parous Mexican-origin Hispanic and non-Hispanic white women in the Unifed States who resided in the same county and delivered between January 1, 1991 and September 30, 1991. Interpregnancy interval was defined as the number of months between the previous live birth and conception of the index pregnancy. Multivariate logistic regression analysis was used to estimate odds ratios and 95% confidence intervals for the risk of interpregnancy intervals for the risk of interpregnancy interval on very premature (23-32 weeks), moderately premature (33-37 weeks), and gestation (38-42 weeks). Results: Nearly 37% of women had interpregnancy intervals less than 18 months, 45.5% of women had intervals of 18-59 months, and 17.6% of women had intervals over 59 months. After adjusting for confounding variables, women with intervals less than 18 months were 14-47% more likely to have very premature and moderately premature infants than women with intervals of 18-59 months. Women with intervals over 59 months were 12-45% more likely to have very premature and moderately premature infants than women with intervals of 18-59 months. Conclusion: Women with interpregnancy intervals from 18-59 months had the lowest risk of very premature and moderately premature infants. Further study is needed to define the mechanisms through which interpregnancy interval influences pregnancy outcome. (author's)Determinants of maternal zinc status during pregnancy.
Zinc deficiency in pregnant experimental animals limits fetal growth and, if severe, causes teratogenic anomalies. Although the data from human studies are not consistent, similar outcomes have been observed and were associated with poor maternal zinc status. This paper reviews humans studies of zinc status and pregnancy outcome, describes the physiologic adjustments in zinc utilization during pregnancy to meet fetal needs while maintaining maternal status, and identifies dietary, and environmental conditions that may override those physiologic adjustments and put the health of the mother and fetus at risk. Adjustments in intestinal zinc absorption appear to be the primary means by which zinc retention is increased to meet fetal demands. However, transfer of sufficient zinc to the fetus is dependent on maintenance of normal maternal serum zinc concentrations. Conditions that could interfere with zinc absorption include intake of cereal-based diets that are high in phytate, high intakes of supplemental iron, or any gastrointestinal disease. Conditions that may alter maternal plasma zinc concentrations and the transport of zinc to the fetus include smoking, alcohol abuse, and an acute stress response to infection or trauma. Supplemental zinc may be prudent for women with poor gastrointestinal function or with any of these conditions during pregnancy. (author's)This volume addresses the conceptual, ethical, empirical and technical challenges in summarizing the health of populations. This is critical for monitoring whether levels of population health are improving over time and for understanding why health differs across settings. At the same time, it is also important to recognize that improving population health is not the only goal of health policy and to understand the way health improvements interact with these other goals. For that reason, we briefly review the World Health Organization (WHO) framework for assessing the performance of health systems and the role of summary measures of population health (SMPH) in this framework. Following the recent peer review of the methodology used for health system performance by WHO (Anand et al. 2002), this framework will continue to evolve in response to the detailed recommendations of the scientific peer review group and to ongoing scientific debates and research. (excerpt)A critical examination of summary measures of population health.
We review below the range of options for summary measures of population health, and the main challenges and debates underlying them. Because there are many options, we propose criteria that can be used to evaluate different SMPH. The intended use of a measure may have important implications for its design, and we therefore outline the major uses of summary measures. A brief discussion of the information requirements for all summary measures is followed by a typology of summary measures in terms of health expectancies and health gaps. We outline key issues of importance for all summary measures. A number of criteria and other properties are proposed which can be used to evaluate different summary measures. We discuss some of the broad implications of this framework for choosing summary measures and consider the prospects for future progress. This paper should be understood in the context of work under way in WHO on the development of an analytical framework for measuring health system performance (Murray and Frenk 2000). We consider one critical element of this framework, namely the need for measures of population health that capture the average levels of fatal and non-fatal health outcomes in a population. WHO is also developing measures that summarize health inequalities in populations (Gakidou et al. 2000; Murray et al. 1999). Assessments of health systems thus depend on both summary measures of the average level of population health and measures of the distribution of health among individuals. (excerpt)The individual basis for summary measures of population health.
In chapter 1.2, we reviewed some of the uses and conceptual debates relating to summary measures of population health (SMPH) and presented minimal criteria for evaluating SMPH. Much of the literature on SMPH has grown out of the demographic and epidemiological traditions, which take a population perspective as their starting point. For some uses such as measuring inequalities in health across individuals or measuring the health of individuals in clinical settings or intervention trials, it is important to formulate SMPH in terms of the health of some set of individuals. Many of the challenges identified in chapter 1.2 are intimately related to the linkage between population and individual health measures. Distinctions between incidence and prevalence perspectives, or period and cohort perspectives, for example, can be recast in terms of different choices as to the set of individuals (real or hypothetical) whose health is aggregated into a population measure. Recent efforts have been made to develop formal expressions of population health as aggregations of individual health measures (Cutler and Richardson 1997; 1998; Fleurbaey, forthcoming). In this paper, we attempt to set out a systematic framework for characterizing the individual basis for summary measures of population health. To facilitate later debates in this volume, this paper addresses the question “When is one person healthier than another?” Five different answers to this question are formalized in terms of individual-level analogues to population-level health expectancies and health gaps. Precise formalization of these concepts often reveals important issues that will need to be addressed and reflected upon in future work. We end the chapter with some thoughts on the implications of this work for the development of alternative SMPH. (excerpt)Measurement of variance in health state valuations in Phnom Penh, Cambodia.
Initiated in 1992, the Global Burden of Disease (GBD) Study was conducted at the request of the World Bank and in collaboration with the World Health Organization (WHO) to develop a set of consistent estimates of disease and injury rates for 1990, as well as to develop a comparative index of the burden of each disease or injury, either from premature mortality or time lived with less than perfect health. This comparative index is the summary measure of population health, the disability-adjusted life year (DALY) (Murray and Lopez 1994; WHO 1996; World Bank 1993). By 1998, three volumes of the GBD Study’s methodologies and final results were published on behalf of the World Health Organization and the World Bank (Murray and Lopez 1996a; 1996b; 1998), among other publications highlighting key findings or methods (Murray and Lopez 1996c; 1997a–d). The GBD Study’s methods and findings have generated considerable discussion in the literature and international forums, as well as within the organizations collaborating on the study (for example Anand and Hanson 1997; Barker and Green 1996; Paalman et al. 1998; WHO 1998). The potential normative use of the GBD study’s findings by WHO, the World Bank and national governments has raised concerns on the comparability and interpretation of findings across regions, cultures and socioeconomic groups, as well as on the policy relevance and implications for resource allocation in different health system contexts. Much of the debate centres on the construction of DALY as a summary measure of population health, in particular the explicit social values incorporated within DALY. These include social values for severity weights for disability (e.g. disability weights for over 400 different health states partially based on valuations of 22 indicator health states), the discount rate for future health, age-weights across the life cycle, and target expectancy of life. This chapter reports on an empirical investigation of (i) whether the DALY protocol to elicit valuations for indicator health states may be replicated among non-health professionals in a developing country; (ii) whether differences exist between valuations of health states obtained from individuals with different demographic characteristics or health experiences; and (iii) whether differences exist between health and non-health professionals’ valuations. (excerpt)Summary measures of population health: conclusions and recommendations.
We hope that this book will provide a major contribution to that debate by assembling the views and arguments of health policy-makers and experts from a wide range of disciplines including epidemiology, demography, health statistics, health economics, philosophy and ethics. In this concluding chapter, we summarize the important conceptual, empirical and ethical issues identified and debated by contributors, and draw some conclusions and recommendations for the future evolution of summary measures of population health. (excerpt)Applications of summary measures of population health.
Population health status has so many dimensions, classifications and measurements, as well as interactions between these, that patterns and trends often cannot easily be identified. Comparisons between populations and countries are often severely hampered because different data are collected or different classifications are used. Thus the need for comprehensive population health measures and standardization of data collection is obvious and longstanding. This paper describes the possible uses of such summary measures of population health (SMPH) and some conditions that have to be met for their application. But first, summary measures in general and their composition will be discussed briefly. (excerpt)On the uses of summary measures of population health.
By far, the most fundamental use of summary measures of population health (SMPH) is to shift the centre of gravity of health policy discourse away from the inputs (e.g. costs, human resources, and new technologies) and throughputs (e.g. how many surgical procedures) of the health system towards health outcomes for the population.1 This is not to imply that the resources used and activities undertaken by national or regional health systems are unimportant; quite the contrary. But our understanding of their roles and importance is more appropriate if guided by the real “bottom line”, namely their influence on population health. In parallel to this applied use, SMPH can also play a fundamental role in helping to define the agenda and priorities for health research. Ideally, SMPH, and their underlying statistical systems, can be used to highlight the relative burdens experienced by a nation’s or community’s members attributable to various sorts of health problems or causes. These basic roles for SMPH beg several key questions about how they ought to be constructed and presented. I shall comment briefly on these questions in turn. (excerpt)Commentary on the uses of summary measures of population health.
We have been asked to provide a brief commentary on the potential uses of summary health measures because we are officials from a government agency (the Centers for Disease Control and Prevention in the United States) which is involved with the application of public health interventions designed to decrease disease, disability and death. We had the opportunity to attend a World Health Organization sponsored meeting convened in Marrakech, Morocco, that dealt with the technical and ethical dimensions of these measures. Our comments have been informed and enriched by the presentations at this meeting. The disability-adjusted life year (DALY) was first presented in the World Development Report 1993 by the World Bank (1993). Since then, interest in summary health measures has surged. Though frequently regarded as a novel analytic tool, numerous life-year indices had been proffered prior to the DALY, starting in the 1940s with Dempsey’s concept of using “years of life lost” as a metric for assessing the health burden associated with deaths occurring prior to an “ideal” life span of 65 years (Dempsey 1947). Subsequent measures incorporated non-fatal health outcomes using a life-table approach similar to the DALY methodology. In these constructs, the time lived with a disease or injury is “lost” according to the severity of the disability, pain, or distress associated with a particular malady (Erickson et al. 1989). However, even though similar summary measures such as the Years of Healthy Life have been incorporated into the overall health goals for the United States, no previous measure appears to have garnered the attention, interest, and intermittent disdain, as well as perceived usefulness, that has been directed at the DALY (Erickson et al. 1995). (excerpt)Priority-setting in the health sector and summary measures of population health.
This chapter is in three sections. In the first I discuss how priorities are set. I argue that macro-level priority-setting in the health sector, as in most other sectors of the economy, is a social political process which may be aided by technical inputs. I then review a few macro-level priority-setting exercises in the health sector. My emphasis in this review is to identify the technical analytical inputs usually sought for the setting of priorities. Finally I summarize the methodological characteristics that appear common to all priority-setting exercises in public health and discuss the potential uses of summary measures of population health (SMPH), particularly the health gap measures, i.e. summary measures of disease burden. I conclude that summary measures of population health are useful analytical aids to priority-setting in the health sector. (excerpt)There have been few attempts to elicit health state valuations from the general population, and previous studies typically have focused on fully literate populations in economically developed countries such as Canada (Sackett and Torrance 1978) and the United Kingdom (Gudex et al. 1996). Because population-based empirical assessments of health states are extremely limited, new surveys are needed. A study was conducted in Andhra Pradesh (AP) state, India to measure individual preferences regarding various health states. To the best of our knowledge, this is the first community- based health state valuation study in the developing world. Details of the study design, methodology, data collection, analysis and results are reported elsewhere (Mahapatra et al. 2000). In this paper we review the study methodology and the reliability and validity of the measurements very briefly. Results from the community survey are reported in greater detail, including an examination of the distributions of valuations for different health states, and comparison of the disability weights obtained from this study with results from previous valuation studies. (excerpt)The balance of 20 years fight against HIV / AIDS in Argentina.
The first cases of HIV/AIDS in Argentina were seen in 1982 among men who had sex with men, who had brought the infection from northern countries. The first child case was registered in 1966, and the first woman with AIDS in 1987. The male-female ratio diminished from about 20:1 in 1988, to about 3:1 in 2002. This increasing “feminisation” of the epidemic started in the mid 1990s and persists to date, although cases among men still predominate. The national response to the epidemic has been slow, focusing mainly on treatment and care issues while avoiding the often contentious issues related to effective HIV prevention strategies. (author's)Strengthening India's reponse to HIV / AIDS.
At the end of 2OO1, an estimated 40 million adults and children were living with HIV/AIDS worldwide, of whom 8.6 million in the Asia-Pacific region - more than any other region besides sub-Saharan Africa. Sixty percent of Asia-Pacific HIV infections were in India alone, translating into almost 4 million people living with HIV/AIDS (PLWHA), the second largest number after South Africa. Although India's adult HIV-prevalence rate is low at about 0.8%, this converts into staggering numbers due to India's enormous population. HIV is spreading among highly vulnerable groups such as sex workers and truck drivers, and beyond, among the general population. (author's)Objective: To evaluate client and staff views on existing facilities and services, before and after the convergence of sexual, reproductive and women's services. Methods: Evaluation involved questionnaire survey of clients and staff, one-to-one interviews with staff and review of routinely collected clinical activity data. Results: The integration of the three services led to a reduction in stigma associated with attending sexual health services. Despite some staff concerns, the number of men attending the services did not decrease. There was increased satisfaction with the new service, especially the quality of facilities. There were increased numbers of referrals between clinical services in the Sandyford Initiative. Conclusions: Sexual, reproductive and women's services can be integrated to provide improved facilities for clients. (author's)A profile of contraceptive non-use in Kuwait: implications for health and health care.
Objectives: To analyze the characteristics of women who have never used contraception, and do not intend to use it in the future; examine the factors affecting such behavior and intentions; and discuss their health implications. Methods: Survey data from a nationally representative random sample of Kuwaiti households, collected in a study conducted in 1999 and containing 1502 currently married women, were analyzed using logistic regression analysis. Results: Based on the present study, 19% of women had never used contraception and 50% were not using contraception when interviewed. Among current non-users, 42% did not intend to use contraception, and 31% were unsure about use during the following year. Negative attitudes of the respondents and their husbands were the critical factors in non-use and future intentions for non-use. Never-users were older (average age 37.8 years) and of higher parity (6.2) than other women. Conclusion: Being older and of higher parity, never-users constitute a high-risk group that may be in need of counseling. Also, negative attitudes towards contraception need modification. (author's)Spanish population at risk of unwanted pregnancy: results of a national survey.
Objective: We performed a personal survey in 2218 Spanish women aged from 15 to 49 years to establish the contraceptive methods used by this population and to determine the number of Spanish women of childbearing age exposed to unwanted pregnancy. Methods: Stratified random sampling was performed to select the women to be interviewed; this sampling design ensured adequate representation of the sample in Spain. Results: At the time of the survey, 69.1% of the women were using some contraceptive method, but 5% of them used poorly effective contraceptive methods, and their exposure to the risk of an unwanted pregnancy was therefore high. Moreover, among the 30.9% not using any contraceptive method, 21.1% were at risk because they were having sexual intercourse, did not want to become pregnant and did not use a contraceptive method. Conclusions: A little over one million Spanish women are exposed to the risk of having an unwanted pregnancy. Compiling the data on this significant problem is the first step in designing appropriate solutions. (author's)Contraception and abortion attitudes and practices of western Ukraine women.
Objectives: To assess the attitudes and practices of contraceptive behaviors of Western Ukraine women. Methods: A survey of 500 women in the Oblast was conducted to assess their knowledge, attitudes and practices on a variety of health topics. Convenience sampling was used to access the subjects in 16 different towns/villages in nine rayons throughout the Oblast. Respondents were asked more than 100 questions pertaining to their knowledge, attitudes and practices on a variety of health topics, including stress, contraception, breast health, sexually transmitted diseases, parity, abortion, nutrition, alcohol and tobacco use, domestic violence, and depression and mental health. Results: Of married women, 44% (112/256) would terminate their pregnancy while 56% (144/256) said they would keep their baby. Of unmarried women, 35% (31/88) would abort while 65% (57/88) would keep their baby. A large proportion of married women (82%; 222/271) and unmarried women (70%; 52/74) did not use condoms at all. Conclusion: These results suggest lack of birth control education and contribution to poor protection from sexually transmitted infections. Higher abortion practices may also play a role in the infertility issues that Ukrainian women currently face. (author's)An unaddressed issue: domestic violence and unplanned pregnancies among pregnant women in Turkey.
Objective: The aim of this study was to estimate the prevalence and type of domestic violence during pregnancy in Turkey and to compare socioeconomic background factors. Methods: A survey was carried out among a representative sample of 475 pregnant women. Data were collected on the incidence and the nature of domestic violence perpetrated by the woman's spouse or other family members during her current pregnancy and before. Sociodemographic characteristics such as age, duration of marriage, number of children, monthly income, education, occupation of the husband, domestic violence towards children, contribution to family decisions, smoking habits, sexual relations and whether thc pregnancy was planned or not, were also recorded. Results: Of the 475 women screened for domestic violence during pregnancy, 158 (33.3%) reported physical or sexual abuse since they had become pregnant. The source of the domestic violence was mainly the husband in 105 (66.5%) women. Types of abuse were psychological in 71 (44.9%) and physical in 87 (55.1%) women. The rate of women's satisfaction with their sexual life among abused women was 43.67% compared to 61.2% among non-abused women. Abused pregnant women were less educated, had lower income, had more children, had a longer duration of marriage, were applying violence towards their children, were not contributing to family decisions, were less satisfied with their sexual life and were more likely to have unplanned pregnancies when compared to non-abused women. Conclusion: Antenatal care protocols should be modified to address domestic violence and contributing factors during pregnancy so that identified women can be counseled appropriately and attempts can be made to intervene to prevent further episodes of domestic violence in primary care settings. (author's)Recommendation for confidence interval and sample size calculation for the Pearl Index.
A new guideline on the clinical investigation of steroid contraceptives in women, which has been released by the European Agency for the Evaluation of Medicinal Products (EMEA), calls for the calculation era confidence interval for the Pearl Index, a widely used measure to describe the effectiveness of a contraceptive method. However, the interpretation of the Pearl Index as a statistical parameter, for which a confidence interval can be calculated, needs further clarification. The guideline does not provide the necessary definitions. In this paper, two statistical models, the Bernoulli model and the Poisson model, are compared; both can be used for the calculation of the Pearl Index and its upper confidence limit. The Poisson model proved to be more suitable, because it can accommodate incomplete treatment cycles. Unambiguous definitions and statistical formulae for the calculation of overall Pearl Index and the Method Failure Pearl Index are given. Finally, the sample sizes required to fulfill the EMEA's guideline are given. (author's)Changing attitudes towards abortion in Europe. Review.
Objective: To understand how personal and social attitudes are changing regarding more available safe abortion in Europe. Results: Abortion has been commonly practiced for a long time throughout most of the world, either in legal or illegal conditions, but it is a subject that arouses passion and controversy, because abortion raises two important issues, namely sex and life, sometimes mixed with religion and ethics. Over the past few years, we have observed changes in laws, and personal and professional attitudes towards abortion. Social needs modify the attitudes of the authorities and individuals. In many countries where the performance of abortion is illegal, statistics indicate that large numbers of abortions are carried out, but authorities are indifferent, ignore or tolerate it or even unofficially license clinics for the abortion. In some other countries where abortion is technically legal, access to authorized facilities and personnel may be limited, or resources to pay for the abortion may be lacking, resulting in more illegal abortions. There are, therefore, two categories of abortion: legal versus illegal, and safe versus unsafe. However, laws are changing, becoming even more liberal, even it, in certain nations, there are renewed attempts to question the right of' women to decide. Practice is changing and in some cases becoming separate from the law. Basic ideas are changing, because, in a large number of European countries, we are moving from a culture of abortion to a culture of contraception and prevention of abortion, through an effort of governments, women, professionals, and non-governmental organizations. Certainly, important steps have been taken in the different ways of performing an abortion. For example, we have seen the arrival of medical abortion, with the use of mifepristone and misoprostol. Finally, there is also a change in the way of supporting women through humane and complete counseling, which includes attention to follow-up services offering a choice of contraceptive methods to help women avoid another unwanted pregnancy. Conclusions: There is some resistance at different levels, but attitudes are changing in a positive way throughout Europe, offering a good quality of service, good facilities, well-trained practitioners and more open minds. (author's)Objective: To assess the impact of supplementing newborn infants with vitamin A on mortality at age 6 months. Design: Community based, randomised, double blind, placebo controlled trial. Setting: Two rural districts of Tamil Nadu, southern India. Participants: 11 619 newborn infants allocated 24 000 IU oral vitamin A or placebo on days 1 and 2 after delivery. Main outcome measure: Primary outcome measure was mortality at age 6 months. Results: Infants in the vitamin A group had a 22% reduction in total mortality (95% confidence interval 4% to 37%) compared with those in the placebo group. Vitamin A had an impact on mortality between two weeks and three months after treatment, with no additional impact after three months. Conclusion: Supplementing newborn infants with vitamin A can significantly reduce early infant mortality. (author's)Because acute bacterial gastroenteritis is often inflammatory, rapid stool assays that detect intestinal inflammation might be used to distinguish between bacterial and nonbacterial gastroenteritis. We performed metaanalyses to determine the discriminatory power, in developed and in resource-poor countries, of rapid stool assays that test for lactoferrin, fecal leukocytes, fecal erythrocytes, and occult blood. In developed countries, the area under the summary receiver operating characteristic curve (AUC/SROC) was 0.89 for fecal leukocytes and 0.81 for occult blood. In resource-poor countries, the AUC/SROC was 0.79 for lactoferrin, 0.72 for fecal leukocytes, 0.63 for occult blood, and 0.61 for fecal erythrocytes. In developed countries, positive and negative likelihood ratios (LR+ and LR-, respectively) for fecal leukocytes were 4.56 and 0.32 when a threshold of 15 cells/high-power field was used, compared with 2.94 and 0.6 in resource-poor countries; for lactoferrin, LR+ was 1.34 and LR- was 0.17 in resource-poor countries when the threshold was an agglutination rating of “+” and a dilution of 1:50. In developing countries, rapid stool assays performed poorly, whereas in developed countries, tests for fecal leukocytes, lactoferrin, and occult blood were moderately useful and could identify patients who were more likely to benefit from empirical antibiotic therapy. (author's)Cholera, diarrhea, and oral rehydration therapy: triumph and indictment.
Cholera drove the sanitary revolution in the industrialized world in the 19th century and now is driving the development of oral rehydration therapy (ORT) in the developing world. Despite the long history of cholera, only in the 1960s and 1970s was ORT fully developed. Scientists described this treatment after the discovery of the intact sodium-glucose intestinal cotransport in patients with cholera. This new understanding sparked clinical studies that revealed the ability of ORT to reduce the mortality associated with acute diarrheal disease. Despite the steady reductions in mortality due to acute dehydrating diarrheal diseases achieved by ORT, the costly morbidity due to these diseases remains, the result of a failure to globalize sanitation and to control the developmental impact of diarrheal diseases and their associated malnutrition. New advances in oral rehydration and nutrition therapy and new methods to recognize its costs are discussed in this review. (author's)The aim of this pilot study was to determine the differences in family-planning knowledge and compliance with programme guidelines among male and female community-based distributors (CBDs) of contraceptives in Kabarole district, Uganda. A semi-structured questionnaire was used for interviewing 70 CBDs. Results of interviews showed that the knowledge and compliance scores were not significantly associated with gender and age. The female clients of male CBDs were more likely to discuss family planning with their partners, and the female CBDs included other health topics more in their family-planning counselling. Both male and female CBDs had equal knowledge about family planning and equally complied with the established programme protocols. The male CBDs enhanced communication about family planning between spouses. If this could be confirmed, gender should be considered in the recruitment of new CBDs. The results suggest that male CBDs may have a unique role in promoting family planning effectively and in enhancing communication between spouses about family planning. (author's)A cross-sectional study was conducted during May-December 2000 among pregnant women attending an urban maternal and childcare-delivery unit in Dhaka, Bangladesh, to assess the prevalence of bacterial vaginosis, Trichomonas vaginalis, and syphilis. All pregnant women at 16-24 weeks gestation attending the clinic for antenatal check-up irrespective of symptoms were enrolled. Sociodemographic information and obstetric history were obtained from each enrolled subject. High vaginal swabs and serum samples were tested for bacterial vaginosis, and T. vaginalis and syphilis respectively. In total, 284 pregnant women were enrolled. Of them, 17.7% had bacterial vaginosis, 1.4% had Trichomonas infection, and 3% had syphilis. The prevalence of bacterial vaginosis was higher in women with low socioeconomic status. (author's)Factors associated with size and proportionality at birth in term Jamaican infants.
The objective of this study was to identify the factors associated with size and proportionality at birth in a cohort of term infants established to investigate their growth and development. One hundred and forty term low-birth-weight (birth-weight <2,500 g) infants and 94 normal birth-weight infants (2,500- <4,000 g) were recruited within 48 hours of birth at the main maternity hospital, Kingston, Jamaica. Birth anthropometry and gestational age were measured, and maternal information was obtained by interview and from hospital records. Controlling for gestational age, variables independently associated with birth-weight were rate of weight gain in the second half of pregnancy, maternal height, haemoglobin level <9.5 µ/dL, time of first attendance in antenatal clinic, birth order, pre-eclampsia, and consumption of alcohol, with 33% of the variance in birth-weight explained. Birth length was associated only with maternal height and age, while measures of proportionality (ponderal index and head/length ratio) were associated with characteristics of the environment in late pregnancy, including rate of weight gain, weight in late pregnancy, and pre-eclampsia. The variation in maternal characteristics associated with size or proportionality at birth may reflect the times during gestation when different aspects of growth are most affected. (author's)Food supplementation during pregnancy and functional outcomes [editorial]
In summary, inference of the investigators that the BINP actually led to higher weight gains or higher birthweights in supplemented women is undermined by methodologic weaknesses in their study. Nonetheless, there is no reason to doubt that, unless the supplement entirely substituted for (i.e. resulted in a compensatory reduction in) the usual diet, it would have led to modest increases in foetal growth similar to those reported in rigorously controlled trials. As noted at the beginning of this editorial, the more important question is: even if foetal growth was increased as a result of the BINP, what are the long-term benefits, if any? Future studies on maternal food supplementation should go beyond the conventional goals of increasing maternal weight gain and birth-weight and focus on important functional outcomes for children, adults, and future generations. (author's)Monitoring data from the Bangladesh Integrated Nutrition Project and new data collected for this purpose were analyzed to assess the effects of targeted project services, including supplementation of food, on malnourished pregnant women (women with a body mass index [BMI] ofPatterns and properties of haemagglutinins expressed by Shigella serogroups in Lagos, Nigeria.
Forty-five strains of Shigella were screened for haemagglutinin production and broad-spectrum haemagglutination reaction. Mannose-sensitive haemagglutinin (MSHA) was found in 22 strains [Shigella flexneri (7), S. dysenteriae (7), S. sonnei (3), and S. boydii (5)]. Eighteen strains harboured mannose-resistant haemagglutinin (MRHA), and 8 strains were observed to be non-haemagglutinating to guinea pig erythrocyte. With the exception of human erythrocytes (O, A, B, and AB), the observed MSHA and MRHA also agglutinated the erythrocytes of rabbit, sheep, rat, chicken, and horse, suggesting a broad-spectrum haemagglutinating property. Haemagglutinins of S. flexneri and S. dysenteriae elicited a relatively stronger haemagglutinating activity with agglutinability to chicken and rabbit erythrocytes enhanced by trypsinization. Haemagglutination reaction with guinea pig erythrocyte was generally inhibited by sialic acid, while simple sugars, such as D-glucose, D-galactose, N-acetylgalactosamine, N-acetylglucosamine, and D-rhamnose, elicited no inhibitory effect. The results of the study revealed broad-spectrum haemagglutinin expression by circulating Shigella strains in Nigeria. (author's)The study was carried out to determine the prevalence and pattern of antimicrobial resistance of Shigella species among patients with acute diarrhoea in Karaj, Tehran, Iran. The study included all acute diarrhoea patients who visited the hospitals and treatment centres of Karaj during November 2001-October 2002. Of 734 stool samples collected from patients with acute diarrhoea and analyzed for Shigella spp., 123 (16.8%) yielded Shigella spp. (7.5% Shigella flexneri, 5.2% S. sonnei, 2.6% S. dysenteriae, and 1.5% S. boydii). Of the Shigella isolates, 90.8% were resistant to one or more antimicrobial agent(s), and 87.8% were multidrug resistant. The most common resistance was to tetracycline (73.5%), trimethoprim-sulphamethoxazole (70.4%), and amoxicillin-clavulanic acid (50.0%). Resistance to cefixime, ciprofloxacin, ceftriaxone, and nalidixic acid was observed in 6.1%, 3.1%, 2.0%, and 1.0% of the isolates respectively. These findings suggest that Shigella spp. may be an important aetiological agent of diarrhoea with a high rate of drug resistance in this region, which requires further study. (author's)The contraceptive properties of a gel formulation containing sodium lauryl sulfate were investigated in both in vitro and in vivo models. Results showed that sodium lauryl sulfate inhibited, in a concentration-dependent manner, the activity of sheep testicular hyaluronidase. Sodium lauryl sulfate also completely inhibited human sperm motility as evaluated by the 30-sec Sander- Cramer test. The acid-buffering capacity of gel formulations containing sodium lauryl sulfate increased with the molarity of the citrate buffers used for their preparations. Furthermore, experiments in which semen was mixed with undiluted gel formulations in different proportions confirmed their physiologically relevant buffering capacity. Intravaginal application of the gel formulation containing sodium lauryl sulfate to rabbits before their artificial insemination with freshly ejaculated semen completely prevented egg fertilization. The gel formulation containing sodium lauryl sulfate was fully compatible with nonlubricated latex condoms. Taken together, these results suggest that the gel formulation containing sodium lauryl sulfate could represent a potential candidate for use as a topical vaginal spermicidal formulation to provide fertility control in women. (author's)Altogether, there are now 18 women in three, six-person gangs working across the capital in tandem with 40 male colleagues. Their employment was first suggested by the German backers of the city road construction project and then taken up enthusiastically by the women’s affairs unit of the Kabul municipality, which selected them from among the city’s street cleaners. (excerpt)The camp at Barda is situated in the very centre of the country, and officially houses 55,000 Azerbaijanis displaced by the 1991-94 war over Nagorny Karabakh, which the Armenians won. The real number is much smaller, as many people leave as soon as they can fix up better accommodation in Baku and other towns. Azerbaijan has some 750,000 refugees and displaced people left over from the conflict with the Armenians. Barda is one of five bigger camps among the many that are dotted across the country. Here, they live in mud huts, which isn’t so bad considering that elsewhere people have to make do with tents, dugouts or disused railway carriages. (excerpt)WHO looks to ease access to AIDS drugs.
The World Health Organization announced yesterday that it will create a new model to buy antiretroviral AIDS drugs in hopes of dramatically speeding distribution and reducing the cost of the life-saving medication. The plan comes from a collaboration among tuberculosis experts, foremost among them the new WHO director general, Jong-wook Lee. That program, called the TB Drug Facility, purchases drugs in bulk on behalf of countries and then oversees the distribution. (excerpt)Sexual violence and armed conflict.
Sexual Violence in Nepal's Conflict, presents evidence of the horrific scenario during the war. Throughout the armed conflict in Nepal, thousands of women and girls of all ages were subjected to widespread and systematic sexual violence. Nepal's eight years long conflict has been marked by an extraordinary level of brutal human rights abuses, including sexual violence against women. Baburam Bhattarai has also stated that 50 per cent cadres at the lower level, 30 per cent soldiers and 10 per cent members of the central committee of the party are women. (excerpt)Pakistan: special report on maternal mortality.
The National Commission for Human Development is tackling this serious problem in the district and throughout the North West Frontier Province by way of a pilot project launched in November 2002 with the aim of reducing maternal mortality. The project will cover 200,000 people, and provide women in particular with the necessary medical assistance. The project was established following a comprehensive local study of the district. Under the programme, Mardan has been divided into 56 units of 400 homes, each having assigned to it two trained female health workers, two female traditional birth attendants (TBAs) and one trained male health worker. One female worker together with one TBA cover the needs of 200 homes of the unit's total per month, while the other female worker and her TBA colleague deal with the remaining 200. The male worker covers all the unit's homes. "This is the best way to work on this issue as the health worker is always available, easily accessible, it is cheap on our logistical costs and adds to the sustainability," Zaffar said. Each female family health worker is paid 2,000 rupees (US $35) per month and each male worker 2,500 rupees. "The men educate the men of the house on the needs of pregnant women," Zaffar explained. As well as dealing with health issues, the women educate villagers about water sanitation, and also carry out vaccinations. (excerpt)Beyond the magic bullet: introduction of emergency contraceptive pills in India.
This article assesses the potential role of emergency contraception (EC) to increase women’s reproductive choices and prevent unwanted pregnancies and unsafe abortion in India, and examines the steps required to increase access to EC to women throughout the country. (excerpt)Reproductive, maternal and child health in Eastern Europe and Eurasia: a comparative report.
This report summarizes the results of a series of surveys on fertility and reproductive health attitudes and behaviors carried out in 12 countries in Eastern Europe and Central Asia. These countries share a great deal in the way of recent political and economic history, having been either part of the Soviet Union or within its sphere of influence. The collapse of The Soviet Union in 1991 brought a number of social, economic, and political changes to the countries in this region, and the transition to a new market economy has presented formidable challenges. (excerpt)Planning for community-oriented health systems. 2nd ed.
The purpose of this book is to acquaint readers with the field of community health planning. Health planners need to blend the objective with the normative, planning data with politics, and this book attempts to present both kinds of information. The major functions of planning are addressed (e.g., needs assessment, system design, system performance assessment, and quality assessment), performance indicators of perennial importance are reviewed, and examples of planning projects are presented. (excerpt)Objectives: To estimate the prevalence rates of HIV and other sexually transmitted infections (STI) among unregistered sex workers, and to describe their sociodemographic characteristics and sexual behaviours, and the reasons why they were not officially registered as sex workers, in order to design specific public health interventions. Methods: A one-stage cluster-sample survey was conducted in Dakar in 2000. Unregistered sex workers were interviewed in randomly selected establishments (official and clandestine bars, brothels and nightclubs), and blood, endocervical and vaginal samples were collected for laboratory diagnosis. Results: A total of 390 women with a median age of 29 years were recruited. One-seventh of them were under the legal age for prostitution in Senegal (21 years). The median length of prostitution was 24 months and 73.5% of the women stated regular prostitution. Three-quarters of the women were found to have markers for at least one infection. The prevalence rates were as follows: HIV-1, 6.0%; HIV-2, 3.6%; HIV-1+2, 0.4%; syphilis, 23.8%; gonorrhea, 22.0%; chlamydial infection, 20.0%; trichomoniasis, 22.4%; candidiasis, 19.0%; and bacterial vaginosis, 28.8%. The main reported reason for non-registration was ignorance of the legal system and its procedures (19.4%); 18.9% of the women refused to register. One-third of the women reported that their clients used condoms inconsistently or never. Conclusion: This survey suggests that a multidimensional public health response is needed in Senegal, comprising legal information, downwards revision of the legal age for prostitution, and specific medical follow-up based on education, condom promotion and management of STI for non-registered sex workers. (author's)Decomposition methods in demography.
This book is divided into four parts: Part I provides an orientation to his book as well as to the field of study that utilizes decomposition methods. It also describes the special notation used throughout the book. Part II is a literature review of existing decomposition methods, and it is divided into three chapters. There is a description of the developments in decomposition methods and contributions of methodological development to particular demographic fields. Part III speaks of the changing methods over time of demographic functions. Part VI is devoted to comparing direct vs. Compositional decomposition presented in Part III with the previous decomposition methods presented in the preceding literature review provided in Part II. (excerpt)[Impact of HIV / AIDS messages on the 15-49 year-old population of the Tegucigalpa urban center]
The research project that presents "Impact of HIV-AIDS messages on the population from 15 to 49 years of age in the urban area of Tegucigalpa" is framed within the issue of HIV-AIDS, a contemporary problem that has affected millions of people around the world. Concretely, it is a study that analyzes the impact of messages related to HIV-AIDS prevention on the Honduran population, assessing their influence on the knowledge, attitudes, and practices manifested in specific behaviors. This qualitative-quantitative investigation began with a transversal descriptive study based on a questionnaire directed at the studied population, followed by a qualitative stage that took a more in-depth look at some of the issues from the first phase that required more analysis. Here, we worked with previously selected focus groups made up of men and women from the urban area of Tegucigalpa. In the quantitative stage, 1,090 informants explored aspects such as the control and use of the media, the information received, and the level of comprehension and interpretation of the messages, as well as knowledge of preventive actions, their significance, forms of transmission and treatment of the disease, condom use, and the informants' perceptions about the role of women in a sexual relationship. It became necessary to take a more in-depth look at some of the aspects researched, and the following issues were selected: perception of the different messages, knowledge about HIV-AIDS, and condom use. This part constitutes the qualitative stage of the investigation, in which the focus group technique was used to examine these issues in-depth with four population groups, classified by sex and educational level. This made it possible to establish the level of knowledge, attitudes, and practices related to HIV-AIDS among the population studied. The results of the research reveal the value, importance, and interpretation given by the population to the messages, as well as the degree to which they apply them in their daily lives. (excerpt)[Facing AIDS: the challenge and the response of the churches]
Confronting AIDS is the fruit of a transcendental process of more than three years, which included the involvement of a high-level consultative group representing the five continents, churches of a wide variety of denominations and denominational families, organizations, ecumenical organizations, international organizations, and civil society organizations. The elements that have enriched this work include materials such as declarations from churches, personal testimonies, narration of stories, case studies, reflections of local churches, reports of scientific studies, and reports from the United Nations' programs of study. The academic rigor and profound human commitment of the participants have decisively contributed to the results of this study, which bears witness to the great ecumenical spirit that encouraged them to unanimously respond to the serious issue of HIV-AIDS. One of the important characteristics of this study is that it moves us from information to reflection and from there to action, as it contributes material that can be used by the ecclesiastical communities in an experiential and participative way. For these reasons, I believe the Confronting AIDS: The Challenge and Response of the Churches is a response from the sons of God to the cry of creation. (excerpt)Facing AIDS: the challenge, the churches' response. A WCC study document.
The relationship between AIDS and poverty, AIDS and structural violence, and even the question of the origins of AIDS are among the controversial issues in the current HIV/AIDS discourse. The importance of a reprint of this study document cannot therefore be overemphasized. Alongside other WCC publications on the subject, it has been a valuable companion to churches and social organizations seeking to deepen and broaden their understanding of and work on HIV/AIDS. The Church and AIDS in Africa cites WCC publications on HIV/AIDS among the most valued resources materials widely used in Africa. (excerpt)Using data to improve service delivery: a self-evaluation approach.
This guide will help frontline health workers use the data collected at health facilities to: solve common problems in service delivery; and improve their response to community needs. It is intended for doctors, nurses and midwives in community-based health centers. The overall aim of the guide is to promote greater use of existing service data to improve health services. It does not require health workers to collect any additional data. (excerpt)Reproductive Health Survey, Azerbaijan, 2001. Final report.
The survey was designed to collect reproductive health information from a representative sample of reproductive-age women throughout Azerbaijan. The questionnaire covered a wide variety of topics related to reproductive health for all women regardless of marital status and included questions on family life education and sexual behavior for women aged 15-24 as well as questions on the nutritional status of women and their children. (excerpt)The Second National Survey on Family in Japan, 1998.
Japanese families have changed in many ways in recent years. Changes in demographic characteristics which include the aging of the population and the declining birth rate, a growth in the proportion of single households or households married-couple-only, as well as an increase in the labor force participation rate for married women, are considered to be some of the contributing factors to these changes. These changes in families have some impacts on fertility patterns and child rearing, along with the problems related to a rise in the proportion of the elderly who need special care, and they are beginning to take their toll on the Japanese society as a whole. In the face of an ever-increasing elderly population, it is becoming more and more important to get the complete picture of the factors behind these changes in the family functions. In this context, the National Institute of Population and Social Security Research conducted the Second National Survey on Family in Japan in June 1998, following the First survey in 1993. The survey includes questionnaires such as fertility, child rearing, conditions of the elderly who need special care, relationships between family members, and attitudes toward the family. (excerpt)The sections of this toolkit are designed to help increase your knowledge of EC (emergency contraception) and stay up to date. They provide suggestions for increasing EC awareness in the workplace, whether it is a school district, a school, a school-based or school-linked health center, or a CBO. (excerpt)Health in the Americas. 2002 edition. Volume I.
In this 2002 edition, the analysis of Health in the Americas is oriented toward documenting inequalities in health. Volume I's eight chapters bring together the contributions of several of PAHO's technical units to present a Regional perspective on the current health situation. This volume includes analyses of the status and trends of several important health and health-related indicators and determinants, ranging from mortality and changes in life expectancy to the impact of income-level and income-distribution inequalities have on the population's health. Volume I describes the current status and trends in health promotion, environmental health, disease prevention and control, availability of health resources and technology, and external cooperation in health. (excerpt)Health in the Americas. 2002 edition. Volume II.
Volume II presents the most up-to-date health situation analysis for each of the 48 countries and territories of the Americas. This volume is a product of Regionwide analytical effort that is conducted using a common framework that includes an analysis of overall health status, specific health problems, and the response of the health system and services. Emphasis was given to the use of disaggregated core health data available within each country, the documentation of inequalities, and gender approach. Each country's overall health status analysis covers recent political, economic, and social trends, as well ass the degree of implementation of national development plans and these plans' impact on the population's living conditions, health status, and level inequalities. (excerpt)Speaking of health: assessing health communication strategies for diverse populations.
This volume is the product of the Committee on Communication for Behavior Change in the 21st Century: Improving the Health of Diverse Populations, established by the Institute of Medicine in 1999. It focuses on those programs that involve some use of communication technology and have incorporated the transmission or exchange of messages within interventions designed to influence behavior to improve health. Programs exclusively involving interpersonal communication, such as between physician and patient, were not the focus; interventions that include other elements along with communication technology are considered. (excerpt)Objective: To analyse the contribution of maternal survival and HIV status to child (under-5 years) mortality in a rural population cohort in South-west Uganda. Methods: Approximately 10 000 people residing in 15 neighbouring villages were followed between 1989 and 2000 using annual censuses and serological surveys to collect data on births, deaths, and adult HIV serostatus. Mother–child records were linked, child mortality risks (per 1000 births) and hazard ratios (HRs) for child mortality according to maternal HIV serostatus were computed, allowing for time-varying covariates. Results: A total of 3727 children were born, of whom 415 died during 14 110 child years of follow-up. Mother’s HIV status at birth was ascertained unambiguously for 3004 children, of whom 218 were born to HIV-positive mothers. Infant mortality risk was higher for HIV seropositive than seronegative mothers (225 versus 53) as was child mortality risk (313 versus 114). Child mortality risk was also higher for mothers who died (571) than for surviving mothers (128). After controlling for child’s age and sex, independent predictors of mortality in children were: mother’s terminal illness or death (HR = 3.8); mother being HIV positive (HR = 3.2); child being a twin (HR = 2.0); teenage motherhood (HR = 1.7) and maternal absence (HR = 1.7). Conclusion: Maternal survival and HIV status are strong predictors of child survival. The higher mortality in HIV-infected women compounds mortality risks for their children, regardless of children’s HIV status. Programmes aimed at the welfare of children should take into account the independent effect of mothers’ HIV and vital status. (author's)Objective: To monitor HIV-1 and HIV-2 trends in The Gambia, West Africa. Methods: In 1993–1995 a nationwide survey among 29 670 pregnant women attending eight antenatal clinics estimated the seroprevalence of HIV-1 at 0.6%, and of HIV- 2 at 1.1%. Five years later, sentinel surveillance in pregnant women was established, using unlinked anonymous testing in four clinics. A dried blood spot on filter paper was obtained and tested for HIV antibodies. Results: Between May 2000 and August 2001, 8054 analysable samples were collected at four sites. The prevalence of HIV-1 rose sharply in one rural area from 0.6 to 3.0% (P < 0.0001), but the increase was small and non-significant in two other rural sites and in the urban site. The prevalence of HIV-2 did not change significantly at any of the sites. The overall prevalence of HIV-1 was 1.0% [95% confidence interval (CI) 0.8–1.3%], and of HIV-2 0.8% (CI 0.6–1.0%). Site, nationality and higher age were significantly associated with HIV-1 infection, and higher parity and site were significantly associated with HIV-2 infection. Conclusion: Fifteen years after the first case of HIV-1 was described in The Gambia, the epidemic is still at a low level. There is heterogeneity within the country, with one rural area experiencing a fivefold increase in 6 years. The prevalence of HIV-2 in The Gambia is stable. (author's)Maternal hypothyroidism may affect fetal growth and neonatal thyroid function.
OBJECTIVE: To investigate the pituitary–thyroid axis function in the early neonatal period of newborns to hypothyroid mothers who have been apparently adequately treated. METHODS: Among the 27,386 full-term newborns delivered over a 6-year period, 259 were born to 250 treated hypothyroid mothers (0.9%); 246 of these newborns constituted the study group. Controls were 139 term healthy neonates from healthy group-matched mothers. The study infants and controls underwent thyroid function tests in a prospective design. A single blood sample was collected from each infant at 25–120 hours of life. RESULTS: Compared with the controls, serum thyroidstimulating hormone (TSH) levels were higher in the study neonates (P < .005), as were those of serum free thyroxine (T4) (P < .03), particularly at 49 hours of life or older (P < .001). At 49–120 hours, 44.7% of the study group newborns had serum free T4 levels greater than the 95th percentile of the controls (P < .001), and 16.8% had significantly higher TSH levels (P < .001). Serum free T4 correlated positively with TSH in the controls (r = .316) but not in the study newborns (r = .062, P = .36). Neonatal TSH at 49 hours or older correlated positively with maternal TSH during pregnancy in the 18 cases where maternal TSH values during pregnancy were available (r=.751, P<.001). Birth weight and head circumference were significantly lesser in the study group (P < .001). CONCLUSION: The impaired intrauterine growth and the unduly elevated serum values of TSH and serum free T4 found in a substantial fraction of the study newborns might reflect an insufficient level of hormone replacement therapy of their hypothyroid mothers during pregnancy, despite an assumed adequate management. Gestational hypothyroidism requires close monitoring. (author's)Oral contraceptives, tubal sterilization, and functional ovarian cyst risk.
OBJECTIVE: To determine whether current contraceptive method affects functional ovarian cyst risk, with emphasis on oral contraceptives (OCs) and tubal sterilization. METHODS: We conducted a case– control study of 18–39- year-old health maintenance organization enrollees with a functional ovarian cyst diagnosed between January 1, and June 30, 1994, and age-matched female controls randomly selected from enrollment files. In-person interviews as well as medical and pharmacy records were obtained for 78% of cases and 82% of controls; these analyses were based on 392 cases and 623 controls. Odds ratios (ORs) calculated with unconditional logistic regression were used to estimate the risk of a functional ovarian cyst diagnosis associated with current contraceptive method. RESULTS: In multivariable analyses adjusting for age, education, number of live births, and reference year, the overall OR was 0.72 (95% confidence interval [CI] 0.53, 0.99) for current OC use, compared with use of nonsurgical nonhormonal contraception or no contraception. The risk associated with use of 35 µg ethinyl estradiol monophasic OCs (OR 0.69; 95% CI 0.44, 1.10) was slightly lower than that associated with less than 35 µg ethinyl estradiol monophasic (OR 0.79; 95% CI 0.43, 1.47) or multiphasic OCs (OR 0.76; 95% CI 0.49, 1.19). Women with tubal sterilization had a substantially increased risk of a functional ovarian cyst diagnosis (OR 1.70; 95% CI 1.05, 2.75) compared with women using nonhormonal or no contraception. CONCLUSION: Our findings suggest that low-dose OC use has little or no effect on functional ovarian cyst likelihood. The increased risks we found associated with tubal sterilization merit further investigation. (author's)Total versus subtotal hysterectomy: a survey of gynecologists.
OBJECTIVE: To estimate the attitudes and practice of gynecologists in the Washington, DC, Maryland, and Virginia area regarding total versus subtotal abdominal hysterectomy. METHODS: A questionnaire with 18 questions on physicians’ attitudes and practice regarding total versus subtotal hysterectomy was mailed to 1647 gynecologists in Washington, Maryland, and Virginia. RESULTS: The corrected response rate was 51.2%. Forty-five percent of respondents stated that they always removed the cervix. The most common reason cited was to eliminate the risk of cervical cancer. The most common reason for subtotal hysterectomy was surgical difficulty leading to an intraoperative change of procedure. Only 17.8% of respondents always counseled women regarding the advantages and disadvantages of both total and subtotal hysterectomy; 63% rarely or never did. Nineteen percent always offered women a choice between the procedures; 61% rarely or never did. Eighty-eight percent of respondents felt that the risk of cancer in the cervical stump was small or negligible. Gender of the physicians or year of completion of residency made no significant impact on patients being counseled about both procedures or being offered a choice between the two. CONCLUSION: Most gynecologists surveyed favor total abdominal hysterectomy over subtotal hysterectomy. Few counsel women regarding the options of total and subtotal hysterectomy or offer a choice between the procedures. Given that there are no convincing data proving the superiority of either procedure over the other, it may be reasonable to discuss the potential advantages and disadvantages of both procedures with women undergoing hysterectomy for benign disease and to offer them a choice. (author's)OBJECTIVE: To compare the performance of patient- and physician-obtained cytology and human papillomavirus (HPV) testing for the detection of high-grade cervical intraepithelial neoplasia. METHODS: A cross-sectional study was performed involving 334 women seen at three colposcopy clinics (Tucson, Arizona; Hermosillo, Mexico; and Lima, Peru). All women used a cytobrush to self-collect specimens for cervical cytology and HPV testing. Subjects subsequently underwent physician collection for cytology and HPV, followed by a complete colposcopic evaluation with directed biopsy. Cytology was processed using thin-layer technology, and HPV was determined using the polymerase chain reaction technique. Test performance characteristics were determined using the histopathologic diagnosis as the reference standard and designating high-grade cervical intraepithelial neoplasia as clinically significant disease for the purpose of the analysis. RESULTS: The sensitivity of patient-collected cytology was significantly lower (55.0%) and specificity was significantly better (84.1%) than those of physician-directed sampling (85.2% and 73.4%, respectively). Patient-collected HPV had significantly lower sensitivity (49.0%) than physician sampling (82.2%), although specificity did not significantly differ. CONCLUSION: Patient collection is a feasible although inferior alternative to physician-collected cervical cytology and HPV testing. (author's)Rural sex work in Cambodia: work characteristics, risk behaviours, HIV, and syphilis.
Objective: To identify prevalence and risks factors for syphilis and HIV among rural female sex workers (FSWs) in Cambodia and to describe differences between rural and urban FSWs. Methods: Interviews and sera were collected from 114 FSWs and tested for HIV using the Serodia-HIV test and positives confirmed with the enzyme linked immunosorbent assay. Syphilis was tested for with the rapid plasma reagin with passive particle agglutination test for detection of antibody of Treponema pallidum. Study data were merged with data from a study of urban FSWs from Phnom Penh that applied similar questionnaires and sampling design to compare STI prevalence and behaviours. Results: 42% of rural FSWs were HIV positive; 22% had past or current syphilis. In multivariate models HIV was significantly associated with age >25 (OR = 6.1 95% CI: 1.0 to 36.6), a non-commercial partner in the past year (OR= 0.33, 95% CI: 0.11 to 0.93), and prevalence of past or current syphilis (OR = 2.9, 95% CI: 1.0 to 8.8). There was significantly higher active syphilis (14% v4%), older mean age (25 v 21), fewer daily clients (2 v 5), lower monthly income ($61 v $174), and longer duration of sex work (2.3 years v 1.4 years) among rural than among urban FSWs. Conclusions: These findings reveal a high burden of HIV and syphilis among FSWs in rural Cambodia. As FSWs age and become infected with STI/HIV they may move out of cities into less competitive but less savvy markets; their high mobility may contribute to the expansion of the HIV epidemic into rural Cambodia and lower risk populations. (author's)The South African Medicines Control Council (MCC) has unleashed a storm of protest in the country by questioning the validity of a study on which the efficacy of nevirapine is based. The controversial decision to reject the findings of the Ugandan HIVNET012 study has raised the possibility of the drug being banned for mother-to-child transmission (MTCT) of HIV. (excerpt)WHO to strengthen commitment to polio eradication.
“I am immediately upgrading WHO’s capacity to support India, Nigeria, Pakistan, and Egypt in their efforts to immunise every child against polio”, Lee said in his first media encounter as Director-General. 99% of the 235 new cases reported this year up to July 29 have come from these four countries. (excerpt)Africa and China join forces to combat malaria.
States from the continent have started joint workshops with China in a programme that aims in part to reduce the economic burden of malaria, estimated at US$12 billion annually of gross domestic product. The first workshop was held in Nairobi July 29–Aug 3. It focused on developing mechanisms to combat the disease. Lectures and discussions enabled participants get a better understanding of the theory and practice of malaria control and treatment. (excerpt)Research does not indicate future trends in global health [letter]
Our findings suggest that a gap exists between what is being researched and future health issues in developing countries. The reason for this gap could be that researchers pay too much attention to the relative importance of communicable diseases indicated as proportions, irrespective of the high absolute mortality rates and disability adjusted life years (DALYs) lost from non-communicable diseases and injuries. (excerpt)Objective: To identify sexually transmitted infections in rural and remote Indigenous communities in north eastern Australia and examine factors that may influence prevalence. Methods: A cross sectional survey of 26 Aboriginal and Torres Strait Islander communities in northern Queensland was carried out. 3313 people (2862 Indigenous) aged 15 years and over resident in participating communities during the period March 1998 to December 2000. The main outcome measures were community and population prevalence of chlamydia and gonorrhoea and independently associated risk factors. Results: A total of 238 cases of chlamydia, 66 cases of gonorrhoea, and 37 cases of co-infection were detected among Indigenous participants. Prevalence of chlamydia and/or gonorrhoea ranged from 23.0% among 15–19 year olds to 3.5% among those 40 years and older. In the adjusted analysis younger age, female sex, lower socioeconomic status, the use of alcohol and tobacco, and the structure of community health services were independently associated with a higher prevalence of bacterial STI. Conclusion: This study highlights the need for improved STI control in north Queensland Indigenous communities through strategies to improve the reach and accessibility of primary healthcare services. (author's)Don't overlook condoms for HIV prevention [editorial]
While the life saving benefit of antiretroviral therapy is undeniable and treatment is an essential element of comprehensive HIV/AIDS programmes, we are concerned that the attention of the international community is being diverted from the hard work of primary prevention. Progress on treatment access must not come at the expense of prevention by means of behaviour change, including condom promotion. (excerpt)Background: The association between herpes simplex virus type 2 (HSV-2) and human immunodeficiency virus (HIV) and the development of HSV vaccines have increased interest in the study of HSV epidemiology. Objectives: To estimate the age and sex specific seroprevalence of HSV-1 and HSV-2 infections in selected populations in Brazil, Estonia, India, Morocco, and Sri Lanka. Methods: Serum samples were collected from various populations including children, antenatal clinic attenders, blood donors, hospital inpatients, and HIV sentinel surveillance groups. STD clinic attenders were enrolled in Sri Lanka, male military personnel in Morocco. Sera were tested using a common algorithm by type specific HSV-1 and HSV-2 antibody assay. Results: 13 986 samples were tested, 45.0% from adult females, 32.7% from adult males, and 22.3% from children. The prevalence of HSV-1 varied by site ranging from 78.5%–93.6% in adult males and from 75.5%–97.8% in adult females. In all countries HSV-1 seroprevalence increased significantly with age (p<0.001) in both men and women. The prevalence of HSV-2 infection varied between sites. Brazil had the highest age specific rates of infection for both men and women, followed by Sri Lanka for men and Estonia for women, the lowest rates being found in Estonia for men and India for women. In all countries, HSV-2 seroprevalence increased significantly with age (p<0.01) and adult females had higher rates of infection than adult males by age of infection. Conclusions: HSV-1 and HSV-2 seroprevalence was consistently higher in women than men, particularly for HSV-2. Population based data on HSV-1 and HSV-2 will be useful for designing potential HSV-2 vaccination strategies and for focusing prevention efforts for HSV-1 and HSV-2 infection. (author's)Objectives: To measure the prevalence of HIV and other STIs in communities neighbouring new large scale gold mines in northern Tanzania in order to inform the design of a targeted HIV/STI intervention programme. Methods: Cross sectional surveys were conducted in adults aged 16–54 years from different sectors of communities neighbouring two newly opened, large scale gold mines near Lake Victoria. Mine workers, men, women, and female food and recreational facility workers (FRFW) from the community were randomly selected for interview and HIV and STI testing. Results: 207 male Tanzanian mine workers, 206 FRFW, 202 other male and 205 female community members were enrolled. Overall, 42% of FRFW were HIV positive, compared to 6% of male mine workers, and 16% and 18% of other community men and women respectively. HIV prevalence in FRFW was significantly associated with alcohol consumption (adjusted odds ratio (aOR) = 2.5, 95% confidence interval (CI) 1.1 to 5.5), past or present syphilis (TPPA+) (aOR = 2.7, 95% CI 1.4 to 5.1) and single status (aOR = 3.8, 95% CI 1.2 to 11.9). Among FRFW, 24% had active syphilis (RPR+, TPPA+), 9% Chlamydia trachomatis, and 4% Neisseria gonorrhoeae. Overall, 50% of FRFW and 50% of community men never used condoms during sex, and 55% mineworkers, 61% male, and 20% female community members reported receiving/giving payment for sex during the previous year. Conclusions: There is a high prevalence of HIV and other STIs in communities around new goldmines in Tanzania, especially in FRFW. HIV and STI prevalence in the mining workforce is still relatively low, but high risk sexual behaviour is reported by all adult subgroups surveyed in this study. Programmes focusing on HIV/STI prevention, with targeted interventions for high risk women such as FRFW, will be extremely important in such high transmission communities where there is substantial recent in-migration of men and women seeking work. Such programmes have recently been initiated by a private/public/NGO partnership. (author's)Syphilis prevalence has rapidly decreased in South Korea.
Objectives: To determine the current prevalence of syphilis in the general population of South Korea and its trend over the past 20 years. Methods: 15 402 adults, who all were aged over 20 (6888 blood donors, 4951 physical examinees, and 3563 pregnant women) were examined from January 1999 to December 2000. All subjects were screened using a VDRL test, and positive results were confirmed by a FTA-ABS test. The prevalence was compared with the results of previous surveys in similar population groups performed by same authors. Results: The prevalence of syphilis in South Korea was found to be 0.2%. Although has been consistent decreasing trend since 1977 (p<0.0001), there is no statistical difference between 1995 and 2000 (p=0.6992). Conclusions: The prevalence of syphilis has decreased significantly since 1977. However, it has not reduced much since 1995, and it seems that the prevalence has reached a plateau. Until now, not all syphilis patients were registered and followed up by the public health centres because there were so many syphilis patients. However, as this survey shows, the number of syphilis patients has reduced a great deal and it is believed that a more thorough management strategy including all newly diagnosed patients is necessary in order to further reduce the prevalence of syphilis in South Korea. (author's)Effects of two telephone survey methods on the level of reported risk behaviours.
Objective: Reporting bias due to social desirability is an important consideration in carrying out surveys on sensitive issues. The study compared the frequency of self reported sensitive behaviours and response rates between the conventional “telephone interviewer method” (TIM) and a combined interviewer and computerised data capturing method (telephone interviewer and computerised questionnaire method, or TICQM). Methods: A total of 580 males and 582 females were recruited and randomly assigned to either of the two methods in a cross sectional study. The overall response rate was about 51.6%. Results: While the two methods both had high completion and low item non-response rates, the TICQM respondents reported higher frequencies of sensitive risk behaviours. Sexually active female respondents interviewed by the TICQM were more likely to report that their sex partners were their steady boyfriend, instead of their husband; and were also more likely to admit that they had had “one night stand” experiences or had undergone an HIV antibody test, when compared with their counterparts in the TIM group. Similar contrasts were observed for sexually active male respondents, that the TICQM group were more likely to report that they had had sexual intercourse with female sex workers or non-regular sex partners. Sex differences in the strength of association were observed between some studied behaviours (for example, HIV testing and substance abuse) and modes of data collection. Conclusion: The choice of data collection method has a significant impact on the results of sensitive studies; special attention should be given to designing the study and interpreting the results. (author's)South African government to withdraw antiretrovirals for pregnant mothers.
South Africa’s first AIDS conference got off to a painful start last weekend. At the opening of the conference, AIDS activists stood in silent protest at the health minister, Dr Manto Tshabalala Msimang, while others booed her loudly. Days before the opening, the government once more delivered bad news to the AIDS community and devastating news to the hundreds of thousands of HIV positive women who may become pregnant. (excerpt)Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study.
Objective: To determine whether a short interval between pregnancies is an independent risk factor for adverse obstetric outcome. Design: Retrospective cohort study. Setting: Scotland. Subjects: 89 143 women having second births in 1992-8 who conceived within five years of their first birth. Main outcome measures: Intrauterine growth restriction (birth weight less than the 5th centile for gestational age), extremely preterm birth (24-32 weeks), moderately preterm birth (33-36 weeks), and perinatal death. Results: Women whose subsequent interpregnancy interval was less than six months were more likely than other women to have had a first birth complicated by intrauterine growth restriction (odds ratio 1.3, 95% confidence interval 1.1 to 1.5), extremely preterm birth (4.1, 3.2 to 5.3), moderately preterm birth (1.5, 1.3 to 1.7), or perinatal death (24.4, 18.9 to 31.5). They were also shorter, less likely to be married, and more likely to be aged less than 20 years at the time of the second birth, to smoke, and to live in an area of high socioeconomic deprivation. When the outcome of the second birth was analysed in relation to the preceding interpregnancy interval and the analysis confined to women whose first birth was a term live birth (n = 69 055), no significant association occurred (adjusted for age, marital status, height, socioeconomic deprivation, smoking, previous birth weight vigesimal, and previous caesarean delivery) between interpregnancy interval and intrauterine growth restriction or stillbirth. However, a short interpregnancy interval ( < 6 months) was an independent risk factor for extremely preterm birth (adjusted odds ratio 2.2, 1.3 to 3.6), moderately preterm birth (1.6, 1.3 to 2.0), and neonatal death unrelated to congenital abnormality (3.6, 1.2 to 10.7). The adjusted attributable fractions for these associations were 6.1%, 3.9%, and 13.8%. The associations were very similar when the analysis was confined to married non-smokers aged 25 and above. Conclusions: A short interpregnancy interval is an independent risk factor for preterm delivery and neonatal death in the second birth. (author's)Establishing ethical trials for treatment and prevention of AIDS in developing countries.
As the HIV epidemic continues to spread, clinical and prevention trials are needed in developing nations to learn how best to alleviate suffering. Such international trials, however, raise ethical concerns because of great disparities in wealth, power, and medical infrastructure and a history of exploitation. Several reports suggest broad ethical and policy guidelines for trials in developing countries. However, such guidelines may be too general to resolve many controversies that arise in the context of specific trials.4 Because of substantive disagreements regarding such international trials, measures that assure procedural fairness are vital. We argue that partnerships between developed and developing countries are essential to working out ethical problems that arise in particular trials and propose steps to ensure that such partnerships are effective. (excerpt)Ethics guidance for HIV prevention trials.
International trials of HIV prevention strategies are necessary to end the AIDS pandemic, but they present complex ethical challenges that are not uniformly or adequately addressed in existing guidance documents. The HIV Prevention Trials Network has developed ethics guidance that incorporates best practices and emerging consensus on four areas: general principles, meeting local needs and priorities, care and prevention, and informed consent. (excerpt)To describe pregnancy intentions and contraceptive use among a postpartum sample of women with and at risk for HIV infection, 258 HIV-seropositive and 228 HIV-seronegative women were recruited from prenatal clinics in 4 US states between June 1996–November 1998. Participants completed interviews at 24–40 weeks’ gestation and at 6 months postpartum. At the 6-month interview, 78% of women reported vaginal sex, and 2% were pregnant. Among those not pregnant, 86% said that there was no likelihood of a pregnancy in the next 6 months. Condom use was reported by 68% of sexually active women; 65% of users reported consistent use. Those with HIV were more likely to report condom use, more likely to report condom use consistency, and less likely to report use of oral contraceptives than women without HIV (P < 0.05). In multivariate analysis, inconsistent condom use was associated with postpartum alcohol use (odds ratio [OR] 2.80; 95% CI = 1.34–5.84), with the respondent stating that a pregnancy would not be emotionally upsetting (OR 3.06; 95% CI = 1.41–6.59) and reporting an intention to terminate a pregnancy if one were to occur (OR 3.47; 95% CI = 1.58–7.60). HIV-seropositive women who had at least 1 child with HIV infection were less likely than seronegative women to report inconsistent condom use (OR 0.15; 95% CI = 0.03–0.76). Few differences were detected in reproductive behaviors as a function of HIV serostatus, although both cohorts engaged in unprotected sex. Counseling to decrease sexual risk behaviors should begin prior to or early in the postpartum period and include discussion of both reproductive and disease transmission issues. (author's)Context: From 1981 to 2001, 46000 refugees who fled the 36-year civil conflict in Guatemala for Chiapas, Mexico were under the protection of the United Nations High Commissioner for Refugees. Objectives: To estimate the prevalence of mental illness and factors associated with poor mental health of undenerved Guatemalan refugee communities located in Chiapas, Mexico, since 1981 and to assess need for mental health services. Design, Setting, and Participants: Cross-sectional survey of 183 households in 5 Mayan refugee camps in Chiapas representing an estimated 1546 residents (adults and children) conducted November-December 2000. Main Outcome Measures: Symptom criteria of Posttraumatic Stress Disorder (PTSD), anxiety, and depression as measured by the Harvard Trauma Questionnaire and Hopkins Symptom Checklist-25 (Hopkins-25). Results: One adult (aged 216 years) per household (n=170 respondents) who agreed to participate was included in the analysis, representing an estimated 93% of households. All respondents reported experiencing at least 1 traumatic event with a mean of 8.3 traumatic events per individual. Of the respondents, 20 (11.8%) had all symptom criteria for PTSD. Of the 160 who completed the Hopkins Symptom Checklist-25, 87 (54.4%) had anxiety symptoms and 62 (38.8%) had symptoms of depression. Witnessing the disappearance of family members (adjusted odds ratio [AORI, 4.58; 95% confidence interval [CII, 1.35-15.50), being close to death (AOR, 4.19, 95% CI, 1.03-17.00), or living with 9 to 15 persons in the same home (AOR, 3.69; 95% CI, 1.19-1 1.39) were associated with symptoms of PTSD. There was a protective factor found for lacking sufficient food (AOR, 0.08; 95% CI, 0.01-0.59). Elevated anxiety symptoms were associated with witnessing a massacre (AOR, 10.63; 95% CI, 4.31-26.221, being wounded (AOR, 3.22; 95% CI, 0.95-10.891, and experiencing 7 to 12 traumatic events (AOR, 2.67; 95% CI, 1.14-6.27) and 13 to 19 traumatic events (AOR, 2.26; 95% CI, 0.65-7.89). Elevated symptoms of depression were associated with being a woman (AOR, 3.64; 95% CI, 1.47-9.041, being widowed (AOR, 27.55; 95% CI, 2.54-299.271, being married (AOR, 1.93; 95% CI, 0.59-6.33), witnessing disappearances (AOR, 2.68; 95% CI, 1 .I 6-6.19), experiencing 7 to 12 traumatic events (AOR, 1.57; 95% CI, 0.64-3.88), or experiencing 13 to 19 traumatic events (AOR, 7.44; 95% CI, 2.18-25.37). Conclusion: Psychiatric morbidity related to human rights violations, traumatic events, and refugee status was common among Guatemalan refugees surveyed 20 years after the Guatemalan civil conflict. (author's)The recent war in Iraq presents significant challenges for the surveillance and control of communicable diseases. In early April 2003, the World Health Organization (WHO) sent a team of public health experts to Kuwait and a base was established in the southern Iraqi governorate of Basrah on May 3. We present the lessons learned from the communicable disease surveillance and control program implemented in the Basrah governorate in Iraq (population of 1.9 million) in April and May 2003, and we report communicable disease surveillance data through June 2003. Following the war, communicable disease control programs were disrupted, access to safe water was reduced, and public health facilities were looted. Rapid health assessments were carried out in health centers and hospitals to identify priorities for action. A Health Sector Coordination Group was organized with local and international health partners, and an early warning surveillance system for communicable disease was set up. In the first week of May 2003, physicians in hospitals in Basrah suspected cholera cases and WHO formed a cholera control committee. As of June 29, 2003, Iraqi hospital laboratories have con firmed 94 cases of cholera from 7 of the 8 districts of the Basrah governorate. To prevent the transmission of major communicable diseases, restoring basic public health and water/sanitation services is currently a top priority in Iraq. Lack of security continues to be a barrier for effective public health surveillance and response in Iraq. (author's)Micronutrient intake and status in rural Democratic Republic of Congo.
Vitamin, mineral and trace element intakes were assessed in a rural African population using a novel dietary survey method, and compared with status measurements. In addition to the previously described protein deficiency, multiple micronutrient deficiencies were observed. Although vitamin A intakes were generally satisfactory, some low plasma retinol concentrations were observed in adults, due perhaps to the very low protein intakes or infectious diseases. Vitamin B1, B2 and niacin intakes were clearly inadequate, and for the two former were confirmed by status measurements. Whilst B6 intake was low, B6 status was adequate, probably resulting from lower requirements because of low protein intakes. B12 intake was low in some age groups, whereas that of folate was satisfactory. Fe, Cu and Mg intakes appeared to be adequate. Intakes of phosphorus and iodine were low for children and adolescents; those of Zn and Ca were clearly inadequate, except for Zn in women. Dietary interventions to prevent or treat malnutrition in this region should address several micronutrients in addition to protein. (author's)Oral contraceptives and nutritional status in adolescent British girls.
Associations between oral contraceptive pill (OC) use and vitamin, mineral and lipid status were examined in 117 postmenarcheal 16-to-18-year-old British girls, from the 1997 National Diet and Nutrition Survey of young people aged 4 to 18 years. Thirty-nine were taking OCs at the time of blood, anthropometric and sociodemographic assessment, while seventy-eight were not. After adjusting for age, body mass index and smoking, OC use was significantly associated (P<0.05) with higher plasma retinol, 25-hydroxyvitamin D, total iron-binding capacity, total cholesterol, LDL-cholesterol and triacylglycerol concentrations. OC users also had lower concentrations of plasma ß-carotene, t-tocopherol and HDL-cholesterol, and serum vitamin B12. Nutritional status indices that did not differ with OC use included plasma concentrations of vitamin C, a-tocopherol, pyridoxal phosphate, all-but-one iron status indices and zinc. In light of the observed associations, OC use should be taken into account when assessing nutritional status in adolescent girls of childbearing age. (author's)A comparison of selected nutrient intakes in anemic and nonanemic adolescent girls in Kuwait.
In Kuwait, as elsewhere, little information exists on the nutrition status and diet habits of adolescents. Anemia is a widespread problem among Kuwaiti adolescent girls and is most likely caused by iron (Fe) deficiency. We examined anemia and dietary intake to ascertain whether dietary intake was related to hemoglobin (Hb) and/or Erythrocyte Protoporphyrin (EP) values and if the intake of anemia relevant nutrients differed between anemic and nonanemic girls. We measured the Hb, EP, dietary intake (24 Hour Recall), and obtained various background socio-economic data from 255 high schools girls. Dietary intakes (e.g., of Fe and Folate) were below recommended levels in the majority of the girls. Girls whose intakes of Fe or Folate equaled or exceeded the Recommended Dietary Allowance (RDA) had significantly higher mean Hb values. The results indicate that dietary intake of anemic girls is lower in important hematinics nutrients. (author's)The objective of the study was to determine the usefulness of utilizing plasma homocysteine concentrations as an indicator of vitamin B-6 status in subjects with inadequate and adequate status as demonstrated by currently accepted indicators. Plasma homocysteine concentrations of 77 thirdgrade Indonesian children (aged 8–9 y; boys and girls) were measured. About a quarter of these subjects had inadequate vitamin B-6 status as indicated by their plasma pyridoxal-59-phosphate concentrations, erythrocyte alanine aminotransferase activity coefficients, and reported dietary vitamin B-6 intakes. No significant differences in plasma homocysteine concentrations were observed between subject groups shown to have inadequate and adequate vitamin B-6 status using currently accepted indicators. Plasma homocysteine concentrations of the subjects were not correlated with values for other vitamin B-6 indices. Plasma homocysteine concentration was not an indicator of vitamin B-6 status in these children, as it did not differentiate between children shown otherwise to have inadequate and adequate status of the vitamin. (author's)Iron nutrition status assessment.
Haemoglobin and Volume of Packed Red Cell (VPRC) estimations were done on a sample of 2,821 mothers (15-65 years) and children (0-12 years) belonging to low income families, drawn randomly from fifteen remote villages in Andhra Pradesh. Correlation was done between the two sets of values. By the haemoglobin estimate, 84.9, 82.6 and 78.4 per cent of mothers, pre-school and school-age children respectively were anaemic. By the VPRC measure, anaemia was detected only in 49.6, 33.6 and 48.0 per cent of mothers, pre-school and school-age children respectively. The extent of anaemia is greater by haemoglobin estimation, compared to that of VPRC estimation. Correlation was not observed between the two sets of values. Therefore, haemoglobin appears predictive of the degree prevalence of anaemia and is to be preferred in screening population for anaemia. (author's)Targeting strategies used by the Chilean National Supplementary Feeding Programme.
Chile’s National Supplementary Feeding Programme (NSFP) has universal coverage for children under 6 years of age, pregnant and nursing women. We describe the NSFP’s main characteristics and analyse in a historic perspective, the different targeting strategies used since 1975 till the present. In addition, we provide a critical view of the principal evaluations carried out during that period. The information originates from papers and reports published either by investigators or government institutions. The programme provides two levels of benefits: one for participants with normal nutritional status and one for those that are underweight. Beneficiaries are entitled to receive the supplements only at a public health centre after complying with a health visit. Targeting strategies have used anthropometric indicators not only to determine who can become a recipient, but also as discharge criteria. Changes in these strategies have contributed in making the programme more cost effective since impact has been observed in the lowest income groups; approximately 80% of those targeted belong to the two lowest quintiles. In terms of total budget allocation, only 14% is received by the two richest quintiles. A limitation of the analysis we present in terms of identifying the causal relationship between the NSFP and nutritional improvement is the close linkage of the food programme with the primary health programme. Also, improved nutritional impact has been limited to only those with a real deficit, and that proportion is extremely low. (author's)Zinc and human immunodeficiency virus infection.
The importance of zinc in normal immune function - and of its deficiency in immune dysfunction - has led to increased interest in its role in nutrition and immunity in human immunodeficiency virus type 1 (HIV) infection. Zinc deficiency produces reversible immune dysfunction, particularly of T lymphocyte cell-mediated immunity. In developing countries where zinc deficiency is prevalent, zinc supplementation has been shown to reduce morbidity from respiratory and diarrheal illnesses. The relationship between zinc and HIV infection has not been well delineated. Malabsorption, repeated concurrent infections and increased losses probably increase zinc requirements in HIV infection. In some studies, low plasma zinc levels occur frequently in HIV infection and have predicted disease progression and mortality, suggesting supplementation might be beneficial. However, the finding that zinc binding to specific HIV proteins is essential for HIV function and replication and the association in one observational study of zinc intake with higher rates of HIV progression have raised questions regarding the safety of zinc supplementation among HIV-infected individuals. To date, no randomized, placebo-controlled study of moderate zinc supplementation in HIV infection has been published. We believe that available evidence supports the need for and acceptability of such a trial. (author's)Effects of human milk homogenization on fat absorption in very low birth weight infants.
We tested the effects of ultrasonic homogenization of human milk on fat absorption in very low birth weight (VLBW) infants. The study was conducted on 18 VLBW infants divided into two groups: 8 infants whose mothers were able to produce a milk volume sufficient to satisfy their requirements received this milk without pasteurization, and the remaining 10 received their own mother's milk complemented with bank milk. Each group was submitted to two consecutive fat balances in which they received at random homogenized or non-homogenized milk. Gestational age, birth weight and amount of fat ingested did not differ between groups. Fecal fat excretion was significantly lower in the group fed homogenized and non-pasteurized own mother's milk. The groups fed non-pasteurized milk absorbed fat at percentages close to those of the group that received pasteurized and homogenized human milk. The group that received pasteurized and non-homogenized human milk presented the lowest fat absorption. We conclude that the ultrasound homogenization process improved the absorption of human milk fat, suggesting that pasteurized human milk utilized as part of an infant feeding regime should be pre homogenized. (author's)The changes in the circulating levels of growth factors were followed during the first month of life in order to determine any effects of parenteral nutrition on insulin-like growth factors in preterm infants. Thirty-five preterm infants were assigned into two groups. Group one (n = 21, gestational age (GA) 32.1 ± 1.8 wks, birth weight (BW) 1676 ± 112 g) was receiving total parenteral nutrition (TPN) for the first 2–11 days and the other group (n = 14, GA 31.7 ± 1.9 wks, BW 1700 ± 96 g) was milk fed from the 2nd day of life. Serum total and free IGF-I and IGFBP-3 concentrations were determined and auxologic measurements were carried out. One month after birth total and free IGF-I and IGFBP-3 circulating levels had increased similarly in both study groups. However on day 15 the TPN group neonates while they were on lower calorie and protein intakes demonstrated smaller changes in the total IGF-I and IGFBP-3 peptides (IGF-I: 36.3 ± 3.9 vs 58. ± 10.6 ng/mL in the milk fed group, p < 0.05; IGFBP-3: 0.50 ± 0.04 vs 0.60 ± 0.07 mg/mL, p < 0.05). Their body weight gain was also lower for the same period (1681 ± 112 vs 1805 ± 92 g in the milk fed group). No significant differences could be seen in the free IGF-I levels and the free to total IGF-I ratio. However the weight gain was better correlated with free IGF-I and the intake of calories and protein in the TPN group (r = 0.7, p < 0.001, r = 0.5, p < 0.01 and r = 0.5, p < 0.001 respectively) than in the milk fed group (r = 0.6, p < 0.05, r = 0.2 and r = 0.1, NS). Whether increasing the energy intake with TPN will enhance the growth peptides and weight gain which would be of great clinical importance, needs to be verified. (author's)Comparison of three procedures for assessing fetal growth in neonates born in Mexico City.
Objective: To assess if three diagnostic criteria (DC) of alteration of fetal growth can be used interchangeably. Methods: We studied 1812 consecutive live singleton births, free of malformations, whose mothers received prenatal care and had certainty on date of last menstrual periods. Sensitivity and specificity were determined for: birth-weight <2500g (LBW), birth-weightAmino acid profiles in diet, plasma and human milk in Mexican rural lactating women.
This study was designed to assess the relation between the amino acid pattern consumed by marginally nourished lactating women, and the amino acid profiles in plasma and milk. Ten lactating women from a Mexican rural community, with an age of 19-29 (y), a postpartum time 15 (w), and a weight of 49 (kg), were studied in a metabolic unit. Experimental diet was similar to the rural habitual diet and it was given for 10 days. On the last 4 days urine, feces, milk and blood samples were collected. Measurement of total nitrogen in urine, feces and diet, and amino acid analysis in diet, plasma and milk were performed. Amino acid score of the habitual diet was : Lys as a limiting amino acid (18.5%), and Phe+Tyr (137.9%) in excess. Lys intake (21.8 ± 4.6 mg/g protein) was lower than the consumption recommended for lactating women (31 mg/g protein). Nitrogen balance was -9.6 ± 15.4 mg/kg BW/d. Total amino acid concentration in plasma was: 2212.6 ± 176.4 µmol/L, where indispensable and dispensable amino acids were 33% and 67% respectively; the most abundant amino acids were Ala, Glu, Gly, Lys and Val, and the less abundant were Cys and Asp. Total amino acid concentration in milk was: 24090 ± 1228 µmol/L, containing 42% and 58% of indispensable and dispensable amino acids respectively; the most abundant amino acids were Glu, Pro and Leu, and the less abundant were Cys, Trp, and Met. The results showed a correlation between the concentration of some indispensable amino acids present in the diet with those of milk (p<0.05). This study shows novel results about amino acid relation between habitual diet, plasma and milk in rural lactating women studied in balance conditions. (author's)To determine the vitamin A status of children with severe illnesses, we compared retinol concentrations in the liver and serum, histopathology of liver, and clinical complications in subjects who died in a diarrheal hospital. The median age of the study children (12 boys and 11 girls) was 24 months. About 87% (20/23) of the children were severely malnourished, having a median weight-for-age z scores of -4.35 (range, -5.55 to -2.50). All children were admitted with a history of diarrhea. They had multiple diseases or complications leading to death, including pneumonia, septicemia, colitis, and protein energy malnutrition. Stool cultures yielded Shigella in 11, Vibrio cholera in three, and Salmonella group-B in one. Liver and serum retinol concentrations were found inadequate in 79% (15/19) and 89% (17/19) of the subjects, respectively. Concentrations of retinol in the liver and serum correlated strongly even after controlling for liver weight (r = 0.72, p < 0.001) and weight-for-age z scores (r = 0.73, p < 0.001). Liver histopathology showed moderate to diffuse fatty changes in those children who had deficient liver retinol (< 0.07 µmol/g). These results indicate that children with fatal illnesses and complications have markedly decreased liver and serum retinol. (author's)A cross sectional study of maternal iron status of Korean women during pregnancy.
The purpose of this study was to determine the iron status of Korean women during pregnancy and to assess the relationship between maternal iron status and the outcome of their newborns. A total of eighty-one pregnant women living in Gwangju, Korea, participated in the study: 26 women were in the first trimester, 23 in the second trimester, and 32 in the third trimester. Maternal red blood cell (RBC) number, hemoglobin (Hb) concentration, and serum iron and ferritin levels were reduced significantly in the last trimester (p < 0.05) compared to the findings both in the first and second trimesters. On the other hand, total iron binding capacity (TIBC), transferrin level, and the ratio of sTfR to ferritin in the third trimester were higher (p < 0.05) than those both in the first and second trimesters. Dietary intake of iron in the three trimesters was 9.7 ± 2.3, 13.3 ± 4.3, and 10.6 ± 2.5 mg/day, respectively. All were far below the Korean Recommended Dietary Allowances (RDA) of iron for pregnant women. Approximately, ninety percent of the subjects consumed iron supplements after the 20th week of their pregnancies until delivery. The supplemental iron intake in the second and third trimesters was 40 ± 12 and 46 ± 11 mg/day, respectively. There was a significant correlation between the maternal Hb level in the third trimester and the birth weight of infants. In conclusion, maternal iron status deteriorated during pregnancy, although most subjects consumed more than the RDA of iron by taking iron supplements after the 20th week of pregnancy. The results confirm that maternal iron deficiency during pregnancy negatively affects the outcome of newborns. (author's)