The "migrant factor" in a plural society: a South African case study.
Migration usually assumes a disproportionate political significance in societies characterized by sharp racial, ethnic and social cleavages. The reason for this is not difficult to explain, for in these situations the immigrant becomes another weapon in the armoury of group antagonism. Small shifts in numbers take on an actual as well as symbolic importance which can in no way be related to their absolute size. As W. I. Thomas, that pioneering sociologist of migration, frequently emphasized: “If men define situations as real, they are real in their consequences.” This maxim can be extended to the collective level for it is equally true that if groups or societies define immigrants as a threat, the consequences of this perception will be real, no matter how illusory the objective basis of these fears proves to be. Few societies demonstrate the political ramifications of immigration more clearly than South Africa. This paper will focus on only one group of immigrants, those whose country of origin is Britain. South African society has been shaped and influenced by many different migrant groups: Africans from north of the Limpopo drawn to the mines and factories of the Witwatersrand; Dutchmen, Huguenots and Germans who formed the core of the contemporary Afrikaner community; slaves whose “involuntary migration” from the East Indies led to servitude at the Cape; Indians brought as indentured labourers to develop the Natal sugar plantations; and the Chinese introduced by Milner to reconstruct the gold mines in the aftermath of the Anglo-Boer War (1899-1902). However, the study of British migration to South Africa has two particularly interesting features. (excerpt)
Studies of migrant fertility in urban areas date back prior to World War I (Thomas, 1938). In the United States detailed analysis of migrant-native differentials in urban settings began as early as 1938 (Kiser, 1938), and today there is a substantial and growing body of literature concerning the relationship between migration and fertility (for a comprehensive bibliography see Myers and Macisco, 1975). In recent years, however, as information has become available from a wider variety of social settings, and demographers report findings that seem inconsistent, we seem to be suffering from an embarrassment of riches. For it has become increasingly difficult to reconcile contradictions, mush less integrate research results into a meaningful and coherent whole. It is not surprising, therefore, that the concern for additional and more detailed data is acute. Though we share this concern, we fell that such information will be of much greater significance if analyzed in the context of a more profound understanding and appreciation of current knowledge. Existing literature serves, unfortunately, as an inadequate guide to research because of the many unresolved contradictions. The goal of this paper is to account for and suggest ways of reconciling these inconsistencies. To the extent that we are successful we should be in a better position to discern and interpret empirical regularities. (excerpt)
A number of tools exist and have been applied and calibrated. There are rich experiences and lessons which can be cascaded as good practice. Need to learn from other sectors such as education in terms of what is being done in the field of HR management Many studies have been done on the impact of HIV/AIDS on health workers and need to have these replicated in different countries so as to allow for informed decision-making in development of HR policies. Managing HIV/AIDS is a systematic problem that requires a systematic response and not one-off projects. Unless we use the system thinking approach to mainstream HIV into HR planning and management we will only be dealing with symptoms and sustainability will be the problem. Many documents and tools and strategies are available. It seems people are continuously reinventing the wheel. This was a big opportunity to share knowledge/experience/tools on the state of the HRH initiative Feedback to survey respondents in education/health service delivery is essential. Health workers no better off than the general population on HIV prevalence. (excerpt)
Objective: To compare serum müllerian-inhibiting substance (MIS) concentrations in adolescent girls with polycystic ovary syndrome (PCOS) or normal menstrual cycles. Design: Prospective study. Setting: University department of obstetrics and gynecology. Patient(s): Thirty-one girls (12-18 years old) with PCOS and 17 girls (12-9 years old) with normal menstrual cycles. Intervention(s): Serum was collected from girls with PCOS or normal cycles during the early follicular phase of the menstrual cycle, stored frozen until assayed. Main Outcome Measure(s): Serum levels of MIS, E(-2), free-T, androstenedione, LH, and FSH. Result(s): Serum MIS levels in girls with PCOS were significantly higher compared with normal girls (4.1 ± 2.2 [SD] and 2.4 ± 1.0 ng/mL, respectively). The subjects were stratified for body mass index (BMI) (< and >25 kg/m(2). Serum MIS levels in PCOS girls (4.2 ± 3.0 ng/mL [BMI <25 kg/m(2)] and 4.0 ± 1.6 [BMI >25 kg/m(2)]) were significantly higher compared with normal girls (2.2 ± 0.8 and 2.6 ± 0.7 ng/mL, respectively). Conclusion(s): Adolescent girls with PCOS have significantly higher serum MIS levels compared with normally cycling girls. Serum MIS levels in PCOS were not influenced by BMI. Increased MIS production may represent an early manifestation of the disease. (author's)
Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination.
Objective: To determine the optimal interval of ejaculatory abstinence for couples undergoing IUI. Design: Retrospective analysis. Setting: Reproductive endocrinology and infertility center. Patient(s): Infertile couples undergoing ovulation induction and IUI with partner’s semen. Intervention(s): Ovulation induction with clomiphene citrate and a single IUI procedure per cycle. Main Outcome Measures(s): Clinical pregnancy rates as a function of abstinence intervals. Result(s): Four hundred seventeen women underwent 929 cycles from June 1999 to October 2002 for a median of 4 IUI attempts per couple. The median ejaculatory abstinence interval was 4 days (range 0-30) with an overall pregnancy rate of 12% per cycle. Abstinence correlated positively with inseminate sperm count but negatively with motility. Variations in inseminate parameters did not correlate with pregnancy rates. However, abstinence intervals significantly affected pregnancy rates. The highest pregnancy rate was observed with an abstinence interval of 3 days or less (14%) and the lowest pregnancy rate seen with an abstinence interval of 10 days or more (3%). Conclusion(s): An abstinence interval of 3 days or less was associated with higher pregnancy rates following IUI. Prolonged abstinence decreases pregnancy rates, independent of other sperm parameters, perhaps as a result of sperm senescence and functional damage not readily identified by standard semen analysis. Abstinence intervals should be controlled for in studies examining pregnancy outcome in assisted reproduction. (author's)
The social demography of Filipino migrations abroad.
Migratory movements have always been present as an underlying element of continuity in Philippine history. From the earliest colonizations (Yengoyan 1967), to the major frontier movements of the twentieth century, long-distance migration--often permanent, frequently disruptive socially, but generally positive in its motivation--has been the recurrent theme. One such pattern of frontier movement is the focus of this essay: the migration of Filipinos across the borders of their nation to places beyond. The purpose of this article is to place the facts of Filipino migration to the United States, the most important foreign destination, in demographic perspective. This is accomplished by setting forth the statistical evidence in two general areas: 1) the basic demography of Filipinos in the Philippines (emphasizing, of course, marked patterns of internal migration and redistribution); 2) the changing social and demographic structure of the Filipino population in the United States. As these topics are explored, there will be occasion to emphasize a number of significant commonalities in the Filipino migration experience: similarities across the various internal migrations, and between these internal movements and the external flows. Coverage of these topics is necessarily selective, generally in ways which reflect the author’s research interests as well as the availability of firm data. (excerpt)
International migration in Southern Africa.
In the context of Southern Africa the term migrant tends to be defined as meaning a worker who oscillates between his home and his place of work over a distance which is greater than can be traveled on a daily commuting basis. In terms of this definition migrants, always Black in Southern Africa, may be workers who live either inside or outside the borders of the Republic of South Africa, or Southern Rhodesia, but who, either way, are living at work without their families. On the gold mines of the Witwatersrand and the Orange. Free State, for example, virtually all (99 percent) of the three hundred eighty thousand or so Black workers employed during the first half of the 1970s were housed as single men in hostels or compounds each holding between one thousand and eight thousand persons who came both from within the Republic of South Africa as well as from countries further afield. From many employers’ points of view there is little difference between workers whether they come from Lesotho or from the Ciskei, but for the purposes of this paper we shall be considering only those migrants whose homes are across international boundaries. Once one starts looking only at the international flows one must also take into account the movements of people for longer than the conventional contract periods of the oscillating migrants. In South Africa, in Southern Rhodesia, and in Zambia there has, over the years, been a certain amount of more permanent migration of foreign-born Africans moving in and setting. Nevertheless the most striking feature of the international migration within the Africa subcontinent is the extent to which it has been, and still is, of an oscillating nonsettled nature. (excerpt)
Migration to the slum and squatter communities of Cagayan de Oro city, The Philippines.
With regard to Southeast Asia, and especially the Philippines, there have been several social scientists who have examined squatter and slum populations in the urban centers. An overview into the urban squatter phenomenon in Southeast Asia is provided by Jackson who states that “squatters now comprise between a quarter and a third of the total population of most of the region’s capitals” (1974:24; see also Poethig, 1971). In the Philippines, several social scientists have examined the socioeconomic problems and characteristics of squatter and slum areas in various cities and these studies have all been on one, or only a few, of the communities within the city. Thus, Laquian (1969), Hollnsteiner (1972; 1973), Juppenlatz (1970), Stone and Marsella (1968), and Poethig (1969) have investigated squatter areas in Manila. Laquian (1972) and his colleagues (Cariño, 1971) have reported findings on an in-depth analysis of one squatter community in each of six intermediate-sized Philippine cities; the study compares the social and economic characteristics of the six communities. And the Hackenbergs (1973) and their colleagues (Feldman, 1973) have carefully analyzed several of the squatter communities in Davao City, on Mindanao. These studies have all examined the socioeconomic characteristics of the low-income populations under study and in this regard they are valuable for comparative purposes. After reviewing squatter and slum research completed on Southeast Asia (and Hong Kong), however, there are at least three areas in which research is lacking. First, there has been very little research published which discusses the migration origins, trends, and characteristics of the squatter and slum population. Second, there have been few investigations of squatter areas in the intermediate-sized cities of Southeast Asia; in Southeast and East Asia the primate cities of Manila, Kuala Lumpur, and Hong Kong have been given the most attention. Third, and as explained above, there have been no empirical studies completed which examine the entire squatter and slum population of a single city. The purpose of this paper is to begin to fill these research gaps. Specifically, the paper will examine the migration characteristics of the entire squatter and slum population of one intermediate-sized city in the southern Philippines; Cagayan de Oro City, the largest city on the northern coast of Mindanao Island. (excerpt)
Fertility and migration: the case of Puerto Rico.
The effect of migration on fertility is primarily of interest when the areas of origin and destination differ with respect to reproductive norms and behavior. Typically, the area of origin is one of high fertility and the area of destination is one of low fertility. It is expected that migration itself and exposure to the milieu of low fertility will bring about lower fertility among migrants than among their non-migrant contemporaries at place of origin. It is also expected that, because of socialization in an area of high reproductive norms and behavior, migrants will have higher fertility than their non-migrant contemporaries at place of destination. Of these two propositions, the latter has received the bulk of the research attention--for reasons of data availability. Since censuses and surveys are geographically bounded, it is quite common to have migrants and comparable non-migrants at place of destination included in the same census or survey. However, migrants and comparable non- migrants at place of origin are not included in the same census or survey unless the distances involved are relatively small. This paper compares the fertility of Puerto Ricans who migrated to the United States with the fertility of their non-migrant counterparts who remained in Puerto Rico. As such, this paper examines the effect of the migration itself and the subsequent exposure to a low fertility milieu on fertility, rather than contrasting differential fertility socializations. To do so, we have combined the 1-in-a-100 Public Use Sample of the 1970 Census for the Commonwealth of Puerto Rico with the records of all United States resident Puerto Ricans from the 1-in-a-100 Public Use Sample for the United States Census of 1970. (excerpt)
Most of the major immigrant receiving countries of the world possess policies at least implicitly propitious to the highly skilled. Such policies are no doubt strongly influenced by the trend towards the greater global integration of the skilled labor market (Weiermair, 1970). Immigration policy, together with a host of push and pull factors, has raised the proportionate share of the specialized human capital component in recent international migration. What are record flows of high talent manpower have become an increasing source of controversy. Much of this controversy derives from the character of the origin and the destination. For commonly it is the developing nations which are beset by a large net outflow and developed nations, most notably the United States, which emerge as the principal recipients (See, for example, Beijer, 1967; Thomas, 1867). As part of the pursuit of further knowledge concerning the movement of specialized human capital between developed and developing nations, this paper focuses on South America as the origin and the United States as the destination. Specifically, the objective is to explore whether or not legislative changes effected through the Immigration Act of 1965 may have induced an expansion in the absolute and relative number of highly skilled South Americans emigrating to the United States. Is this Act, as it applies to South America, generating or exacerbating what “nationalists” would label “brain drain?” (excerpt)
Two hundred thirty-four Gambian children with severe falciparum malaria who were admitted to the pediatric ward of a rural district hospital each were matched for age with a same-sex control subjects presenting as an outpatient with uncomplicated falciparum malaria. Severe malarial anemia (SMA) was the most common presentation (152 cases), followed by cerebral malaria (38 cases) and hyperparasitemia (26 cases). Children presenting with SMA were significantly younger and more likely to carry gametocytes than were children with other severe presentations. Alleles of the genes pfcrt and pfmdr1 associated with chloroquine-resistant parasites occurred together among cases presenting with SMA alone more often than among their matched controls (odds ratio, 2.08 [95% confidence interval, 1.04-4.38]; P = .039). Costs of travel to the hospital of more than US $0.20, use of mosquito repellents, and carriage of resistant parasites were identified as independent risk factors for severe malaria in the case-control analysis. We conclude that, in this setting, poor access to the hospital and a high prevalence of chloroquine-resistant parasites lead to a delay of adequate treatment for young children with malaria, who may then develop SMA. (author's)
Background: Adolescent girls in the United States and around the world are at a heightened risk for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). Objective: To determine the efficacy of a skill-based HIV/STD risk-reduction intervention in reducing self-reported unprotected sexual intercourse among African American and Latino adolescent girls. Design: Randomized controlled trial with 3-, 6-, and 12-month follow-ups. Setting and Participants: Sexually experienced African American and Latino adolescent girls recruited from the adolescent medicine clinic of a children’s hospital serving a low-income inner-city community (N = 682, mean age, 15.5 years); 88.6% were retained at the 12-month follow-up. Interventions: Three 250-minute interventions based on cognitive-behavioral theories and elicitation research: an information-based HIV/STD intervention provided information necessary to practice safer sex; a skill-based HIV/STD intervention provided information and taught skills necessary to practice safer sex; or a health-promotion control intervention concerned with health issues unrelated to sexual behavior. Main Outcome Measures: Primary outcome measure was self-reported frequency of unprotected sexual intercourse; secondary outcomes included the frequency of sexual intercourse while intoxicated, the number of sexual partners, biologically confirmed STDs, and theoretical mediator variables, including the intention to use condoms, beliefs about using condoms, and condom- use knowledge. Results: No differences between the information intervention and the health control intervention were statistically significant. Skills-intervention participants (mean [SE], 2.27 [0.81]) reported less unprotected sexual intercourse at the 12-month follow-up than did information intervention participants (mean [SE], 4.04 [0.80]; P = .03), or health control-intervention participants (mean [SE], 5.05 [0.81]; P = .002). At the 12-month follow-up, skills-intervention participants (mean [SE] 0.91 [0.05]) reported fewer sexual partners (P = .04) compared with health control-intervention participants (mean [SE], 1.04 [0.05]) and were less likely to test positive for STD (mean [SE], 10.5% [2.9%]) than were health control-intervention participants (mean [SE], 18.2% [2.8%]; P = .05). No differences in the frequency of unprotected sexual intercourse, the number of partners, or the rate of STD were observed at the 3- or 6-month follow-up between skill-intervention participants and information- intervention or health control-intervention participants. Conclusion: Skill- based HIV/STD interventions can reduce sexual risk behaviors and STD rate among African American and Latino adolescent girls in clinic settings. (author's)
Knowledge and attitude of males regarding birth spacing and contraception.
A cross sectional study with 368 males (husbands of women delivered at Regional Institute of Medical Sciences hospital) revealed that 89% of them were aware of contraception. But only the meaning of birth spacing was known to 13% of them correctly. Education, income and parity were significantly associated with knowledge on birth spacing. (author's)
Background: This descriptive cross-sectional study was conducted among prospective couples referred from Faith-Based Organisations in Port Harcourt, Nigeria for pre-marital HIV screening. The study sought to establish the sero- prevalence of human immunodeficiency virus (HIV) in this peculiar study group. Methods: A total of 84 healthy heterosexual couples who required pre-marital HIV screening were tested between January 2000 and December 2003 using a Double ELISA confirmatory test of Immunocomb and Genscreen HIV I&II Kits. Results: Amongst the 168 individuals tested, 35 (20.8%) were found positive. Sero-prevalence was significantly higher among females 23 (27.4%) compared to males 12 (14.3%). Infection rate was highest in the 25-29 years group (29.7%, n=22) and lowest in those of 35-39 years (6.1%, n=2), though this difference was not statistically significant (p-value=0.058). Infection rate was significantly higher among females (p-value=0.036); among prospective couples from Orthodox churches (p-value=0.021); couples with prolonged courtship (>6 months) (p- value=0.0001); couples with history of pre-marital sex (p-value=0.0001); and couples with history of cohabitation (p-value=0.0001). Conclusion: Our findings prompt a wake-up call for faith-based organizations (FBOs) to urgently initiate or be more receptive of measures that emphasize behavioural and social changes amongst members. Government and non-governmental organizations should organise capacity building training for religious based organizations to enable them cope with the challenges of HIV/AIDS. The outcomes of this study further underscores the value of voluntary counselling and confidential HIV testing and especially pre- and post-test counseling as the basis of pre-marital HIV testing. (author's)
Human resources for control of tuberculosis and HIV-associated tuberculosis.
The global targets for tuberculosis (TB) control were postponed from 2000 to 2005, but on current evidence a further postponement may be necessary. Of the constraints preventing these targets being met, the primary one appears to be the lack of adequately trained and qualified staff. This paper outlines: 1) the human resources and skills for global TB and human immunodeficiency virus (HIV) TB control, including the human resources for implementing the DOTS strategy, the additional human resources for implementing joint HIV-TB control strategies and what is known about human resource gaps at global level; 2) the attempts to quantify human resource gaps by focusing on a small country in sub- Saharan Africa, Malawi; and 3) the main constraints to human resources and their possible solutions, under six main headings; human resource planning; production of human resources; distribution of the work-force; motivation and staff retention; quality of existing staff; and the effect of HIV/AIDS. We recommend an urgent shift in thinking about the human resource paradigm, and exhort international policy makers and the donor community to make a concerted effort to bridge the current gaps by investing for real change. (author's)
Objective: The intent of this study was to evaluate the standard routine dose (500 IU) of Rh immune globulin (RHIG) therapy, which is offered routinely to all RhD-negative mothers delivering RhD-positive babies in Sudan. Methods: Blood samples from 140 pregnant women who were admitted for delivery to various Khartoum State hospitals were tested by the Kleihauer technique to determine the amount of fetomaternal haemorrhage (FMH) in the maternal circulation. Results: The results of the study demonstrated that the circulation of 10 out of 140 mothers (7.1%), tested by the Kleihauer method, contained more than 4ml of foetal blood. In addition, the association between foetal haemorrhage and mothers’ age, duration of pregnancy, baby weight, circumcision of the mother (cutting of the clitoris), type of delivery, and mothers’ gravida was statistically insignificant. Conclusions: The study concluded that 7.1% of mothers had a possibility of greater than 4ml of FMH. For these mothers, the standard RHIG dose of 500IU would be inadequate and they would need additional RHIG to prevent sensitization and potential harm to future babies. It is recommended to test all RhD-negative women delivering RhD-positive babies routinely with the Kleihauer method for detection and quantitation of FMH in order to determine the correct dose of RHIG to be administered. (author's)
HIV / AIDS epidemic features and trends in Saudi Arabia.
Background: More than 60 million persons have been infected since AIDS was described in 1981. By the end of 2003, an estimated 40 million individuals were living with HIV globally. The surveillance of HIV/AIDS still faces challenges in Saudi Arabia. This study describes the pattern and characteristics of HIV/AIDS cases in Saudi Arabia. Methods: This descriptive analytic study describes the reported HIV/AIDS data for all notifiable cases during the period 1984 to 2003 in the Kingdom of Saudi Arabia. Case definitions based on ELISA and Western Blot tests were used. Age, sex and regional distribution were studied in addition to survival rates. Results: As of 2003, 1743 Saudi nationals and 6064 non-Saudi HIV cases were reported. Among Saudis, 872 were AIDS cases. Males accounted for 1329 HIV infections, comprising 77%, with a male-to-female ratio of about 3:1. Adults 15-49 years constituted 78% of cases, including 46% of cases infected through sexual activity, while 33% of reported HIV seropositive cases had already died. Most cases (67%) were registered in Jeddah, Riyadh and Dammam. Infection through blood transfusion declined with no reported cases since 2001. Conclusion: The number of reported HIV infections in KSA has increased in the last few years. Using the coverage rate estimating method, the number of Saudi HIV infections since the emergence of the epidemic was estimated to be 2640 cases as of the beginning of the year 2004. The estimated number of HIV infections is almost one and one-half times the reported number, indicating that a problem of underreporting of HIV/AIDS cases still exists. (author's)
To describe a low-cost Papanicolaou staining procedure that can be applied to conventional and monolayer gynecologic preparations. Study Design The amount of alcohol consumed in the procedure, which normally accounts for >80% of the cost of processing, was reduced drastically by (1) using only 1 modified cytoplasmic counterstain (EA type), thereby (2) reducing the number of alcohol rinses by over half. Orange-G dye is omitted. Result The resultant effect of the modified staining protocol is quite satisfactory and attractive to screening eyes: nuclear details are sharp and crisp, while the cytoplasm contains transparent differential staining with blue-green and pink. Conclusion A reduction in the cost of staining should encourage cervical cancer screening, especially in developing countries, where cost is a limiting factor, thus making it possible for more women to be screened without increasing the cost of the program. (Acta Cytol 2005;49:169-172). (author's)
Objective: To determine the effect of self-medication with chloroquine and pyrimethamine on malaria infection and anaemia during pregnancy. Subjects and Methods: The study involved 210 women who attended Ade Oyo Maternity State Hospital, Ibadan, Nigeria. Of these, 156 were pregnant women while 54 were not pregnant (controls). Of the pregnant women, 66 were primigravidae, while 90 were multigravidae. History of treatment of malaria with antimalarial drugs was obtained from the subjects. Gravidity and gestation period were also documented. Two millilitres of blood was withdrawn from each subject, for haematological parameters. Thin and thick films were prepared for malaria parasite identification and quantification. Results: Of the primigravidae and multigravidae 68 and 16.4%, respectively, had taken antimalarial drugs prior to booking. Among primigravidae, only 18% of those with drugs compared with 32% without drugs were malaria-positive. The parasite density was significantly lower among those who took antimalarial drugs than among those who did not (976 ± 60 versus 2,421 ± 78, p < 0.05). Similarly, among multigravidae, only 16.4% of those who took antimalarial drugs compared with 34% of those who were not malaria-positive. The parasite density was also significantly lower in multigravidae with drugs than among those without drugs (350 ± 45 versus 1,000 ± 65, p < 0.05). The prevalence of anaemia (packed cell volume, PCV <33) was high, 89% in primigravidae and 70% in multigravidae. Severe anaemia (PCV <21) was more common in malaria-positive primigravidae and multigravidae than in malaria- negative women. Conclusion: The findings indicate that self-medication with chloroquine and pyrimethamine at booking was able to reduce the prevalence of malaria and anaemia in pregnancy. (author's)
Misoprostol in obstetrics and gynaecology - benefits and risks.
The well-documented effectiveness of misoprostol in several gynaecological and obstetric applications has resulted in enthusiasm for its use that has overtaken the need for careful assessment of potential risks. Since misoprostol has become freely available for termination of pregnancy (TOP) and for induction of labour at or near term, we have seen an increase in the incidence of uterine hyper stimulation, preterm labour, induced abortion above 20 weeks’ gestation, meconium-stained liquor in the latent phase of labour, fetal distress and cases of uterine rupture associated with the use of high doses of misoprostol. The purpose of these case reports and brief literature review is to highlight the benefits and risks associated with the current unregistered use of misoprostol in clinical practice and in the community. (excerpt)
Higher estrogen levels in premenopausal women have a protective effect against arteriosclerosis. In contrast, hormonal contraceptives are often connected with an increased cardiovascular risk, and opinions differ on whether or not smoking increases this risk. The aim of this study was to determine the influence of oral hormonal contraceptives and smoking on the production of nitric oxide metabolites (nitrites/nitrates). We investigated plasma concentrations of nitrites and nitrates in a group of 24 young women using hormonal contraceptives and a group of the same size of women not using such contraception. Both groups were further divided into smokers and non-smokers. The measurements of nitrites and nitrates were performed by a sensitive high- performance liquid chromatography method with two connected detectors. Plasma nitrate levels in women using hormonal contraceptives were lower in comparison with the control group of women not using such contraceptives. A statistically significant difference was also found when comparing nitrate concentrations between both groups of female smokers as well as between both groups of non- smokers. The lowest values were recorded in female smokers simultaneously using oral contraceptives. We have demonstrated lower plasma concentrations of nitrites and nitrates in contrast with the control group in premenopausal women using oral contraceptives in the long-term. Hormonal contraception and simultaneous smoking substantially decreases the plasma concentrations of nitric oxide metabolites (nitrites/nitrates), which can be evidence of vascular homeostasis defect and increased cardiovascular risk. (author's)
Prevalence of HIV infection in pregnant women in remote rural areas of Maharastra State, India.
In a study of 304 pregnant women, the prevalence of HIV infection in remote rural areas of western India was 0.7% (confidence interval 0.08-2.3%). It is nearly 2½ times higher than the presumed prevalence for this part of the country. (excerpt)
Treatment of human immunodeficiency virus (HIV) in children using antiretroviral drugs.
Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is having a devastating impact on African men, women and children. Antiretroviral treatment of children has lagged behind that of adults in Africa and globally. Fortunately, several national and international initiatives are helping to catalyze access of HIV-infected children to treatment. In general, the principles of antiretroviral treatment are the same for resource-rich and resource-poor settings. However, the more rapid progression of HIV disease often observed among children in Africa and some other resource-poor settings may argue for a more aggressive approach to initiation of treatment. In addition, numerous barriers to treatment of HIV-infected children in Africa and other resource-poor settings exist and must be overcome, including the expense of antiretroviral medications, lack of pediatric drug formulations, and poor human capacity and infrastructure for treatment administration. The 2.2 million African children currently living with HIV/AIDS, and many more living in poor countries on other continents, are dependent on all of us to work creatively to overcome barriers to the large-scale implementation of programs for health-restoring, life-prolonging antiretroviral treatment. (author's)
Risk factors for active tuberculosis after antiretroviral treatment initiation in Abidjan.
Rationale: In sub-Saharan Africa: (1) tuberculosis is the first cause of HIV-related mortality; (2) the incidence of tuberculosis in adults receiving highly active antiretroviral therapy (HAART) is lower than in untreated HIV-infected adults but higher than in HIV-negative adults; and (3) factors associated with the occurrence of tuberculosis in patients receiving HAART have never been described. Objective: To look for the risk factors for active tuberculosis in HIV-infected adults receiving HAART in Abidjan. Methods: Seven-year prospective cohort of HIV-infected adults, with standardized procedures for documenting morbidity. We analyzed the incidence of active tuberculosis in patients who started HAART and the association between the occurrence of tuberculosis and the characteristics of these patients at HAART initiation. Main Results: A total of 129 adults (median baseline CD4 count 125/mm(3)) started HAART and were then followed for 270 person-years (P-Y). At HAART initiation, 31 had a history of tuberculosis and none had current active tuberculosis. During follow-up, the incidence of active tuberculosis was 4.8/100 P-Y (95% confidence interval [CI], 2.5-8.3) overall, 3.0/100 P-Y (95% CI, 1.1-6.6) in patients with no tuberculosis history, and 11.3/100 P-Y (95% CI, 4.1-24.5) in patients with a history of tuberculosis (adjusted hazard ratio, 4.64; 95% CI, 1.29-16.62, p = 0.02). Conclusion: The risk of tuberculosis after HAART initiation was significantly higher in patients with a history of tuberculosis than in those with no tuberculosis history. If confirmed by others, this finding could lead to assessment of new patterns of time-limited tuberculosis secondary chemoprophylaxis during the period of initiation of HAART in sub-Saharan African adults. (author's)
Risk factors for pre-eclampsia in Lagos, Nigeria.
Background: Pre-eclampsia is an important cause of maternal mortality. Although there have been many studies worldwide on pre-eclampsia, not many have come from black Africa. Study design: A case-control study was conducted in a tertiary hospital in Nigeria (the black African nation with the highest population) between February 2001 and August 2002 to determine the risk factors for eclampsia. Information on socio-demographic characteristics, pre-pregnancy weight, medical history and previous obstetric history, and level of stress at home and at work was obtained by face-to-face interviews. Analysis: Multiple logistic regression analysis was used to determine the risk factors for pre-eclampsia. Results: One hundred and thirty seven (7.6%) of the 1803 women who delivered during the period had pre-eclampsia/eclampsia. Of these, 128 (93.4%) were analysed. Ninety-one (71.1 %) women were primigravidae. Age = 19 years was not considered a risk factor. The risk factors that were associated with increased risk of pre-eclampsia were: nulliparity (OR 4.77; 95% CI 2.90-7.78), stressful work during pregnancy (OR 2.10; 95% CI 1.20-3.71), stressful home environment (OR 1.97; 95% CI 1.27-3.69), previous pre-eclampsia (OR 11.68; CI 3.81-37.61), history of chronic hypertension (OR 2.21; 95% CI 1.17-6.20), a body weight greater than 8O kg (OR 2.01; 95% CI 1.05-3.87); and multiple pregnancy (OR 2.71; 95% CI 1.27-6.13). Conclusions: Risk factors for pre-eclampsia among Nigerian women are not different from those that have been reported in other studies. Weight reduction, good control of chronic hypertension, and reduction of stressful conditions at home and in pregnancy could be steps towards the primary prevention of this disorder. (author's)
Background: yellow fever remains one of the great burdens for public health in the endemic regions in Africa and South America. The under reporting of yellow fever cases in the respective regions and lack of international interest leads to an underestimation of the constant danger in these areas. Non- vaccinated travelers take a high risk without the effective protection of YFV 17D vaccination. Objectives: Two YF cases were imported to Europe in the last 4 years. We characterized two yellow fever virus (YFV) isolates from severely infected patients coming back from Africa, Ivory Coast and The Gambia, by genome sequencing and phylogenetic analysis. Study design: The virus infections in different organs were analyzed with pathological, immunohistological, electronmicroscopical and quantitative real-time PCR methods. Results and Conclusion: High virus loads in spleen and liver (2.4 x 10(6) to 3 x l0(7) GE/mL) demonstrated by real time PCR show massive virus replication leading to extraordinary progression of the disease in these patients. Immunohistological and electronmicroscopica1 analysis confirms virus particles in liver tissue. In all other organs no virus could be detected. A fast, specific and sensitive virus PCR detection is recommended for diagnostic of acute infections. The further sequence alignments show that the new isolates belong to the type II West African strain with great homology to over 40-year old YF isolates from Senegal and Ghana. The divergence observed was on average 3.3%, ranging from 0.0% to 5.0% in the coding region of Gambia2001 strain and 2.9%, ranging from 0.0% to 4.3% in the coding region of the IvoryC1999 strain. Most mutations (5.0%/4.3%, respectively) occurred in the envelope protein. (author's)
Setting: The Sudan National Tuberculosis Programme serves internally displaced and settled populations in Khartoum, Sudan. Objectives: To investigate whether treatment in the camps is satisfactory compared to the settled population and to World Health Organization (WHO) standards, and to map certain characteristics of the clinics that may explain differences in treatment outcome. Design: A register analysis was done on sputum smear-positive and retreatment tuberculosis patients registered consecutively in the first and second quarters of 2000. The nine health facilities from which the patients were selected were investigated using a questionnaire. State tuberculosis officers were interviewed about regional treatment policies. Results: Two hundred and ninety-five internally displaced and 154 settled patients from respectively five and four clinics were included. The cure and completion rates among new sputum smear-positive cases were significantly higher among displaced (65% and 9.3%) than among settled persons (43.5% and 21%). Displaced groups had better adherence to 5 and 8 month smear examinations, and the quantity of health education was higher in the camps than among the settled population. Conclusion: Tuberculosis treatment among the displaced population in Khartoum compares favourably with the neighbouring settled population, but both groups still face serious challenges to fulfill the WHO goals. (author's)
We have considered trends in incidence and mortality in 28 European countries using incidence data from successive volumes of Cancer Incidence in Five Continents and mortality from the WHO database. Countries with the highest rates in the early 1960s included the Nordic countries, Austria, Germany and the United Kingdom, but trends in these areas have tended to decline over recent calendar periods, particularly with regard to mortality. Southern European countries showed upward trends, at least until the early 1980s for France and Italy. Likewise, in most central and eastern European countries, ovarian cancer incidence and mortality rates were originally relatively low, but tended to rise over time. Falls in mortality, but not in incidence, over recent years were observed in the Czech Republic and Hungary. In several countries, mainly in northern Europe, trends were more favorable at younger age (25-49 years) than in the subsequent age groups. Thus, recent trends in ovarian cancer have led to a leveling of rates across various areas of the continent, although a 2.5-fold variation was still observed in the late 1990s between the highest mortality rate of 9.3/100,000 in Denmark and the lowest one of 3.6 in Portugal. These patterns should be viewed in the light of an observed reduction in parity, mainly in southern and eastern Europe, and the spread of oral contraceptive use, mainly in northern Europe, since these are the best recognized protective factors with regard to ovarian carcinogenesis. The declining mortality trends can also in part be ascribed to improvements in treatment. (author's)
The perilous road from evidence to policy: five journeys compared.
Comprehensive reviews of the available research are generally considered to be the cornerstone of contemporary efforts to establish 'evidence- based policy'. This article provides an examination of the potential of this stratagem, using the case study of ‘mentoring’ programmes. Mentoring initiatives (and allied schemes such as ‘coaching', 'counselling', 'peer education' and so on) are to be found in every corner of public policy. Researchers have been no less energetic, producing a huge body of evidence on the process and outcomes of such interventions. Reviewers, accordingly, have plenty to get their teeth into and, by now, there are numerous reports offering review-based advice on the benefits of mentoring. The article asks whether the sum total of these efforts, as represented by five contemporary reviews, is a useful tool for guiding policy and practice. Our analysis is a cause for some pessimism. We note a propensity for delivering unequivocal policy verdicts on the basis of ambiguous evidence. Even more disconcertingly, the five reviews head off on different judgmental tangents, one set of recommendations appearing to gainsay the next. The article refrains from recommending the ejection of evidence baby and policy bathwater but suggests that much closer attention needs to be paid to the explanatory scope of systematic reviews. (author's)
Patents and the faster introduction of new drugs in developing countries.
Very little attention has been devoted to studying the impact of patent rights on the introduction of new drugs across countries. It is expected for patents to imply higher prices, and greater profits, which in turn, encourage patent holders to launch new drugs in low and middle-income countries soon after they are launched in the USA. It is hypothesized that the patent owner will be more prone to enter if patents are granted than if not. In a patent regime, the marketing efforts of the patent owner will not spill over to other potential entrants during the patent term that would otherwise eventually come into the market. This spillover effect within products that contain the same drugs is important because drugs are experience goods in which firms invest heavily in to inform doctors and patients about the characteristics of each drug. This paper uses sales data on HIV/AIDS drugs in a sample of 34 low and middle-income countries between 1995 and 1999. It estimates a reduced-form probit model to assess empirically the impact of market exclusivity on introduction of new drug therapy. The main finding is that the patent regime had a positive effect on the introduction of new HIV/AIDS drugs in the subset of countries of the sample used with relatively equally distributed incomes. (excerpt)
Objective. To evaluate health care providers’ adherence to management guidelines for acute respiratory infection and diarrhoea in children under 5 years old in Botswana primary health care. Design. Cross-sectional prospective field survey. Data collection was carried out through observation of consecutive consultations at 30 randomly assigned clinics and health posts in three purposely chosen districts. Study participants. This study comprises 185 cases of acute respiratory infection and 85 cases of diarrhoea. Main measures. Criteria for acceptable standards of history taking and physical examination for acute respiratory infection and diarrhoea were defined as well as criteria for categorizing the appropriateness of antibiotic prescription. The percentage of oral dehydration salts provided in cases of diarrhoea was calculated. Results. Acute respiratory infection and diarrhoea accounted for 270 (including 15 missing cases) of all main diagnoses (n = 539). In 262 cases (97%) health care providers were nurses or enrolled nurses; in 3% family welfare educators. Acceptable history taking, physical examination, and both combined in acute respiratory infection was found in 113 (63%), 32 (18%), and 28 (16%), and in diarrhoea in 45 (58%), 26 (34%) and 20 (26%) cases, respectively. Antibiotics were prescribed in 76 of 255 (30%) cases. Prescription was assessed as inappropriate in 56 of 76 (74%) of all cases; in 41 of 52 (79%) cases with acute respiratory infection, in none of the pneumonia cases, and in all 15 cases of diarrhoea. Oral rehydration salts were prescribed in 74 (87%) of the diarrhoea cases. Conclusions: Health care providers’ adherence to guidelines on history taking was suboptimal in acute respiratory infection and diarrhoea but poor on examination in both conditions. A high level of inappropriate antibiotic prescription was found in acute respiratory infection and diarrhoea. Overall, there is considerable scope for improving diagnostic and therapeutic management of these major childhood diseases in Botswana primary health care. (author's)
Objective: To explore the widening role of home-based care (HBC) organisations in the management of TB patients in Lusaka, Zambia, in 1999. Design: In a purposeful sample of eight HBC organisations and 1 hospice in Lusaka, 142 TB patients under HBC, 54 care givers, 42 TB patients not under HBC and 9 managers were interviewed. Results: At least 50% of TB patients in Lusaka are cared for by HBC. The role of HBC in management of TB patients included food aid, practical and emotional support through the visits of voluntary care givers and, often, medical advice and treatment. TB diagnosis is carried out within the government health facilities. Five HBC organisations supplied anti-tuberculosis drugs, and three tried to carry out direct observation of treatment. The majority of the TB patients said their situation improved under HBC. Management was undermined by poor record keeping, sporadic anti-tuberculosis drug supplies, stigmatising preventive messages, limited supervision of care givers and poor coordination with the District Health Services. Conclusion: HBC organisations have become a key partner in TB control, looking after half the TB patients in Lusaka from diagnosis onwards, and complementing the public system. However, the quality of their management of TB and their partnership with government need to improve. (author's)
Objectives To determine how well antibiotic treatment is targeted by simple clinical syndromes and to what extent drug resistance threatens affordable antibiotics. Design Observational study involving a priori definition of a hierarchy of syndromic indications for antibiotic therapy derived from World Health Organization integrated management of childhood illness and inpatient guidelines and application of these rules to a prospectively collected dataset. Setting Kilifi District Hospital, Kenya. Participants 11 847 acute paediatric admissions. Main outcome measures Presence of invasive bacterial infection (bacteraemia or meningitis) or Plasmodium falciparum parasitaemia; antimicrobial sensitivities of isolated bacteria. Results 6254 (53%) admissions met criteria for syndromes requiring antibiotics (sick young infants; meningitis/encephalopathy; severe malnutrition; very severe, severe, or mild pneumonia; skin or soft tissue infection): 672 (11%) had an invasive bacterial infection (80% of all invasive bacterial infections identified), and 753 (12%) died (93% of all inpatient deaths). Among P falciparum infected children with a syndromic indication for parenteral antibiotics, an invasive bacterial infection was detected in 4.0-8.8%. For the syndrome of meningitis/encephalopathy, 96/123 (76%) isolates were fully sensitive in vitro to penicillin or chloramphenicol. Conclusions Simple clinical syndromes effectively target children admitted with invasive bacterial infection and those at risk of death Malaria parasitaemia does not justify withholding empirical parenteral antibiotics. Lumbar puncture is critical to the rational use of antibiotics. (author's)
Average annual risk of tuberculosis infection in India.
Estimates of the prevalence of tuberculous infection among children 1-9 years of age were available for four defined zones of India from a recently concluded tuberculin survey. These were pooled together and the average annual risk of infection in the country was computed as 1.5%. It was higher in urban areas, at 2.2%, than in rural areas, at 1.3%. The results call for further intensification of tuberculosis control activities, especially in urban areas, greater involvement of private practitioners and information, education and communication (IEC) for high-risk groups, to reduce the diagnostic and treatment delay thereby reducing the transmission of infection in all settings. (author's)
Hepatitis virus and HIV infections in inmates of a state correctional facility in Mexico.
We sought to determine the prevalence and associated characteristics of hepatitis A, B, C and D viruses and HIV infections in a prison in Durango, Mexico. Sera from 181 inmates were analysed for HAV antibody, hepatitis B core antibody (HBcAb), hepatitis B surface antigen (HBsAg), HCV antibody, HDV antibody, HIV antibody and HCV genotypes. Prevalence of HAV antibody, HBcAB, HBsAg, HCV antibody, HDV antibody and HIV antibody were 99.4, 4.4, 0.0, 10.0, 0.0 and 0.6% respectively. HCV genotype 1a predominated in HCV-infected inmates (62.5%), followed by HCV genotype 1b (25%) and HCV genotype 3 (12.5%). An association between HBV infection and age > 30 years found. HCV infection was associated with being born in Durango City, history of hepatitis, ear piercing, tattooing, drug abuse history, intravenous drug use and lack of condom use. We concluded that the prevalence of HAV, HBV, HDV and HIV infections in inmates in Durango, Mexico were comparable to those of the Mexican general population and blood donors, but lower than those reported in other prisons around the world. However, HCV infection in inmates was higher than that reported in Mexican blood donors but lower than those reported in other prisons of the world. These results have implications for the optimal planning of preventive and therapeutic measures. (author's)
Purpose: Many unintended pregnancies occur in women who use contraception. We conducted this study to determine if increasing body weight is associated with oral contraceptive (OC) failure. Methods: This retrospective cohort study consists of the 1916 women who reported using OCs in January 1993 and provided complete covariate information on the 1993 National Health Interview Survey and 1995 National Survey of Family Growth. Body weight and body mass index (BMI) were self-reported in 1993. The outcome was defined to be any conception occurring in women reporting OC use during the month of conception. Cox proportional hazards models were used to model the body weight/BMI-OC failure association. Results: Women with a BMI = 30 had a statistically significant increased risk of having an OC failure as compared to women with BMIs of 20 to 24.9 (HR = 1.80, 95% CI, 1.01, 3.20). However, after adjustment for age, marital status, education, poverty, race/ethnicity, parity, and dual method use, this increased risk was attenuated and no longer statistically significant (HR = 1.51, 95% CI, 0.81, 2.82). Increasing body weight was not associated with an increased risk of OC failure in the unadjusted or adjusted models. Conclusions: We did not find a strong or statistically significant association between increasing body weight/BMI and OC failure among this population of women. Prospective studies specifically designed to examine this association are needed to determine if heavier women should be advised to use a contraceptive method other than OCs to prevent pregnancy. (author's)
The use of a monitoring tool to assess counselling and HIV testing in the public sector in Malawi.
Scaling up of counselling and HIV testing (VCT) services requires a system of regular monitoring and evaluation. AVCT monitoring tool was developed through a consultative process and used to assess counselling and HIV testing services in 16 government an mission hospitals in Malawi, which had started expanded HIV-TB activities in July 2003. The essential components of the VCT monitoring tool included assessments of: (i) the hospital VCT personnel, in particular the number of counsellors (full-time and part-time) and those trained in and performing whole blood rapid HIV testing; (ii) the hospital laboratory service, in particular the protocols for HIV testing; (iii) the number, structure and function of dedicated VCT rooms; (iv) registers for patients, clients and donors having HIV tests; and (v) the quality of VCT through structured interviews with HIV-positive patients with TB. The main findings were: 9644 patients and clients were HIV tested between July and September 2003; HIV testing protocols were not standardized and differed between hospitals; there was little in the way of external quality assurance and there were deficiencies in the counselling process. In each hospital, the mean time taken to obtain the data and complete the VCT monitoring tool was 3 h. The VCT monitoring tool is straightforward to use, and the data collected should help to improve standardization, quality and future planning of VCT services in the country. (author's)
Relevant factors for cervical cancer among young women in Taiwan.
Objective: To evaluate the relevant factors for cervical cancer among young women in Taiwan. Materials and Methods: A case-control study was conducted between 1986 and 1992. The cases included 45 women younger than 36 years with histologically confirmed invasive cervical cancer. The controls were 54 women younger than 36 years with non-neoplastic conditions judged to be unrelated to any of the risk factors for cervical cancer. Questions were asked about demography, contraception, reproductive history, sexual history, diet, cigarette smoking, and cooking practices. Results: Cross tabulation and Pearson’s Chi- squared test showed that monthly income, age at first birth, parity, numbers of vaginal deliveries, age at first intercourse, history of sexually transmitted disease, husband visiting prostitutes, and cooking practice were significantly different between the case and control groups. However, after conditional logistic regression analysis, only cooking practice remained associated with cervical cancer among young women. Among young women reporting to cook on a daily basis, the risk of cervical cancer tended to increase among those who fried five times or more per month (OR = 7.4) compared with women who fried less often. Conclusion: The results from this study indicated that cooking practice may be a risk factor for the development of cervical cancer among young women in Taiwan. (author's)
Effectiveness of the non-profit organisation, "grandmothers against poverty and AIDS" - A study.
Arising out of and based on a pilot intervention project of the Albertina and Walter Sisulu Institute of Ageing in Africa, a non-profit organisation called Grandmothers Against Poverty and AIDS (GAPA) was formed. GAPA has been operating in Khayelitsha since October 2001. In that time the number of grandmothers participating in GAPA activities, namely workshops and psychosocial support groups, has been growing steadily. Anecdotal evidence suggests that the grandmothers are developing the capacity to cope with the effects of the AIDS crisis and are becoming empowered members of their communities. (author's)
Setting: Farms in the Boland health district, Western Cape Province, South Africa. Objective: To evaluate the effect of lay health workers (LHWs) on tuberculosis (TB) control among permanent farm workers and farm dwellers in an area with particularly high TB prevalence. Design: Pragmatic, unblended cluster randomised control trial. Methods: This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms, and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomization, and analysis was by intention to treat. Results: A total of 164 adult TB patients were recruited into the study, 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042, 95% CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group. Conclusion: Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established health service, despite reduction of services. (author's)
The great population debate: an opinion paper.
The debate over the ongoing explosion of population in the developing countries has become more muted since the 1960s, but the author maintains that population pressure is a major cause of the contemporary problems that plague so much of the Third World. He also argues that the wide disparity in regional birthrates threaten the peace of the world, and advocates the diversion of greater resources toward the provision of contraceptives to those countries that are too poor to provide them to their own people. Many impoverished Third World countries are currently doubling their population every twenty to twenty five years, and funds spent on ameliorating the demographic problem would not only reduce much of the misery afflicting these countries but would result in far greater savings in other areas. (author's)
Evaluation of renal functions in asphyxiated newborns.
Renal injury due to perinatal asphyxia has not been systematically evaluated. The available studies have used variable definitions, incomplete investigations and none had a control group. The aim of this study was to evaluate systemically the renal functions in severely asphyxiated newborns and to find if abnormal renal function tests can predict adverse outcome (death or neurologic abnormality at discharge). In a prospective case-control design, 25 inborn babies =34weeks gestation having asphyxia(5 min Apgar =6 or needing resuscitation =5min) were enrolled as ‘cases’. Simultaneously 25 gestation and weight matched babies with no asphyxia were as ‘controls’. Renal function tests, calculated renal indices using timed urine collections and excretion of ß(-2)- microglobulin and N-acetyl-ß-D-glucosaminidase (NAG) were monitored in both the groups for first 4 days of life. Fourteen (56 percent) asphyxiated babies had acute renal failure (ARF) as compared to 1 (4 percent) control (p = 0.002). Blood urea and serum creatinine values were significantly higher in asphyxiated babies on day 4 but not on day 2. Renal failure index and FeNa were higher in asphyxiated babies on both day 2 and day 4, but creatinine clearance was not different. Urinary excretion of both ß(-2)-microglobulin and NAG was higher in the asphyxiated babies on day 2 as well as day 4. Five minute Apgar =6 had the best sensitivity to predict renal failure. A combination of high serum creatinine and high blood urea had 100 percent sensitivity and negative predictive value to predict adverse outcome while serum creatinine >1.5mg/dl alone had the best specificity and positive predictive value. The renal parameters were however poorer predictors of adverse outcome in comparison to clinical markers like 5 min Apgar =3 and HIE stage II/III. Both glomerular and tubular involvement was seen commonly in babies with birth asphyxia. Clinical markers of asphyxia were better predictors of adverse outcome than renal function tests. (author's)
Anaemia, iron deficiency and vitamin A status among school-aged children in rural Kazakhstan.
Objectives: To investigate the prevalence of anaemia and iron deficiency and vitamin A status among school-aged children in rural Kazakhstan and identify factors associated with anaemia in this population. Design: A cross-sectional design. Setting: School-aged children in rural Kazakhstan. Subjects: Socio-economic and anthropometric information was collected from 159 school-aged children living in the Kzyl-Orda region of Kazakhstan. Blood samples were collected and the concentrations of haemoglobin (Hb), serum iron, serum ferritin (SF), erythrocyte protoporphyrin (EP), serum retinol and ß-carotene, total iron binding capacity (TIBC), transferring saturation (TS) and other haematological indices were measured. Results: Among the 159 children, the prevalence of anaemia and iron deficiency defined by the multiple criteria models (SF, TS, and EP) was 27% and 13%, respectively. Nine percent had iron-deficiency anaemia and 21% had serum retinol value <1.05 µmoll(-)(1). Mean SF and serum iron concentrations and TS were significantly lower in anaemic children than in their non-anaemic peers, while TIBC and EP were significantly higher in children with anaemia. Hb was significantly correlated with serum iron and retinol concentrations. Serum retinol and SF concentrations and mean corpuscular volume were significantly correlated with Hb by multiple regression analysis. Conclusions: Anaemia among school-aged children in rural Kazakhstan appears to be related to iron indices and vitamin A status. (author's)
Background: The insulin-like growth factor (IGF) system is implicated in the pathogenesis of diabetes and cardiovascular disease. Objective: We report the effects of total energy intake on the IGF system in two populations with markedly different dietary macronutrient intake and cardiovascular event rate. Design, subjects and setting: Dietary macronutrient intake was measured in a specific Gujarati migrant community in Sandwell, UK (n = 205) compared with people still resident in the same villages of origin in India (n = 246). Fasting IGF-I, IGF-binding protein (IGFBP)-1 and IGFBP-3, insulin and glucose (0 and 2 hour) were measured. Results: Total energy and fat intake were higher in UK migrants, as were IGFBP-3 and IGF-I (mean 95% confidence interval): 145.9 (138.1-153.6) vs. 100.9 (94.6-107.3) ng ml(-)(1); F = 76.6, P < 0.001). IGFBP-1 was lower in UK migrants (29.5(25.9-33.0) vs. 56.5 (50.6-62.5) µgl(-)(1); F = 48.4, P < 0.001). At both sites, IGF-I correlated positively with total energy (Spearman’s ? = 0.45, P < 0.001) and total fat (? = 0.44, P < 0.001) as did IGFBP-3 with total energy (? = 0.21, P < 0.05) and fat (? = 0.26, P < 0.001). Conversely, in Indian Gujaratis, IGFBP-1 fell with increasing total energy (? = -0.27, P < 0.001) and fat intake (? = -0.26, P < 0.01) but not in UK Gujaratis. Multiple linear regression modeling showed that increasing quartiles of fat intake were associated with higher IGF-I (ß = 0.42, P = 0.007) independent of age, body mass index, plasma insulin, fatty acids and 2-hour glucose. Conclusion: In these genetically similar groups, migration to the UK and adoption of a different diet is associated with marked changes in the IGF system, suggesting that environmental factors profoundly modulate serum concentrations and actions of IGFs. (author's)
Objective: To determine the serum levels of three lipid-soluble antioxidants (retinol, ß-carotene and a-tocopherol) in pregnant women attending an antenatal clinic (ANC) in Gondar, Ethiopia. Design: A cross-sectional study involving laboratory determination of serum levels of retinol, a-tocopherol and ß-carotene using high-performance liquid chromatography and questionnaire-based assessment of socio-economic status. Setting: ANC of a university teaching hospital. Subjects: Three hundred and twenty-two healthy pregnant women in their third trimester, who attended the ANC. Results: Mean serum levels of retinol, a- tocopherol and ß-carotene were found to be 1.23 ± 0.5, 25.5 ± 0.9 and 0.21 ± 0.09 µmoll(-)(1), respectively. The prevalence of vitamin A deficiency (<1.05 µmoll(-)(1)) among pregnant women was 38.5%. Women having low retinol (vitamin A) levels were highly likely to live in earth-floored and mud-walled houses, and less likely to own a house and to have a latrine. Conclusion: The study shows that serum levels of lipid-soluble antioxidants were low among ANC attendees in northern Ethiopia. It also indicates that some socioeconomic factors (such as poor housing standard) are associated with vitamin A deficiency. (author's)
Insulin resistance in adolescents with menstrual irregularities.
Purpose: To assess the presence of insulin resistance as well as the incidence of polycystic ovary syndrome (PCOS) in adolescents with menstrual disorders. Methods: A case-control study was conducted with 34 adolescents during the period of 2 to 4 years after menarche. The patients were divided into two groups: group I (G I) with 22 patients with menstrual irregularity, and group II (G II) with 12 patients with regular menstrual cycles. Body mass index and Ferriman-Gallway index were calculated for all patients, who also received a pelvic ultrasound. We measured DHEA-S, 17 hydroxyprogesterone, testosterone, TSH, LH, FSH, and prolactin in serum sample and conducted the glucose tolerance test with 75 mg dextrose with measurement of glucose and insulin. Results: Mean ± SD ovary volume was larger in G I (11.38 ± 4.06 cm(3)) than in G II (7.72 ± 5.59 cm(3)); P < 0.05. DHEA-S (G I = 47.23; G II = 38.38 µg/dl) and testosterone (G I = 54.19; G II = 32.53 ng/dl) levels were higher in patients with menstrual irregularity. In G I we detected two patients with diabetes mellitus and one patient with glucose intolerance. Sixteen patients in this group had clinical or hormonal characteristics of PCOS. The mean values of the area under the insulin curve (AUIC) were higher in patients with menstrual irregularities (8,556.52 µIU/mL/2 h) than in controls (5,743.38 µIU/mL/2 h); P < 0.05. Conclusions: The presence of PCOS was detected in 95% of the adolescents with menstrual irregularity. Patients with menstrual disorders presented higher AUIC values than controls. (author's)
Adolescent use of the monthly contraceptive injection.
Study Objective: To compare weight and continuation among adolescents using monthly medroxyprogesterone acetate (MPA)/ethinyl estradiol cypionate (E2C), tri-monthly depot MPA (DMPA), and daily oral contraceptive pills (OCP). Design: Medical records were reviewed for body mass index, demographics, and sexual history at baseline; and weight and continuation at 3, 6, 9, and 12 months. Bivariate analyses were performed by method, and continuation functions were compared by the log-rank and Wilcoxon tests. The effect of method on use duration was assessed by Cox regression. Setting: Hospital adolescent clinic. Participants: 12- to 21-year-old patients who initiated MPA/E2C, DMPA, or OCPs in 2001. Main Outcome Measures: Weight gain and method continuation. Results: MPA/E2C was initiated by 40 (18%) patients, DMPA by 63 (28%), and OCPs by 119 (54%, P < 0.001). OCP users were younger (P = 0.005) and more likely to be white, privately insured, and in school (P < 0.004) than MPA/E2C or DMPA users. Previous DMPA and OCP use, pregnancy, and sexually transmitted infections (STI) were more common among MPA/E2C than DMPA or OCP users (P = 0.001). Baseline BMI was lowest (P = 0.06) among DMPA users, and MPA/E2C users were most likely to be overweight (P = 0.03). There were non-significant differences in weight change. Continuation functions differed by the method only in the first three months of use (P = 0.03). Leading reasons for discontinuation were unavailability of MPA/E2C (20%), bleeding with DMPA (22%), and forgetting OCPs (17%). Duration of use was independently associated with white race (P < 0.005) and STI-never (P < 0.0001) but not with method type. Conclusions: Although MPA/E2C use was associated with overweight status and early discontinuation, it also was associated with previous use of other methods. For all methods, poor continuation at one year supports the ongoing search for effective contraceptive alternatives. (author's)
Husbands share responsibility.
Sichuan is China’s most populous province; its population in 1992 was 110 million, which is almost as large as Bangladesh or Pakistan. This province is well known for its effective control of population growth: both the birth rate and total fertility rate are below the national average. Sichuan’s successful family planning programme is partly attributed to the exemplary role played by husbands in practising family planning. About 15 million men have accepted male sterilization in Sichuan, which is about half of the national total and about one-fourth of the global total. In Sichuan Provinczed, 31% of all married men have been sterilized and the ratio of sterilized husbands to sterilized wives is 5:1. (excerpt)
A new way to distribute contraceptives.
It is a common practice of many restaurants in Beijing to offer their customers little souvenirs such as lighters, toothpicks and fans after dinner. But the newly opened Red Lotus Restaurants sometimes embarrasses its clients by providing them with contraceptives as gifts. The restaurant is sponsoring an activity titled “Special Love for Joyful Families” Its scope is so wide that it has won high appraisal from Peng Peiyun, State Councilor and Minister of the State Family Planning Commission (SFPC) who even visited the restaurant in person to extend her congratulations. Near the counter of the restaurant, colored strips are hanging from above with such slogans as “Never forget family planning while enjoying yourself” and “Special love for joyful families.” Displayed on the tables are all types of contraceptives as well as pamphlets about healthier childbirth and better upbringing of children, and general knowledge for the newly married. What is most attractive is the table for displaying birth control counselling materials. (excerpt)
Upgrade reproductive health services to better protect women.
Since the introduction and expansion of the family planning programme in 1971, China has made remarkable accomplishments in controlling the population size. The natural increase rate declined from 2.6% in 1970 to 1% in 1997. The average number of children born to a Chinese woman in her lifetime has dropped from six before 1970 to two. Despite the relatively low fertility level, China still sees an annual net population increase of 13 million, almost twice the size of the population of New York City. It is predicted that China’s population will top 1.3 billion by 2000, 1.4 billion by 2010, but achieving zero growth in the mid – 21st century before the population size hits the ceiling of 1.6 billion. In view of the serious situation, China’s family planning programme should be practiced for a considerably long period. Protecting the rights and interests of women and enabling women to have access to good health services have long been a critical issue deserving constant concern in all aspects, in the course of implementing the family planning policy. To initiate the programme was for the very purpose to improve women’s livelihood and raise their social status. (excerpt)
Report on reproductive health survey.
The major objective of the RH/FP project, jointly established by the Chinese Government and the United Nations Population Fund (UNFPA), is to facilitate the Chinese Government to fulfill the targets set forth by ICPD and other related international conferences such as the World Submit on Children held in 1990 and the Fourth World Conference on Women held in 1995, especially those on reproductive health and reproductive rights. For a further explanation, the Project is to contribute to the promotion of responsible reproductive behavior and practice through strengthening the dissemination of RH/FP information and knowledge, and to contribute to improved access to quality, client-oriented RH/FP services for women of childbearing age, men and adolescents. In order to realize the targets set out by the project, in July 1998, several surveys were conducted in 32 selected counties throughout China. This one, among others, focuses on the individual reproductive health status of women of childbearing age. (excerpt)
A reproductive health survey of rural women in Hebei.
A reproductive health survey, supported by the China Family Planning Association and American Welfare Foundation, and in collaboration with the Hebei Family Planning Association, was conducted in 1995, on 657 women aged 18-49 in rural areas of Tangshan City, Zhuozhou City and Xingtai City of north China’s Hebei Province. Among them, 620 were married, 37 single and six widowed. Findings and analysis I. The integration of family planning with MCH care has greatly protected and vigorously promoted rural women’s reproductive health. Fertility decline has mitigated the harm from high-parity births to women’s health. The implementation of the family planning programme has given rural women freedom to decide the desirable number of children and the birth interval. This has helped to eliminate undesired pregnancies and unwanted births. The risk of reproductive tract disease and other diseases is also decreasing. The survey indicates most of the women had one or two children, and only 15% had three or more. (excerpt)
Contraceptive choice and reproductive health -- A survey report on reproductive health in Hunan.
Since the initiation of the national family planning programme in China in the early 1970s, the contraceptive prevalence rate (CPR) and composition of contraceptive methods used by couples of childbearing age have changed dramatically. The three large-scale fertility surveys conducted by the State Family Planning Commission in 1982, 1988 and 1992 indicated CPRs of married women of childbearing age in the country increased from 70.9% in 1982 to 72.1 in 1988 and 83.5% in 1992. It should be noted that CPR in 1992 reached that of the north European countries, the highest level in the world. As for the composition of contraceptive methods, sterilization increased from 35.4% in 1982 to 53.5% in 1992, while IUD used dropped from 50.1% to 40.1 and other methods, including pills, contraceptive injectables, spermicides and condom, etc., decreased from 14.5% to 6.4%. Therefore, the characteristics of contraception practice of China’s couples of childbearing age can be basically summarized as a high CPR and high proportion of sterilization. (excerpt)
Reproductive Health Training Centre of Tibet.
The Reproductive Health Training Centre of Tibet, established in August 1996, is situated at No. 24, North Linkuo Road in the centre of Lhasa. It is a base for training technicians for delivering reproductive health and maternal and child health care. In 1996, the centre started three classes (twenty days for each class) to train maternal and child health workers at the grassroots level. Forty participants in total attended these classes. This year the centre is going to start another two training courses for the IEC (information, education and communication) workers for family planning. The centre hasn’t so far been equipped with necessary teaching aids, such as computers, slide projectors, transparent film projectors and others due to lack of fund. They have to borrow from Tibet University or hospitals in Lhasa. (excerpt)
Joint efforts to improve reproductive health.
Since 1991, the Ford Foundation, in cooperation with Beijing Medical University’s College of Public Health and the Association of Public Health from the University of California at Berkeley, has explored the feasibility of conducting a project focusing on reproductive health for women in poverty- stricken areas of Yunnan Province in the People’s Republic of China. The groups spent one year investigating the potential need for the programme and in developing project objectives. Among the preparations for the project, several significant steps were taken which included gaining feedback from many important reference groups. (excerpt)
China holds '95 Advance Seminars on Reproductive Health.
Many seminars and panels related to reproductive health issues have been conducted by Chinese scholars and relevant professionals since the International Seminar on Women’s Reproductive Health was held in 1994 in Beijing. Reproductive health is a new concept put forward in recent years. It is one of the burning topics at international conferences in such fields as population and development, women issues, maternal and child health, etc. Chinese workers engaged in maternal and child health, family planning and social work as well as other administrators are rather unfamiliar with the definitions and implication of the concept. To enable more people to get to know the relevant content of reproductive health, it is of vital importance to conduct academic training. This is the fundamental premise for the implementation of the reproductive health programme. (excerpt)
Advance supply of emergency contraception: a randomized trial in adolescent mothers.
Objective: To examine whether the advanced provision of emergency contraception (AEC) to parenting youth would increase emergency contraception (EC) utilization, and whether AEC would impact the rates of unprotected sex and contraception use. Design: Subjects were randomized to receive either information about EC or information and an actual supply of AEC. Subjects were interviewed at baseline, 6 and 12-month follow-up. Setting: Urban non-medical case management office. Participants: 160 adolescent mothers (ages 13 to 20) who were receiving case management services. Intervention: Advance supply of emergency contraception. Main outcome measures: Emergency contraception use, sexual activity, unprotected intercourse contraceptive methods and use. Results: Parenting teens who received AEC were much more likely to have used it than the control group at the 6-month interview (83% vs. 11%) and the 12-month interview (64% vs. 17%). Teens in the AEC treatment group were more likely to have unprotected sex at the 12-month follow-up interview (69% vs. 45%). There was no difference in condom use between the groups at either the 6-month, or the 12- month follow-up interviews. Conclusion: Advance provision of emergency contraception in parenting teens increases the likelihood of its use, and does not affect the use of condoms, or hormonal methods of birth control. Parenting teens who receive AEC may be more likely to have unprotected sex. (author's)
Bone mineral density differences between adolescent dancers and non-excercising adolescent females.
Study Objective: To compare the bone mineral density (BMD) of the axial and appendicular skeleton between regularly exercising collegiate dancers and age matched non-exercising young females between the age of 17 and 19 to assess the impact of weight-bearing exercises and menstrual status on BMD. Design: Prospective observational cohort. Setting: Sports clinic in a collegiate school of dance and a hospital-based adolescent clinic. Participants: The adolescent dancers consisted of full-time collegiate dance students from a tertiary Performing Arts Institute (n = 35). The non-exercising controls consisted of eumenorrhoeic patients of the same age presenting to the Adolescent Clinic (n = 35). Interventions: All subjects had a full hormonal profile, bio-impedance estimation of body fat, and dual energy X-ray absorptiometry and quantitative peripheral CT scans (pQCT) to determine bone density. Main outcome measures: Comparison of the mean bone mineral density in the axial and appendicular skeleton between the two groups. Results: The incidence of oligo/amenorrhoea in the dancers was 20%. The lumbar spine BMD (1.006 g/cm(2) vs. 0.938, P = 0.048) and hip BMD (neck of femur 0.978 g/cm(2) vs. 0.838, P < 0.001; Ward’s triangle 0.816 g/cm(2) vs. 0.720, P = 0.003; trochanter 0.777 g/cm(2) vs. 0.682; P < 0.001) were significantly higher in the eumenorrhoeic dancers as compared to controls. The radial BMD as measured by pQCT did not differ between the two groups, but the core trabecular tibial BMD was also higher in the dancers (321 mg/cm(3) vs. 286, P = 0.006). When only oligo/amenorrhoeic dancers (n = 7) were compared with the controls, the same differences in BMD values were to longer observed. Conclusion: Young women undergoing regular intensive weight-bearing exercises as in the collegiate dancers here studied have higher BMD in the axial and appendicular skeleton as compared to non-exercising females of the same age if they remain eumenorrhoeic during their training. This advantage was apparently lost when they developed oligo/amenorrhoea. (author's)
The National Food Consumption Survey (NFCS): South Africa, 1999.
Objective: The aim of the National Food Consumption Survey (NFCS) in South Africa was to determine the nutrient intakes and anthropometric status of children (1-9 years old), as well as factors that influence their dietary intake. Design: This was a cross-sectional survey of nationally representative sample of all children aged 1-9 years in South Africa. A nationally representative sample with provincial representation was selected using 1996 Census information. Subjects: Of the 3120 children who were originally sampled data were obtained from 2894, a response rate of 93%. Methods: The sociodemographic status of each household was assessed by a questionnaire. Dietary intake was assessed by means of a 24-hour recall and a food-frequency questionnaire from the caregivers of the children. Food purchasing practices were determined by means of a food procurement questionnaire. Hunger was assessed by a modified hunger scale questionnaire. Nutritional status was determined by means of anthropometric measurements: height, weight, head circumference and arm circumference. Results: At the national level, stunting (height-for-age below minus two standard deviations (< -2SD) from the reference median) was by far the most common nutritional disorder, affecting nearly one in five children. The children least affected (17%) were those living in urban areas. Even with regard to the latter, however, children living in informal urban areas were more severely affected (20%) compared with those living in formal urban areas (16%). A similar pattern emerged for the prevalence of underweight (weight-for-age < - 2SD), with one in 10 children being affected at the national level. Furthermore, one in 10 (13%) and one in four (26%) children aged 1-3 years had an energy intake less than half and less than two-thirds of their daily energy needs, respectively. For South African children as a whole, the intakes of energy, calcium, iron, zinc, selenium, vitamins A, D, C and E, riboflavin, niacin, vitamin B(-6) and folic acid were below two-thirds of the Recommended Dietary Allowances. At the national level, data from the 24-hour recalls indicated that the most commonly consumed food items were maize, sugar, tea, whole milk and brown bread. For South African children overall, one in two households (52%) experienced hunger, one in four (23%) were at risk of hunger and only one in four households (25%) appeared food-secure. Conclusion: The NFCS indicated that a large majority of households were food-insecure and that energy deficit and micronutrient deficiencies were common, resulting in a high prevalence of stunting. These results were used as motivation for the introduction of mandatory fortification in South Africa. (author's)
Objective: To describe how urbanisation influences the nutrition and health transition in South Africa by using data from the THUSA (Transition and Health during Urbanisation of South Africans) study. Design: The THUSA study was a cross-sectional, comparative, population-based survey. Setting: The North West Province of South Africa. Subjects: In total, 1854 apparently healthy volunteers, men and women aged 15 years and older, from 37 randomly selected sites. Pregnant and lactating women, those with diagnosed chronic diseases and taking medication, with acute infections or inebriated were excluded but screened for hypertension and diabetes mellitus. Subjects were stratified into five groups representing different levels of urbanisation in rural and urban areas: namely, deep rural, farms, squatter camps, townships and towns/cities. Outcome measures and methods: Socio-economic and education profiles, dietary patterns, nutrient intakes, anthropometric and biochemical nutrition status, physical and mental health indicators, and risk factors for non-communicable diseases (NCDs) were measured using questionnaires developed or adapted and validated for this population, as well as appropriate, standardized methods for the biochemical analyses of biological samples. Results: Subjects from the rural groups had lower household incomes, less formal education, were shorter and had lower body mass indices than those in the urban groups. Urban subjects consumed less maize porridge but more fruits, vegetables, animal-derived foods and fats and oils than rural subjects. Comparing women from rural group 1 with the urban group 5, the following shifts in nutrient intakes were observed: % energy from carbohydrates, 67.4 to 57.3; from fats, 23.6 to 31.8; from protein, 11.4 to 13.4 (with an increase in animal protein from 22.2 to 42.6 g day (-)(1); dietary fibre, 15.8 to 17.7 g day(-)(1); calcium, 348 to 512 mg day(-)(1); iron from 8.4 to 10.4 mg day(-)(1); vitamin A from 573 to 1246 µg retinol equivalents day(- )(1); and ascorbic acid from 30 to 83 mg day(-)(1). Serum total cholesterol, low-density lipoprotein cholesterol and plasma fibrinogen increased significantly across groups; systolic blood pressure > 140 mmHg was observed in 10.4-34.8% of subjects in different groups and diabetes mellitus in 0.8-6.0% of subjects. Women in groups 1 to 5 had overweight plus obesity rates of 48, 53, 47, 61 and 61%, showing an increase with urbanisation. Subjects from group 2 (farm dwellers) showed the highest scores of psychopathology and the lowest scores of psychological well-being. The same subjects consistently showed the lowest nutrition status. Conclusions: Urbanisation of Africans in the North West Province is accompanied by an improvement in micronutrient intakes and status, but also by increases in overweight, obesity and several risk factors for NCDs. It is recommended that intervention programmes to promote nutritional health should aim to improve micronutrient status further without leading to obesity. The role of psychological strengths in preventing the adverse effects of urbanisation on health needs to be examined in more detail. (author's)
Fortification of maize meal improved the nutritional status of 1-3-year-old African children.
Objective: To evaluate the effectiveness of a vitamin-fortified maize meal to improve the nutritional status of 1-3-year-old malnourished African children. Design: A randomised parallel intervention study was used in which 21 experimental children and their families received maize meal fortified with vitamin A, thiamine, riboflavin and pyridoxine, while 23 control children and their families received unfortified maize meal. The maize meal was provided for 12 months to replace the maize meal habitually consumed by these households. Methods: Sixty undernourished African children with height-for-age or weight- for-age below the 5th percentile of the National Center for Health Statistics’ criteria and aged 1-3 years were randomly assigned to an experimental or control group. Baseline measurements included demographic, socio-economic and dietary data, as well as height, weight, haemoglobin, haematocrit, serum retinol and retinol-binding protein (RBP). Anthropometric, blood and serum variables were measured again after 12 months of intervention. Complete baseline measurements were available for 44 children and end data for only 36. Changes in these variables from baseline to end within and between groups were assessed for significance with paired t-tests, t-tests and analysis of variances using the SPSS program, controlling for expected weight gain in this age group over 12 months. Relationships between changes in variables were examined by calculating correlation coefficients. Results: The children in the experimental group had a significantly (P = 0.05) higher increase in body weight than control children (4.6 kg vs. 2.0 kg) and both groups had significant (P = 0.05) but similar increases in height. The children in the experimental group showed non- significant increases in haemoglobin and serum retinol, while the control children had a significant (P = 0.007) decrease in RBP. The change in serum retinol showed a significant correlation with baseline retinol (P = 0.014), RBP (P = 0.007) and weight (P = 0.029), as well as with changes in haemoglobin (P = 0.029). Conclusion: Despite a small sample size, this study showed positive effects of a vitamin-fortified maize meal on weight gain and some variables of vitamin A status in 1-3-year-old African children. The study confirmed the relationship between vitamin A and iron status. The results suggest that fortification of maize meal would be an effective strategy to address micronutrient deficiencies in small children in South Africa. (author's)
Sexual and reproductive health and HIV / AIDS: a framework for priority linkages.
This framework proposes a set of key policy and programme actions to strengthen linkages between SRH and HIV/AIDS programmes. These linkages work in both directions, by integrating HIV/AIDS issues into ongoing SRH programmes, and conversely, SRH issues into HIV/AIDS programmes. This should enhance SRH, contribute to reversal of the AIDS epidemic and mitigate its impact. Based on experience and programming realities, four priority areas have been identified (see figure) where linkages are likely to lead to important public health benefits. Selecting which action to support will depend on the national context and the local situation, including HIV prevalence, as well as the organization and use of health services. For example, in settings with high prevalence of HIV infection and high utilization of family planning services, offering all family planning clients the opportunity to learn their HIV status would likely enhance the quality of family planning services and make an important contribution to HIV prevention efforts. This approach may not be as useful, however, in settings with low HIV prevalence and poor utilization of family planning services. (excerpt)
Integrating the fields of sexual and reproductive health and HIV / AIDS.
Several recent meetings have focused renewed attention on needed synergies between the reproductive health and AIDS fields. At the same time, the SRH field has been working to incorporate gender and SRH perspectives into the eight United Nations millennium development goals (MDGs), the new focus of development priority setting and funding. The field published several practical tools and guidance documents in 2004. These efforts are a few of many to link the two fields, from a narrow focus on creating a rationale for family planning within the AIDS field to insuring full reproductive and sexual rights of HIV-positive women within the MDG frameworks. The reviews have highlighted many critical issues, and much has been accomplished to articulate an agenda for collaboration and synergy both at the service delivery level and at policy levels. In this report, we review major activities undertaken to link the two fields, highlight “values” that each field brings to the collaboration, and point out shortcomings and gaps in the AIDS response that neither field has sufficiently addressed. We conclude with specific recommendations to address these gaps and to foster better synergy and effectiveness in a linked HIV and SRH response. (excerpt)
Sexual and Reproductive ill Health accounts for one-third, of the global burden of disease, amongst women of reproductive age, and one-fifth of the burden of disease among the population overall. HIV/AIDS indirectly accounts for many maternal deaths and is the direct cause of death of many individuals and their family members. HIV/AIDS is overwhelmingly transmitted by unprotected sex – particularly in the poorest countries. Regrettably, Sexual and Reproductive Health specialists have not taken a leading role in the fight against HIV/AIDS and many donor countries have prioritised HIV/AIDS at the expense of Sexual and Reproductive Health. The All-Party Parliamentary Group on Population, Development and Reproductive Health decided to investigate what happened to the link between Sexual and Reproductive Health and HIV/AIDS and what has been missed as a result? On the tenth anniversary of Cairo, the International Conference on Population and Development in 1994, the group conducted research, held Parliamentary Hearings and heard evidence from experts from both specialties. There are many reasons why the separation occurred. HIV/AIDS first achieved prominence when intravenous drug users and men having sex with men were the main high-risk groups; The focus of the developed world was on the search for drugs to keep HIV positive people alive; Many in the Sexual and Reproductive Health world were slow or unwilling to embrace the complicated problem of HIV/AIDS; The development of separate donor funding streams for HIV/AIDS and Sexual and Reproductive Health; and The antipathy of the Bush Administration in the United States toward Sexual and Reproductive Health choices. (excerpt)
This article reviews field experiences with provision of family planning services in prevention of mother-to-child transmission (PMTCT) programs in ten countries in Africa, Asia, and Latin America. Family planning is a standard component of most antenatal care and maternal–child health programs within which PMTCT programs are offered. Yet PMTCT sites often miss opportunities to provide HIV-positive clients with family planning counseling. Demand for family planning among HIV positive women varies depending on the extent of communities’ openness about HIV/AIDS, fertility norms, and knowledge of PMTCT programs. In Kenya and Zambia, no differences were observed in use of contraceptives between HIV-positive and HIV-negative women in the study communities, but HIV-positive women have more affirmative attitudes about condoms and use them significantly more frequently than do their HIV-negative counterparts. In the Dominican Republic, India, and Thailand, where HIV prevalence is low and sterilization rates are high, HIV-positive women are offered sterilization, which most women accept. This article draws out the policy implications of these findings and recommends that policies be based on respect for women’s right to informed reproductive choice in the context of HIV/AIDS. (author's)
At present, laparoscopy is the best sterilization procedure, Dr. E. Sapire recently said at the Obstetric and Gynecology Research Day at the University of Cape Town. The morbidity is low, the failure rate is very low, little pain is involved and the patient can soon return to work. In general, medical practitioners do not like their work to be examined and are apathetic toward the auditing thereof, even if they do it personally. The Royal College of Obstetricians and Gynecologists' confidential enquiry into laparoscopy was done over a period of one year. This review included 50,000 patients. A questionnaire was compiled about each patient's medical background, indications for surgery, the status of the surgeon and anesthetist, anesthesia, technique and complications. In Scotland the operation was performed proportionally more often than in England and the sterilization figure varied even more from area to area. The techniques, namely methods of insufflation and volume of gas used, surprised the observers even more. (excerpt)
[Inconveniences and complications after insertion of IUDs by general practitioners]
Introduction: In Denmark most IUDs are inserted by general practitioners (GPs). The aim of this study was to describe the safety and inconveniences of and complications countered during the use of IUDs in general practice. Materials and methods: All 232 GPs in Frederiksborg County were invited to participate, and 38% took part. Their age, the number of years they had worked as GPs and the length of their gynecological education were registered. Anamnesis, insertion procedure, inconveniences and complications were registered when the IUD was inserted and at two control visits six weeks and six months later. Results: 562 women were included, of which 25 insertions were abandoned. 434 copper IUDs and 98 gestagen-releasing IUDs were inserted. In 5 cases the type of the inserted IUD was not registered. 91.0% of the women reported that they were satisfied with the IUD at visit 2 and 85.2% at visit 3 without difference between the two types of IUD. Women who had a gestagen-releasing IUD complained about irregular bleeding more often in the beginning, while pain and heavy bleeding were more frequent among users of copper IUDs. General complaints were about pain, bleeding problems and discharge, which were also the most frequent reasons for removing the IUD. An IUD was most often removed from a woman who was using an IUD for the first time. Removal was independent of the age of the woman, menstrual history, the GP's experience and the circumstances of the insertion. In all, 51 women had their IUD removed because of complications. The rate of removal during the first half year was estimated at 7.7%. Discussion: The incidence of complications after insertion of an IUD inserted by a GP was low and corresponded to the results obtained by gynecologists and birth control clinics. (author's)
[Contraception -- and insertion of intrauterine devices in particular (editorial)]
Some decades ago, a Danish physician could practice medicine in the Danish healthcare system during decades without ever dealing with the topic of contraception. It was certainly a rare thing, but today - as general medicine is an integrated part of a doctor's residency - all Danish physicians face the subject of contraception, which is a natural part of general health services. The majority of patient and physician consultations with regard to the prevention of pregnancy seem to take place in the primary sector. The current issue of "Ugeskriftet" (Weekly Journal) presents a small piece of research from an average-size Danish county, where the authors have examined conditions pertaining to insertion of intrauterine devices as part of general medicine. Unfortunately, the article includes only 38% of the general practitioners in the area, and there is no comparison done with the insertion of intrauterine devices by specialists or at contraceptive clinics. Still, this research is important in many respects: Firstly, the focus is again on specific side effects caused by a frequently used method of contraception. Just this kind of focus enables us as physicians to improve the "side effect profile." Secondly, it may again lead to the recognition that there is no universal method of contraception. (excerpt)
[Father's role in pregnancy and childbirth]
Since the overwhelming majority of childbirths in Denmark moved into the hospitals in the course of the 1960s, fathers have increasingly been present at the birth of their children, and have gradually also participated in the pregnancy prophylactic. Today, about 95% of Danish fathers are present at childbirth. In Sweden, the father's presence at childbirth is also around 95%, whereas the statistics for England and Australia, for example, seem to indicate between 60-80%. In a cross-cultural study of the father's presence at childbirth in Montreal and Tokyo, the father's presence was 63% and 68% for English and French Canadian fathers, respectively, and 52% for Japanese fathers living in Montreal, but 19% for Japanese fathers living in Tokyo. Studies indicate that the continuous presence of an experienced support person at childbirth has the effect of reducing complications and need for medical intervention. According to the same examinations, the same positive effect does not seem to be valid for the father's presence. However, this should be examined more closely since the societies, in which the importance of the father's presence has been researched, are not representative of Nordic conditions. But thus far there is no documentation of the positive medical and obstetric effects of a fathers' presence at the birth of his child. (excerpt)
Perinatal health in Pakistan: a review of the current situation.
The perinatal mortality rate of 63–92/1000 births as reported from two provinces of Pakistan is unacceptably high. A vast majority of births and neonatal deaths occur at home and remain unregistered. In spite of a number of child survival programmes of proven efficacy in place, the impact on perinatal health is poor. Initiatives such as behaviour change communication, skill-based training of birth attendants and reaching the un-reached may be the key future strategies to reduce perinatal losses. (author's)
U.S. federal funding for HIV / AIDS: the FY 2006 budget request.
On February 7, 2005, the President introduced the Fiscal Year (FY) 2006 federal budget request to Congress, which includes an estimated $21.0 billion for domestic and global HIV/AIDS activities. This represents a 7% increase ($1.3 billion) over FY 2005 HIV/AIDS funding of $19.7 billion, although funding for HIV/AIDS is less than 1% of the overall federal budget. Approximately $18.0 billion (86%) of the FY 2006 HIV/AIDS request is for domestic programs; $3.0 billion (14%) is for global HIV/AIDS. Congress will now consider the budget request and is expected to finalize spending levels in late 2005. See Table 1 for detailed data on the request. (excerpt)
The future of the international family planning movement.
The last five decades have seen a revolution in the availability, use, and funding of family planning worldwide—a development many analysts credit with dramatically reducing fertility levels and slowing population growth in developing countries. However, contraceptive use remains low and need for it high in some of the world's poorest and most populous places. But after rising to prominence in the 1970s and 1980s, family planning has recently yielded the global policy spotlight as well as substantial amounts of funding to issues such as HIV/ AIDS and poverty alleviation. Paradoxically, the perceived successes of family planning might have led to its recent loss of visibility, as policymakers and the public view "the population problem" to have been largely solved. As funding continues to decline and a younger crop of leaders has yet to emerge for the field, many of those committed to family planning are asking hard questions about the movement's next steps. (excerpt)
Gender equality and empowerment: a statistical profile of the ESCAP region.
The purpose of this paper was originally to assist the deliberation of the High-Level Intergovernmental Meeting, Beijing +10, (Bangkok 7-10 September, 2004) by presenting a summary of the current situation of women in relation to men in a number of key areas in the Asia-Pacific region. This revised version forms the first volume in a series of two papers, all aimed at addressing major developments in the situation of women in the Asia-Pacific region. The Asia- Pacific region as defined by ESCAP’s membership includes some 50 countries in the region and some 9 territories covering East and North-East Asia, North and Central Asia, South and South-West Asia, South-East Asia and the Pacific. It has repeatedly been demonstrated that data are key to catalyzing and monitoring progress, as well as supporting country-level planning and local accountability. Gender statistics has therefore been a priority area in ESCAP’s statistical capacity building work for many years. As a result, considerable statistical progress has been achieved in the region since the Beijing Declaration and Platform for Action in 1995 adopted the strategic objective “to generate and disseminate sex-disaggregated data and information for planning and evaluation”. (excerpt)
Gender equality: new opportunities for moving ahead.
Ten years after the Fourth World Conference on Women, held in Beijing in 1995, women’s advocates are targeting new international mechanisms in their bid to erase inequalities between men and women and promote the advancement of women and girls. They have found that the Millennium Declaration and its time-bound and measurable goals, which have become a prime focus of development work throughout the world, provide an opportunity to mobilize governments and the international community to support the Beijing agenda. As a strategy for women’s empowerment, the agenda adopted in Beijing spells out critical areas for action to remove obstacles to women’s active participation in all spheres of public and private life. While the latest review of this Platform for Action shows some areas of progress, women are still commonly excluded from full participation in economic, social, cultural, and political decisionmaking. (excerpt)
Gender and income inequalities and HIV / AIDS pandemic. Draft.
This paper decomposes the impact of the determinants on the evolution of HIV/AIDS pandemic in sub-Saharan Africa from 1997 to 2001. We classify our determinants in socio-economic, epidemiological and sociologic and cultural. Our analysis shows that epidemiological and sociocultural variables have a greater impact than socio-economic ones. Furthermore, within the group of socio-economic variables, education and women’s economic independence is more important than country income in determining the curse of the pandemic. We then recommend that cost-effectiveness analyses be done before funds are allocated; so that there go were they are most effective in reducing the curve of the pandemic. (author's)
Getting it right, doing it right: gender and disarmament, demobilization and reintegration.
Disarmament is the collection of small arms and light and heavy weapons within a conflict zone. It frequently entails the assembly and cantonment of combatants; it should also comprise the development of arms management programmes, including the safe storage and final disposition of weapons, which may entail their destruction. De-mining may also be part of this process. Demobilization refers to the process by which parties to a conflict begin to disband their military structures and combatants begin the transformation into civilian life. It generally entails registration of former combatants; some kind of assistance to enable them to meet their immediate basic needs; discharge; and transportation to their home communities. It may be followed by recruitment into a new, unified military force. Reintegration refers to the process which allows ex-combatants and their families to adapt, economically and socially, to productive civilian life. It generally entails the provision of a package of cash or in-kind compensation, training and job- and income-generating projects. These measures frequently depend for their effectiveness upon other, broader undertakings, such as assistance to returning refugees and internally displaced persons; economic development at the community and national level; infrastructure rehabilitation; truth and reconciliation efforts; and institutional reform. Enhancement of local capacity is often crucial for the long-term success of reintegration. (excerpt)
Good health still eludes the poorest women and children.
This year's World Health Day theme, "Make Every Mother and Child Count," provides an excellent opportunity to review some of the leading indicators of health for women of reproductive age as well as the gap in maternal and child health between wealthy and poor countries. Women and girls have made steady gains in a number of health areas over the past decade, including increases in the use of modern contraceptives and declines in the number of births per woman. But women and children everywhere still face formidable obstacles to good health. Far too many women still lack access to family planning or face social or cultural barriers to using it. Deaths related to pregnancy and childbirth show no signs of abating in the developing world, and 4 million children die in the first month of life, with 98 percent of these newborn deaths occurring in developing countries. Women also account for one-half of all new HIV infections worldwide, a proportion that has been increasing steadily as heterosexual transmission of the virus becomes more common. And the poorest women and children worldwide face greater health risks and are less likely to use key health services than those who are better off. (excerpt)
To have and to hold: Congressional vows on marriage and sex.
This article discusses what the government has already done to promote abstinence-unless-married programs and marriage, and what it proposes to do with the reauthorization of the welfare law. The article then discusses the relationship between marriage and pregnancy prevention, including research findings on the influence of childbearing on marriage. It then concludes with some recommendations on what Congress could do in the reauthorization of PRWORA to ensure that funding for abstinence-unless-married programs and marriage promotion truly meet the needs of the populations for which it is intended. (excerpt)
This report presents the vital registration and maternal and child health data gathered from Matlab, Bangladesh, in 2003. The data were collected by the Health and Demographic Surveillance System of ICDDR,B: Centre for Health and Population Research. The surveillance area is divided into a ICDDR,B service area and a Government service area. Government area receives government services and ICDDR,B area receives only ICDDR,B services. In the surveillance area as a whole, fertility remained the same in 2003 compared to 2002. The total fertility rate (TFR) was 3.1 per women and the crude birth rate (CBR) was 25.7 per thousand population. In the ICDDR,B area, CBR was 26.4 and TFR was 3.1, and in the Government area, CBR and TFR were 25.1 and 3.2 respectively. The crude death rate was 6.8 per 1,000 population in the ICDDR,B area, while in the Government area it was decreased to 7.0 in 2003 compared to 7.3 in 2002. The infant mortality rate was 42.1 per 1,000 live births in the ICDDR,B area, and in the Government area it was 47.5. The mortality rate among children aged less than 5 years has decreased in both the areas; in the ICDDR,B area it has decreased to 55.2 per 1,000 live births in 2003 from to 61.1 per 1,000 live births in 2002, and in the Government area it was 62.9 in 2003 down from to 73.6 in 2002. The rate of in-migration decreased to 40.4 per 1,000 population in 2003 from 45.7 in 2002, and the rate of out-migration increased to 55.4 per 1,000 in 2003 from 52.4 in 2002. The net out-migration rate was 15.0 per 1,000 population, thereby offsetting the rate of natural increase, which amounted to 18.8 per 1,000 in 2003. The overall annual population growth rate was 0.4%. The marriage rate was 14.1 per 1,000 population, and the divorce rate was 101.1 per 1,000 marriages. (excerpt)
Nepal community involvement. Support communication to enhance young mothers' reproductive health.
From 2000 to 2003, FRONTIERS supported a study by the Center for Research on Environment, Health, and Population Activities (CREHPA) to test communication-based models for improving young couples’ access to and use of reproductive health information and services in the Udaypur district of eastern Nepal. The 14-month intervention, undertaken as part of a reproductive health project implemented by the Nepal Red Cross Society (NRCS) and the Center for Development and Population Activities (CEDPA), sought to improve social norms that leave young women vulnerable to health risks related to early marriage and childbearing and limited access to reproductive health services. The study compared two experimental models with two control groups. In the experimental models, information, education, and communication (IEC) materials were provided for: (1) “youth communication action groups,” formed in ten village development committees (VDCs) made of young married women under the age of 25; and (2) existing or reactivated village mothers’ groups in ten VDCs made of women aged 15-49 (formed as part of government health services). The two experimental groups received training, assistance with group interaction, outreach, and educational materials about sexually transmitted infections (STIs) and condom use. Members of both groups met monthly and were encouraged to organize special events such as health fairs, talk programs, and educational events for husbands. (excerpt)
India community involvement. Broad representation supports credibility of village committees.
India’s decentralized reproductive and child health program directs health workers to involve village leaders to promote community participation in the program. Evaluations have shown, however, that community involvement in the program has not been achieved. In response, from 2000 to 2002 the Foundation for Research in Health Systems (FRHS), a nongovernmental organization (NGO), with support from FRONTIERS, tested a new community-based health committee model in Karnataka state in southwestern India. Sixty-four village health committees, each with about 15 members, were formed in a rural subdistrict of Mysore. Committee members were chosen from clusters of 50-60 households representing the various castes and communities of 216 villages. The roles of village health committees were to: (1) undertake activities to create health awareness about existing and new health services; (2) foster understanding between community members and government health staff; and (3) participate in the development of action plans to meet local health needs. The study also sought to identify the best way to form village committees. Committees were formed through four processes: (1) council meetings during which community members suggested candidates; (2) nomination by health workers and local leaders; (3) nomination by local government representatives; and (4) nomination by health workers and members of community-based organizations. (excerpt)
Enhancing girls' life skills requires long-term commitment.
In 2001, the Population Council teamed with CARE India to test a pilot intervention to enhance skills and expand life choices for adolescent girls living in the slums of Allahabad. The 10-month intervention, which was incorporated into CARE’s ongoing reproductive health program for slum dwellers, tested the effect of the skills intervention on the girls’ reproductive health knowledge, social contacts and mobility, self-esteem, and perception of gender roles. The quasi-experimental design compared pre- and post-intervention changes among girls aged 14 – 19 in the intervention site with a similar population in a control site. Adolescents in both sites received reproductive health education from peer educators. In addition, participants in the experimental area received courses on such skills as embroidery, pottery decoration, and candle-making, help with the establishment of savings accounts, and follow-up counseling. A total of 19 courses, most lasting one to two weeks, were conducted at the homes of peer educators and in training centers outside the slum. The impacts of the intervention were assessed using survey responses from girls who were interviewed in both baseline and endline surveys. (excerpt)
Senegal. Female genital cutting. Community education program increases dialogue on FGC.
From 2000 to 2003, FRONTIERS collaborated with the Senegalese nongovernmental organization Tostan to evaluate the effects of a community-based education program on awareness, attitudes, and behavior regarding reproductive health and female genital cutting (FGC). The Tostan program provides modules in local languages on hygiene, problem solving, women’s health, and human rights. It was designed to improve women’s health and promote social change by enabling participants, mainly women, to analyze and find solutions to community problems. Tostan implemented the education program as part of a scale-up effort in 90 communities in the Kolda district of southern Senegal in cooperation with the Ministry of the Family and Social Development with funding from the GTZ’s Supra Regional Project for the Elimination of FGC. About 350 women and 84 men took part in the training. Participating villages established committees to coordinate classes and related public events, and class participants were encouraged to share their new knowledge with others in their villages. The FRONTIERS evaluation took place as part of the project and compared changes in knowledge, attitudes, and behavior of men and women in 20 villages in the intervention area (including both study participants and nonparticipants) with those living in 20 non-intervention villages. Changes were measured using pre- and postintervention surveys of women and men in the intervention and control areas (including nonparticipating men and women in the intervention villages), and qualitative interviews with key community members (including traditional excisors, healers, and local civic and religious leaders). They also assessed pre- and post-intervention changes in the number of girls under 10 who had been cut. (excerpt)
Burkina Faso. Female genital cutting. Community education program scaled-up in Burkina Faso.
The government of Burkina Faso is committed to the improvement of women’s reproductive health. Within this context, the Population Council’s FRONTIERS Program collaborated with two nongovernmental organizations (NGOs), Tostan in Senegal and Mwangaza Action in Burkina Faso, to replicate the Tostan community-based education program. Originally developed in Senegal (see ORS 54), this program provides modules in local languages on hygiene, problem solving, women’s health, and human rights as a means of promoting community empowerment to facilitate social change. The intervention, implemented from 2000-2003 in the provinces of Bazega and Zoundwéogo in Burkina Faso with funding from the GTZ Supra Regional Project for the Elimination of FGC, compared the performance of 23 participating villages with that of 23 control villages. Overall, 578 women and 448 men participated in the program. To measure the program’s impact on awareness, attitudes, and behavior regarding reproductive health and FGC, researchers conducted pre- and post-intervention surveys of women and men in the intervention and control areas, and qualitative interviews with key community members (including village chiefs and nurses). To measure the diffusion of knowledge, researchers also surveyed men and women who lived in the intervention area but did not participate in the study. They also assessed pre-and postintervention changes in the number of girls under 10 who had been cut. (excerpt)
Data quality improved with biomarkers.
Current Demographic and Health Surveys often include biological testing for a large variety of health conditions, from HIV infection to nutritional deficiencies and chronic conditions. In the face of emerging pandemic infectious diseases, the demand for biomarker data is growing, and MEASURE DHS continues to develop new ways of measuring disease in populationbased demographic surveys. Biomarkers are biological and physiological measures of health conditions. Since 1986, DHS has been measuring the height, weight and BMI of women and children to evaluate their nutritional status. Anemia testing became a standard component of the DHS survey protocol after the 1995 Kazakhstan survey showed that respondents were comfortable with providing blood specimens for the test. Over the years, more biomarkers have been added to DHS surveys in more than 50 countries. DHS surveys have tested for syphilis, chlamydia, hepatitis B, gonorrhea, bacterial vaginosis and trichomonas, the herpes simplex virus, vitamin A, lead exposure, high blood pressure, diabetes, and immunity from vaccine-preventable diseases like measles and tetanus. As of March 2005, 22 surveys have included anonymous testing for HIV infection. (excerpt)
Current Demographic and Health Surveys often include biological testing for a large variety of health conditions, from HIV infection to nutritional deficiencies and chronic conditions. In the face of emerging pandemic infectious diseases, the demand for biomarker data is growing, and MEASURE DHS continues to develop new ways of measuring disease in populationbased demographic surveys. Biomarkers are biological and physiological measures of health conditions. Since 1986, DHS has been measuring the height, weight and BMI of women and children to evaluate their nutritional status. Anemia testing became a standard component of the DHS survey protocol after the 1995 Kazakhstan survey showed that respondents were comfortable with providing blood specimens for the test. Over the years, more biomarkers have been added to DHS surveys in more than 50 countries. DHS surveys have tested for syphilis, chlamydia, hepatitis B, gonorrhea, bacterial vaginosis and trichomonas, the herpes simplex virus, vitamin A, lead exposure, high blood pressure, diabetes, and immunity from vaccine-preventable diseases like measles and tetanus. As of March 2005, 22 surveys have included anonymous testing for HIV infection. (excerpt)
Partnerships for gender equality: the role of multilateral and bilateral agencies in Africa.
The time is now to act on the goals of the documents, to put political will to the test and implement the dreams that forged these instruments. The time is now to support the leadership of women in Africa: women, who, driven by conscience and commitment, have made positive contributions to peace-building and reconstruction. Women who are organizing in communities to halt and reverse the spread of HIV/AIDS. Women who, in cities, towns and villages have sustained communities and nations as political activists, caregivers, entrepreneurs and educators. The goal of this report is to highlight the efforts of multilateral and bilateral agencies to support African women in their valiant struggles. It describes projects and programmes based on the strategic objectives of the Beijing Platform for Action and shows how that document is linked to the other instruments and declarations that are now available. It calls on the nations of Africa to continue to implement the laws and declarations that have been passed by regional and national entities, and to ratify the Protocol on Women’s Rights. It reminds all of us engaged in development and human rights work to support the efforts of women in Africa to reshape their continent and achieve the Millennium Development Goals. (author's)
Global Fund policy is to manage grants in a transparent and accountable manner, disbursing funds to recipients based on their demonstrated performance as measured against agreed-on targets. In implementing this performance-based funding system, Global Fund officials are to periodically assess whether the grant’s principal recipient has made sufficient progress to warrant its next disbursement. After 2 years, the Global Fund is to determine whether to continue funding the grant for an additional 3 years. In making an assessment, officials consider several information sources, including the recipient’s reports on its performance and expenditures and an independent agent’s verification of the recipient’s reports. Recipient countries’ capacity to implement grants has been an underlying factor in grant performance, according to Global Fund and other knowledgeable officials. These officials, as well as principal recipients, also cited guidance, coordination, planning, and contracting and procurement as factors associated with challenges or successes in grant performance. For example, recipients in three countries reported that they could not meet their targets because they had not received national treatment guidelines. However, several grant recipients reported that, under certain circumstances, Global Fund guidance allowed them to quickly redirect funds, thereby enabling them to meet their targets. (excerpt)
The blind hydra. USAID policy fails to control malaria.
Although several papers in academic journals have discussed the efficacy of individual malaria programs, and other publications have analyzed the functioning of the United States Agency for International Development, this is the first comprehensive analysis of the Agency’s overall approach to malaria control. USAID is found wanting: its lack of transparency makes detailed economic assessments of performance impossible; its organizational structure and methods of information management hinder opportunities for collaboration with other donors and prevent necessary assessments of ongoing programs; it avoids accountability for program performance by deflecting responsibility onto contractors; it fails to condition funding for these contractors on relevant outcome measurements; it has influenced the construction of a system wherein the vast majority of funding for malaria either never leaves the United States or funds the employment of U.S. citizens; it ensures continued Congressional support by maintaining key beltway contractors who lobby for increased funding; it spends less than five percent of its malaria budget purchasing actual life-saving interventions; and lastly, it bases its choice of malaria interventions on extraneous political consideration, not on best practice, unnecessarily costing lives. Based on this analysis, this paper recommends several steps to improve USAID’s performance. First, it should increase the transparency of its programs and funding decisions. Such a move will instigate necessary upgrades in organization and data management, improve the Agency’s capacity to work with other donors and allow external experts to contribute useful suggestions for performance improvements. Second, USAID should ensure that programs have the necessary funding and scope to achieve success—a sustainable reduction in the malaria burden—and measure their progress with appropriate interim results. At present, USAID spreads its funds too thinly to run such robust programs. By focusing on fewer countries, USAID could provide tangible results, lowering criticism of its performance and establish best practice models for other countries to follow, saving more lives. Third, where its comparative advantage lies in providing technical assistance, it should coordinate with other agencies that provide actual medical interventions (bed nets, insecticides, drugs) in order to ensure a robust effort. Lastly, it must not inhibit countries from using interventions that its staff opposes for reasons other than effectiveness in combating malaria. (excerpt)
In its second year of implementation, Philippine TIPS continued developing the necessary tools for the expansion of private sector providers of DOTS by the twenty-first month of the project. With the certification process and the TB benefits package in place in Year 1 of the project, the opening months of Year 2 focused on increasing capacity for DOTS in the private sector. The expansion of DOTS capacity outside Metro Manila and Southern Luzon was aggressively pursued through a road show in early 2004. This attracted 600 private practitioners in 22 cities and large municipalities. The documentation and standardization of best practices from the first DOTS implementers now include workplace models. While early lessons were made part of the road show, distilled lessons from the early implementers are not expected to trickle down to the private sector implementers until Year 3 of the project. Capacity for certification was also pursued and expanded to cover all regions of the country with support from the Philippine Coalition Against Tuberculosis (PhilCAT), the Department of Health (DOH) and the Philippine Health Insurance Corporation (PHIC). More than 60 assessors were in place before the May presidential elections but they were not immediately utilized by the certifying authorities due to unclear organizational processes. Despite efforts to disseminate the certification instruments to over 100 potential DOTS providers, both public and private, it would take another four months for the process to be firmly in place in the regions that would implement certification and accreditation. (excerpt)
Two external consultants carried out the Final Evaluation of the Gujarat Health System Development Project (GHSDP) in October 2004, funded under a Matching Grant (MG) from USAID, Office of Private and Voluntary Cooperation. This was Aga Khan Foundation’ (AKF) fifth MG. Under MG IV (1994-1997), Aga Khan Health Services, India (AKHS,I) established physical assets including health centers (HCs) and diagnostic centers (DCs), developed human resources, fostered a strong volunteer base and recovered about 75% of the HCs operating costs. The final evaluation recommendations of MG IV were, to: 1) expand coverage of services to non-Ismaili populations; 2) expand the range of services from a traditional maternal and child health (MCH) approach to comprehensive Reproductive and Child Health (RCH) interventions; 3) test service delivery models in non-Ismaili villages; and 4) enhance financial sustainability. Since MG IV was judged successful because of the large Ismaili volunteer base in the communities that supported the program, AKHS,I. was asked to extend coverage into non-Ismaili areas to assess the validity of the approach. Thus, MG V had four main objectives, to: 1) improve access to and use of quality services; 2) enhance organizational efficiency, 3) increase financial self-sufficiency; and 4) document best practices. GHSDP operates in two areas, Sidhpur and Junagadh. The main livelihood options are agriculture and wage labor. In 1998, there was a significant Ismaili population in general and the “old villages” had a large Ismaili volunteer base. There was also limited private sector competition. (excerpt)
The Gujarat Health System Development Project (GHSDP), implemented by the Aga Khan Health Service, India and managed by Aga Khan Foundation, India sought to improve the health status of 86,000 rural residents, primarily women of reproductive age (15-45) and children under three, in Patan, Banaskantha and Junagadh districts of Gujarat State, India. The Project was part of the fifth USAID Matching Grant awarded to Aga Khan Foundation U.S.A., entitled “Promoting Health Reform in Three Countries in Central and South Asia and East Africa through Institutional Capacity Building, Partnership Strengthening and Documenting and Disseminating Best Practices” and built upon achievements made during Matching Grant IV, previously awarded in 1994. This report is concentrated on the completion and achievements of the GHSDP. Other projects under the Matching Grant V were previously completed and closed-out. The Project commenced in October 1998 and was initially scheduled to end on September 30, 2003. Due to a slow start-up, the 2001 earthquake and 2002 communal riots in Gujarat, a 15-month no-cost extension was granted by USAID, thereby changing the end date to December 31, 2004. In September 2000, an internal review required that the project team amend their strategies, interventions and activities based on a changed operating context and market feasibility analysis. Project objectives were revised and commensurate modifications were made in the Detailed Implementation Plan. After the Mid-Term Review conducted in September 2001, added emphasis was placed upon increasing cost-recovery and consolidating lessons learned as per the recommendations of the review team. A team of external health experts conducted a final evaluation as per grant requirements in October - November 2004. (excerpt)
The goal of MG98 was to achieve a sustained improvement in the status of reproductive women and children under five years of age in Gorno-Badakhsan Autonomous Oblast (GBAO), Tajikistan. The grant accomplished its goal in that the status of women and children has significantly improved; however, the program is not yet sustainable in its current stage of development. The oblast-wide PHC delivery system put in place to improve health status is operating effectively throughout the oblast. Yet, institutionalization and sustainability have not yet been achieved due, in part, to the lag in health sector reform. The MG98 grant, in structuring together the simultaneous development of health sector reform, procurement and supply of essential drugs, and a system of PHC delivery throughout the oblast, has put in place accessible quality services to the rural population of GBAO. Survey data and qualitative evaluation data validated significantly greater village level health promotion activity, improved health knowledge and practices of mothers, and decreased disease morbidity among children under five. (excerpt)
Under the Institutional Capacity Strengthening (ICS) Project of the Matching Grant (MG), the Community Health Department (CHD) of the Aga Khan Health Service, Kenya (AKHS,K) successfully accomplished its two objectives – 1) to build the internal capacity of CHD to provide technical assistance to local stakeholders/partners, i.e., CBOs, NGOs, government entities and/or private sector and 2) to improve the capacity of local stakeholders/partners to provide health-related services to communities. In so doing, CHD has directly and indirectly helped to ensure the sustained provision of primary care services and forward health sector reform in Kenya by giving communities and local organizations more control over the management, provision and financing of their health services. CHD has developed and validated the effectiveness of a robust model for enhancing the confidence and competence of community organizations, i.e., the village health committees and the dispensary health committees. (excerpt)
Accelerating the fight against malaria. USAID fact sheet. [Press release].
On June 30, 2005, President Bush challenged the world to reduce the burden of malaria dramatically as a major killer of children in sub-Saharan Africa, and pledged to increase funding of malaria prevention and treatment by more than $1.2 billion over five years. The goal of this effort is reduce malaria deaths by 50 percent in each of the target countries after three years of full implementation. To launch this initiative, the United States will significantly expand resources for malaria in Angola, Tanzania and Uganda beginning in 2006, and will expand to at least four more highly endemic African countries in 2007, and at least five more in 2008. By 2010, the U.S. Government will provide an additional $500 million per year for malaria prevention and treatment. This effort will eventually cover more than 175 million people in 15 or more of the most affected African countries. The President makes this commitment as the U.S. contribution to a larger international effort needed to reduce the burden of malaria, and calls on other donors, foundations, public, private, and voluntary organizations to complement United States commitments by providing, by 2008, $1.2 billion annually in additional funding. These complementary efforts could expand the initiative to reach 650 million total beneficiaries and control malaria in the most affected countries in Africa. (excerpt)
The RPM Plus child survival portfolio aims to contribute to increasing access (geographic accessibility, availability, affordability, and cultural accessibility/acceptability) to and appropriate use of essential (efficacious, safe, and cost-effective quality) medicines, vaccines and related supplies for child survival. Over the last few months RPM Plus has been exploring options with counterparts in Tanzania for developing a package of linked interventions in the private sector with the aim of enhancing access and appropriate use of essential medicines for child survival. A meeting was held in Tanzania in February 2005, immediately following the MSH SEAM Duka la Dawa Muhimu (DLDM) evaluation meeting, to determine how RPM Plus could help the TFDA maintain and further improve access to medicines and the quality of care in DLDMs with a focus on child health. The meeting allowed participants to discuss key components of successful interventions elsewhere and to choose which pieces they wanted to include in a program in Tanzania. The key recommendations were: Utilize peer-to-peer and neighbor-to-neighbor behavior change activities to increase knowledge of child illness and appropriate treatment; Incorporate local supportive supervision systems in the intervention; Integrate key components of the IMCI and Malaria programs into the DLDM structure to ensure streamlining of activities and messages; Design the intervention such that its successes are easily included in the national rollout of the DLDM program. (excerpt)
Lesotho currently does not have either a USAID or CDC-Global AIDS Program (GAP) office and is a non-focus country for the President’s Emergency Plan for AIDS Relief (PEPFAR). In recent years, through the Corridors of Hope Initiative, the Ambassador’s initiative on HIV/AIDS and other support to non-government organizations, the United States Government (USG), primarily through the regional offices of CDC and USAID, has emphasized prevention of HIV/AIDS among high risk groups such as migrant men, low income women, women working in the textile industry, truck drivers, taxi drivers, and female sex workers. Additionally, VCT and BCC projects have been supported. Anticipating increased funding for Lesotho for fiscal year 2005, a rapid appraisal of the USG strategy was conducted from September 5th to September 13th with a team comprising USAID, CDC and FHI technical staff from both Washington and the regional offices and a Senior Health Consultant from Lesotho. The major objectives of the rapid appraisal were to plan a joint USG strategy for Lesotho and to make recommendations for reorientation of the program within the context of a generalized epidemic. In addition, although Lesotho is not a focus country for the President’s Emergency Plan, it is receiving financial support through this initiative and can clearly contribute to and benefit from aligning itself with the Emergency Plan goals of treating 2 million PLWHA, preventing 7 million HIV infections and caring for 10 million PLWHA and orphans and vulnerable children by 2008. The rapid appraisal was not designed to be a formal evaluation of interventions previously or currently supported by the USG or other donors. The findings of the rapid appraisal team are presented in detail below. The team noted substantial opportunities for rapid expansion of HIV/AIDS activities. The people of Lesotho, referred to as Basotho, have a strong traditional system comprised of principle, area and local chiefs whom community members will first approach on social issues. They have a very solid cultural foundation of mutual assistance. They have survived numerous challenges with remarkable resilience and dignity. Lesotho is a small country with a homogenous population with one major ethnic group and language (Sesotho). Literacy rates are high (93.4 percent) among women and relatively high (72.6 percent) among men. Despite the mountainous geography of Lesotho, a relatively good transportation system and health care infrastructure provide a solid foundation upon which to build. Lesotho is also currently seeking opportunities to utilize its strong community structures and networks to even greater advantage. A cadre of community health care workers (CHCWs) was established in the 1970s and is being revitalized. In addition, an emerging model of support groups is showing great promise. (excerpt)
Swaziland currently does not have either a USAID or CDC office and is a non-focus country for the President’s Emergency Plan for AIDS Relief (PEPFAR). In recent years, through the Corridors of Hope Initiative (COH), the Ambassador’s initiative on HIV/AIDS and other support to non-government organizations (NGOs) and to the National Emergency Response Committee on HIV/AIDS (NERCHA), the United States Government (USG), primarily through the regional offices of CDC and USAID, has emphasized prevention of HIV/AIDS among high risk groups such as truck drivers, taxi drivers, seasonal agricultural workers and commercial sex workers. In addition, PMTCT, VCT and BCC projects have been supported. Anticipating increased funding for Swaziland for fiscal year 2005, a rapid appraisal of the USG strategy was conducted from August 22nd to August 30th with a team comprising USAID, CDC and FHI technical staff from both Washington and the regional offices of the respective agencies. The major objectives of the rapid appraisal were to plan a joint USG strategy for Swaziland and make recommendations to reorient USG programs within a generalized epidemic. In addition, although Swaziland is not a focus country for PEPFAR, the program can clearly contribute to and benefit from aligning itself with the Emergency Plan goals of treating 2 million PLWHAs, preventing 7 million HIV infections and caring for 10 million PLWHA and orphans and vulnerable children (OVC) by 2008. The rapid appraisal was not designed to be a formal evaluation of interventions previously or currently supported by the USG or other donors. (excerpt)
Since FY 1999, USAID’s Africa Bureau has been providing funding to FHI/IMPACT, PSI and the POLICY Project (among others) to intensify the prevention and care response for mobile populations who frequently cross international borders among ten countries in Southern Africa, and for vulnerable populations at busy border trade towns. The rationale for a regional prevention response includes studies showing increased vulnerability among mobile populations, the continued importance of targeting high-risk groups in high prevalence settings, and providing a means for sharing and transferring project success across borders more efficiently than could be obtained by conventional means. FHI’s approach to HIV/AIDS programming has always been grounded in partnership. In this program FHI works through partners and to date, project activities have been established with partners in 5 countries and implementation of project activities at 23 sites. FHI’s activities under RHAP are in four main areas: prevention and care interventions for highly vulnerable populations; coordination and management; capacity building for partner organizations and assessment and surveillance. The prevention and care interventions are implemented by the partners through peer educators and drop in centres. The main interventions are BCC messages through group and one-to-one meetings; distribution of free condoms; counseling and referral for STI treatment and VCT; and some care and support services. (excerpt)
This report is the result of a secondary data analysis, document review, and field visits to Corridors of Hope sites. It is designed to be a brief summary of the successes and challenges faced in three key areas: 1) Behavior Change Communication Strategy; 2) Service Delivery; and 3) Monitoring and Evaluation, in order to inform the program review team of the Corridors of Hope Regional HIV/AIDS Cross-Border Prevention Program that will take place in January 2005. The Corridors of Hope (COH) initiative was launched in September 2000 as a part of the Regional HIV/AIDS Program for Southern Africa (RHAP) to target high transmission populations at cross border sites primarily with prevention interventions. COH has three core activities: 1) Sexually Transmitted Infection (STI) treatment and referral; 2) Condom social marketing; and 3) Behavior change promotion. The initiative now works in eight countries, of which four are focus countries of the President’s Emergency Plan for HIV/AIDS: South Africa, Zambia, Namibia, and Mozambique; two are USAID and CDC non-presence countries: Lesotho and Swaziland; and two have bilateral missions: Malawi and Zimbabwe. In addition, Angola and Botswana are a part of the RHAP region, although they do not yet have COH activities. (excerpt)
This report shares findings from a pilot of the POLICY Project’s Gender Equitable Male Involvement (GEMI) Assessment Tool. In October 2002, the POLICY Project used the GEMI tool to conduct an assessment of the policy environment related to gender-equitable male involvement in Jamaica, with a focus on male youth. Based on interviews with key stakeholders from a cross-section of government, civil society, and youth-serving organizations, the assessment sought to Describe the current policy environment related to gender-equitable male involvement; and Identify priority areas for developing or strengthening policies to support gender-equitable male involvement, and the related advocacy and policy dialogue, information, and capacity building needed to support this. (excerpt)
Kenya National Health Accounts 2002: estimating expenditures on general health and HIV / AIDS care.
The government of Kenya (GoK) faces the dilemma of combating a growing burden of disease, regulating quality, and improving equity in health care distribution within the context of declining public financing that is forcing rationalization of health service delivery. To help resolve the dilemma, Kenyan policymakers need a comprehensive understanding of the organization and financing of the country’s health care system, including the expenditures on health care made by donors, public sector entities, and the private sector, particularly households. One tool that the government is using to understand health care expenditures is National Health Accounts (NHA), an internationally accepted framework for tracking the expenditures from their sources to their end uses. (excerpt)
Quantification of antimalarial medicines requirements for Madagascar.
Malaria is a major cause of morbidity and mortality in Madagascar. As part of its efforts to reduce the public health impact of malaria, Madagascar is currently revising its National Malaria Policy and will adopt an artemisinin-based combination treatment (ACT) to replace chloroquine (CQ) as the first-line treatment for uncomplicated malaria at health facilities. It also plans to adopt intermittent preventive treatment (IPT) with sulfadoxine/pyrimethamine (SP) as the national policy for the prevention of malaria during pregnancy. Madagascar submitted a proposal to support this transition to the Global Fund to Fight AIDS, Tuberculosis and Malaria during round four. This grant request was successful, and the funding will soon be available to assist in implementing the new policy. Until 2004, the recommended treatment in Madagascar for those with uncomplicated malaria was CQ. Concern has been rising about the effectiveness of CQ in the country, especially because high resistance to CQ has been documented in all the neighboring countries. Recent studies in Madagascar have found elevated resistance levels to CQ. A 2001 study done by the Institut Malgache de Recherches Appliquées found that the resistance to CQ in Ankazobe District was 39 percent. A study in Sainte Marie Island by the Institute Pasteur in Madagascar that was completed in 2004 found that the resistance to CQ was 36.9 percent. These studies have provided the impetus leading to the change in national policy by the National Malaria Control Program (Service National de la Lutte contre le Paludisme, or SNLP) and its Roll Back Malaria (RBM) partners. (excerpt)
The objectives of the mission were to work with Burundi’s RBM partnership to— 1. Define the technical support requirements for need-based malaria treatment policy implementation over the next 36 months. 2. Develop priority lists of technical support requirements that the MAC and other RBM partners could provide within the next 12–18 months. 3. Develop a MAC operational plan (activities, timeline, budget, and responsible MAC partner) for providing technical support in the next 12–18 months. 4. Develop a medium-term (three-year) need-based plan (activities, timeline, and budget) for technical support for resource mobilization. 5. Identify available in-country expertise that could potentially be used to provide technical support to Burundi’s National Malaria Control Program (NMCP). (excerpt)
Best practices in financial sustainability plans for immunization programs.
This paper examines the nominated “best practices” in financial sustainability plans (FSPs) submitted to the Global Alliance on Vaccines and Immunizations in late 2003. It develops and applies a method for identifying a “best practice.” The result is the classification of practices in seven areas of FSP preparation from eight countries as some form of good practice. The lessons from the identified good practices should serve as a guide to the preparation of future FSPs and to the revision of ones already prepared. (author's)
Jordan assessment team report (draft document).
In 2003, USAID/Jordan developed a new assistance strategy for Jordan, which redefined the mission’s strategic objectives for the period 2004-2008. This strategy was developed and agreed to as a result of a process outlined below: Feb 2003: Team evaluates USAID Jordan’s population and health programs, Aug 2003: USAID Jordan concept paper produced, “Gateway to the Future”, Oct 2003: USAID, MOH and other sectors develop a “Strategic Framework” for Jordan, Oct 2003: Two-day workshop to develop approaches to the Strategic Framework, Nov-Dec 2003: Complete strategy is developed for Jordan (“Improved Health Status for All Jordanians”), Jan-Sep 2004: First year of implementing new strategy. USAID/Jordan requested a PHRplus team to travel to Jordan to assess how its current program might be amended in light of the Mission’s new strategy. The team was asked to meet with stakeholders in the Ministry of Health and with other representatives of the health sector to assess whether to retain, modify or eliminate aspects of the current PHRplus Country Activity Plan; and, to recommend additional new activities that would help the Jordan health sector move rapidly toward achieving the goals outlined in the new strategic framework. (excerpt)
The Good Practice Model: community participation in Luweero district, Uganda.
The Partners for Health Reformplus Project, in conjunction with the Uganda Community-based Health Financing Association, conducted an analysis of the community-based health financing (CBHF) schemes in Luweero district, Uganda, to document the CBHF ‘Good Practice Model in Community Participation’ of Save for Health Uganda (SHU). Information was gathered through review of how credit and mixed insurance/credit scheme models work, and through key informant interviews and focus group discussions. The analysis found a significant level of community participation and stakeholder partnership (financial and technical assistance to schemes), and practical operating and governance structures that encourage participation and coordination among scheme members, elected leaders, and partners. Although SHU has reduced its financial support to schemes, schemes still depend on SHU technical assistance, which may affect long-term sustainability. The paper closes with recommendations to expand use of the Good Practice Model and to otherwise strengthen CBHF schemes in Uganda. (author's)
Costing artemisinin-based combination therapy for malaria in Tanzania.
Malaria continues to be a major contributor to the burden of disease in Tanzania, with a prevalence of 33.39 percent nationally. As antimalarial resistance to sulfadoxine-pyrimethamine in Tanzania continues to grow, the government is in the process of changing its national policy regarding first-line treatment for uncomplicated malaria to an artemisinin-based combination therapy (ACT). ACT, a new type of antimalarial drug combination, has proved to be effective at treating malaria and reducing malaria transmission. The PHRplus project, on behalf of the Roll Back Malaria Partnership in conjunction with the World Bank, undertook a costing study to estimate the five-year financing needs and identify financing gaps for procurement of three possible ACT combinations, Coartem, artesunate amodiaquine (ART AQ), and Artecom. The Global Fund to Fight AIDS, Tuberculosis and Malaria award for malaria during the fourth round of proposals will cover the majority of the first year of public sector ACT implementation if Coartem (with a financing gap of US$1.4 million) is chosen, or the bulk of public sector implementation for the full five-year period under ART AQ or Artecom. ACT funding must be secured for the medium- to long-term future. Financing for the purchase of ARTs is likely to come from the Global Fund, the World Bank, and the various other partner agencies. (excerpt)
The Corridors of Hope has been active in Zimbabwe since September 2000. Eight (8) towns are covered under the program with activities that include intensified (male and female) condom social marketing; late night access to STI services provided through partnerships with health facilities in these towns; peer education and in some sites VCT services through PSI/Zimbabwe’s New Start Center network. PSI/Zimbabwe has issued 2 sub awards to the Project Support Group (PSG) and Development Aid from People to People (DAPP) to implement peer education activities in border sites. Condom sales during this reporting period saw the sale of over 4.7 million pieces of Protector Plus male condoms and 180,000 pieces of care the female condom. During peer education activities which include home meetings, bar based meetings, one on one discussions with key members of our target groups and public meetings, over 2.6 million contacts were made. (excerpt)
This is the first edition of Guidelines for Safe Immunization Practices and Monitoring Immunization Programs at the Facility and District Levels in Yemen. It is a compendium of revised EPI (Expanded Programme on Immunization) documentation; recordkeeping and reporting requirements of the Ministry of Public Health and Population; current guidelines for immunization data analysis and utilization; and materials for monitoring and evaluating the immunization system and provider performance. The guidelines will be piloted in Amran Governorate in 2005; recommendations based on pilot experience will be incorporated into revised guidelines for use nationwide. The manual is designed primarily for health personnel who are responsible for the implementation of the immunization program at the facility and district levels. The section on evaluation of the work at facilities can guide both the facilities in doing self-evaluations and district immunization managers in monitoring and supervising facility-level work. The worksheets contained in this manual for monitoring immunization work are illustrative. A full set of worksheets has been published separately in an immunization workbook for districts. (author's)
This workbook accompanies Guidelines for Safe Immunization Practices and Monitoring of Immunization Programs at District and Facility Levels in Yemen. It is a tool designed primarily for personnel of district-level EPI (Expanded Programme on Immunization) offices to help them monitor and evaluate immunization work, use of vaccine and adequacy of cold chain on their services territory. It helps EPI managers to establish the link between information systems’ data and response, as well as to document the data analysis and utilization for management purposes. The current version of the workbook has been developed for piloting in the Amran Governorate in 2005. Based on pilot experiences, it will be revised for use nationwide. (author's)
Demography and health in Eastern Europe and Eurasia.
The Eastern Europe & Eurasia region (EE) is the only region worldwide to have experienced a contraction in population from 1991-2002. The transition region overall witnessed a contraction in population from 1991-2002 of -0.1%. To contrast, high-income economies witnessed population growth of 0.7% in this period and low-income economies, 2%. The population contraction in the transition region is more pronounced (-0.3%) if one excludes the 6 Muslim-majority transition countries (which experienced population growth of 1.4%). Eighteen of 27 transition countries experienced a contraction in population in this period. The trend in declining population in the transition region was particularly pronounced with the collapse of communism through the mid-1990s. The transition region had a population of 412 million people in 1990. By 2003, the transition region population had declined to 404 million persons, while world population had increased from 5.3 billion in 1990 to 5.7 billion in 2003. Hence, the transition region experienced a significant drop in the proportion of world population, from 7.8% in 1990 to 6.4% in 2003. The high income economies witnessed a much smaller drop in this period, from 16.9% to 15.5%, while all the developing country regions witnessed increases. (excerpt)
Tanzania HIV / AIDS Indicator Survey, 2003-04.
This report presents the major findings of the 2003-04 Tanzania HIV/AIDS Indicator Survey (THIS). The Tanzania Commission for AIDS (TACAIDS) authorised the National Bureau of Statistics (NBS) to conduct the THIS. The THIS is the first household survey of its kind to be conducted in Tanzania. The survey covered the Tanzania Mainland only. The main objective of the survey was to provide HIV/AIDS programme managers and policymakers with information needed to guide planning and implementation of interventions, including resource mobilisation and allocation, monitoring and evaluation of existing programmes, and designing new and effective strategies for combating the epidemic. (excerpt)
Serbia family planning and reproductive health assessment. Final report.
Although the current USAID/Serbia strategy does not include a specific focus on health sector activities, beginning with FY 2002 funding, the mission has programmed $1.5 million annually in support of the E&E Bureau’s targets for Family Planning and Reproductive Health (FP/RH) directed funds. All health sector activities are managed and implemented under the Community Revitalization Though Democratic Action (CRDA) program. This assessment is intended to assist USAID/Serbia in determining how best it might utilize its FP/RH funds within the new mission strategy. Even prior to the FP/RH directive, health was among the priorities identified at the community level under the CRDA program. A total of 267 health sector projects in 81 municipalities have been financed under CRDA, of which 118 projects in 49 municipalities have been financed using FP/RH directed funds. CRDA partners have raised community awareness of FP/RH priorities and, as a result, have shifted the focus of the health sector activities financed under CRDA toward preventive programs targeted to women and young people. Although USAID funding for the health sector is low relative to other donors and international organizations, USAID is one of the only contributors to community-level FP/RH services programs. CRDA partners, therefore, have had a significant impact on raising the awareness and availability of FP/RH information and services at the community level in Serbia. (excerpt)
Quantification workbook for USG-funded ARVs.
This quantification workbook is a tool to assist pharmacy staff to quantify requirements of United States Government (USG)-funded ARVs to order to support the ART Program. The workbook is designed to take the pharmacy staff through the process step by step Each step has a table to be completed which either requires data to be collected or a calculation to be done. Some of the tables require data to be collected over a number of months (usually the last six months). It is anticipated that during the scale up phase that the site will place an order for ARVs every month – therefore a quantification workbook will be completed every month. Use the data collected for the previous workbook to complete the data collection tables for each new workbook to minimise work. Some of the calculations e.g. for estimating the quantities needed for new patients, will not need to be done every month. Once the program has stabilised you can use the same estimates from month to month making adjustments for fluctuations in recruitment if needed. It is suggested that you review this data every 3 to 6 months after the program has stabilised. When instructed to round up or down to the nearest whole number, for numbers where the first decimal place is 0.5 or higher round up (e.g. for 6.7 round up to 7) and where the first decimal place is less than 0.5 round down (e.g. for 3.3 round down to 3). When instructed to round up or down to 2 decimal places, for numbers where the third decimal place is 0.005 or higher round up (e.g. for 1.008 round up to 1.01) and where the third decimal place is less than 0.005 round down (e.g. for 0.033 round down to 0.03). (excerpt)
Quantification workbook for GOK NASCOP ARVs.
This quantification workbook is a tool to assist the pharmacy staff at Coast Provincial General Hospital (CPGH) to quantify needs of ARVs for the GOK ART Program. The workbook is designed to take the pharmacy staff through the process step by step. Each step has a table to be completed which either requires data to be collected or a calculation to be done. Some of the tables require data to be collected over a number of months (usually the last six months). It is anticipated that during the scale up phase that CPGH will place an order for ARVs every month – therefore a quantification workbook will be completed every month. Use the data collected for the previous workbook to complete the data collection tables for each new workbook to minimise work. Some of the calculations e.g. for estimating the quantities needed for new patients, will not need to be done every month. Once the program has stabilised you can use the same estimates from month to month making adjustments for fluctuations in recruitment if needed. It is suggested that you review this data every 3 to 6 months after the program has stabilised. When instructed to round up or down to the nearest whole number, for numbers where the first decimal place is 0.5 or higher round up (e.g. for 6.7 round up to 7) and where the first decimal place is less than 0.5 round down (e.g. for 3.3 round down to 3). When instructed to round up or down to 2 decimal places, for numbers where the third decimal place is 0.005 or higher round up (e.g. for 1.008 round up to 1.01) and where the third decimal place is less than 0.005 round down (e.g. for 0.033 round down to 0.03) (excerpt)
Mr. Nun (a pseudonym) is one of many Cambodians who suffer from AIDS. What is unique about Mr. Nun is that his physical condition is better now than it was last year and that his improvement happened after receiving HIV care and treatment from a local hospital. Mr. Nun is the beneficiary of a new collaborative initiative in Moung Russey Operational District (OD) between the district health services, the National Center for HIV/AIDS, Dermatology and STD (NCHADS), communities, people living with HIV/AIDS (PLHA), and international and local non-government organizations. These partners have worked together to improve health services for PLHA by instituting a continuum of care (CoC) for HIV/AIDS clients that provides complementary health care services in both the hospital as well as in the clients’ homes. In less than six months, with a strategic set of inputs, this partnership has implemented specially designed services in the Moung Russey Referral Hospital (RH) that prevent HIV infection, provide testing and counseling for suspected HIV cases, and make available diagnostic and treatment services for PLHA suffering from HIV-related illnesses such as opportunistic infections (OIs) and TB, including the provision of INH preventive therapy (IPT) for PLHA. These services are integrated within the referral hospital system and fully linked with community and home-based care provided through partnerships between community groups, local NGOs (LNGOs), and health center staff. The best news is that NCHADS has made ARV available for 150 PLHA in Moung Russey OD, beginning in June 2004. The Moung Russey experience has shown that dedicated partners, working together, can make major strides in a relatively short time in instituting new services as well as improving existing services as they develop a continuum of care for PLHA in a resource-poor setting. This document chronicles the successes achieved and the lessons learned from the early stages of implementing a CoC for PLHA in Moung Russey. It also provides guidance to individuals and organizations that plan to implement CoC for PLHA elsewhere in Cambodia or the region. (excerpt)
Assessing the socioeconomic effects of HIV / AIDS at the level of households in Cameroon.
The Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is a problem impacting on all countries in the world. It has the potential to create severe economic impacts in countries where the prevalence is significant. The epidemic has become the single biggest obstacle to reducing poverty and to achieving the Millennium Development Goals (MDG). While HIV/AIDS is not strictly a .disease of poverty since it affects people at all income levels. HIV infections disproportionately affect the poor and illiterate, with young women topping the list. The impact of HIV/AIDS is unique, because the disease hits adults in the prime of their lives, thus depriving families, communities and entire nations of their most productive citizens. Cameroon already has more than its fair share of ill health to cope with. Indeed, health indicators are now worse than they were 10 years ago. The additional burden caused by the HIV epidemic is worsening and promoting the spread of poverty. It is reversing human development, exacerbating gender inequalities, eroding government capacity to provide essential services and reducing labor productivity. HIV/AIDS thus has far-reaching ramifications for MDG attainment and related national poverty targets. HIV/AIDS infections represent a major public health problem in Cameroon, a country in central Africa. According to the Cameroonian Ministry of Public Health, the incidence in the sexually active population was 11 percent in 2000 and 11.8 percent in 2002. This is more than 23 times greater than its incidence in 1987 when it was only 0.5 percent. The number of declared cases has risen from 221 in 1986 to above 35000 in 2002 showing a progression of more than 10 percent per year. Of the reported cases, 4.6 percent are in the 0 to 14 age group and above 43 percent are between 15 and 35 years of age, showing that about 90 percent of HIV/AIDS positive individuals are in the active age group. Among the seropositive, there are two men to every three women and the proportion is higher in urban than in rural areas. In response to the growing social and economic threat of the epidemic, the government launched “The strategic Document for the National Plan for the Fight against HIV/AIDS in Cameroon 2000 – 2005.” This sets out the basis for collaboration between the state, national actors and bilateral and multilateral partners in combating the pandemic. HIV/AIDS impacts on the economy at the household, firm and economy wide levels through four key avenues: a reduction in the capacity of the labour force; shifts in the composition of demand, a drop in domestic savings which leads to lower investments and the psychological impact on the population especially those who have to support the afflicted. Current literature thus confirms that this pandemic affects the three main determinants of economic growth: the physical, human and social capital. HIV/AIDS also impacts on the long-term growth potential if children are removed from school, if nutrition falls to critical levels for a significant part of the population, and if institutions that provide social services and essential infrastructure deteriorate. Due to the magnitude of the epidemic, it has overrun the bounds of a pure health issue and has rather become fundamental in the socio-economic development of Cameroon like in other countries where prevalence is high. This study is thus interested in assessing the socioeconomic effects of the pandemic at the household level since this constitutes the basic production unit. Specific objectives therefore include examining the demographic evolution in Cameroon from 1985 to 2002, assessing the effects on output of households, their savings and thus investment behaviour and on the costs and their changing patterns of consumption, identifies the factors that propagate the pandemic and makes recommendations on how to better manage the epidemic and its impacts. Secondary sources of information are used in achieving these objectives. Findings from this study provide major guidelines not only on health policy reforms but also on key socioeconomic development issues in Cameroon and other societies with a high prevalent rate. (author's)
This report of the CSIS Task Force on HIV/AIDS Working Committee on Prevention provides an overview of the HIV prevention indicators that are being tracked by PEPFAR in the 15 focus countries. It also compares them to indicators used by other major international initiatives. The overview is designed to inform policymakers and other experts in an area that is complex, often controversial, and one that will become increasingly important over the long haul, and to suggest some pragmatic next steps for Congress and OGAC. The overview does not, however, seek to validate the indicators chosen or analyze the preliminary data recently provided by OGAC to Congress. (excerpt)
Prevention first. Personal decisions, personal responsibilities.
NARAL Pro-Choice America is committed to maintaining personal freedom and encouraging personal responsibility – to keeping politicians out of women’s most private choices, and empowering individuals to control their own reproductive health and destiny. While America has long been divided over abortion rights, we believe all Americans should be able to agree that women, families, and this country would be better off if we could reduce the number of unintended pregnancies and the need for abortion. (excerpt)
Resource guide for gender theme groups.
This resource guide was developed to: Provide practical guidance to UN Theme Groups (UNTGs) working on gender equality, focusing on how to more effectively collaborate around women’s empowerment and gender equality issues at the country level; Serve as a tool to strengthen the role of UN theme groups in mainstreaming gender equality concerns and advocacy for women’s and girls’ rights into Common Country Assessment/UN Development Assistance Framework (CCA/UNDAF) exercises, the Millennium Development Goals (MDGs), Poverty Reduction Strategy Papers (PRSPs) and other coordinated support mechanisms at the national level. The guide contains information based on feedback from theme groups in more than 30 countries. It synthesizes the opportunities and challenges that exist to promote gender equality and women’s human rights in the context of UN reform and greater coordination among wide-ranging development actors. The practical guidance and support comes in the form of tips, examples, and good practices summarized from the work of experienced theme groups. Source material from a cross-section of UN system agencies has been added to the base of experience. (excerpt)
A review of the efficiency of interventions in HIV infection, 1994-2003.
HIV/AIDS is the fastest-growing health problem in the world today. Given the limited resources available to the healthcare system in many of the most heavily affected countries it is crucially important to know the effectiveness, efficiency, equity and acceptability of the interventions being considered to contain this pandemic. This review examined the peer-reviewed literature on the efficiency of prevention, treatment and care interventions published between 1994 and 2003, findings reported by these studies and methods used. The results varied by geographical setting and population studied. Some interventions were clearly cost-effective: prevention efforts and testing programmes among vulnerable populations; blood screening in high-income nations and in sub- Saharan Africa; providing anti-retroviral drugs and other interventions to expectant mothers and infants; treating certain opportunistic infections; and providing combination anti-retroviral therapy. However, most studies were set in the USA, while only one in six dealt with sub-Saharan Africa. No studies could be identified from Asia, Latin America or Eastern Europe. Three-quarters of all papers focused on hospital or primary care settings, with only a few prevention studies evaluating community-based interventions. Because of a paucity of primary data, outcomes or costs were frequently modelled, using data from multiple sources in the absence of context-specific data. Establishing multicentre prospective monitoring systems on the use, cost and outcome of HIV service provision in middle- and lower income countries may provide data, to fill some of the large gaps which exist in the literature on interventions in these countries. This results in gaps in the scientific literature, limiting its ability to guide policy-makers in those settings where the epidemic is most intense. Increased research in such settings and dissemination of their findings is urgently required, especially given the need for intensified prevention strategies to complement the scaling up of HIV treatment and care services in these countries. (author's)
The goal of the present study is to explore the circumstances in Thailand under which the migration of rural adult children to urban areas takes place, with attention to how parents and their situation influence these decisions, and the consequences for the social and economic well-being of parents who remain behind in the rural areas after the children leave. The analysis relies primarily on 27 open ended interviews conducted in 2004 with older age parents with migrant children from four purposively selected rural communities that were studied 10 years earlier. Our findings suggest that for many, probably most rural Thai elderly parents, the migration of children to urban areas contributes positively to their material well-being. Negative impacts of migration on social support, defined in terms of maintaining contact and visits, have been attenuated by the advent of technological changes in communication and also by improvements in transportation. Phone contact, especially through mobile phones, is now pervasive in sharp contrast to the situation 10 years earlier when it was extremely rare. Much of the change in Thailand in terms of the relationships between rural parents and their geographically dispersed adult children is quite consistent with the concept of the ‘modified extended family’, a perspective that has become common in discussions regarding elderly parents in industrial and postindustrial societies but rarely is applied to the situation of elderly parents in developing country settings. (author's)
Community reaction to persons with HIV / AIDS and their parents in Thailand.
We systematically examine community reaction to persons with HIV/AIDS (PHAs) and their families in Thailand from multiple perspectives using several types of data. We explore these community reactions during the time of the PHAs’ illness and after their deaths. Quantitative data sources include a survey of young adult PHAs (n=425); a survey of parents who suffered the death of an adult child to AIDS (n=394 cases); a KAP study of AIDS that includes both older and young adults (n=1174); and quantitative data from local key informants about cases in their area (n=286 cases). This extensive quantitative information is supplemented with several sources of qualitative data. Data were collected during 1999 – 2001 from a wide range of settings throughout Thailand. We find community reaction to PHAs and their families to vary by features of the case, social group, and type of observer, but overall these reactions are much more positive than is widely assumed. The overwhelming majority of key informants’ assessments and of PHA parents’ reports indicate either a generally positive community response or a neutral one. Results from our sample of PHAs, who are recruited from PHA support groups, are more mixed. For those who were treated poorly, it is suggested by at least some of our data sources that living in the city, living in an area without an NGO working on AIDS, being described as having problematic character, or being at either extreme of the socioeconomic spectrum may elevate the risk of experiencing negative community reaction. We conclude that much existing research on community reaction to AIDS neglects both a rich body of social theory on stigma and a strong tradition of population-based empirical research. Much existing research also fails to adequately distinguish between key aspects of the social settings where most AIDS cases occur and the social settings where most of the stereotypes surrounding AIDS-related stigma have originated. Sociologists have much to offer to further investigations of this critically important dimension of the AIDS epidemic. (author's)
Russia is home to one of the fastest-growing and potentially massive AIDS epidemics in the world, but the government has done little to address the problem. As a result, the Russian public today, though highly educated, is almost as ignorant of HIV and how it is spread as it was ten years ago, when AIDS was hardly known in Russia. A great many medical personnel still remain grossly uninformed and even hostile toward HIV-positive patients. The general public’s knowledge of the virus is, accordingly, extremely limited. And the fact that injection drug users account for 80 percent of persons registered as living with HIV/AIDS does not encourage society to adopt greater tolerance or understanding. There is widespread belief that high-risk individuals—drug users and commercial sex workers—got what they deserved. Recent surveys in Moscow—where there is a higher prevalence of HIV/AIDS and greater access to information than in many parts of the country—revealed that more than half of those responding believe that one can be infected by drinking from the same glass as an HIV-positive person. Even more alarming, nearly half of the respondents believe that HIV-positive people should be isolated from society. (excerpt)
Japan's baby bust: causes, implications, and policy responses.
This paper describes the trend in fertility in Japan, analyzes the causes and implications of the baby bust after 1973, and discusses the Japanese government’s efforts to raise fertility, which by 2003 had fallen to 1.29 children (i.e., births) per woman, as indicated by the total fertility rate. Also addressed are the questions of why the government’s efforts to raise fertility have not been effective and what additional steps the government might take. The total fertility rate (TFR) is the measure of fertility most frequently used in this paper. The TFR for a particular calendar year is defined as the number of births that a woman would have by age 50 if, hypothetically, she lived through her reproductive years experiencing the age-specific fertility rates that prevailed in the population in the particular calendar year. An age-specific fertility rate (ASFR) in a particular calendar year is calculated as the number of births that occurred during the year to women at a given age, divided by the midyear number of women at that same age. An ASFR has units of births per woman per year. The TFR is calculated by summing the ASFRs (births per woman per year at each age) between the ages of 15 and 50. (excerpt)
Priorities for family planning and HIV / AIDS integration.
Reaching the United Nations General Assembly goal of reducing HIV infections among infants by 50% by 2010 requires preventing unintended pregnancies among HIV-positive women. There are important synergies between Voluntary Counseling and Testing (VCT) and Family Planning (FP) services. HIV-positive women, especially those on antiretrovirals (ARVs), can have increased need for access to voluntary FP services. A wide range of contraceptive options are safe and should be available for HIV positive women including those on ARVs. (excerpt)
Focused antenatal care: a better, cheaper, faster, evidence-based approach.
Traditionally, antenatal care (ANC) programs have mirrored those in developed countries. Too often, programs are poorly implemented and do little to promote the health of mothers and newborns. Until recently, many of the components of antenatal care had not been rigorously evaluated. Now the World Health Organization (WHO) has developed a focused ANC package that includes only counseling, examinations, and tests that serve immediate purposes and have proven health benefit. (excerpt)
Active management of the third stage of labor: a simple practice to prevent postpartum hemorrhage.
Postpartum hemorrhage (PPH) is the leading direct cause of maternal death in developing countries. Most cases of PPH occur within 24 hours after delivery. About 70 percent of cases of PPH are due to uterine atony, which can be prevented with Active Management of the Third Stage of Labor (AMTSL). Any woman can face life-threatening blood loss at the time of delivery; women with anemia are particularly vulnerable since they may not tolerate even moderate blood loss. AMTSL reduces the incidence of PPH, quantity of blood loss, need for blood transfusion, and need for medical intervention to stop bleeding. (excerpt)
Private providers: a vast untapped resource to improve women's health.
Networks of private providers can be highly effective in reaching women with Family Planning/Reproductive Health (FP/RH) services. Advantages: service delivery points are already in place, often financially sustainable, and have excess capacity. Private midwives provide 46% of all contraceptive use in Indonesia. A "linking organization" is key to link providers, identify incentives, develop a plan to meet service objectives and broker training, supplies, quality, and outreach to customers. (excerpt)
Family planning for postpartum women: seizing a missed opportunity.
Postpartum women have a high unmet need for family planning (FP). Health services often pay little attention to postpartum care, including FP. Women who are breastfeeding have special needs when selecting a FP method; however, in the right circumstances, all methods of modern contraception may be used. The goals of a postpartum FP program are to: reduce unmet need; improve contraceptive choice; promote optimum health for both mother and baby through breastfeeding; encourage birth spacing of three to five years; and integrate FP with other maternal health and newborn services. Contraception is the primary method of reducing mother-to-child transmission of HIV. (excerpt)
Taking stock of women's progress.
The advancement of girls and women has been on many governments’ agendas in the last decade and was central to the plan of action of the Fourth World Conference on Women, held in Beijing in 1995. Gathering data about women—especially about their health, education, and political and economic status—is a critical part of efforts to monitor progress toward achieving the goals of Beijing and other international conferences. The data provide reasons for both optimism and concern, according to the Population Reference Bureau’s Women of Our World 2005. On the positive side, girls and women have seen steady gains in a number of areas over the past decade. In most developing countries, girls’ school enrollments have risen markedly, more couples are using modern contraception, and women are choosing to have fewer children. In addition, women’s share of the nonfarm workforce and of seats in national parliaments has edged up slightly. (excerpt)
LAM users. Transition to other modern methods of contraception after six months postpartum.
This issue of Spotlight provides reproductive health and maternal and child health programs with new information (from a 2004 LINKAGES study in Jordan) to advocate for the offering of the lactational amenorrhea method (LAM) as a means to increase use of effective birth spacing methods and optimal infant feeding practices. LAM is a modern contraceptive method based on the natural infertility resulting from the following three criteria: (1) full or nearly full breastfeeding, (2) the absence of menses, and (3) use during the first six months postpartum. LAM is more than 98% effective when typically used, compared to 99% for intrauterine devices (IUDs), 92-94% for combined oral contraceptives, and 86% for condoms. (excerpt)
Women, peace and security: UNIFEM supporting implementation of Security Council Resolution 1325.
SECURITY COUNCIL RESOLUTION 1325 (henceforth “resolution 1325”) was passed on 31 October 2000 and has been hailed as groundbreaking because of the sheer breadth of issues it addresses, which ranges from conflict prevention to peace negotiations to post-conflict reconstruction. This resolution is also considered historic because of the depth of change – in procedure, assessment, delivery, attitudes and habits – that will be necessary for it to be fully implemented. By adopting resolution 1325, the Security Council set ambitious goals for itself, but also reminded governments of standards that had already been set for gender equality and that still remain unmet. In 2000, the Government of Namibia invited UNIFEM to prepare background materials for the historic debate on women, peace and security, and to address the Council together with the Office of the Special Adviser on Gender Issues and the Advancement of Women (OSAGI). UNIFEM and the NGO Working Group on Women, Peace and Security supported women peace advocates from Guatemala, Somalia, Sierra Leone and the Organization of African Unity Women’s Committee for Peace and Development to speak to Security Council members during an Arria Formula meeting, in order to share stories of the effects war has had on their lives and communities. Their powerful testimonies evoked a strong response from Council members and helped to create an atmosphere in which a strong resolution could be passed. (excerpt)
This study analyzes the costs and use of HIV/AIDS services by people living with HIV/AIDS (PLWHA) who are members and non-members of the Community Health Fund (CHF), a prepaid health scheme in the Hanang district of Tanzania. The study comprised multi-facility, retrospective, and analytical analyses of HIV/AIDS services for the year 2002. Medical utilization data through a retrospective review of the facility records and 1,666 medical charts of 464 PLWHA were analyzed. The study collected data on the direct costs of providing HIV/AIDS services within the CHF package of benefits. Members are 1.6 times more likely to access outpatient care than non-members. CHF members use outpatient services more regularly than non-members, with an average number of revisits per patient per year of 1.8 for members versus 1.6 for non-members. CHF members are 40 percent less likely to have inpatient care compared to non-members and require a shorter inpatient stay. Voluntary counseling and testing services are underused in the district. Members consume 30 percent more outpatient resources per year but consume 40 percent less inpatient resources than non-members. There is no appreciable difference between the two populations for the cost of care per visit or admission. No major differences are found between services provided to the two groups. Major differences in costs exist with regards to the facility where the inpatient stay takes place. The total cost of care of PLWHA is on average Tanzanian shillings (TSh) 6,543 for members and TSh 5,960 for non-members. The total cost of care used by an individual PLWHA is on average 65 percent of the annual premium for a household. (author's)
The human and financial resource requirements for scaling up HIV / AIDS services in Ethiopia.
Ethiopia is currently one of the countries most seriously affected by HIV/AIDS, with the sixth highest number of infections in the world. To combat this epidemic, the government of Ethiopia has launched a national HIV/AIDS program focused on decreasing the vulnerability of individuals and communities to the disease, providing care and support for people living with HIV/AIDS, and reducing the adverse socioeconomic consequences of the epidemic. As the country scales up HIV/AIDS services, increased attention is focused on identifying constraints to program expansion. One of the most important constraints is that of human resources, though this issue has received little attention nationally. Recent data suggest that Ethiopia is facing a critical shortage of human resources to deliver even basic health services. In 1999, the physician to population ratio in Ethiopia was 1:48,000, one of the lowest in the world. The current (2003) ratio of 1:34,000 is still more than five times lower than the sub-Saharan Africa average and that of nurses (1:4,900) is more than four times lower. It is envisioned that significant numbers of health care personnel will be needed to provide antiretroviral treatment and other AIDS-related medical services since more than half of all hospital beds are occupied by AIDS patients. It is vital to point out that expanding HIV/AIDS services and shifting resources towards achieving HIV/AIDS targets may have unintended effects on other essential programs such as malaria, immunization, and maternal and child health. Developing and implementing comprehensive capacity-development measures are not likely to be accomplished cheaply. Yet, this expansion of human capacity will be critical if the goals of the President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Health Organization’s 3 by 5 Initiative, and Millennium Development Goals are to be achieved. (author's)
Malaria is one of the largest causes of morbidity and mortality in the Democratic Republic of Congo (DRC), leading to a dramatic loss of life and productivity. As a result of increasing resistance to traditional antimalarials in various parts of the country, the government of DRC (GoDRC) is in the process of changing its malaria treatment policy to focus on artemisinin-based combination therapy (ACT). Working in collaboration with the Roll Back Malaria partnership, the Partners for Health Reformplus project undertook a costing study to estimate the five-year financing needs for ACT drug procurement under two possible ACT combinations: Coartem and artesunate amodiaquine (ART AQ). In order to estimate financing needs for ACT procurement, the variables population, agespecific malaria incidence, health center utilization, health center coverage, and drug pricing were estimated for the years 2005-2009. It is anticipated that given the current epidemiological situation, utilization of health services, and costs of the various ACTs, ACT financing needs for DRC will reach US$84.8 million per year for Coartem and US$44.4 million per year for the ART AQ combination. Following the preliminary results of the costing, the GoDRC has made a policy change to name ART AQ as the national first-line treatment for malaria. Once current Global Fund to Fight AIDS Tuberculosis and Malaria ACT procurement resources are exhausted in Year 2 of implementation, ACT funding must be secured for the medium- to long-term future. ACT funding is likely to come from the Global Fund, the World Bank, and the various other partner agencies. (author's)
Benin: system-wide effects of the Global Fund: interim findings.
This paper reports on interim findings from research conducted in Benin on the system-wide effects of the Global Fund (SWEF). SWEF is a collaborative research network that seeks to understand how monies being disbursed by the Global Fund affect the broader health systems of recipient countries. The main objective of the report has been to provide an overview of key interactions between Global Fund activities and the health system in Benin at an interim stage, with the aim of informing several potential audiences in Benin, at the Global Fund, and in the broader donor community. Findings highlight several areas of concern, such as gaps in the knowledge and participation of key health system stakeholders with respect to Global Fund activities; a lack of harmonization between Global Fund activities and existing policies on decentralization and cost recovery; and parallel systems for procurement of bed-nets and anti-retrovirals. Several positive effects on the system were also noted, such as the creation of many new public/private partnerships, as well as Global Fund training activities and infrastructure strengthening that are benefiting other health priorities beyond the three focal diseases. The findings presented here are preliminary, and will be developed further through follow-up research as Global Fund activities are implemented further in Benin. (author's)
The Women’s Commission for Refugee Women and Children visited 10 of the 11 refugee camps in eastern Chad in January 2005 as part of a nearly three-week mission to examine the protection of adolescent girls, with a particular focus on education and reproductive health in the camps. Two filmmakers accompanied the Women’s Commission for a part of the mission, which was funded by the Ford Foundation. As in many refugee situations, each camp had different characteristics, strengths and weaknesses. Given time constraints, staff of the Women’s Commission were not able to systematically assess the education and reproductive health situation of adolescent girls, but tried as much as possible to ask the same questions in each camp about the lives of adolescent girls, education and reproductive health. In some camps, staff were able to speak with educators, in others with women’s groups, and in still others with healthcare personnel; when there was more time, staff was able to meet with more than one group. The report begins with background information, then moves to chapters on adolescent girls, education and reproductive health, as well as additional information about the situation in Chad. Each chapter contains recommendations for action. (excerpt)
Tracking and reducing maternal deaths presents major challenges.
Among the development challenges that the international community hopes to tackle in the next decade, reducing the death and suffering associated with pregnancy and childbirth in the world's poorest communities remains one of the most daunting. Despite heightened attention to the issue in the last two decades, progress in reducing these deaths (the number of which is particularly difficult to estimate) has so far eluded governments. But the international community has renewed its commitment to the issue by setting a 2015 deadline for a significant worldwide reduction in pregnancy-related deaths and for improving maternal health globally. Progress toward this and other UN Millennium Development Goals (MDGs) set by world leaders in 2000 will be weighed at a high-level session of the UN General Assembly in New York in September 2005. Discussions are expected to include a focus on ways of measuring the problem and on the most effective strategies for reducing maternal mortality. (excerpt)
WHAT is the Resource for Participants? This participant’s manual is a companion document to a trainer’s guide, Training in Qualitative Research Methods for PVOs & NGOs: Trainer’s guide to strengthen program planning and evaluation. The trainer’s guide provides lesson plans for a set of training sessions over a 12 Day training period. This participant’s manual includes key reference materials, handouts of information discussed in the training sessions, data collection forms, instructions for group activities and assignments, and examples of notes of qualitative data collection activities. WHO will be the participants of the training? This training is designed for persons who will design and lead qualitative studies for the purpose of managing a community health, development or transition program. Usually, these persons will be program officers, management information system specialists, and educators working in community-based programs. Participants usually will be staff or partners of private, voluntary organizations (PVOs) or non-governmental organizations (NGOs). The training design also assumes that participants will have completed secondary school or equivalent and can write fairly well in the national language. (excerpt)
This guide is a resource for giving staff and partners of PVO/NGO programs the knowledge, skills and attitudes necessary for carrying out qualitative research for program management purposes. The guide provides guidance on preparing the training and lesson plans for training sessions over a 12 Day training period. This training includes basic qualitative principles and methods, management and analysis of qualitative data, and design of applied qualitative studies to answer programmatic questions and make programmatic decisions. (excerpt)
Resilience in the darkness: an update on child and adolescent night commuters in northern Uganda.
This report provides information on the conditions and security of night commuters in Gulu and Kitgum Districts. The section on Gulu does not provide as much detail as the Kitgum section due to fewer investigations conducted in Gulu. The Women’s Commission was unable to conduct specific investigations amongst the night commuters in Gulu due to a new shelter policy instructing night commuters to not answer questions from nonstaff members. Each section provides an overview on sleeping accommodations; basic health and sanitation; and safety and security. There are separate sections discussing the impact of gangs on the night commuters, and on genderbased violence. The report concludes with a section on responses to the night commuter crisis and recommendations. This report provides a glimpse into the continuing night commuter conditions and is not comprehensive. The issues covered in this report need continued investigation and documentation, and call for an immediate and comprehensive response from the international community. (excerpt)
The less they know, the better. Abstinence-only HIV / AIDS programs in Uganda.
Widely hailed as a leader in the prevention of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), Uganda is redirecting its HIV prevention strategy for young people away from scientifically proven and effective strategies toward ideologically driven programs that focus primarily on promoting sexual abstinence until marriage. Although endorsed by some powerful religious and political leaders in Uganda, this policy and programmatic shift is nonetheless orchestrated and funded by the United States government. Pioneered in the United States in 1981, “abstinence until marriage” programs (also known as “abstinence only” programs) teach that abstaining from sex until marriage is the only effective method of HIV prevention and that marriage between a man and a woman is the expected standard of human sexual behavior. Numerous U.S.-funded studies have shown these programs to be ineffective at changing young people’s sexual behaviors and to cause potential harm by discouraging the use of contraception. The effect of Uganda’s new direction in HIV prevention is thus to replace existing, sound public health strategies with unproven and potentially life-threatening messages, impeding the realization of the human right to information, to the highest attainable standard of health, and to life. (excerpt)
The struggle between migration control and victim protection: the UK approach to human trafficking.
Five years ago, the British public was horrified to learn of the brutal death of an eight-year-old girl from the Ivory Coast, Victoria Climbié, who had been trafficked to the United Kingdom (UK). During her nine months in the UK she had been sexually abused and tortured. She had endured daily beatings with various instruments, including a bicycle chain; burned with cigarettes and hot water; forced to sleep in the bathtub in an unheated bathroom, her hands bound and her body tied into a garbage bag in which she was forced to urinate and defecate; and made to eat her food from a dish on the floor like a dog. After her death, an autopsy revealed that she had died from malnourishment, hypothermia and organ failure, and had suffered almost 130 nonaccidental injuries to her body. Two years later, British police fished from the River Thames the torso of a boy who they believed to be somewhere between the ages of four and six and of West African origin. His exact identity unknown, he was dubbed “Adam.” His arms, legs and head had been chopped off. Authorities suspected that he had been trafficked to the UK to be used in a fetish ritual, his blood drained, his body parts kept as trophies and the rest of his body later disposed of by his murderers. Twenty-one people who were suspected of having trafficked “Adam” were arrested on immigration charges. (excerpt)
The impoverishing pandemic. The impact of the HIV / AIDS crisis in Southern Africa on development.
Well over a third of the people with HIV/AIDS in the world at the end of 2003 were living in a single subregion, Southern Africa. As the epicenter of the global HIV/AIDS pandemic, Southern Africa continues to shoulder the major burden of the HIV/AIDS crisis in 2004. Southern Africa was home to an estimated 14.4 million people living with HIV/AIDS at the end of 2003, in a global total estimated by UNAIDS at 37.8 million. Moreover, more than 10 per cent of the people with HIV/AIDS in the world lived in a single country in this subregion, South Africa, estimated by UNAIDS to have 5.3 million people living with HIV at the end of 2003. In addition to having the largest number of people living with HIV/AIDS, Southern Africa was home to approximately 5.91 million orphans ‘due to AIDS’ at the end of 2003. According to UNAIDS, 1.2 million adults and children died from AIDS-related illness last year in Southern Africa. Overall, an average HIV prevalence rate of 17.9 per cent was found in adults aged 15 to 49 at the end of 2003, spread across 13 countries in Southern Africa. Yet the range of adult HIV prevalence rates across these countries last year was broad. Adult HIV prevalence rates in 2003 ranged from a high of 38.8 per cent in Swaziland in a total population of 1,1 million people to 1.7 per cent in Madagascar in a total population of nearly 17 million people. (excerpt)
Re-sexualising the epidemic. Desire, risk and HIV prevention.
Even in the ‘era of treatment’ successful HIV prevention remains an enormous challenge. In this article Jonathan Berger argues that there is a need to pay more attention to sex and desire in the design of HIV prevention programmes and to move away from stereotyped explanations of vulnerability that ignore agency and desire in the decisions that people make about sex. The article also warns against the continued marginalisation of people who engage in ‘dirty sex’ from access to HIV prevention programmes and services. (excerpt)
Moving beyond the public. The challenge of women's political organising in the time of AIDS.
High vulnerability to HIV and high rates of infection amongst women and girls is an entrenched part of the epidemiology of AIDS in Africa. In this article Sisonke Msimang and Sharon Ekambaram question why, despite our knowledge of ‘women’s vulnerability’, little seems to be done to overcome the social and political determinants of HIV infection in women. They link their explanation to the inability of the women’s movement to contest gender inequality in the private spaces of life, and argue that HIV shows the need for a movement of poor, unemployed and peasant women to challenge power relations. (excerpt)
For the last five years, a great deal of controversy has surrounded aspects of the South African government’s response to HIV and AIDS. In the keynote article that follows, Mark Heywood attempts to document and explain South African President Thabo Mbeki’s association with ‘AIDS denialism’ and the response of the Treatment Action Campaign (TAC). He argues that ‘AIDS denialism’ was a shift away from the ANC’s own policy on HIV, and that it has impacted adversely on the implementation of a national AIDS policy that, on paper at least, is one of the best in the world. (excerpt)
Challenges facing civil society in Zimbabwe.
Zimbabwe is more in the news for its political and economic crisis than because of its AIDS epidemic. In the following article Tapiwanashe Kujinga explains how, for many years, civil society led the Zimbabwean response to HIV but warns that the political crisis is now having a negative effect on the capacity of civil society to continue to mount a response to HIV and AIDS. (excerpt)
The challenges facing civil society in Zambia.
The following article by Holo Hachonda illustrates how Zambia is no different from other countries in experiencing antagonism and distrust between civil society and government. However, he suggests that of late a new spirit of partnership is emerging. (excerpt)
Civil society response to HIV / AIDS in Angola.
The AIDS epidemic in Angola has been overshadowed by years of destructive civil war that has left Angolan society unprepared to manage the epidemic. In this article Collette Campher describes the challenges facing civil society in Angola in building a genuine partnership with government, and in ensuring respect for and promotion of human rights in the various responses. (excerpt)
Are we censoring ourselves? New issues facing the human rights response to HIV / AIDS.
There is wide acceptance by governments and civil society in SADC that a human rights-based response is justified in the implementation of HIV prevention and treatment programmes. However, policy and practice are usually different things. In this article, Holo Hachonda and Richard Adudah explain some of the key principles that inform the human rights approach to HIV and AIDS, but ask why these principles are not being applied to prisoners, sex workers and gay men who continue to be marginalised and denied access to HIV prevention. They conclude by introducing a debate which is currently taking place about new approaches to HIV testing – ‘routine testing’ or the ‘routine offer’ of testing. (excerpt)
Of gifts and return gifts. Beyond the political and practical deficits of donor assistance.
Donor aid for AIDS constitutes a major part of the funds that are available for HIV prevention and treatment in Southern Africa. While this money is vital and welcome, Peris Jones warns that it is also replete with dangers. In this article he reviews the history of donor interventions in development, examines some of the fine print of donor aid for HIV prevention and treatment, and highlights its pitfalls. (excerpt)
Bridge over troubled waters. The research-policy-implementation gap.
Europe has butter and tomato mountains. AIDS has research mountains. In the article that follows Geoffrey Setswe examines the place of research in the response to HIV. He reviews some of the literature on the role of research and questions whether research findings are being properly integrated into HIV prevention. Although superficially it might appear that most AIDS research is a self-perpetuating activity that has lost its connection with the epidemic it analyses, Setswe concludes that – properly planned and co-ordinated – research remains an important part of our response. (excerpt)
Overview of treatment access in the SADC region.
In the following article, Adila Hassim offers an overview of the state of antiretroviral treatment programmes in the SADC region. She also highlights some of the major challenges that confront the region if treatment programmes are to continue to expand and be sustained. (excerpt)
Botswana's HIV / AIDS programme: a model for SADC?
Since 2000 the Botswana government has been a model of political commitment in addressing the HIV and AIDS epidemic. Today its public sector ARV treatment programme is the largest in Africa. In this article, Christine Stegling describes the background to the Botswana AIDS programme, explains how Botswana has integrated the response to HIV with its development goals, looks at the issue of ‘routine’ HIV testing and human rights, and highlights some of the challenges that lie ahead. (excerpt)
The following article is by Fareed Abdullah, the head of the AIDS programme in the Western Cape Province of South Africa. It offers a unique account of treatment roll-out from the perspective of a programme manager in government. Abdullah’s article illustrates that with sufficient will and ingenuity, and on the basis of genuine partnerships, antiretroviral treatment can be provided in a manner that both saves lives and improves the health system as a whole. (excerpt)
Reflections and lessons from frontline treatment providers.
Providing access to antiretroviral treatment in Southern Africa is very different from doing the same thing in North America or Europe. In the following article, Belinda Beresford reports on the progress of several treatment programmes in urban settings in South Africa and Botswana. Based on interviews with doctors and patients, she provides a number of important insights on the challenges that lie ahead. (excerpt)
Pioneering treatment access in a rural area of South Africa.
Providing access to antiretroviral treatment in an urban setting is very different to rural provision, which brings its own set of challenges. However, with commitment and dedication, nothing is impossible, and Belinda Beresford reports movingly from the ‘’frontline’ of the Transkei area of South Africa, on the significant achievements that are being realised in this remote rural area. (excerpt)
States have the primary responsibility for protecting refugees. The Office of the United Nations High Commissioner for Refugees (UNHCR) works to ensure that governments take all actions necessary to protect refugees, asylum-seekers and other persons of concern who are on their territory or who are seeking admission to their territory. UNHCR, the sole international organization mandated to protect refugees globally, also strives to secure durable solutions for refugees so they can resume their normal lives. This manual aims to: Foster a common understanding of international protection among all UNHCR staff; Familiarize UNHCR partners, whether governmental, intergovernmental or non-governmental, with the basic principles of international protection; Contribute to the realization of the goals of the Agenda for Protection, which is an initiative between States, NGOs, IGOs and UNHCR, that seeks to enhance the protection of refugees worldwide. (excerpt)
Provide legal assistance, encourage Serbia and Montenegro (SCG) to adopt a law on refugees, create a national asylum system, and establish fair and efficient Refugee Status Determination (RSD) procedures; assist the most vulnerable IDPs and facilitate their return to Kosovo if possible; ensure consistent integration of the five commitments to women in all UNHCR’s assistance programmes; responsibly scale back assistance to post-Dayton refugees by ensuring their inclusion in development programmes and focus on assisting only the most vulnerable (earlier predictions of a more rapid withdrawal were found to be too optimistic by the Assistant High Commissioner’s mission to the Balkans in March 2004). (excerpt)
A thematic compilation of the Executive Committee conclusions. 2nd ed.
This compilation consists of selected paragraphs of the Conclusions of UNHCR’s Executive Committee grouped by subject. It seeks to show the progressive development of Executive Committee deliberations on a given topic over time, and to add a reference tool to the chronological arrangement of Executive Committee Conclusions already published by UNHCR. The first edition of this compilation was published in 2001 to mark the 50th anniversary of the 1951 Convention relating to the Status of Refugees. This 2nd edition includes Executive Committee conclusions from 1975, when they were first adopted, to 2004. The compilation is separated into 66 major chapters, arranged alphabetically. Many of the chapters are then divided into several subchapters, which are also arranged alphabetically. The conclusions are in chronological order within each subchapter, or within the chapter if there are no subchapters. (excerpt)
In 2004, UNHCR took a number of steps to strengthen the implementation of policy priorities on refugee women, refugee children and older persons. Following the three independent evaluations on refugee women, refugee children and the role of community services in refugee operations. In January 2004, the Section for General Equality and Refugee Women, Refugee Children, Community Development and Education (WCCDS) was created within the Division of Operational Support (DOS). A Steering Committee, composed of donors, UN agencies, NGOs and UNHCR was established to support implementation of the key recommendations of the evaluations. These included the launching of an age and gender mainstreaming pilot project in February 2004. By the end of the year, country assessments had been conducted in Colombia, Ecuador, Egypt, Greece, Guinea, India, The Islamic Republic of Iran, Jordan, Lebanon, North Caucasus/Russian Federation, Sierra Leone, Syria, Venezuela and Zambia. The pilot countries established multi-functional gender and age mainstreaming teams and country-level work plans. Implementation of these workplans is being monitored at Headquarters and senior staff will be held accountable for results. (excerpt)
The ten objectives of the strategy are: 1) Protection - to ensure that refugees, asylum-seekers and other persons of concern who are affected by HIV and AIDS can live in dignity, free from discrimination, and that their human rights are respected, including their non-discriminatory enjoyment of the highest attainable standard of physical and mental health; 2) Coordination and mainstreaming - to ensure that HIV policies and interventions for refugees are coordinated, mainstreamed and integrated with those at the international, regional, sub-regional, country and organisational levels ; 3) Durable solutions - to develop and incorporate HIV policies and interventions into UNHCR’s programmes for durable solutions, including voluntary repatriation, local integration and resettlement, in order to mitigate the long-term effects of HIV; 4) Advocacy - to advocate for HIV-related protection, policy and programme integration, and sub-regional initiatives for refugees and other persons of concern in a consistent and sustained manner at all levels; 5) Quality HIV programming - to ensure appropriate, integrated HIV interventions for refugees, returnees and other persons of concern, in concert with national programmes in host countries and countries of return; 6) Prevention - to reduce HIV transmission and HIV morbidity through the implementation of culturally and linguistically appropriate health and community-based interventions; 7) Support, care and treatment - to reduce HIV morbidity and mortality; this includes access to antiretroviral therapy when available to surrounding host populations when appropriate; 8) Assessment, surveillance, monitoring and evaluation - to improve programme implementation and evaluation; 9) Training and capacity building - to improve HIV-related skills and capacities of UNHCR, its partners and refugees; and, 10) Resource mobilization - to increase funds and move beyond traditional donors to ensure the objectives stated in this Strategic Plan are achieved. (excerpt)
These guidelines are the product of collaboration between the International Labour Organization and the World Health Organization. In view of their complementary mandates, their long-standing and close cooperation in the area of occupational health, and their more recent partnership as co-sponsors of UNAIDS, the ILO and the WHO decided to join forces in order to assist health services in building their capacities to provide their workers with a safe, healthy and decent working environment, as the most effective way both to reduce transmission of HIV and other blood-borne pathogens and to improve the delivery of care to patients. This is essential when health service workers have not only to deliver normal health-care services but also to provide HIV/AIDS services and manage the long-term administration and monitoring of anti-retroviral treatments (ART) at a time when, in many countries, they are themselves decimated by the epidemic. (excerpt)
Women in 2005: Are they making progress?
A decade ago, governments and women’s rights activists from around the globe gathered for the Fourth World Conference on Women in Beijing, calling for the advancement and empowerment of girls and women. Since that time, gathering data about women—especially about their health, education, and political and economic status—has become a central part of the effort to monitor our progress on the Beijing plan of action. To contribute to these monitoring efforts, this year’s Women of Our World 2005 data sheet, the fourth edition published by the Population Reference Bureau since 1995, provides updated estimates on women’s status and progress in reproductive health, education, work, and public life. (excerpt)
Lifetime Births per Woman (TFR): The total fertility rate, defined as the number of children a woman would have if current age-specific fertility rates remain constant throughout her childbearing years. Percent of Women Ages 15-19 Giving Birth in One Year: Births per 1,000 women ages 15-19 (the age-specific fertility rate), divided by 10. Contraceptive Use: The percentage of married or “in-union” women ages 15-49 who are currently using contraception. “Any method” includes modern and traditional methods. “Modern” methods include clinic and supply methods such as the pill, injectables, implants, IUD, condom, and sterilization. Percent of Births Attended by Skilled Personnel: Skilled personnel include doctors, nurses, and midwives. Maternal Deaths per 100,000 Live Births: Also known as the maternal mortality ratio, the number of deaths to women per 100,000 live births that result from conditions related to pregnancy, delivery, and related complications. Lifetime Chance of Dying From Maternal Causes: The probability that a woman will die during her lifetime from causes related to pregnancy and delivery. The measure combines the probability of becoming pregnant and the risk of death from each pregnancy (as measured by the 2000 maternal mortality ratio). (excerpt)
How U.S. unilateralism harms women.
At the United Nations, where countries and interest groups meet to decide economic, social and political issues, the United States wields enormous influence. As a permanent member of the Security Council, it has veto power over UN decisions. Whether or not the U.S. cooperates and compromises with other nations largely determines whether the UN can succeed in its mission of promoting global equality, development and peace. Thus far, the United States has tried to use its influence to establish a double standard of international rules, seeking to condemn its enemies but exempting itself from UN scrutiny. Portraying itself as a world leader in human rights and environmental issues, the U.S. has failed to sign or ratify many major treaties or “conventions.” U.S. unilateralism is not new, but the George W. Bush administration has taken it to new extremes. The pre-emptive war in Iraq is the most explicit case to date. A multilateral U.S. foreign policy would advance international law and human rights, including women’s rights and support a strong and effective multilateral system with the United Nations at its center. (excerpt)
The adolescent population of Bangladesh has, generally, a poor understanding of sexual and reproductive health. This is associated with early marriage, adolescent pregnancy, and increasing occurrence of high-risk sexual practices. Additionally, adolescents in Bangladesh live in a community which hold traditional beliefs and practices that still restrict the discussion and flow of accurate reproductive health information in the household, the community and schools. Access to accurate information on key reproductive health issues, such as reproductive physiology, sexuality, family planning, and sexually transmitted disease (STD), is severely restricted at all levels. Despite the increased enrollment of students in both urban and rural schools, results of the Bangladesh Demographic and Health Survey (BDHS) 1999-2000 showed that the proportion of adolescents dropping out from school continued to be high. A large number of adolescents were also found to be out-of-school in the ‘needs assessment study’ of ICDDR,B conducted in 1999. Hence a community-based intervention was considered as a possible strategy for a large proportion of adolescents, especially those not in school, to improve their knowledge about messages and information on reproductive health (RH). The study aimed at determining the relative benefits of an integrated adolescent-development programme that combined reproductive health education, community sensitization, livelihood skill-training (ST), and a savings and credit scheme. (excerpt)
Human Rights Watch world report, 2005. Events of 2004.
This report is Human Rights Watch’s fifteenth annual review of human rights practices around the globe. It summarizes key human rights issues in sixty-four countries, drawing on events through November 2004. Each country entry identifies significant human rights issues, examines the freedom of local human rights defenders to conduct their work, and surveys the response of key international actors, such as the United Nations, European Union, Japan, the United States, and various regional and international organizations and institutions. The volume begins with four essays addressing human rights developments of global concern in 2004. The lead essay examines far-reaching threats to human rights that emerged during the year: large-scale ethnic cleansing in Darfur in western Sudan, and detainee abuse at Abu Ghraib prison in Iraq, symptomatic of a broader problem of torture and mistreatment of detainees by U.S. forces. It argues that the vitality of human rights defense worldwide depends on a firm response to both of these threats. (excerpt)
Community-based family planning in Kenya: meeting new challenges.
Although Kenya has been touted as one of Africa’s family planning successes, with a relatively high contraceptive prevalence rate of 39% and a long history of making services available, there is still significant unmet need for family planning services. Poor access to family planning services is a major constraint to contraceptive use in large parts of the country, particularly in Coast, Nyanza and Rift Vally provinces, the sites of Pathfinder’s ongoing efforts to support FP programs in Kenya. Delays and setbacks are endemic in the implementation of a new contraceptive logistics system and new decentralization policies. Attempts to reform the government package of free health services will most certainly encounter obstacles. In this context, the unmet need for FP is difficult, if not impossible to address, without significant NGO and private sector involvement. The situation is made still more complex by strong community demands for HIV/AIDS information and services, which calls for maximizing resources and expertise by integrating efforts at both the community and clinic level. (excerpt)
Dominican Republic and Mexico: Promote condom use by emphasizing personal benefits.
Studies in the Dominican Republic and Mexico showed that regular condom users obtained personal benefits from condom use, including a sense of security. Condom promotion initiatives should emphasize the positive aspects of condom use and make condoms available through alternative venues. (author's)
Bolivia and Mexico: System-wide planning is needed for decentralized postabortion care.
Sharp curettage and manual vacuum aspiration, the most common treatments for incomplete abortion in developing countries, are equally safe and effective and can be provided on an outpatient basis. Integrating clinical treatment with family planning counseling and services increased clients’ knowledge and contraceptive use. However, integrated postabortion care requires a strategic approach that examines system-wide requirements for care. (author's)
Contraception for college students.
An important issue for human beings is the acquisition of normal sexual health, including the understanding and application of reproductive health when needed. Comprehensive sexuality education is not a topic provided to many children, adolescents, or college students in the United States, however. Students who were sexually active in high school may continue to be at risk for pregnancy and sexually transmitted diseases (STDs) in their college life; those who chose abstinence in high school may abandon this concept in college, choosing coital behavior at all levels of university life-freshman through graduate levels. One study noted that 35% of students in college reported having six or more lifetime coital partners. There are more than 15 million cases of STDs in the United States, and more than 60% of these occur in young people younger than 25 years. (excerpt)
The central aim of this article is to investigate the impact of HIV/AIDS upon the social and educational development of orphans of AIDS in child-headed households in the rural areas of Kwa-Zulu Natal, South Africa. The study explores, describes and interprets the phenomenon of HIV/AIDS within the context of the participants' perspectives of their life-world. The research abides by a qualitative methodology and an interpretive approach since the adolescents have been studied in their natural settings of their homes. Findings of the study have revealed that HIV/ AIDS has a definitive negative impact on the social and educational development of adolescents orphaned by AIDS in child-headed households. These adolescents are forced to abandon their schooling either temporarily or permanently because they have to take care of ailing parents and assume adult responsibilities in their homes. Further inhibiting factors on these adolescents' development are generated by abject poverty, the lack parental, social and educational support and social discrimination. The article analyzes and describes how the above-mentioned problems influence these AIDS-affected adolescents cognitively, emotionally, morally, socially and connotatively. (author's)
Violence and exploitation of children in Tajikistan.
Since the dissolution of the Soviet Union, Tajikistan has faced the immense challenge of building a democratic republic, and transitioning from a state-controlled to a free market economy. This transition has been complicated by consequences of civil war that had significant financial and social costs, including a sharp drop in government expenditures on health, social welfare and educational services. The reduction in expenditures resulted in the closure of many health, social welfare and educational services and programmes that were previously financed and supported by the government, as well as deterioration of social infrastructures, such as roads, transportation, hospitals, schools and public welfare institutions. In Tajikistan, the impact of civil war, and economic and social restructuring has been immense, including: an unemployment rate of over 30 per cent; low wages that do not even cover basic household necessities (the average monthly salary is less than US$7 per month); extremely high levels of inflation that have severely diminished or eliminated the savings of most families, causing those at the lowest income levels to sink more deeply into debt; price instability that has created great economic pressures; and the migration of many men to Russia and other countries in search of work. As a result, many individuals and families now suffer from a pervasive sense of financial insecurity, economic pressure and poverty. (excerpt)
The aims of this exploratory qualitative study were to increase our understanding of heterosexual young adults’ knowledge and beliefs about sexually transmitted infections (STIs) other than HIV, to explore their beliefs about the factors that influence condom use for STI prevention, and to explore their ideas about how best to promote condom use for STI prevention. Data came from a qualitative study that used 11 group discussions with 53 heterosexual men and women aged 18–25. Respondents thought that STI infection and unplanned pregnancy were equally likely, but were less concerned about STIs than unplanned pregnancy. Respondents gave several reasons for their low levels of concern about STIs. They also suggested several means to promote condom use for STI prevention. They supported multi-faceted condom promotion campaigns, using multiple styles of communication and a variety of media. The range of suggestions given by participants suggests that rather than employing a ‘one size fits all’ strategy, a variety of different approaches are needed to promote condom use for STI prevention. (author's)
We tested a social-cognitive intervention to influence contraceptive practices among men living in rural communes in Vietnam. It was predicted that participants who received a stage-targeted program based on the Transtheoretical Model (TTM) would report positive movement in their stage of motivational readiness for their wife to use an intrauterine device (IUD) compared to those in a control condition. Aquasi-experimental design was used, where the primary unit for allocation was villages. Villages were allocated randomly to a control condition or to two rounds of intervention with stage-targeted letters and interpersonal counseling. There were 651 eligible married men in the 12 villages chosen. A significant positive movement in men’s stage of readiness for IUD use by their wife occurred in the intervention group, with a decrease in the proportions in the precontemplation stage from 28.6 to 20.2% and an increase in action/maintenance from 59.8 to 74.4% (P < 0.05). There were no significant changes in the control group. Compared to the control group, the intervention group showed higher pros, lower cons and higher self-efficacy for IUD use by their wife as a contraceptive method (P < 0.05). Interventions based on social-cognitive theory can increase men’s involvement in IUD use in rural Vietnam and should assist in reducing future rates of unwanted pregnancy. (author's)
Several recent studies on child sexual abuse (CSA) in Chinese society have shown that the problem is not uncommon, and is associated with poor mental health and health-related risk behaviors of abused youth. It is very important to understand and improve public awareness of CSA prevention, especially for the parents. However, there are few published reports on the problem of parents’ awareness. To fill this gap, knowledge, attitudes and practice of CSA prevention education were explored in 385 parents of Grade 3 pupils from four schools in Fuxin City of Liaoning Province in the northeast part of China by self-administered anonymous questionnaires. Among this sample, more than 80% of parents approved of school CSA prevention education. However, at the same time, 47.3% of parents expressed some concern that this education may induce the children to learn too much about ‘sex’. Overall, about 60% of parents had told their children that their ‘private parts’ should not be touched by others and discussed strategies of ‘Say ‘‘No!’’, Leave and Tell’ in dealing with CSA situations or the situations that may lead to CSA. Only 4.2% of parents had provided books or other material about CSA prevention for their children. The parents’ CSA prevention knowledge was inadequate. The findings from this research will be useful in developing CSA prevention education programs in schools and communities, designed to improve parents’ knowledge and practice of CSA prevention. (author's)
Incidental detection of a transmigrated intrauterine device.
The intrauterine device (IUD) is among the most effective forms of birth control available, with important advantages over other methods of contraception. The most striking adverse event associated with IUD use is uterine perforation and migration of the device. Contrary to what one might assume, perforation is often silent and the wayward device is either detected after further sequellae or found incidentally by imaging. The radiologist should be aware of the natural course, presentations, diagnostic evaluation and treatment (if any) for this misplaced foreign body. (author's)
Scaling up AIDS treatment in developing countries: a review of current and future arguments.
Until recently, antiretroviral treatment against AIDS was perceived to be beyond the reach of the majority of patients in developing countries. This situation has changed drastically as international funding for AIDS treatment has swelled to several billion dollars a year. What has brought about this change? Analysis of the merit of six arguments often put forward against scaling up AIDS treatment in developing countries makes it clear that the most significant (and perhaps only) real change has been the large reduction in the price of the drugs. Although affordability is obviously a central issue, it is noticeable that most of the remaining arguments continue to be unresolved. This underlines the dangers of proceeding too fast towards treatment goals. (author's)
Preventing pregnancy-induced hypertension: Are there regional differences for this global problem?
Developing countries have had persistently higher rates of maternal and child mortality due to pre-eclampsia in comparison with developed countries. Moreover, evidence from studies of interventions to prevent pre-eclampsia have given contradictory results. In this review, we discuss the underlying causes of pre-eclampsia, and the results of clinical trials performed to prevent this disease, that support the proposal that the causes and strategies to prevent pre-eclampsia are different in developed and developing countries. We also suggest that the establishment of an adequate prenatal care is the only effective way to reduce the incidence of pre-eclampsia in populations from developing countries, especially in women at high risk of pregnancy-induced hypertension. (author's)
In December 2003, the US Department of State initiated a resettlement program for 15,707 Hmong refugees who had been displaced from Laos and were living on the grounds of Wat Tham Krabok, a Buddhist temple in Thailand. In January 2005, reports of tuberculosis (TB) cases among refugees still in Thailand and refugees who had arrived in the United States, including some cases caused by multidrug-resistant* (MDR) strains, prompted a 1-month travel suspension. After enhanced screening in Thailand and intensified TB-control measures in the United States, resettlement resumed on February 16. A majority of the Hmong refugees in Thailand and the United States with TB diagnosed were started on treatment and monitored. As of July 15, no additional TB cases had been diagnosed among newly resettled Hmong refugees. U.S. health departments should continue to ensure careful monitoring for TB among this refugee group. (excerpt)
The debate about over-the-counter emergency contraceptive pills.
Many prescription drugs have been converted to over-the-counter (OTC) status in recent years. Another drug that has been proposed for OTC status is a levonorgestrel-only emergency contraceptive pill. The debate surrounding OTC access to emergency contraceptive pills echoes issues encountered in previous reclassification processes and raises new challenges. This article discusses the emergency contraceptive pill, the evolution of its access options, and the context and implications of changing its status from a prescription to an OTC medication. (author's)
Inconsistent use of oral contraceptives (OCs) exposes women to risks of unintended pregnancy. This study explored women’s self-described reasons for missed OC pills. Data from diary cards completed by 141 women were studied to see how reasons for missing pills were related to patterns of pill use. The findings suggest that practitioners might improve OC use by focusing on the reasons that women miss pills, thus providing a more tailored approach that addresses individual risks based on women’s personal experiences. (author's)
Multidrug-resistant tuberculosis (MDR-TB) in India: an attempt to link biosocial determinants.
Multidrug-resistant tuberculosis (MDR-TB) has emerged as a possible threat to global tuberculosis control efforts in recent years. It is a challenge not only from a public health point of view but also in the context of global economy, especially in the absence of treatment for MDR-TB at national-level programs in developing countries. Biological accounts are insufficient to understand the emergence and dynamics of drug resistance. This article focuses essentially on the need for a holistic perspective, linking biosocial determinants that would probably lead to better insights into MDR-TB control strategies. (author's)
Detection of Plasmodium parasites in healthy blood donors using polymerase chain reaction.
Malaria is an important tropical disease in terms of morbidity and mortality. It is difficult to identify hidden contaminated cases through the use of ordinary techniques, such as microscopic methods, in endemic regions. In the present study, two techniques were used to assess the rate of contingent malaria contamination in healthy inhabitants: microscopic study (thin and thick blood smears) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). One hundred blood samples were collected from healthy individuals who lived in Chabahar, southeastern Iran, in June 2002, during peak mosquito season. Three positive samples (3%) were detected by PCR method, all of which had been reported negative by microscopic examination. It seems that the most appropriate method for population-based screening of blood donors for malaria parasites could be through the detection of parasite nucleic acids using PCR. Such a strategy would also reduce transfusion-transmitted malaria in endemic areas. (author's)
Human immunodeficiency virus (HIV) infection and. acquired immunodeficiency syndrome (AIDS) are becoming increasingly common in India. Currently, antenatal prevalence is a surrogate marker for HIV prevalence in the community. The association between antenatal and community prevalence of HIV needs to be validated so that estimates can be verified or adjusted appropriately. A probability proportional to size cluster survey was conducted in the Kaniyamdi block of Vellore district and in the urban wards of Vellore town to estimate the prevalence of antibodies to rubella from August 1999 to February 2000. All personal identifier data from the serum samples were removed to yield a collection for which only the age and sex were known. Estimation of antibodies to HIV in sera from individuals between 15 and 40 years of age, was carried out by one screening ELISA and the reactive sera were further subjected to a supplementary test, We tested 1512 serum samples from subjects residing in rural areas and 1358 samples from those residing in urban areas. The seropositivity among rural samples was 0.66% and among urban samples 1.4%. The prevalence was almost equal among men and women and the youngest infected individual was 15 years old. The prevalence of HIV during the period of study was similar to the national surveillance data for Tamil Nadu based on antenatal women. HIV prevalence differs in urban and rural Tamil Nadu, with urban areas having a higher burden of the disease. (author's)
Practical guidance on sexual lifestyle and risk.
This article advocates using a critical thinking framework as a health promotion tool to help nurses promote thought and discussion in relation to sexual lifestyles. The aim is to encourage clients or confidants to assess sexual risk for themselves and others, and to promote safe sex. (author's)
Climate variability and malaria epidemics in the highlands of East Africa.
Malaria epidemics in the highlands of East Africa garner significant research attention, due, in part, to their proposed sensitivity to climate change. In a recent article, Zhou et al. claim that increases in climate variance, rather than simple increases in climate mean values, have had an important role in the resurgence of malaria epidemics in the East African highlands since the early 1980s. If proven, this would be an interesting result but we believe that the methods used do not test the hypothesis suggested. (author's)
The purpose of this study was to explore the comparative contribution that (a) multiple sources of education about sexual topics (peers, media, school and other adults), and (b) the timing of this sex education, make on American adolescent sexual attitudes and behavior. Participants were 672 ethnically and economically diverse male and female, high-school adolescents. Regression analyses revealed that earlier learning from most sources and more learning from schools about various sexual topics, including the importance of using birth control and consequences of teen pregnancy, were generally significantly predictive of less frequent oral sex and sexual intercourse. Other sources of sex education (peers, media, other adults) seemed to be less important in influencing outcomes. Ethnic/racial and gender variations also resulted. (author's)
U.S. foreign aid and foreign policy: building strong relationships by doing it right!
Foreign aid policies cannot be more successful than their implementation, which inherently involves people and institutions. But people have their own interests and cultural frameworks, and institutions are inevitably grounded in culture and politics. Inattention to the agendas of individuals involved on both sides of foreign aid to Central and Eastern Europe played a major role in its shortcomings. A recent court decision holding two Harvard university scholars guilty of defrauding the U.S. government while running a flagship project to reform the Russian economy underscores the pitfalls in outsourcing traditional functions of government to small, well-connected groups that are not fully accountable in serving the public interest. Drawing on the author's experience studying informal systems and networks over several decades, this article illuminates the importance of foreign policy and aid relationships- how they are set up, who wins and who loses, and how their lack of accountability can contribute to the derailment of nation-building and constructive relations among countries. (author's)
"Learning to fly" in a world of information overload.
Q: What is knowledge management? A: It’s mainly common sense. Every time we send an email, talk to one another or pick up the phone we are sharing knowledge with one another. Paradoxically, you can’t manage knowledge, but you can create an environment where knowledge flows easily. For me, it’s less important to capture all the knowledge we have and it’s more important to be connected to the people who have the knowledge. When I am planning a vacation, I can go to a travel agent and watch a TV programme. But if you talk to a person who has been there, you can ask them everything you need to know. That’s when knowledge flows easily because you get the knowledge you want. Q: Why do we need help to make knowledge flow more easily? Why do you think staff at WHO are not communicating properly with each other? A: Imagine what we could achieve if all of us knew what each of us knows. But people are driven by their own focus and priorities. Where you have a common goal it’s much easier to help one another get there. It’s like sailing. If a crew of people sailing are all going in different directions, they won’t get anywhere. If you are very clear on which port you are trying to reach, even when you have done your task you are quite happy to help someone achieve theirs. At WHO, on occasions it seems that some people have lost sight of the fact they are trying to improve world health and reduce mortality, and their publication or report becomes an end in itself. (excerpt)
Delivery options for contraceptives.
Although a steady increase in contraceptive use has been observed in developed and less-developed countries, the contraceptive needs of a significant proportion of couples have not yet been met, resulting in an increase in unplanned pregnancies. Several new contraceptive products have reached the market during the past few years. Among these are new implants, a medicated intrauterine device, contraceptive vaginal rings, transdermal patches and several new regimen of combined oral contraceptives. These new or improved methods have been developed to expand the contraceptive choices available to women and men as well as to respond to the unmet need for contraceptives with long-term activity. New targets are being identified both in the ovary and the testes for a more specific non-hormonal contraception. This futuristic approach still keeps in mind the need for better access to existing contraceptive methods, as well as the discovery of new contraceptives that are simple to use, safe, reversible and inexpensive. In recent years, there has been great interest in agents that provide dual protection against pregnancy and sexually transmitted infections (STI), especially human immunodeficiency virus (HIV). A contraceptive method providing dual medical benefits might increase motivation for consistent use, thus reducing contraceptive failures and unwanted pregnancies. (author's)
The impact of HIV / AIDS on the control of tuberculosis in India.
Epidemics of HIV/AIDS have increased the tuberculosis (TB) caseload by five or more times in East Africa and southern Africa. As HIV continues to spread, warnings have been issued of disastrous AIDS and TB epidemics in "new-wave" countries, including India, which accounts for 20% of all new TB cases arising in the world each year. Here we investigate whether, in the face of the HIV epidemic, India's Revised National TB Control Program (RNTCP) could halve TB prevalence and death rates in the period 1990-2015, as specified by the United Nations Millennium Development Goals. Using a mathematical model to capture the spatial and temporal variation in TB and HIV in India, we predict that, without the RNTCP, HIV would increase TB prevalence (by 1%). incidence (by 12%). and mortality rates (by 33%) between 1990 and 2015. With the RNTCP, however, we expect substantial reductions in prevalence (by 68%), incidence (by 41%). and mortality (by 39%) between 1990 and 2015. In India, 29% of adults but 72% of HIV-positive adults live in four large states in the south where, even with the RNTCP, mortality is expected to fall by only 15% between 1990 and 2015. Nationally, the RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015. HIV-infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatment for TB. (author's)
The perceptions of adolescents, parents and teachers on the same adolescent health issues.
The aim of this study was to explore and compare the views of Hong Kong Chinese adolescents, parents and teachers on the same adolescent health issues. A total of 22 focus groups were conducted with Form 1 students (aged from 11 to 13) who attended the Basic Life Skills Training program organized by the Student Health Service, Department of Health in Hong Kong. The program covered a wide range of topics including emotions, self-image, stress management, drinking, smoking and substance abuse, self-esteem and interpersonal skills. Responses from the three types of participants were somewhat different and inconsistent on the issues of changes during puberty, stress and stress management, smoking, drinking and substance abuse. Compared to the West, Chinese adolescents tended to report more stress from studying and under-report socially undesirable behaviour. The use of focus groups was recommended as an effective method of collecting qualitative data with Chinese populations. Focus groups can help maximize data collection, and sometimes, the groups can also help different individual members to gain more insights or new ideas. (author's)
In July, 1999, a single dose of live-attenuated SA 14-14-2 Japanese encephalitis vaccine was given to children aged 1–15 years in the Terai region of Nepal. Cases of natural infection occurred almost immediately. Our aim was to assess the long-term protective effect of this vaccination. In 2000, this same population had a second seasonal exposure to the virus. We therefore did a case-control study to measure the prevalence of vaccination against Japanese encephalitis in 35 patients hospitalised for the disease 1 year after immunisation, and in age-sex matched village controls. Of 35 children resident in Bardiya and Banke districts admitted to the Bheri Zonal Hospital with serologically confirmed Japanese encephalitis, only one had been vaccinated in 1999. In 430 age-sex matched village controls, 234 (54.4%) were vaccinated. We calculated a median unbiased estimate of the odds ratio of 0.0155, with lower and upper confidence limits of 0.0004 and 0.0986. The protective effect of vaccine after 12–15 months was 98.5% (CI 90.1–99.2%). Our study provides evidence of sustained high protection afforded by one dose of live attenuated SA 14-14-2 vaccine in Nepalese children. (author's)
Body image and risky sexual behaviors: an investigation in a tri-ethnic sample.
The impact of negative body image on risky sexual behaviors has not been extensively investigated. The present study examined the relationship between two aspects of body image, appearance shame and appearance investment, and potentially risky behaviors. The study employed a tri-ethnic sample of 1547 women seeking services at two family planning clinics. Logistic regression was utilized to examine the relationship between potential risk behaviors and shame and investment. Results supported that these aspects of body image were significant predictors of inconsistent condom use, having multiple sex partners in the past year, and having sex after chinking alcohol ox using drugs, and that demographic variables (e.g., age, marital status, ethnicity) could not fully account for these relationships The importance of future research investigating the relationships among body image, perceived relationship security, affect-management strategies, and risky sexual behaviors is emphasized. (author's)
Multiple role adaptation among women who have children and re-enter nursing school in Taiwan.
This study assessed multiple role adaptation within maternal and student roles among female RNs who had children and returned to school for baccalaureate degrees in Taiwan. Using Roy's Adaptation Model as the theoretical framework, relationships were explored among demographic (number of children, age of youngest child, employment status), physical (sleep quality, health perception, activity), and psychosocial factors (self-identity, role expectation, role involvement, social support) and multiple role adaptation (role accumulation). The sample included 118 mother-students who had at least one child younger than age 18 and who were studying in nursing programs in Taiwan. The highest correlation was found between activity and role accumulation followed by significant correlations between sleep quality, health perception, maternal role expectation, and age of youngest child and role accumulation. In regression analyses, the complete model explained 46% of the variance in role accumulation. Implications for education and future research are identified. (author's)
Population-based family studies in genetic epidemiology.
Designs that involve families (the traditional strength of genetic epidemiology) and population-based sampling (the traditional strength of environmental epidemiology) allow investigation of both genes and environment, separately or together, and allow valid inference to the population. These case-control-family designs (including those involving twin pairs), can be regarded as retrospective cohort studies of relatives, and can be used for: determining familial risks and genetic models; estimating risk (penetrance) for measured genotypes; genetic association studies; stratifying risks by family history and known mutation status; and studying modifiers of risk in genetically susceptible individuals. Follow-up of families allows genetic and environmental risks to be studied prospectively. We discuss statistical methods, theoretical and practical strengths, limitations, and other issues. Given their versatility, population-based family studies could become a principal framework in epidemiology, and move genetics from its traditional focus on high-risk families to give it a wider clinical and population health relevance. (author's)