Volume 8, Number 23
9 June 2008

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ADOLESCENT HEALTH RESEARCH

Barriers and facilitators to human papillomavirus vaccination among Chinese adolescent girls in Hong Kong: A qualitative -- quantitative study
(Abstract; subscription needed for full text; Asia)
Sexually Transmitted Infections. 2008 Jun;84(3):227-232.
Kwan TT | Chan KK | Yip AM | Tam KF | Cheung AN
The objectives were to explore perceptions towards cervical cancer, human papillomavirus (HPV) infection and HPV vaccination and to identify factors affecting the acceptability of HPV vaccination among Chinese adolescent girls in Hong Kong. Six focus groups were conducted with Chinese adolescent girls (median age 16 years, age range 13-20, n = 64) in Hong Kong in April 2007. Thematic analysis was employed to identify major themes related to cervical cancer and HPV vaccination. A supplementary questionnaire was administered to all participants before and after group discussion to assess their knowledge, attitudes and intention to be vaccinated and to collect demographic information. Participants' knowledge on cervical cancer was limited and HPV was largely unheard of. They had difficulty understanding the mechanism linking cervical cancer with HPV infection. Participants held a favourable attitude towards HPV vaccination but the perceived timing of vaccination varied. Barriers to vaccination include high monetary cost, uncertain length of vaccine effectiveness, low perceived risk of HPV infection, no immediate perceived need of vaccination, anticipated family disapproval and fear of the pain of injection. Factors conducive to vaccination include perceived family and peer support and medical reassurance on safety and efficacy of vaccine. The differences on knowledge, attitudes, intention to be vaccinated now and willingness to conform to significant others before and after the discussion were statistically significant, with an increased tendency towards favouring vaccination after the focus group. Participants favoured HPV vaccination despite not feeling an immediate need to be vaccinated. Interventions could focus on providing professional information on HPV vaccination and raising adolescents' perceived need to take preventive measures against HPV infection.

Adolescent pregnancy in Argentina: Evidence-based recommendations for public policies
(Abstract; subscription needed for full text; South America)
Reproductive Health Matters. 2008 May;16(31):192-201.
Gogna M | Binstock G | Fernandez S | Ibarlucia I | Zamberlin N
In Argentina adolescent pregnancy is still regarded as a public health problem or a "social epidemic". However, it is necessary to ask from which perspective and for whom it is a problem, and what type of problem. This article presents the findings of a large quantitative and qualitative study conducted in five Northern provinces and two metropolitan areas of Argentina in 2003-2004. Based on the results of a survey of adolescent mothers (n=1,645) and ten focus group discussions with adolescent girls and boys, it addresses the connections between school dropout, pregnancy and poverty, and makes recommendations on how to tailor health care and sexuality education to address local realities. The findings indicate a need to develop educational activities to promote safer sex and address gender power relations in programmes working with deprived communities. Sexuality education with a gender and rights perspective, and increasing accessibility to contraceptive methods for adolescent girls and boys is also crucial. Antenatal and post-partum care, as well as post-abortion care, should be improved for young women and viewed as opportunities for contraceptive counselling and provision. Male participation in pregnancy prevention and care also needs to be promoted.

FAMILY PLANNING RESEARCH

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia
(Research Article; North Africa)
Eastern Mediterranean Health Journal. 2008 May-Jun;14(3):615-627.
Letaief M | Hmida AB | Mouloud B | Essabbeh B | Aissa RB
We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures.

Cervical dysplasia and cancer: Use of hormonal contraceptives in Jamaican women
(Research Article; Central America and the Caribbean)
BMC Women's Health. 2008 May 30;8:9.
McFarlane-Anderson N | Bazuaye PE | Jackson MD | Smikle M | Fletcher HM
This study was conducted to determine whether use of hormonal contraceptives is associated with cervical dysplasia and cancer in a population where there is widespread use of hormonal contraception and the rates of cervical cancer remain high at 27.5/100,000. A case-control study was conducted among women visiting the colposcopy and gynaelogical clinics at a tertiary referral hospital. Two hundred and thirty six cases CIN I (72), II (59), III (54), cancer (51) and 102 controls, consented and were interviewed on use of contraceptives using a structured questionnaire. Logistic regression was used to determine odds ratios (ORs) and 95% confidence intervals (CIs) associated with use of hormonal contraception in cases and controls and in low and high risk cases. Recruitment was carried out from 2001 -2002. Contraceptives used were: oral contraceptives - 35%, injections (depot medroxy progesterone acetate (Depo-provera) -10%, Intrauterine devices - 2%, combinations of these and tubal ligation - 30%. 23% reported use of 'other' methods, barrier contraceptives or no form of contraception. Barrier contraceptive use was not significantly different between cases and controls. Current and / or past exposure to hormonal contraceptives (HC) by use of the pill or injection, alone or in combination with other methods was significantly higher in the cases. In multivariate analysis with age and number of sexual partners as co-variates, use of hormonal contraception was associated both with disease, [OR, 1.92 (CI 1.11, 3.34; p = 0.02] and severity of the disease [OR, 2.22 (CI 1.05, 4.66) p = 0.036]. When parity and alcohol consumption were added to the model, hormonal contraception was no longer significant. The significant association with high risk disease was retained when the model was controlled for age and number of sexual partners. Depo-provera use (with age and number of sexual partners as covariates) was also associated with disease [OR, 2.43 (CI 1.39, 4.57), p = 0.006] and severity of disease [OR 2.51 (1.11, 5.64) p = 0.027]. With parity and alcohol added to this model, depo-provera use retained significance. Exposure to HC greater than 4years conferred more risk for disease and severity of disease. Hormonal contraception did confer some risk of dysplasia and women using HC should therefore be encouraged to do regular Pap smear screening.

Occurrence of menses or pregnancy after cessation of a continuous oral contraceptive
(Abstract; subscription needed for full text; Global)
Fertility and Sterility. 2008 May;89(5):1059-1063.
Davis AR | Kroll R | Soltes B | Zhang N | Grubb GS
The objective was to evaluate the time to return to spontaneous menses in women after 1 year of daily continuous levonorgestrel (LNG) 90 mg/ethinyl E2 (EE) 20 mg. The design used was an observational study. The setting was gynecologic and primary care practices. The patients studied were women aged 18-49 years with a history of regular menstrual cycles. After participation in an openlabel, continuous oral contraceptive (OC) trial for at least 6 months, participants agreed to enroll in a separate study of the return to menses or pregnancy. The main outcome measure was the time to return to spontaneous menses or pregnancy. The 198 subjects had a mean age of 30.4 plus or minus 6.6 years with 72% white, 13% Hispanic, and 7% African American. The mean duration of continuous LNG/EE treatment before enrollment was 349 plus or minus 41 days. Of the 187 (94%) subjects who completed this study, 181 returned to spontaneous menses and 4 became pregnant within 90 days after the last dose of LNG 90 mg/EE 20 mg. The median time to return to menses in the completer population was 32 days, and the incidence of spontaneous menses or pregnancy at day%90 was 98.9%. The duration of amenorrhea during continuous LNG/ EE use before stopping treatment was unrelated to the time to the return to menses. Spontaneous menses or pregnancy occurred in 98.9% of women after cessation of continuous LNG/EE.

Depot-medroxyprogesterone acetate: An update
(Abstract; subscription needed for full text; Global)
Archives of Gynecology and Obstetrics. 2008 Jul;278(1):1-12.
Bakry S | Merhi ZO | Scalise TJ | Mahmoud MS | Fadiel A
Depo-Provera is a contraceptive approved by the US Food and Drug Administration (FDA) since 1992 and used worldwide by more than 90 million women. Despite the fact that progestins are endogenous hormones that are secreted by the body, its excess might lead to detrimental health effects. Whether progestins as contraceptives are friends or foes is a questionable matter. In this manuscript, we drive the attention to both usage and side effects Depo-Provera. Depot-medroxyprogesterone acetate (DMPA) is a highly effective, convenient non-daily hormonal contraceptive option that has been available worldwide for many years. The experience with DMPA provides a large body of long-term data regarding the efficacy and safety of this contraceptive method; this long-term experience has established that the use of DMPA does not increase the risk of cardiovascular events, breast cancer, other gynecologic malignancy, or postmenopausal fracture; however, patients are often more concerned about the relatively immediate effects of contraceptives such as potential changes in menstrual cycle, body weight, and mood disturbances. Concerns about such issues may lead to reluctance to initiate therapy or premature discontinuation. Counseling and understanding of women's concerns and experiences using Depo-Provera is important and could help health care providers redesign counseling strategies to improve contraceptive continuation and improve patient adherence.

Contraceptive knowledge and practices in two districts of Sindh, Pakistan: A hospital based study
(Abstract; subscription needed for full text; Asia)
Journal of the Pakistan Medical Association. 2008 May;58(5):254-258.
Bibi S | Memon A | Memon Z | Bibi M
The purpose of this study was to assess contraceptive knowledge, practices, availability and accessibility of family planning services and reasons for non-utilization of family planning services in interior of Sindh province, Pakistan. A hospital based cross-sectional survey was conducted in 2003. In person interviews were carried out with attendees of Gynaecology and Obstetrics out patient clinics of two districts hospitals in Tando Allahyar and Jamshoro. Data was collected regarding socio-demographic features, reproductive profile, availability and accessibility of family planning services and reasons for non-use of contraception. Current contraceptive practice at the time of survey was 29%. However, use of family planning was more in district Tando-Allahyar as compared to district Jamshoro (p less than 0.001) inspite of similar socio-demographic and reproductive profile. Mean age of marriage of wife and husband was 17.73 +or- 3.8 and 23.82 +or- 5.8 years respectively. In both districts mean parity and number of living children was around 4. Contraceptive use increased with increasing age of mother, parity and number of living children. Tubal ligation (9.5%) and condoms (9.0%) were the most popular methods of family planning. Mass media was the primary source of information in approximately 72.5% of the study population. Fear of side effects was the main reason given by non-users. The current contraceptive practices are not at the expected levels. Community health workers have provided good services at raising awareness.

GENDER and HEALTH RESEARCH

Health services for survivors of gender-based violence in northern Uganda: A qualitative study
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Reproductive Health Matters. 2008 May;16(31):122-131.
Henttonen M | Watts C | Roberts B | Kaducu F | Borchert M
The 20-year war in northern Uganda has resulted in up to 1.7 million people being internally displaced, and impoverishment and vulnerability to violence amongst the civilian population. This qualitative study examined the status of health services available for the survivors of gender-based violence in the Gulu district, northern Uganda. Semi-structured interviews were carried out in 2006 with 26 experts on gender-based violence and general health providers, and availability of medical supplies was reviewed. The Inter-Agency Standing Committee (IASC) guidelines on gender-based violence interventions in humanitarian settings were used to prepare the interview guides and analyse the findings. Some legislation and programmes do exist on gender-based violence. However, health facilities lacked sufficiently qualified staff and medical supplies to adequately detect and manage survivors, and confidential treatment and counselling could not be ensured. There was inter-sectoral collaboration, but greater resources are required to increase coverage and effectiveness of services. Intimate partner violence, sexual abuse of girls aged under 18, sexual harassment and early and forced marriage may be more common than rape by strangers. As the IASC guidelines focus on sexual violence by strangers and do not address other forms of gender-based violence, we suggest the need to explore this issue further to determine whether a broader concept of gender-based violence should be incorporated into the guidelines.

Age-specific prevalence of high-risk human papillomavirus infection in a Hungarian female population with positive cytology
(Abstract; subscription needed for full text; Europe)
European Journal of Obstetrics, Gynecology and Reproductive Biology. 2008 Jun;138(2):194-198.
Sapy T | Poka R | Szarka K | Konya J | Huga S
Patients with positive screening results and persistence of high-risk human papillomavirus (HPV) infection represent the population at the highest risk for developing cervical cancer. To describe the epidemiology in this high-risk population, data were collected and analysed at the referral centre for patients with positive cytology. Between January 1997 and December 2002 the authors performed 3480 virus identifications using the Digene Hybrid Capture system in a female population with positive cytology at cervical cancer screening. Age-specific prevalence data were evaluated and compared between the age groups by running the x/2 and Pearson x/2 tests. Subgroup analysis was performed to estimate monthly clearance rates among eligible women with positive HR-HPV results. Low-risk (LR), high-risk (HR) and double infections were detected in 91 cases (2.6%), 1072 cases (30.8%) and 59 cases (1.7%), respectively. A significantly higher incidence of high-, rather than low-risk HPV infections was found in all age groups (p less than 0.001). Also, in this high-risk population with positive screening a significant decrease was detected in the prevalence of both high- and low-risk infections beyond 35 years of age (p less than 0.001). However, the decline in the HR-HPV types occurred later than in the case of LR infections, and HR-HPV was of remarkable frequency in the older age groups, which might represent both incidental and prevalent cases. Subgroup analysis for estimating monthly clearance rates revealed no significant differences between the various age groups and between women with various cytology results. In a population with positive cytology the prevalence of HPV drops with age while the relative frequency of high-risk HPV infection remains at the same level as that of the youngest age group.

Increase of oxidative stress in human sperm with lower motility
(Abstract; subscription needed for full text; Asia)
Fertility and Sterility. 2008 May;89(5):1183-1190.
Kao SH | Chao HT | Chen HW | Hwang TI | Liao TL
The objective was to investigate the causal role of oxidative-stress status on human sperm motility. The design was to demonstrate that sperm with higher oxidative damage have a lower antioxidant capacity. The setting was the University hospital infertility center. Seventy-eight semen samples were obtained from 35 healthy donors who had normal semen characteristics and from 43 infertile or subfertile males. The levels of oxidative damage (8-hydroxy-20-deoxyguanosine [8-OHdG] and lipid peroxides) and antioxidants (retinol, a-tocopherol, ascorbate, and protein thiols) in the spermatozoa and/or seminal plasma were measured. We analyzed the specific content of 8-OHdG and lipid peroxides by using highperformance liquid chromatography (HPLC)-electrochemical detection and HPLC-fluorescence analysis, respectively. Retinol and alpha-tocopherol were analyzed by using an HPLC system, whereas ascorbate and protein thiols were determined by using spectrophotometry. 8-Hydroxy-2-deoxyguanosine was visualized by immunofluorescent staining with an anti-8-OHdG antibody that was conjugated with fluorescein isothiocyanate conjugate. Lipid peroxides in spermatozoa were stained with a fluorescent dye, C11-BODIPY/581/591. Statistically significant negative correlations were revealed between sperm motility and 8-OHdG and between motility and lipid peroxides. Statistically significant positive correlations were found between sperm motility and the levels of retinol, a-tocopherol, ascorbate, and protein thiols of seminal plasma. 8-Hydroxy-2-deoxyguanosine and lipid peroxides in spermatozoa were found to be present mostly in mitochondria. Oxidative stress and oxidative damage were increased significantly in spermatozoa with declined motility, and the antioxidant capacities in the spermatozoa and seminal plasma were lower in males who had infertility or subfertility.

Gender inequality increases women's risk of HIV infection in Moshi, Tanzania
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Biosocial Science. 2008 Jul;40(4):505-525.
Sa Z | Larsen U
This study examined the hypothesis that multiple dimensions of gender inequality increase women's risk for HIV infection using a population based survey of 1418 women aged 20 to 44 in Moshi, Tanzania. Three forms of HIV exposures were assessed reflecting gender power imbalance: economic exposures (age difference between partners and partner's contributions to children's expenses), physical exposures (coerced first sex and intimate partner violence) and social exposures (ever had problems conceiving). Behavioural risk factors included number of sexual partners for women in the last three years, partner had other wives or girlfriends, non-use of condom and alcohol use at least once a week in the last 12 months. Multivariate logistic regression analysis showed that a woman had a significantly elevated risk for HIV if she had a partner more than 10 years older (OR=2.5), her partner made low financial contributions to children's expenses (OR=1.7), or she experienced coerced first sex before age 18 years (OR=2.0) even after taking into account the effects of risk behaviour factors. The association between ever had problem conceiving and HIV infection was explained away by risk behaviour factors. The findings lend support to the hypothesis that economic deprivation and experience of sexual violence increase women's vulnerability to HIV, providing further evidence for extending the behavioural approach to HIV interventions to incorporate women's economic empowerment, elimination of gender-based violence and promotion of changing attitudes and behaviours among men.

HIV/AIDS and STIs RESEARCH

The effectiveness of a national communication campaign using religious leaders to reduce HIV-related stigma in Ghana
(Abstract; subscription needed for full text; Sub-Saharan Africa)
African Journal of AIDS Research. 2008 May;7(1):133-141.
Boulay M | Tweedie I | Fiagbey E
This article describes the effects of a national mass media and community-level stigma-reduction programme in Ghana, in which national and local religious leaders urged their congregations and the general public to have greater compassion for people living with HIV or AIDS (PLHA). Data were collected from men and women living in three regions, first in 2001 (n = 2 746) and again in 2003 (n = 2 926). Attitudes related to a punitive response to PLHA both improved over time and were positively associated with exposure to the programme's campaign, controlling for potential confounding variables. Respondents in the 2003 survey were 20% more likely than respondents in the 2001 survey to be willing to care for an HIV-infected relative in their own household and 40% more likely to believe that an HIV-infected female teacher should be allowed to continue teaching. Overall, respondents exposed to the campaign were 45% more likely than those not exposed to it to be willing to care for a HIV-infected relative, and 43% more likely to believe that an HIV-infected female teacher should be allowed to continue teaching. Respondents exposed to the campaign also had significantly more favourable scores on an attitude scale measuring the belief that HIV-infected individuals should be isolated from others. The results of this evaluation suggest that mass media channels and religious leaders can effectively address HIV-related stigma on a national scale.

Anthropometric and immunological success of antiretroviral therapy and prediction of virological success in west African adults
(Report; Sub-Saharan Africa)
Bulletin of the World Health Organization. 2008 Jun;86(6):435-442.
Messou E | Gabillard D | Moh R | Inwoley A | Sorho S
The 6 month assessment of the response to antiretroviral therapy (ART) is a critical step. In sub-Saharan Africa, few people have access to plasma viral-load measurement. We assessed the gain or loss in body mass index (BMI), alone or in combination with the gain or loss in CD4+ T-cell count (CD4), as a tool for predicting the response to ART. In a cohort of 622 adults in Abidjan, Cote d'Ivoire, we calculated the sensitivity, specificity and predictive values of BMI and CD4 for treatment success defined as viral-load undetectability (less than 300 copies/ml) as gold standard. After 6 months of ART, the median change in BMI was an increase of 1.0 kg/m/2 (interquartile range, IQR: 0.0-2.1), the median change in CD4 an increase of 148/microl (IQR: 54-230) and 84% of patients reached viral-load undetectability. The distribution of change in BMI was similar among patients who reached undetectability and those who did not (increases of 1.06 kg/m/2 versus 0.99 kg/m/2, P = 0.51). With larger changes in BMI, the specificity for treatment success increased but its sensitivity decreased and its positive predictive value was stable around 85%. All results remained similar when combining changes in BMI with those in CD4 and when stratifying by groups of baseline BMI or CD4. In settings where viral-load measurement is not available, a high BMI gain does not reflect virological success, even when combined with a high CD4 gain. In our population, most patients with detectable viral-load had probably adhered to the drug regimen sufficiently to reach significant gains in body mass and CD4 count but had adhered insufficiently to reach viral suppression.

HIV / AIDS in Haiti: Key findings of the Mortality, Morbidity, and Utilization of Services Survey, EMMUS-IV, 2005-2006
(Abstract; subscription needed for full text; Central America and the Caribbean)
Calverton, Maryland, Macro International, MEASURE DHS, [2008]. [26] p.
The Mortality, Morbidity, and Utilization of Services Survey (Enquete Mortalite, Morbidite et Utilisation des Services en Haiti), or EMMUS-IV, was carried out on a nationally representative sample. It is the fourth survey of its kind in Haiti and it updates the health and demographic indicators collected during the previous surveys of 1994-1995 and 2000. EMMUS-IV field staff interviewed approximately 10,000 households between October 2005 and June 2006, including 10,000 women between the ages of 15 and 49 and 5,000 men between the ages of 15 and 59. The data are representative at the national level, for urban and rural residence, for the Capital Area, and for all administrative departments (North, North-East, North-West, Center, Artibonite, South, South-East, Grande-Anse, Nippes, and West excluding the Capital Area of greater Port-au-Prince). In the course of the EMMUS-IV, approximately 10,000 respondents agreed to provide a small blood sample for an anonymous HIV test. The results of this test were used to estimate HIV prevalence in the general population. This report presents survey findings on HIV prevalence in Haiti and other related results, including knowledge of HIV/AIDS, attitudes toward people living with HIV, and sexual behavior.

Antiretroviral therapy for HIV-infected tuberculosis patients saves lives but needs to be used more frequently in Thailand
(Abstract; subscription needed for full text; Asia)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Jun;48(2):181-189.
Sanguanwongse N | Cain KP | Suriya P | Nateniyom S | Yamada N
The impact of antiretroviral therapy (ART) on HIV-infected tuberculosis (TB) patients in public health programs in resource-limited settings is not well documented due to problems with statistical bias in observational studies. We measured the impact of ART on survival of HIV-infected TB patients in Thailand using a propensity score analysis that adjusted for factors associated with receiving ART. Of 626 HIV-infected TB patients started on ART during TB treatment, 68 (11%) died compared with 295/643 (46%) of patients not prescribed ART (relative risk 0.24, 95% confidence interval: 0.19 to 0.30); in patients with very low CD4 (less than 10), 12/56 (21%) patients receiving ART died compared with 35/43 (81%) patients not receiving ART (relative risk 0.26, 95% confidence interval: 0.16 to 0.44). Patients treated in the private sector and in rural areas were less commonly prescribed ART. After controlling for propensity to receive ART, the hazard ratio for death among patients treated with ART was 0.17 (95% confidence interval: 0.12 to 0.24). Patients who received ART had one sixth the risk of death of those not receiving ART. The survival benefit persisted even for those with a very low CD4 count. Expanding use of ART in HIV-infected TB patients will require increasing ART use in the private sector and rural areas.

A study on HIV and hepatitis C virus among commercial sex workers in Tallinn
(Abstract; subscription needed for full text; Europe)
Sexually Transmitted Infections. 2008 Jun;84(3):189-191.
Uuskula A | Fischer K | Raudne R | Kilgi H | Krylov R
Estonia is confronted by a dramatic expansion of the initially injection drug use-driven HIV epidemic. Little is known about HIV occurrence in population groups at high risk other than injection drug users. The objective was to obtain data on the prevalence of HIV and hepatitis C virus (HCV) among female sex workers (FSW) in Tallinn. The design was an unlinked, anonymous, cross-sectional survey of FSW recruited in Tallinn from October 2005 to May 2006. 227 FSW were recruited for the survey and biological sample collection (HIV, HCV antibodies detection) using a combination of time-location, community and respondent-driven sampling. Among 227 women the HIV and HCV prevalences were 7.6% (95% CI 4.6% to 12.5%) and 7.9% (95% CI 4.5% to 12.6%), respectively. HIV prevalence was higher among FSW working in the street (odds ratio (OR) 6.4; 95% CI 1.1 to 35.6) and at the brothels and apartments supervised by the organised sex industry (OR 5.0; 95% CI 1.3 to 18.4). The duration of sex work was negatively associated with HIV prevalence (OR 0.78; 95% CI 0.63 to 0.97). Prevention needs of FSW in this area include increasing rates of HIV testing and putting in place effective programmes that can help extend HIV prevention behaviours across a range of sexual and drug use risk behaviours.

MATERNAL AND CHILD HEALTH RESEARCH

The state of Africa's children 2008. Child survival
(Annual Report; Global)
New York, New York, UNICEF, 2008 May. 54 p.
Every year, the United Nations Children's Fund (UNICEF) publishes The State of the World's Children, the most comprehensive and authoritative report on the world's youngest citizens. The State of the World's Children 2008, published in January 2008, examines the global realities of maternal and child survival and the prospects for meeting the health-related Millennium Development Goals (MDGs) - the targets set by the world community in 2000 for eradicating poverty, reducing child and maternal mortality, combating disease, ensuring environmental sustainability and providing access to affordable medicines in developing countries. This year, UNICEF is also publishing the inaugural edition of The State of Africa's Children. This volume and other forthcoming regional editions complement The State of the World's Children 2008, sharpening from a worldwide to a regional perspective the global report's focus on trends in child survival and health, and outlining possible solutions - by means of programmes, policies and partnerships - to accelerate progress in meeting the Millennium Development Goals.

Urine dipstick as a screening test for urinary tract infection
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Annals of Tropical Paediatrics. 2008 Jun;28(2):117-122.
Antwi S | Bates I | Baffoe-Bonnie B | Critchley J
Febrile illnesses are common among children in Ghana and are often diagnosed as malaria, thus overlooking urinary tract infection (UTI) as a possible cause of fever. The aims were to determine the prevalence of UTI among febrile children less than 5 years and to estimate the sensitivity, specificity and positive and negative predictive values of urine dipstick as a screening test. From March to July 2004, children aged 3-60 months attending an outpatient clinic at Komfo Anokye Teaching Hospital, Kumasi were systematically screened for UTI using Combi 10 dipstick (CyBow TM). All dipstick-positive and a sample of dipstick-negative urines underwent microscopy and culture (i.e. gold standard) from clean-catch or catheterised urine. Of 1393 children (median age 20 months), 112 (8%) had a positive dipstick and 29 of these (25.9%) had UTIs; 118/1278 (9.2%) children with a negative dipstick had urine cultured, one of whom (0.8%) had a UTI. The prevalence of UTIs was 2.1% (30/1393) and was higher among females (RR 3.99, 95% CI 1.76-9.04). 70% of UTIs were in children less than 2 years of age (p = 0.08). The sensitivity, specificity and positive and negative predictive values of dipstick were 96.7%, 58.8%, 26.1% and 99.2%, respectively. Use of dipstick as a screening test for UTI was comparable to microscopic analysis for pyuria. 90% of all UTIs were clinically misdiagnosed (70% as malaria). Escherichia coli was the predominant isolate (60%). Co-trimoxazole and ampicillin, commonly used to treat uncomplicated UTIs at first level in Ghana, showed 0% and 8.3% in-vitro sensitivities, respectively. Ciprofloxacin and cefuroxime (widely used at regional/tertiary level) showed good sensitivities, 99.0% and 86.2%, respectively. Urine dipstick should be promoted as a screening test for UTI. First-line use of cotrimoxazole and ampicillin for UTI should be reviewed.

Long-term trends in fetal mortality: Implications for developing countries
(Research Article; Global)
Bulletin of the World Health Organization. 2008 Jun;86(6):460-466.
Woods R
This paper discusses the problems of defining and measuring late-fetal mortality (stillbirths). It uses evidence from 11 developed countries to trace long-term trends in fetal mortality. Issues associated with varying definitions and registration practices are identified, as well as the range of possible rates, key turning points and recent convergence. The implications for developing countries are spelt out. They emphasize the possible limitations of WHO estimation methods and survey-based data by examining the cross-sectional associations among 187 countries in the year 2000. The important role of skilled birth attendants is emphasized in both data sets, but the different effects on maternal mortality and late-fetal mortality are also noted.

Reducing child mortality in Nigeria: A case study of immunization and systemic factors
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Social Science and Medicine. 2008 Jul;67(1):161-164.
Ngowu R | Larson JS | Kim MS
The purpose of the study is to assess the outcome of the Expanded Program on Immunization (EPI) in Nigeria, as well as to examine systemic factors influencing its high under-five mortality rate (UFMR). The principal objective of the EPI program when it was implemented in 1978 was to reduce mortality, morbidity and disability associated with six vaccine preventable diseases namely tuberculosis, tetanus, diphtheria, measles, pertussis and poliomyelitis. The methodological approach to this study is quantitative, using secondary time series data from 1970 to 2003. The study tested three hypotheses using time series multiple regression analysis with autocorrelation adjustment as a statistical model. The results showed that the EPI program had little effect on UFMR in Nigeria. Only the literacy rate and domestic spending on healthcare had statistically significant effects on the UFMR. The military government was not a significant factor in reducing or increasing the UFMR. It appears that Nigeria needs a unified approach to healthcare delivery, rather than fragmented programs, to overcome cultural and political divisions in society.

Diurnal blood pressure variation in the evaluation of early onset severe pre-eclampsia
(Abstract; subscription needed for full text; Sub-Saharan Africa)
European Journal of Obstetrics, Gynecology and Reproductive Biology. 2008 Jun;138(2):141-146.
Steyn DW | Odendaal HJ | Hall DR
The objective was to study the association between diurnal variation in blood pressure, the mean daily blood pressure and various complications of pregnancy in patients presenting with severe pre-eclampsia before 34 weeks' gestation. Forty-four women presenting to a tertiary hospital in South Africa with severe pre-eclampsia between 28 and 34 weeks' gestation were managed expectantly for at least 8 days. We measured maternal blood pressure every 30 min with the pregnancy validated Spacelabs 90209 automated blood pressure monitor for 24 h periods on alternative days. The mean 24-h diastolic blood pressure measurement, the mean diastolic blood pressure for daytime and nighttime, the day-night blood pressure difference and the night-day ratio were compared with the occurrence of abruptio placentae, gestational age at delivery, neonatal intensive care unit admission, birth weight, abnormal umbilical artery Doppler FVW and reason for delivery. One hundred and seventy-six 24-h studies were analyzed. The day-night blood pressure difference decreased with increasing mean diastolic blood pressure (r = -0.323, p less than 0.0001). A combination of normal mean diastolic blood pressure and normal day-night blood pressure difference was associated with increased gestational age and lower caesarean section rates. The combination of mean diastolic blood pressure and day-night blood pressure difference may be a supplementary measurement of disease severity in early onset severe pre-eclampsia and seems to be of prognostic value.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Has the Navrongo Project in northern Ghana been successful in altering fertility preferences?
(Abstract; subscription needed for full text; Sub-Saharan Africa)
African Population Studies. 2007;22(1):87-106.
Doctor HV
Has the Navrongo Community Health and Family Planning (CHFP) Project been successful in changing fertility preferences? Using linked data from panel surveys conducted in the Kassena-Nankana district of northern Ghana in 1995 and 2002 as part of the CHFP, we compare reproductive behavior against prior fertility preferences and show the transition of women from wanting to not wanting more children. Descriptive and multinomial logistic regression results show that the acceptance of smaller family sizes (i.e., 1-3 children) and high proportions of women reporting no intention to have more children in the future reflect that the combination of mobilizing community volunteerism and retraining and redeploying nurses to village-based locations results in a change in reproductive behavior. Implications for policy are discussed.

Characteristics of women in consanguineous marriages in Egypt, 1988 -- 2000
(Abstract; subscription needed for full text; North Africa)
European Journal of Population. 2008 Jun;24(2):185-210.
Weinreb AA
This article reviews three mechanisms related to autonomy, wealth, and local cultural factors, which are said to underly the high prevalence of consanguineous marriage in Arab societies. It then assesses each of them empirically in two stages. The first uses a pooled dataset constituted by the most recent marriage cohorts in the 1992 and 2000 waves of the Egyptian Demographic and Health Surveys. Three results stand out. The frequency of consanguinity in the most recent marriage cohorts (i) is strongly correlated with the frequency among older cohorts, signaling the strong clustering of underlying institutional (and unobserved) supports; (ii) tends to be more common among women who are poorer in absolute term, though wealthier than average in their communities; and (iii) varies temporally and across the rural-urban divide in its relationship to women's autonomy. A subsidiary analysis, using only the 2000 data, then identifies wealth and autonomy differences between first cousin patrilateral and matrilateral wives.

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