Volume 8, Number 34
25 August 2008

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ADOLESCENT HEALTH RESEARCH

Reducing adolescent girls' vulnerability to HIV infection: Examining microfinance and sustainable livelihood approaches. A literature and program review
(Technical Report; Global | Sub-Saharan Africa)
Washington, D.C., Constella Futures, Health Policy Initiative, 2008 Jul. [60] p. (USAID Contract No. GPO-I-01-05-00040-00)
Lukas T
Increasing women's access to income and productive resources is one of the five priority gender strategies of the President's Emergency Plan for AIDS Relief (Emergency Plan) (PL 108-25). In late 2007, the Gender Technical Working Group (GTWG) of the Office of the U.S. Global AIDS Coordinator met with staff of the USAID | Health Policy Initiative, Task Order 1, to discuss ways to advance this strategy in Emergency Plan country programs in sub-Saharan Africa. In particular, the GTWG's wanted to examine the applicability of microfinance programs in preventing HIV infection among adolescent girls, ages 10-19 years old. The discussions resulted in a scope of work that included the following deliverables: (1) a literature and program review of microfinance programs and an assessment of their contribution to reducing adolescent girls' susceptibility to HIV infection; (2) based on the review findings, the development of a framework or informal reference tool to assist U.S. government (USG) country teams with identifying what kind of USG investment is warranted in microfinance projects and related economic strengthening efforts-to help prevent HIV infection within the target group; (3) a pilot assessment of the framework with implementing partners in two African countries; and (4) a final framework or tool for use by all USG country teams and implementing partners, as warranted. Part 1 of this literature and program review focuses on youth-centered programs to prevent HIV infection among vulnerable female adolescents-including microfinance (MF) and sustainable livelihood programs. Part 2 analyzes the relationship between microfinance and HIV prevention in the general population, with a focus on women and the oldest adolescents in the target group. Adapting the traditional microfinance model to meet the needs of this sub-group could prove to benefit not only these adolescents but also the microfinance industry.

Ethiopian adolescents' attitudes and expectations deviate from current infant and young child feeding recommendations
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Adolescent Health. 2008;43:253-259.
Hadley C | Lindstrom D | Belachew T | Tessema F
Suboptimal infant and child feeding practices are highly prevalent in many developing countries for reasons that are not entirely understood. Taking an anthropological perspective, we assessed whether nulliparous youth have formulated attitudes and expectations in the domain of infant and child feeding behaviors, the extent to which these varied by location and gender, and the extent to which they deviated from current international recommendations. A population-based sample of 2077 adolescent girls and boys (13-17 years) in southwest Ethiopia answered a questionnaire on infant and young child feeding behaviors. Results indicate high levels of agreement among adolescents on items relating to infant and young child feeding behaviors. Attitudes and intentions deviated widely from current international recommendations. Youth overwhelmingly endorsed items related to early introduction of nonbreast milk liquids and foods. For girls, fewer than 11% agreed that a 5-month infant should be exclusively breastfed and only 26% agreed that a 6-month infant should be consuming some animal source foods. Few sex differences emerged and youth responses matched larger community patterns. The results indicate that attitudes and expectations deviate widely from current international child feeding guidelines among soon to be parents. To the extent that youth models are directive, these findings suggest that youth enter into parenthood with suboptimal information about infant and child feeding. Such information will reproduce poor health across generations as the largest cohort of adolescents ever become parents. These results suggest specific points of entry for adolescent nutrition education interventions.

Controversies in contraception
(Abstract; subscription needed for full text; Global)
Current Opinion in Pediatrics. 2008;20:383-389.
Pitts SA | Emans SJ
New research is constantly being published regarding hormonal contraceptives and bone health, migraine headaches, thrombosis risk, hypertension, weight gain, and obesity, as well as emergency contraception. At times, these studies can be clarifying, but they can also raise new controversies and questions. It is important for providers to be aware of the emerging issues regarding contraceptive care for adolescent patients. Research suggests that Depo-Provera (depot medroxyprogesterone acetate; Pfizer, New York City, New York, USA) and, perhaps, low-dose oral contraceptive pills can have adverse effects on adolescent bone health, although the data demonstrating reversibility of bone loss after discontinuation of these contraceptives are reassuring. Additionally, estrogen-containing contraceptives pose risks for patients, including the onset of or exacerbation of migraine headaches, venous thromboembolism, and hypertension. Depo-Provera has been implicated in weight gain, especially in girls who are already overweight. Obesity may decrease the efficacy of some hormonal contraceptives. Finally, the mechanism of action of emergency contraception is still unknown, although studies continue to suggest that it has primarily preovulatory, not postovulatory, effects. Adolescent health providers need to be aware of the new research and controversies in contraceptive care in order to counsel and care for patients effectively.

FAMILY PLANNING RESEARCH

Changing fortunes: Analysis of fluctuating policy space for family planning in Kenya
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health Policy and Planning. 2008;23:339-350.
Crichton J
Policies relating to contraceptive services (population, family planning and reproductive health policies) often receive weak or fluctuating levels of commitment from national policy elites in Southern countries, leading to slow policy evolution and undermining implementation. This is true of Kenya, despite the government's early progress in committing to population and reproductive health policies, and its success in implementing them during the 1980s. This key informant study on family planning policy in Kenya found that policy space contracted, and then began to expand, because of shifts in contextual factors, and because of the actions of different actors. Policy space contracted during the mid-1990s in the context of weakening prioritization of reproductive health in national and international policy agendas, undermining access to contraceptive services and contributing to the stalling of the country's fertility rates. However, during the mid-2000s, champions of family planning within the Kenyan Government bureaucracy played an important role in expanding the policy space through both public and hidden advocacy activities. The case study demonstrates that policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues even after they have reached the policy agenda.

Understanding operational barriers to family planning services in conflict-affected countries: Experiences from Sierra Leone
(Technical Report; Sub-Saharan Africa)
Washington, D.C., Constella Futures, Health Policy Initiative, 2008 Aug. [47] p. (USAID Contract No. GPO-I-01-05-00040-00)
Sonneveldt E | Shaver T | Bhuyan A
Recognizing the importance of a sound policy environment and the operational guidelines necessary for putting policies into practice, the USAID | Health Policy Initiative, Task Order 1, conducted a study in Sierra Leone in 2007 to explore refugee/IDP family planning needs before, during, and after conflict; determine the root causes of the barriers to quality, accessible services; build capacity of local groups to analyze operational barriers to services; and devise policy actions and recommendations for overcoming barriers-that are applicable both in-country and in other conflict-affected countries. This study highlights issues affecting provision of family planning in conflict-affected settings. It is important to note, however, that a range of complementary reproductive health services (e.g., safe motherhood, prevention of gender-based violence, HIV/STI prevention) are essential and have been identified as part of the Minimum Initial Services Package (MISP) for reproductive health in crisis situations.

Strengthening postnatal care services including postpartum family planning in Kenya
(Report; Sub-Saharan Africa)
Washington, D.C., Population Council, Frontiers in Reproductive Health, 2008 Jun. [48] p (USAID Cooperative Agreement No. HRN-A-00-98-00012-)
Mwangi A | Warren C | Koskei N | Blanchard H
To improve the health and survival of mothers and infants in the postnatal period, the Ministry of Health (MOH) in Kenya increased both the recommended timing and content of postnatal services a women and her infant should receive to at least three assessments within the first six weeks after childbirth. The feasibility and acceptability of providing postnatal care at these times has not been evaluated, however, and most providers are not aware of this change in policy or how to implement it. The objectives of the study were develop and introduce a strengthened postnatal care package into one hospital and four health centers in one district, to document the feasibility, acceptability and quality of care of the strengthened postnatal care, and to evaluate the effectiveness of the postnatal package on women's reproductive health behaviors. The study was implemented jointly by the Population Council's Frontiers in Reproductive Health (FRONTIERS) project and by Jhpiego's ACCESS-FP project, both funded by USAID. The study was conducted in Embu district, Eastern Province, between 2006 and 2008. The study used a pre-post intervention design for assessing quality of care received within the facilities and compared stratified samples of postpartum women recruited and interviewed following childbirth and again six months later before and after introduction of the intervention. For the quality of care assessment, data were collected through interviews with health care providers, structured observations of client -provider interactions during the postnatal consultations and a facility inventory for assessing availability of equipment, drugs, family planning commodities and supplies. Postpartum women were recruited and interviewed following childbirth on the postnatal ward in Embu Provincial General Hospital and interviewed again in their community after six months. A postnatal care -family planning (PNC-FP) orientation package for providers was developed by ACCESS-FP, DRH and FRONTIERS. This incorporated relevant maternal and newborn health care services in the postnatal period with a specific focus on postpartum family planning. Job aids were also produced. The three day orientation training included staff from the maternity and MCH- FP units from the four health facilities, as well as provincial and district RH trainers/supervisors. In total, 73 health care providers were oriented in the PNC -FP package, as well as in the use of a new postnatal register recently released by the MOH. Regular supportive supervision visits were made during the intervention period to reinforce application of the package.

The contextual effects of gender norms, communication, and social capital on family planning behaviors in Uganda: A multilevel approach
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health Education and Behavior. 2008 Aug;35(4):461-477.
Lee B | Salmon CT | Witte K
This study hypothesized a multilevel model to examine the contextual effects of gender norms, exposure to health-related radio programs, interpersonal communication, and social capital on family planning behavior in Uganda. The results of hierarchical linear modeling showed that all of the four variables were significant predictors of family planning behavior. The authors found that gender norms as a contextual factor significantly interacted with the individual-level perceived benefit. The significant cross-level interaction effect was also observed between individuals' interpersonal communication and contextual variation in listening to a health-related radio program. Practical implications for family planning communication campaigns are discussed.

GENDER and HEALTH RESEARCH

Association of combatant status and sexual violence with health and mental health outcomes in postconflict Liberia
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAMA. Journal of the American Medical Association. 2008 Aug 13;300(6):676-690.
Johnson K | Asher J | Rosborough S | Raja M | Panjabi R
Liberia's wars since 1989 have cost tens of thousands of lives and left many people mentally and physically traumatized. The objective was to assess the prevalence and impact of war-related psychosocial trauma, including information on participation in the Liberian civil wars, exposure to sexual violence, social functioning, and mental health. A cross-sectional, population-based, multistage random cluster survey of 1666 adults aged 18 years or older using structured interviews and questionnaires, was conducted during a 3-week period in May 2008 in Liberia. Symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), social functioning, exposure to sexual violence, and health and mental health needs among Liberian adults who witnessed or participated in the conflicts during the last 2 decades. In the Liberian adult household-based population, 40% (95% confidence interval [CI], 36%-45%; n=672/1659) met symptom criteria for MDD, 44% (95% CI, 38%-49%; n=718/1661) met symptom criteria for PTSD, and 8% (95% CI, 5%-10%; n=133/1666) met criteria for social dysfunction. Thirty-three percent of respondents (549/ 1666) reported having served time with fighting forces, and 33.2% of former combatant respondents (182/549) were female. Former combatants experienced higher rates of exposure to sexual violence than noncombatants: among females, 42.3% (95% CI, 35.4%-49.1%) vs 9.2% (95% CI, 6.7%-11.7%), respectively; among males, 32.6% (95% CI, 27.6%-37.6%) vs 7.4% (95% CI, 4.5%-10.4%). The rates of symptoms of PTSD, MDD, and suicidal ideation were higher among former combatants than noncombatants and among those who experienced sexual violence vs those who did not. The prevalence of PTSD symptoms among female former combatants who experienced sexual violence (74%; 95% CI, 63%-84%) was higher than among those who did not experience sexual violence (44%; 95% CI, 33%-53%). The prevalence of PTSD symptoms among male former combatants who experienced sexual violence was higher (81%; 95% CI, 74%-87%) than among male former combatants who did not experience sexual violence (46%; 95% CI, 39%-52%). Male former combatants who experienced sexual violence also reported higher rates of symptoms of depression and suicidal ideation. Both former combatants and noncombatants experienced inadequate access to health care (33.0% [95% CI, 22.6%-43.4%] and 30.1% [95% CI, 18.7%-41.6%], respectively). Former combatants in Liberia were not exclusively male. Both female and male former combatants who experienced sexual violence had worse mental health outcomes than noncombatants and other former combatants who did not experience exposure to sexual violence.

Intimate partner violence and HIV infection among married Indian women
(Abstract; subscription needed for full text; Asia)
JAMA. Journal of the American Medical Association. 2008 Aug 13;300(6):703-710.
Silverman JG | Decker MR | Saggurti N | Balaiah D | Raj A
Despite reductions in prevalence of human immunodeficiency virus (HIV) infection among the general population of India, women account for a rising percentage of all HIV cases with husbands' risk behavior described as the major source of women's infection. Intimate partner violence (IPV) has been described as being associated with heterosexual transmission of HIV to women in India and elsewhere. Objective To assess the relationship between experiencing IPV and the occurrence of HIV infection in a nationally representative sample of married Indian women tested for HIV. The Indian National Family Health Survey 3 was conducted across all Indian states in 2005 through 2006. The nationally representative sample included 124,385 married women; analyses conducted in 2007 and 2008 were limited to 28,139 married women who provided IPV data and HIV test results via systematic selection into respective subsamples. Prevalence estimates of lifetime IPV and HIV infection were calculated and demographic differences assessed. Intimate partner violence was conceptualized as physical violence with or without sexual violence and then was further categorized as physical violence only vs physical and sexual violence. Regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for HIV infection among Indian women based on experiences of IPV after adjusting for demographics and women's HIV risk behaviors. One-third of married Indian women (35.49%) reported experiencing physical IPV with or without sexual violence from their husbands; 7.68% reported both physical and sexual IPV, and 27.80% reported experiencing physical IPV in the absence of sexual violence. Approximately 1 in 450 women (0.22%) tested positive for HIV. In adjusted models, married Indian women experiencing both physical and sexual violence from husbands demonstrated elevated HIV infection prevalence vs those not experiencing IPV (0.73% vs 0.19%; adjusted OR, 3.92; 95% CI, 1.41-10.94; P=.01). Physical IPV alone was not associated with risk of HIV infection. Women's personal sexual risk behaviors were not associated with HIV infection. Among married Indian women, physical violence combined with sexual violence from husbands was associated with an increased prevalence of HIV infection. Prevention of IPV may augment efforts to reduce the spread of HIV/AIDS.

Attitudes toward wife beating: A cross-country study in Asia
(Abstract; subscription needed for full text; Asia | Europe)
Journal of Interpersonal Violence. 2008 Aug 15;:[27] p.
Rani M | Bonu S
Using demographic and health surveys conducted between 1998 and 2001 from seven countries (Armenia, Bangladesh, Cambodia, India, Kazakhstan, Nepal, and Turkey), the study found that acceptance of wife beating ranged from 29% in Nepal, to 57% in India (women only), and from 26% in Kazakhstan, to 56% in Turkey (men only). Increasing wealth predicted less acceptance of wife beating, except in Cambodia and Nepal. Higher education level was negatively associated with acceptance in Turkey and Bangladesh. Younger respondents justified wife beating more often, with some exceptions, showing persistent intergenerational transmission of gender norms. Working women were equally or more likely to justify wife beating compared to nonworking women. Men were significantly more likely to justify wife beating in Armenia, Nepal, and Turkey. Targeted proactive efforts are needed to change these norms, such as improving female literacy rates and other enabling factors.

Sexual behaviour and inheritance rights among HIV-positive women in Abia State, Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Tanzania Journal of Health Research. 2008 Aug;10(2):73-78.
Enwereji EE
In developing countries, culture favours males for economic ventures more than females. There is evidence that allowing HIV positive women inheritance rights will mitigate negative economic consequences of HIV/AIDS and other related risks. This study aimed to examine the extent to which HIV positive women have access to family resources in Abia State, Nigeria. Data collection instruments were questionnaire, focus group discussion and interview guides using 98 HIV positive women in network of people living with HIV/AIDS. Five key informants were also interviewed to authenticate women's responses. Results showed that 85 (86.7%) of the women were denied rights to family resources. Thirty-eight (64.4%) of them had negative relationship with their family members for demanding their husbands' property. Because of limited financial assistance, the women took two types of risks in order to survive in the communities. Twenty-five women (25.5%) earned their livelihood by acting as hired labourers to others in the farm. More that half (55.1%) of the HIV positive women were practicing unprotected sex. Although as high as 79.6% of women were aware of risks of unprotected sex, 54 (55%) of them practised it. The commonest reason for taking the risk was sex partners' dislike for condom use. The high proportion of HIV positive women who were denied access to family resources, could suggest lack of care and support. If this denial continues, Government's efforts to reduce HIV prevalence would yield no significant result. There is therefore need for organized community education programme that emphasizes the benefits of empowering women living positively with HIV/AIDS economically.

HIV/AIDS and STIs RESEARCH

Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in sub-Saharan Africa
(Research Article; Sub-Saharan Africa)
PLoS One. 2008 Aug 6;3(8):e2679.
Auvert B | Marseille E | Korenromp EL | Lloyd-Smith J | Sitta R
Trials in Africa indicate that medical adult male circumcision (MAMC) reduces the risk of HIV by 60%. MAMC may avert 2 to 8 million HIV infections over 20 years in sub-Saharan Africa and cost less than treating those who would have been infected. This paper estimates the financial and human resources required to roll out MAMC and the net savings due to reduced infections. We developed a model which included costing, demography and HIV epidemiology. We used it to investigate 14 countries in sub-Saharan Africa where the prevalence of male circumcision was lower than 80% and HIV prevalence among adults was higher than 5%, in addition to Uganda and the Nyanza province in Kenya. We assumed that the roll-out would take 5 years and lead to an MC prevalence among adult males of 85%. We also assumed that surgery would be done as it was in the trials. We calculated public program cost, number of full-time circumcisers and net costs or savings when adjusting for averted HIV treatments. Costs were in USD, discounted to 2007. 95% percentile intervals (95% PI) were estimated by Monte Carlo simulations. In the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to 2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10 000 adults. In years 6-10, the number of circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of rolling out MAMC in the public sector was $919 million (95%PI: 726 to 1 245). The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to 1 021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4). A rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by MAMC's substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability.

The role of state and non-state actors in the policy process: The contribution of policy networks to the scale-up of antiretroviral therapy in Thailand
(Abstract; subscription needed for full text; Asia)
Health Policy and Planning. 2008;23(5):328-338.
Tantivess S | Walt G
Antiretroviral therapy (ART) is difficult in poor settings. In 2001, the Thai government adopted the policy to scale-up its treatment initiative to meet the needs of all its people. Employing qualitative approaches, including in-depth interviews, document review and direct observation, this study examines the processes by which the universal ART policy developed between 2001 and 2007, with the focus on the connections between actors who shared common interests-so-called policy networks. Research findings illustrate the crucial contributions of non-state networks in the policy process. The supportive roles of public-civic networks could be observed at every policy stage, and at different levels of the health sector. Although this particular health policy may be unique in case and setting, it does suggest clearly that while the state dominated the policy process initially, non-state actors played extremely important roles. Their contribution was not simply at agenda-setting stages-for example by lobbying government-but in the actual development and implementation of health policy. Further it illustrates that these processes were dynamic, took place over long periods and were not limited to national borders, but extended beyond, to include global actors and processes.

The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS Research and Therapy. 2008 Aug 1;5(17):[29] p.
Shetty AK | Marangwanda C | Stranix-Chibanda L | Chandisarewa W | Chirapa E
Prevention of mother-to-child transmission of HIV (PMTCT) is a major public health challenge in Zimbabwe. Using trained peer counselors, a nevirapine (NVP)-based PMTCT program was implemented as part of routine care in urban antenatal clinics. Between October 2002 and December 2004, a total of 19,279 women presented for antenatal care. Of these, 18,817 (98%) underwent pre-test counseling; 10,513 (56%) accepted HIV testing, of whom 1986 (19%) were HIV-infected. Overall, 9696 (92%) of women collected results and received individual post-test counseling. Only 288 men opted for HIV testing. Of the 1807 HIV-infected women who received posttest counseling, 1387 (77%) collected NVP tablet and 727 (40%) delivered at the clinics. Of the 1986 HIV-infected women, 691 (35%) received NVPsd at onset of labor, and 615 (31%) infants received NVPsd. Of the 727 HIV-infected women who delivered in the clinics, only 396 women returned to the clinic with their infants for the 6-week follow-up visit; of these mothers, 258 (59%) joined support groups and 234 (53%) opted for contraception. By the end of the study period, 209 (53%) of mother-infant pairs (n=396) came to the clinic for at least 3 follow-up visits. Despite considerable challenges and limited resources, it was feasible to implement a PMTCT program using peer counselors in urban clinics in Zimbabwe.

Survival from 9 months of age among HIV-infected and uninfected Zambian children prior to the availability of antiretroviral therapy
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Clinical Infectious Diseases. 2008 Sep 15;47(6):837-844.
Sutcliffe CG | Scott S | Mugala N | Ndhlovu Z | Monze M
Few prospective studies have measured survival rates among human immunodeficiency virus (HIV)-infected children in sub-Saharan Africa prior to the availability of antiretroviral therapy. In the context of an observational study of the immunogenicity of measles vaccine in Zambia, we prospectively followed up children from approximately 9 months of age and assessed survival rates, risk factors for mortality, and circumstances at the time of death according to HIV-infection or HIV-exposure status. There were 56 deaths among 492 study children during follow-up to 3 years of age. Thirty-nine percent of the 105 children with HIV infection died during the study period, compared with 5.0% of the 260 HIV-seropositive but uninfected children and 1.6% of the 127 HIV-seronegative children. Estimated survival probabilities from 9 through 36 months of age were 52% among HIV-infected children, 95% among initially HIVseropositive but uninfected children, and 98% among HIV-seronegative children. In multivariable analyses, history of a clinic visit within the 4 weeks prior to study entry (adjusted hazard ratio, 4.6; 95% confidence interval, 1.5-13.5), hemoglobin level less than 8 g/dL at study entry (adjusted hazard ratio, 4.4; 95% confidence interval, 1.5-12.6), and CD4+ T lymphocyte percentage less than 15% at study entry (adjusted hazard ratio, 3.2; 95% confidence interval, 1.1-9.5) were associated with mortality among HIV-infected children. Only approximately one-half of HIV-infected Zambian children who were alive at 9 months of age survived to 3 years of age, supporting the urgent need for the prevention of mother-to-child transmission of HIV and the early diagnosis and treatment of HIV infection in children in sub-Saharan Africa.

MATERNAL AND CHILD HEALTH RESEARCH

Perinatal outcomes during 1986-2005 in Tuzla Canton, Bosnia and Herzegovina
(Abstract; subscription needed for full text; Europe)
Journal of Maternal-Fetal and Neonatal Medicine. 2008 Aug;21(8):567-572.
Radoncic F | Hudic I | Balic A | Fatusic Z
The objective of this study was to determine the incidence rate and causes of perinatal mortality and make a comparison between the incidence rate and causes of perinatal mortality in the prewar (1986-1991), war (1992-1995) and postwar (1996-2005) periods in Tuzla Canton, Bosnia and Herzegovina. We retrospectively collected data from the databases of University Department for Gynecology and Obstetrics Tuzla. Data on the number of live births, stillbirths, early neonatal deaths, causes of death, gestational age and birth weights were collected. There were 101712 deliveries altogether in the above mentioned period, out of which 101638 resulted in liveborn children. Perinatal mortality gradually declines in the period of 1986-2000. The decline owns mostly to early neonatal mortality more than to fetal which also shows the trend of decrease. Statistically significant difference in perinatal mortality was found between period 2001-2005 and other analysed periods, and the most difference was found between 1991-1995 and 1996-2000 (p less than 0.01). Statistically significant difference in fetal mortality was found between period 2001-2005 and 1986-1990. Statistically significant difference in early neonatal mortality was found between period 2001-2005 and 1986-1990 (p = 0.005; p less than 0.005). Perinatal mortality in Tuzla Canton was significantly higher during the war, mainly due to lower adequacy and accessibility of perinatal health care. During the peace period a significant decline of perinatal mortality is registered, due to early neonatal death.

Reduction in hospitalizations of children
(Abstract; subscription needed for full text; South America)
Acta Paediatrica. 2008 Jul 30;:[5] p.
Santos E | de Sousa AG | Marques AP | Bussamra MH | Zukerman E
The aim of the study was to reduce the number of hospitalizations in a population of children enrolled in the Einstein Program of the Paraisopolis Community, in Sao Paulo, Brazil, particularly hospitalizations caused by respiratory diseases. All hospitalizations of this paediatric population enrolled in the Einstein Program of the Paraisopolis Community Outpatient Clinic were followed up between 2002 and 2004. The following four strategies to reduce or control respiratory diseases with an impact on hospitalizations were established: specific protocol, educational activities, vaccination against pneumococci and vaccination against influenza. In 2002, 1025 hospitalizations due to all causes were recorded. This number significantly decreased to 862 hospitalizations in 2004 after implementation of the program, corresponding to a reduction of 15.9% (p less than 0.0001). Hospitalizations due to respiratory diseases decreased by 23.37% (p less than 0.02), and those due to cases of wheezing bronchitis fell by 51.61% (p less than 0.001). The strategies chosen and implemented in the Einstein Program of the Paraisopolis Community Outpatient Clinic over the first 6 months of 2003 were effective in reducing the number of children's hospital admissions due to respiratory disease.

Humoral immune response of dengue hemorrhagic fever cases in children from Tegucigalpa, Honduras
(Abstract; subscription needed for full text; Central America and the Caribbean)
American Journal of Tropical Medicine and Hygiene. 2008;79(2):262-266.
Lorenzana De Rivera I | Parham L | Murillo W | Moncada W | Vazquez S
The humoral immune response in Honduran dengue hemorrhagic fever (DHF) hospitalized pediatric cases from the epidemics of 2004 and 2005 was studied in sera collected from 5 to 7 days of fever onset. A total of 145 cases were included in the study: 40 classified as primary with DHF Grade I or II and 86 classified as secondary; from them, 73 were DHF Grade I or II and 13 were dengue shock syndrome (DSS) Grade III or IV. The highest number of primary cases was found in children less than 1 year of age. The highest number of secondary cases was observed in children between 5 and 10 years of age. The IgA values showed a statistically significant difference between primary and secondary groups. The relationship between antibody responses and severity grade is discussed. This is the first study related to the humoral immune response and severity grade in DHF cases in Honduran children.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Measurement of HIV prevention indicators: A comparison of the PLACE Method and a Demographic Health Survey in Rwanda
(Report; Sub-Saharan Africa)
Chapel Hill, North Carolina, University of North Carolina at Chapel Hill, Carolina Population Center, MEASURE Evaluation, 2008 Jun. 28 p. (Array)
The 2005 Rwandan Demographic Health Survey (DHS) found that nearly 90 percent of the general population knew about HIV and prevention methods; however, it also found that condom use was very low (only 20 percent of people used a condom with a non-cohabiting partner). To respond better to the large gap between knowledge and safe sexual behavior, and to coordinate local efforts better in the fight against AIDS, the Commission Nationale de Lutte contre le SIDA (CNLS), with technical assistance from MEASURE Evaluation, implemented the Priorities for Local AIDS Control Efforts (PLACE) protocol in 12 provinces. The 2005 PLACE and Rwandan DHS results are useful tools for program managers wishing to focus scarce resources in effective HIV prevention. The DHS results provide information concerning the general population and provide a global picture of people's HIV knowledge, attitudes, and behaviors. The PLACE results provide information about populations that exhibit riskier sexual behavior than the general population. Together, the survey results from PLACE and DHS can provide program managers and other stakeholders working in HIV/AIDS comprehensive information on knowledge, attitudes, and practices in both the general population and specific subgroups. The aim of this report is to compare results between the two surveys and illustrate how both surveys can be used together, giving HIV/AIDS program managers and policymakers a better picture of certain determinates of the generalized epidemic in Rwanda.

The exceptionally high life expectancy of Costa Rican nonagenarians
(Abstract; subscription needed for full text; Central America and the Caribbean)
Demography. 2008 Aug;45(3):673-691.
Rosero-Bixby L
Robust data from a voter registry show that Costa Rican nonagenarians have an exceptionally high life expectancy. Mortality at age 90 in Costa Rica is at least 14% lower than an average of 13 high-income countries. This advantage increases with age by 1% per year. Males have an additional 12% advantage. Age-90 life expectancy for males is 4.4 years, one-half year more than any other country in the world. These estimates do not use problematic data on reported ages, but ages are computed from birth dates in the Costa Rican birth-registration ledgers. Census data confirm the exceptionally high survival of elderly Costa Ricans, especially males. Comparisons with the United States and Sweden show that the Costa Rican advantage comes mostly from reduced incidence of cardiovascular diseases, coupled with a low prevalence of obesity, as the only available explanatory risk factor. Costa Rican nonagenarians are survivors of cohorts that underwent extremely harsh health conditions when young, and their advantage might be just a heterogeneity in frailty effect that might disappear in more recent cohorts. The availability of reliable estimates for the oldest-old in low- income populations is extremely rare. These results may enlighten the debate over how harsh early-life health conditions affect older-age mortality.

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