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1 September 2008

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ADOLESCENT HEALTH RESEARCH

Depressive symptoms in youth heads of household in Rwanda. Correlates and implications for intervention
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Archives of Pediatrics and Adolescent Medicine. 2008 Sep;162(9):836-843.
Boris NW | Brown LA | Thurman TR | Rice JC | Snider LM
The objective of this study was to examine the level of depressive symptoms and their predictors in youth from one region of Rwanda who function as heads of household (ie, those responsible for caring for other children) and care for younger orphans. A cross-sectional survey was taken in four adjoining districts in Gigonkoro, an impoverished rural province in southwestern Rwanda. Trained interviewers met with the eldest member of each household (n=539) in which a youth 24 years old or younger was caring for 1 child or more. The main outcome measures were rates and severity of depressive symptoms using the Center for Epidemiologic Studies Depression scale; measures of grief, adult support, social marginalization, and sociodemographic factors using scales developed for this study. Of the 539 youth heads of household, 77% were subsistence farmers and only 7% had attended school for 6 years or more. Almost half (44%) reported eating only 1 meal a day in the last week, and 80% rated their health as fair or poor. The mean score on the Center for Epidemiologic Studies Depression scale was 24.4, exceeding the most conservative published cutoff score for adolescents. Multivariate analysis revealed that reports of depressive symptoms that exceeded the clinical cutoff were associated with having 3 basic household assets or fewer, such as a mattress and a spare set of clothes (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.70), eating less than 1 meal per day (OR, 1.68; 95% CI, 1.09- 2.60), reporting fair health (OR, 1.32; 95% CI, 0.76- 2.29) or poor health (OR, 2.33; 95% CI, 1.17-4.64), endorsing high levels of grief (OR, 2.67; 95% CI, 1.73- 4.13), having at least 1 parent die in the genocide as opposed to all other causes of parental death (OR, 1.83; 95% CI, 1.10-3.04), and not having a close friend (OR, 1.91; 95% CI, 1.17-3.12). There was an interaction between marginalization from the community and alcohol use; youth who were highly marginalized and did not drink alcohol were more than 3 times more likely to report symptoms of depression (OR, 3.07; 95% CI, 1.73-5.42). When models were constructed by grouping theoretically related variables into blocks and controlling for other blocks, the emotional status block of variables (grief and marginalization) accounted for the most variance in depressive symptoms. Orphaned youth who head households in rural Rwanda face many challenges and report high rates of depressive symptoms. Interventions designed to go beyond improving food security and increasing household assets may be needed to reduce social isolation of youth heads of household. The effect of head-of-household depressive symptoms on other children living in youth-headed households is unknown.

Retrospective report of social withdrawal during adolescence and current maladjustment in young adulthood: Cross-cultural comparisons between Australian and South Korean students
(Abstract; subscription needed for full text; Asia | Oceania)
Journal of Adolescence. 2008 Oct;31(5):543-563.
Kim J | Rapee RM | Oh KJ | Moon HS
The current study investigated associations between the frequency of and motivations for social withdrawal during adolescence and emotional distresses in young adulthood. Perceived motivations for social withdrawal included unsociability, isolation, shyness, and low mood. Social withdrawal during adolescence was assessed using a retrospective questionnaire completed by Australian and Korean university students. They also completed measures of general self-worth, social relationships, loneliness, social anxiety, and depression at university. Partial correlations and path analyses revealed that different motivations for social withdrawal had different risk status for later adjustment across the two samples. In particular, it appeared that shy and unsociable individuals in Korea showed better social and emotional adjustment than their counterparts in Australia. In contrast, social relationships of sad/depressed and isolated respondents in Korea appeared to be more seriously impaired than their Australian counterparts. These cross-cultural differences are discussed in terms of socio-cultural values and environments unique to the two countries.

Anxieties in mainland Chinese and Singapore Chinese adolescents in comparison with the American norm
(Abstract; subscription needed for full text; Asia)
Journal of Adolescence. 2008 Oct;31(5):583-594.
Li H | Ang RP | Lee J
There is a growing literature base on child and adolescent anxiety. Cross-cultural research on child and adolescent anxiety, however, has been relatively limited. This study examined whether there were similarities and differences in the self reported anxieties in Mainland Chinese and Singapore Chinese adolescents (12-17 years of age), and whether these similarities or differences were related to gender and/or grade. This study also compared anxiety levels of Mainland Chinese and Singapore Chinese adolescents with the American normative sample (12-17 years of age). The results indicate that the levels of anxieties did not differ based on country (China and Singapore). Gender differences were evident. Gender and grade interaction effects were found on the anxiety scales. Mixed results were found when comparing Mainland Chinese and Singapore Chinese with the American normative sample on the different anxiety scales.

FAMILY PLANNING RESEARCH

Ethiopian women's perspectives on reproductive health. Results from a PEER study in the Guraghe zone
(Report; Sub-Saharan Africa)
Swansea, United Kingdom, University of Wales, Centre for Development Studies, Options, 2008 May. 56 p.
Hemmings J | Wubshet T | Lemma S | Antoni T | Cherinet T
This study was conducted to learn about the social context in which reproductive health decisions are made among women of childbearing age in rural and peri-urban areas of the Guraghe Zone, Ethiopia. Results will inform MSI-E's advocacy programme, communications design, and development of social marketing tools. Using the PEER approach, local women developed their own research questions, interviewed their friends, and fed back findings to the research team. They collected detailed qualitative data on gender dynamics, socioeconomic conditions, attitudes to family planning, and experience of health services and communications. The study was conducted in and around Wolkite, a town 150km south west of Addis Ababa on the main road to Jinna. The women recruited were broadly typical of the area's population: of reproductive age, a mixture of Christian and Muslim, engaged in farming and trading in local markets, and busy with young families and domestic work. (excerpt)

Healthy timing and spacing of pregnancy: a trainer's reference guide
(Teaching and Training Material; Global)
Washington, D.C., Pathfinder International, Extending Service Delivery Project, 2008 Aug. [144] p. (USAID Award No. GPO-A-00-05-00027-00)
The Extending Service Delivery (ESD) project has developed Healthy Timing and Spacing of Pregnancy: A Trainer's Reference Guide as a resource for trainers in developing in-service training for facility-based healthcare providers and community health workers (CHWs) who already have some basic experience with and understanding of RH/FP. This is not a training manual, but a reference guide which can be used and adapted by trainers based on whether or not trainees are are facility-based or community-based. HTSP training will enable providers to disseminate up-to-date and correct information and education on the health and social benefits of HTSP as part of RH/FP counseling and other health services. This information can help women better use FP to delay, space or limit their pregnancies, within a context of informed contraceptive choice.

Domestic violence, contraceptive use, and unwanted pregnancy in rural India
(Abstract; subscription needed for full text; Asia)
Studies in Family Planning. 2008 Sep;39(3):177-186.
Stephenson R | Koenig MA | Acharya R | Roy TK
This study examines the relationship between male-to-female physical domestic violence and unwanted pregnancy among women in three economically and culturally diverse areas of India. A central methodological focus of the study is the examination of retrospective and prospective measures of pregnancy unwantedness, contrasting their usefulness for specifying levels of unwanted pregnancy and its relationship with domestic violence. Data from India's 1998-99 National Family Health Survey and a 2002-03 follow-up survey for which women in four states were reinterviewed are analyzed, and the factors associated with the intersurvey adoption of contraception and the experience of an unwanted pregnancy are examined. Women who experience physical violence from their husbands are significantly less likely to adopt contraception and more likely to experience an unwanted pregnancy. A prospectively measured indicator of unwanted pregnancy identifies a higher prevalence of unwanted pregnancies than do the traditionally employed retrospective measures and is more successful in establishing a relationship between unwanted pregnancies and domestic violence. The results demonstrate a clear relationship between a woman's experience of physical violence from her husband and her ability to achieve her fertility intentions. The need to improve the measurement of pregnancy intendedness is clear, and a move toward using prospective measures as the standard is necessary.

The effects of a communication program on contraceptive ideation and use among young women in northern Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Studies in Family Planning. 2008 Sep;39(3):211-220.
Babalola S | Folda L | Babayaro H
This study assesses the effects of a communication campaign designed to encourage young people in northern Nigeria to use modern family planning methods to avoid unwanted pregnancies. The analyses are based on a sample of 819 sexually experienced women. Using multivariate probit regression, we attempt to correct for possible endogeneity among campaign exposure, contraceptive ideation, and contraceptive use. Our analysis reveals that the direct effect of campaign exposure on the probability of contraceptive use is only marginally significant, but the effect of exposure on contraceptive ideation is robust, as is the effect of contraceptive ideation on contraceptive use. The findings demonstrate not only the success of the program but also the relevance of incorporating ideation into analytic models assessing the effects of communication campaigns.

Knowledge and opinions of emergency contraceptive pills among female factory workers in Tijuana, Mexico
(Abstract; subscription needed for full text; North America)
Studies in Family Planning. 2008 Sep;39(3):199-210.
Garcia SG | Becker D | Martinez de Castro M | Paz F | Diaz Olavarrieta C
Workers in Mexico's maquiladoras (assembly plants) are mainly young, single women, many of whom could benefit from emergency contraceptive pills (ECPs). Because ECPs are readily available in Mexico, women who know about the therapy can obtain it easily. Do maquiladora workers know about the method? Could worksite programs help increase awareness? To investigate these questions, we conducted a five-month intervention during which workers in three maquiladoras along the Mexico-United States border could attend educational talks on ECPs, receive pamphlets, and obtain kits containing EC supplies. Among the workers exposed to our intervention, knowledge of ECPs increased. Reported ECP use also increased. Although our intervention apparently increased workers' knowledge and use, the factory proved to be a difficult intervention setting. Problems we experienced included a factory closure and management/staff opposition to certain project elements. Future studies should continue to investigate work-site interventions and other strategies to reach workers.

GENDER and HEALTH RESEARCH

Perpetration of intimate partner aggression by men and women in the Philippines. Prevalence and associated factors
(Abstract; subscription needed for full text; Asia)
Social Science and Medicine. 2008 Sep 3;:[12] p.
Ansara DL | Hindin MJ
This study uses data from the 2002 Cebu Longitudinal Health and Nutrition Survey to examine the prevalence of and factors associated with intimate partner violence perpetration by husbands and wives in Cebu, Philippines. Multinomial logistic regression was used to identify the factors associated with wife-only, husband-only, and reciprocal perpetration. About 26% of women reported that either they or their partner perpetrated at least one physically aggressive act during the past year, whereas 22% reported sexual coercion by their husband during their relationship. The most common reason cited for hurting the partner was his or her alcohol use, partner nagging, the wife fighting back, and jealousy. In the regression analysis, the wife's alcohol use and violence between the wife's parents were predictors of all three perpetrator groups. The importance of regular church attendance and husband control and dominance varied for the groups. Research and prevention implications are discussed.

Some peace of mind: Assessing a pilot intervention to promote mental health among widows of injecting drug users in north-east India
(Research Article; Asia)
BMC Public Health. 2008 Aug 22;8(294):[39] p.
Kermode M | Devine A | Chandra P | Dzuvichu B | Gilbert T
HIV prevalence in north-east India is high and injecting drug use (IDU) is common. Due to HIV-related deaths there are increasing numbers of IDU widows, many of whom are HIV infected, and experiencing poor health, social isolation, discrimination and poverty, all factors likely to be compromising their mental health. There is increasing recognition of the links between HIV and mental health. The aim of this study was to pilot a peer-facilitated, participatory action group (PAG) process and assess the impact of the intervention on the mental health of participants. The intervention consisted of 10 PAG meetings involving 74 IDU widows. Changes in quality of life (WHOQOL-BREF), mental health (GHQ12) and somatic symptoms were assessed. The value of the intervention from the perspective of the participants was captured using a qualitative evaluation method (Most Significant Change). Participants' quality of life, mental health and experience of somatic symptoms improved significantly over the course ofthe intervention, and the women told stories reflecting a range of 'significant changes'. This pilot intervention study demonstrated that a participatory approach to mental health promotion can have a positive impact on the lives of vulnerable women, and the potential to contribute to HIV prevention. Further investigation is warranted.

Women's social position and health-seeking behaviors: Is the health care system accessible and responsive in Pakistan?
(Abstract; subscription needed for full text; Asia)
Health Care for Women International. 2008 Sep;29(8-9):945-959.
Shaikh BT | Haran D | Hatcher J
To make the health care system more accessible and responsive to women particularly in developing countries, it is imperative to study the health-seeking behaviors and factors determining utilization of health care services. This study was carried out in close collaboration with Aga Khan Health Services, Pakistan (AKHSP) and the Health Department of Northern Areas of Pakistan. Key findings indicate that more than one-third of women did not know the cause of their reported illness. There is a median delay of 3 days before a consultation. Local women utilize AKHSP services far more than other health services due to the quality of services offered and the availability of female health staff. The perception of receiving the required treatment is lowest for government health services. Consulting faith healers is a common practice. Health education and health promotion campaigns are needed to change existing health-seeking behaviors among women. Social arrangements should be thoughtfully considered to make the health system more responsive. More female staff needs to be deployed in government health facilities. A public-private partnership seems to provide a means to strengthen the health care system and consequently to promote women's health.

HIV/AIDS and STIs NEWS

Kenya: Male circumcision sparks controversy
(News Article; Sub-Saharan Africa)
11 Sep 2008
IRIN PlusNews

HIV/AIDS and STIs RESEARCH

Assessing HIV / AIDS stigma and discrimination in developing countries
(Abstract; subscription needed for full text; Asia | Sub-Saharan Africa)
AIDS and Behavior. 2008 Sep;12(5):772-780.
Genberg BL | Kawichai S | Chingono A | Sendah M | Chariyalertsak S
HIV/AIDS-related stigma and discrimination are barriers to HIV prevention effectiveness, voluntary counseling and testing uptake, and accessing care in many international settings. Most published stigma scales are not comprehensive and have been primarily tested in developed countries. We sought to draw on existing literature to develop a scale with strong psychometric properties that could easily be used in developing countries. From 82 compiled questions, we tested a 50-item scale which yielded 3 dimensions with 22 items in pilot testing in rural northern Thailand (n = 200) and urban and peri-urban Zimbabwe (n = 221). The three factors (shame, blame and social isolation; perceived discrimination; equity) had high internal consistency reliability and good divergent validity in both research settings. Systematic and significant differences in stigmatizing attitudes were found across countries, with few differences by age or sex noted within sites. This short, comprehensive and standardized measurecan be easily incorporated into questionnaires in international research settings.

Behavior surveillance: Prevalence and factors associated with high-risk sexual behavior among HIV-infected men in Brazil in the post-HAART era
(Abstract; subscription needed for full text; South America)
AIDS and Behavior. 2008 Sep;12(5):741-747.
Guimaraes MD | Grinsztejn B | Chin-Hong PV | Campos LN | Gomes VR
A cross-sectional analysis was conducted to describe unsafe sexual practices among HIV-infected men under care in two Brazilian urban areas. Data were collected by face-to-face interviews. Twenty-five percent practiced unprotected sex in the previous year, 16% were abstinent, 33% had sex with men only, 45% with women only, 48% had male/female stable partners, 84% were on HAART and 48% had AIDS. Illicit drug use, number of female partners, having stable partners, and STD diagnosis were associated with unsafe sex. Interventions to reduce risk taking behavior among HIV-positive men under care in these settings are urgent, especially among heterosexual stable couples.

Behavioural strategies to reduce HIV transmission: How to make them work better
(Abstract; subscription needed for full text; Global)
Lancet. 2008 Aug 23-29;372(9639):669-684.
Coates TJ | Richter L | Caceres C
This paper makes five key points. First is that the aggregate effect of radical and sustained behavioural changes in a sufficient number of individuals potentially at risk is needed for successful reductions in HIV transmission. Second, combination prevention is essential since HIV prevention is neither simple nor simplistic. Reductions in HIV transmission need widespread and sustained efforts, and a mix of communication channels to disseminate messages to motivate people to engage in a range of options to reduce risk. Third, prevention programmes can do better. The effect of behavioural strategies could be increased by aiming for many goals (eg, delay in onset of first intercourse, reduction in number of sexual partners, increases in condom use, etc) that are achieved by use of multilevel approaches (eg, couples, families, social and sexual networks, institutions, and entire communities) with populations both uninfected and infected with HIV. Fourth, prevention science can do better. Interventions derived from behavioural science have a role in overall HIV-prevention efforts, but they are insufficient when used by themselves to produce substantial and lasting reductions in HIV transmission between individuals or in entire communities. Fifth, we need to get the simple things right. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved. That, presently, is not the case.

HIV prevention among vulnerable populations: The Pathfinder International approach
(Report; Global)
Watertown, Massachusetts, Pathfinder International, 2008 Jun. 38 p. (Technical Guidance Series No. 6)
Israel E | Laudari C | Simonetti C
Three particular populations in most countries are highly vulnerable to HIV infection: sex workers, men who have sex with other men, and injecting drug users. All over the world, legal frameworks, social stigma, and discrimination have rendered these populations voiceless in the decision-making processes that affect their lives, including those related to HIV. On the other hand, in places where they have been encouraged, or have fought to participate actively in prevention programming, these vulnerable groups have been among the most efficient players in slowing or even stopping the epidemic. Based on several thorough situational assessments of the levels of individual, programmatic, and social vulnerability in which they live, effective HIV prevention strategies for these groups should integrate three key elements: 1) identify, develop, and pursue effective interventions that promote individual behavior and social change; 2) guarantee equal access to comprehensive quality health services; and 3) promote respect of fundamental human rights. This technical guidance offers insight and suggestions for designing such programs. It recognizes that vulnerability itself must be understood - especially of the groups addressed - followed by practical action planning and intervention based on that understanding. It requires the full participation and guidance of each of these groups. Such a client-centered approach to prevention is an urgent priority within the anti-AIDS movement. This technical guidance should serve as a practical guide for Pathfinder International country offices, local partners, collaborating agencies, and others, for implementing effective interventions aimed at the reduction of HIV and AIDS among the most vulnerable and susceptible groups. It promises to have a measurable and positive impact on the lives of those we intend to support.

Measuring HIV-related stigma among Chinese service providers: Confirmatory factor analysis of a multidimensional scale
(Abstract; subscription needed for full text; Asia)
AIDS and Behavior. 2008 Sep;12(5):789-795.
Stein JA | Li L
An HIV-related stigma scale for health care workers needs to be multidimensional in that it should encompass attitudes that might be experienced by the general public about people living with HIV/AIDS (PLWHA) (e.g., fear, shame, blame) and, further, specifically capture perceptions of appropriate professional care and medical responsibilities regarding PLWHA. A 17-item, 5-factor multidimensional HIV-related stigma scale was developed and validated using both exploratory and confirmatory factor analysis among 1,101 service providers in China. The sample was divided into a development sample (N = 551) and a validation sample (N = 550). The fit of the final confirmatory factor model with five hypothesized subscales was excellent in both samples. The final stigma subscales included: Discrimination Intent at Work, Opinion about Health Care for HIV/AIDS Patients, Prejudiced Attitudes, Internalized Shame, and Fear of PLWHA.

Rationale and design of a community-based double-blind randomized clinical trial of an HPV 16 and 18 vaccine in Guanacaste, Costa Rica
(Abstract; subscription needed for full text; Central America and the Caribbean)
Vaccine. 2008 Sep 2;26(37):4795-4808.
Herrero R | Hildesheim A | Rodriguez AC | Wacholder S | Bratti C
We report the rationale, design, methods and details of participation of a community-based, double-blind, randomized clinical trial of an HPV 16 and 18 vaccine conducted in two provinces of Costa Rica to investigate the efficacy and population impact of the vaccine in the prevention of cervical cancer precursors. More than 24,000women between 18 and 25 years of age were invited to participate and pre-screened for eligibility, with recruitment of 7466 women (30% of those pre-screened, 59% of those eligible) who were randomized to receive 3 doses of the HPV vaccine or hepatitis A vaccine as control. A complex protocol of data and specimen collection was applied, including an interview, pelvic exam for sexually active women, blood for serology and cell-mediated immunity, cervical secretions for local immunity and cells for HPV, Chlamydia trachomatis and gonorrhea testing. Eighty percent of the women received three doses, 12.4% two doses and 7.4% one dose. At visits, compliance with data and specimen collection was close to 100%. Baseline characteristics and age-specific prevalence of HPV and cervical neoplasia are reported. Overall prevalence of HPV was high (50%), with 8.3% of women having HPV 16 and 3.2% HPV 18. LSIL was detected in 12.7% of women at baseline and HSIL in 1.9%. Prevalence of Chlamydia was 14.2%. There was very good agreement in HPV detection between clinician-collected and self- collected specimens (89.4% agreement for all types, kappa 0.59). Follow up will continue with yearly or more frequent examinations for at least 4 years for each participant.

Male circumcision for HIV prevention in sub-Saharan Africa: Who, what and when?
(Abstract; subscription needed for full text; Global)
AIDS. 2008 Sep 12;22(14):1841-1850.
White RG | Glynn JR | Orroth KK | Freeman EE | Bakker R
Male circumcision (circumcision) reduces HIV incidence in men by 50-60%. The United Nations Joint Programme on HIV/AIDS (UNAIDS) recommends the provision of safe circumcision services in countries with high HIV and low circumcision prevalence, prioritizing 12-30 years old HIV-uninfected men. We explore how the population-level impact of circumcision varies by target age group, coverage, time-to-scale-up, level of risk compensation and circumcision of HIV-infected men. An individual-based model was fitted to the characteristics of a typical high-HIV-prevalence population in sub-Saharan Africa and three scenarios of individual-level impact corresponding to the central and the 95% confidence level estimates from the Kenyan circumcision trial. The simulated intervention increased the prevalence of circumcision from 25 to 75% over 5 years in targeted age groups. The impact and cost-effectiveness of the intervention were calculated over 2-50 years. Future costs and effects were discounted and compared with the present value of lifetime HIV treatment costs (US$ 4043). Initially, targeting men older than the United Nations Joint Programme on HIV/ AIDS recommended age group may be the most cost-effective strategy, but targeting any adult age group will be cost-saving. Substantial risk compensation could negate impact, particularly if already circumcised men compensate. If circumcision prevalence in HIV-uninfected men increases less because HIV-infected men are also circumcised, this will reduce impact in men but would have little effect on population-level impact in women. Circumcision is a cost-saving intervention in a wide range of scenarios of HIV and initial circumcision prevalence but the United Nations Joint Programme on HIV/AIDS/WHO recommended target age group should be widened to include older HIV-uninfected men and counselling should be targeted at both newly and already circumcised men to minimize risk compensation. To maximize infections-averted, circumcision must be scaled up rapidly while maintaining quality.

MATERNAL AND CHILD HEALTH RESEARCH

Serological response to hepatitis B virus vaccine in HIV-infected children in Tanzania
(Abstract; subscription needed for full text; Sub-Saharan Africa)
HIV Medicine. 2008 Aug;9(7):519-525.
Pippi F | Bracciale L | Stolzuoli L | Giaccherini R | Montomoli E
HIV-infected children have a lower seroconversion rate to hepatitis B virus (HBV) immunization than healthy children. Previous studies have produced conflicting results on CD4 cell counts as predictors of vaccine response. No study has evaluated the response rate to HBV vaccination in HIV-infected children receiving highly active antiretroviral therapy (HAART). Our aim was to vaccinate HIV-infected children living in a close community and to investigate the anamnestic response rate after vaccination with its predictors. Eighty-four HIV-positive children aged 1-10 years who were negative for antibodies to the HBV core antigen (anti-HBc) completed immunization with three doses of 5 mg HBVAXPRO (Aventis, Milan, Italy). Quantitative testing for antibodies to the HBV surface antigen (anti-HBs) was performed: a seroprotective titre was defined as anti-HBs410 mUI/mL. After the vaccination, the anti-HBs seroconversion rate was 59.5%. It was higher in individuals in Centers for Disease Control and Prevention (CDC) immune category 1 than in those in CDC categories 2 and 3. Seroconversion was found in 70.8% of HAART-treated and 44.4% of treatment-naive children. In multivariable models, HAART use and absolute CD4 cell counts were independently associated with probability of seroconversion and with higher anti-HBs titres. We found a higher seroconversion rate compared with previous studies in HIV-infected children. In children who are candidates to receive antiretroviral therapy, it may be advisable to defer HBV vaccination until after treatment initiation.

Stress in mothers of preterm infants in Bangladesh: Associations with family, child and maternal factors and children's neuro-development
(Abstract; subscription needed for full text; Asia)
Child: Care, Health and Development. 2008 Aug 21;34(5):657-664.
Khan NZ | Muslima H | Bhattacharya M | Parvin R | Begum N
The aim of this paper was to ascertain stress experienced by mothers of prospectively followed up preterm infants, and associations with family, child and maternal factors and children's neuro-development. Within a follow-up study of preterm infants less than 33 weeks gestational age at a Child Development Center in Dhaka Shishu Hospital, mothers were interviewed with the Self-Report Questionnaire (SRQ) at each visit. Association between SRQ scores and child, family and maternal variables at first and final visit and children's neuro-developmental outcomes was determined. Low income mothers were more compliant (54%) compared with the defaulters (31%) (P = 0.0001) among the 159 mothers enrolled. Of the 88 mothers who were followed up until a mean age of 22 months of their child, 29.3% were at high risk for psychiatric morbidity at first visit compared with 23.9% on their last visit. Use of abortifacients (P = 0.026) and higher maternal age (P = 0.040) were significantly associated with maternal stress at first visit; while at last follow-up, total number of visits had the most significant association (P = 0.041). Twenty-five per cent and 19% of mothers were at risk for psychiatric morbidity in children developing normally and those with neuro-developmental impairments respectively. Mothers at risk for psychiatric morbidity can be helped through follow-up support within public hospitals close to their homes, which is most availed by low income families. Neuro-developmental monitoring of high-risk infants closer to homes may be more feasible in resource poor countries than reliance on hospital visits, which increase stress. Biological markers of stress and coping strategies need further research.

HIV / AIDS awareness and risk behaviour among pregnant women in Semey, Kazakhstan, 2007
(Research Article; Asia)
BMC Public Health. 2008 Aug 22;8(295):[23] p.
Sandgren E | Sandgren S | Urazalin M | Andersson R
Central Asia has one of the most rapidly increasing HIV prevalence in the world. The aim of this study was to evaluate current knowledge, risk behaviour and attitudes to voluntary counselling and testing concerning HIV/AIDS among pregnant women in Semey, Kazakhstan. We collected 226 questionnaires in a consecutive sample from a population on 520 pregnant women. The results were related to ethnicity, age and education level. Ninety-six percent had heard about HIV. Positive findings were that 89% and 86% of the women were aware of the two main routes of transmission: sexual intercourses without a condom and sharing needles while injecting drugs. The women had first heard about HIV/AIDS through the media with, 52%, and at school with 40.0%. Only 46% and 68% of the women pointed out breastfeeding and mother-to-child transmission during pregnancy or delivery as routes of transmission. Eighty-three percent were prepared not to breastfeed their baby if they were found to be HIV positive. Slightly more, 86%, accepted the need to take medicine, but fewer women, 68%, were positive to Caesarean section. Negative findings were that only 28% answered that there are ways to protect oneself against sexually transmitted HIV/AIDS and specified that this was condom use. The pregnant women in Semey have poor knowledge about specific mother-to-child HIV transmission and do not know about the means of reducing mother-to-child HIV infection. The information in the public health program needs to be improved. However, most of the women in Semey were positive to prevention strategies for mother-to-child transmission after hearing about it.

Antiretroviral therapy in pregnant women with advanced HIV disease and pregnancy outcomes in Abidjan, Cote d'Ivoire
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS. 2008 Sep 12;22(14):1815-1820.
Ekouevi DK | Coffie PA | Becquet R | Tonwe-Gold B | Horo A
Pregnancy outcomes in women receiving highly active antiretroviral treatment (HAART) in Africa are not well described. HIV-1-infected pregnant women in the ANRS Ditrame Plus and the MTCTPlus projects were included. Between March 2001 and July 2003, when HAART was not yet available, women eligible for HAART received a short-course antiretroviral regimen, zidovudine (ZDV) or (ZDV + lamivudine) and single dose of nevirapine for preventing mother-to-child transmission (PMTCT group). Between August 2003 and August 2007, eligible women for HAART received it (HAART group). The frequencies of low birth weight (LBW) ( less than 2500 g), stillbirth and infant mortality are reported. Risk factors associated with LBW were investigated using a logistic regression model. Of the 326 HIV-infected pregnant women, 175 women received short-course antiretroviral (median CD4 cell count 177 cells/ul) and 151 received HAART (median CD4 cell count 182 cells/ul). At 12 months, three paediatric infections (2.3%) occurred in the HAART group vs. 25 (16.1%) in the PMTCT group (P less than 0.001). The rate of LBW was 22.3% in the HAART group and 12.4% in the PMTCT group (P=0.02). In multivariable analysis (n=309), after adjustment on maternal CD4 cell count, WHO stage, age and maternal BMI, HAART initiated before pregnancy [adjusted odds ratio (OR) 2.88, 95% confidence interval (CI) 1.10-7.51] and during pregnancy (adjusted OR 2.12, 95% CI 1.15-4.65) and maternal BMI at delivery (adjusted OR 2.43, 95% CI 1.20-4.91) were associated with LBW. HAART in pregnant African women with advanced HIV disease substantially reduced mother-to-child transmission, but was associated with LBW.

Factors affecting women's health-related behaviors and safe motherhood: A qualitative study from a refugee camp in eastern Sudan
(Abstract; subscription needed for full text; North Africa)
Health Care for Women International. 2008 Sep;29(8-9):884-905.
Furuta M | Mori R
We aim to provide a deeper understanding of a broader range of potential factors affecting risk behaviors related to safe motherhood among refugee women in Eastern Sudan, thus creating a basis for further research in behavioral change. Risk behaviors chosen for this study follow (1) practice of female genital cutting, (2) adopting family planning (FP) practices, (3) usage of a skilled birth attendant, and (4) response to obstetric complications. Analyzing findings with the PRECEDE-PROCEED model, we found that factors frequently were uncontrollable for an individual woman, suggesting the importance of a supportive political, social, and educational environment for safe motherhood.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Maternal mortality in South Africa in 2001: From demographic census to epidemiological investigation
(Research Article; Sub-Saharan Africa)
Population Health Metrics. 2008 Aug 21;6(4):[30] p.
Garenne M | McCaa R | Nacro K
Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS. The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes. After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15-49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS. Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.

Adult height and the risk of mortality in South Korean women
(Abstract; subscription needed for full text; Asia)
American Journal of Epidemiology. 2008 Sep 1;168(5):497-505.
Song YM | Sung J
To evaluate the association between adult height as a surrogate marker of childhood circumstances and the risk of mortality, 344,519 South Korean women aged 40-64 years categorized into six height groups were prospectively followed for mortality between 1994 and 2004. In Cox proportional hazards regression with adjustment for behavioral and biologic risk factors, there was an inverse association between height and total mortality; mortality risk decreased 7% for each 5-cm increment in height. The association did not materially change after adjustment for behavioral factors and adulthood socioeconomic factors or after full adjustment for all available covariates. When height-associated risks of death from specific causes were evaluated in a fully adjusted analysis, a 5-cm increment in height was associated with lower risks of death from respiratory diseases, stroke, diabetes mellitus, and external causes (hazard ratios were 0.84 (95% confidence interval (CI): 0.74, 0.96), 0.84 (95% CI: 0.80, 0.88),0.87 (95% CI: 0.80, 0.96), and 0.88 (95% CI: 0.83, 0.94), respectively) and with a higher risk of death from cancer (hazard ratio = 1.05, 95% CI: 1.02, 1.09). Given that adult height reflects early-life conditions, the independent associations between height and mortality from all causes and specific causes support the view that early-life circumstances significantly influence health outcomes in adulthood.

Decomposing poverty changes in Zambia: Growth, inequality and population dynamics
(Abstract; subscription needed for full text; Sub-Saharan Africa)
African Development Review. 2008 Sep;20(2):284-304.
Mulenga S | Van Campenhout B
During the 1990s, the Zambian economy underwent major structural adjustments. This paper presents an application of a recently proposed poverty decomposition that attributes changes in poverty to income growth, changes in inequality and population dynamics. Our results confirm earlier findings that the existence of a severe urban bias in the economy effectively shielded large parts of the rural population from the economic slump caused by the structural adjustments. In addition, we find that the exodus from urban centres that followed the adjustments contributed significantly to the increase in national poverty. The latter finding highlights the importance of considering population movements when studying poverty, especially in situations where policy changes affect migrant labour, as was the case for the Zambian copper industry.

The path to replacement fertility in Egypt: Acceptance, preference, and achievement
(Abstract; subscription needed for full text; North Africa)
Studies in Family Planning. 2008 Sep;39(3):161-176.
El-Zeini LO
This study draws upon data from the 2004 Slow Fertility Transition survey, a follow-up to the 2003 Egypt Interim Demographic and Health Survey, to investigate obstacles to achieving replacement fertility. To account for the likelihood of embracing the two-child ideal, the analysis adopts a framework with the acronym APA: Acceptance of the two-child ideal, Preference for that ideal, and Achievement of that preference. The framework posits a hierarchy among the three and hypothesizes that each depends on a set of factors, including gender stratification, economic expectations, perception of the costs and benefits of having children, and the costs of fertility regulation. The results indicate that son preference and the perceived low cost of childrearing are major obstacles to the acceptance of the two-child family. Son preference, other discriminatory gender attitudes, optimistic economic expectations, and fear of contraceptive side effects are associated with a low preference for and ambivalence about having only two children. Given a decisive preference, lower socioeconomic status and strong son preference are the major obstacles to the achievement of the two-child ideal.

2008 world population data sheet
(Report; Global)
Washington, D.C., PRB, 2008. 16 p.
The demographic divide—the inequality in the population and health profiles of rich and poor countries—is widening. Two sharply different patterns of population growth are evident: Little growth or even decline in most wealthy countries and continued rapid population growth in the world’s poorest countries. The Population Reference Bureau's 2008 World Population Data Sheet and its summary report offer detailed information about country, regional, and global population patterns.

Reproductive inequality in sub-Saharan Africa: Differentials versus concentration
(Abstract; subscription needed for full text; Global)
Studies in Family Planning. 2008 Sep;39(3):187-198.
Giroux SC | Eloundou-Enyegue PM | Lichter DT
Within developing countries, our understanding of reproductive inequality-how fertility is distributed within a population-has been shaped largely by studies of fertility differentials, a practical but partial-information measure. In this study, we examine whether exclusive reliance on differentials biases this understanding. Findings based on recent data from sub-Saharan Africa show bias. We find that historical and especially cross-country comparisons can yield substantially different conclusions about the magnitude and even the direction of inequality patterns and trends, depending on whether differentials or fuller-information measures are used. For instance, the fertility differentials associated with education have remained relatively stable as national fertility has fallen, but inequality (as calculated by a fuller measure) has increased. Such results underscore the value of complementing existing studies of fertility differentials with analyses based on fuller-information measures. The analyses also show how change in differential fertility behavior and in the educational composition of national populations has shaped recent variations in reproductive inequality in the region.

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8 35 1 September 2008