Volume 8, Number 9
3 March 2008

Pop Reporter Tip: Did you know you can modify your subscription account? There are four features you can use to personalize your subscription: delivery format, number of topic categories, regions of the world, and type of delivery. Click the "Modify Profile" link on The Pop Reporter Web pages to gain access to your personal account.

Guest Editorials (free with every subscription)

A challenge to behavior change scholars and practitioners: Change your way of thinking

Author: Arvind Singhal, Ph.D., Samuel Shirley and Edna Holt Marston Endowed Professor, University of Texas El Paso

asinghal@utep.edu

The purpose of this editorial is to provoke scholars and practitioners engaged in social change, including those involved in health promotion and education, to think differently about how (behavior) change happens.

The challenge: Why are we so wedded to theorize complex health problems and behavior change goals in linear, individualistic, cognitive-processing frameworks? Are there other theories that will work?

Why do behavior change models, in spite of evidence to the contrary, view individuals as the locus of change? The dominant change frameworks (stages of change, health belief models, and the like), with some variation, essentially advocate for plugging KAP (knowledge, attitude, and practice) gaps, targeting the existing “deficiencies” at the individual level, moving them linearly toward desired behaviors. While they represent one way of conceptualizing behavior change and are thus of some theoretic value, such models also are problematic in that they subscribe implicitly to questionable assumptions: For instance, most individuals are capable of controlling their context, operate in a level playing field, make decisions of their free will, and mainly through a rational cognitive processing framework.

This problematic prevailing mind-set of behavior change stated as -- "if we do this to individuals, they will behave in this way" -- is a result of the overwhelming dominance of cause-effect Newtonian thinking that spilled over to social science and was reified over decades without much questioning. Newton’s laws operated so well in creating predictable machines that we (mistakenly) began to believe that social and organizational systems could be built with precision using blueprints and interchangeable parts, and manipulated like machines with outputs that could be predicted, controlled, and measured. When social systems did not behave in such predictable ways, the blueprint was re-engineered, the parts interchanged, the supervision enhanced. The incremental gains that were made, reinforced the existing paradigm of prediction and control, without calling for any alternative ways of framing the pathways to behavior change.

This editorial challenges us to seek out frameworks that question (and debunks) the “machine” view of a social system, recognizing that living beings cannot be controlled, manipulated, predicted, and/or replaced at free will. They cannot be hierarchically arranged as machine parts and work like clockwork, devoid of feelings, aspirations, and motivations. Let’s find a framework that can simultaneously explain the certainty and uncertainty associated with outcomes, and how those outcomes could be achieved. Let’s conceive a framework where outcomes can be thought about as being dynamic and emergent, and where serendipity, self-organizing, and surprise is valued, and not dismissed as anomaly. This workable framework can account for both linearity as well as non-linearity; that is, why small inputs in a social system can yield surprisingly big outcomes and why often big, expensive interventions yield small, dismal outcomes. We need to account for the simultaneous order and disorder in a system, as well as the co-existence of paradoxes and contradictions.

One framework that views the world in most of its complexity is commonly referred to as “complexity science,” a discipline that provides insights into how social systems self-organize, evolve, and adapt as a result of interactions between its elements. Complexity science debunks highly-planned, linear, individual-centered cause-effect approaches to behavior change, paying attention to the quality of networked interactions, mutual causality, non-linearity, outliers, and contradictions. Nobel laureates and MacArthur "geniuses" such as Murray Gell-Mann in physics, Ilya Prigogine in chemistry, and the late Herbert Simon in psychology have been writing about it for decades; however, the the dominant model of social change, and accompanying bio-medical discourses have continued to silence such alternative ways to frame human behavior changes.

Let me illustrate with a small example from one of my research projects that speaks to the importance of looking at people not just as individuals but as “connected,” interdependent beings. My example points to social change not as a cause-effect linear process, but rather one characterized by small changes in system inputs that can produce big ripple effects. In 2002-2003 the Indian state of Bihar was the site of a radio soap opera broadcast called Taru, designed to promote gender equality (Singhal, Sharma, Papa, & Witte, 2004). In one episode, the feminist protagonist, Taru, arranges with a village family to celebrate the birthday of one of the little girls. In reality, girls’ birthdays are traditionally not celebrated in rural Bihar; whereas a boy’s birthday calls for ritualistic ceremony. However, after this particular episode was broadcast, several villages in Bihar reported the celebration of girls’ birthdays (Singhal, Rao, & Pant, 2006). Also, once a girl’s birthday was celebrated, many other girls in the same village (who attended the birthday party) demanded that their birthdays be celebrated as well. When guests from neighboring villages attended these celebrations, this practice spilled over to other locations. One may ask: Is this just a new fad, complete with cakes, balloons, and sweets? Or is it more? If girls in today’s rural Bihar demand that their birthdays be celebrated on par with boys, are they not likely to demand someday that they also ride the bicycle, or go to school, as their brothers’ do?

Where will the waves of change, riding on networked individuals and communities, stop?

References:

Lacayo Criquillion, V. (2006). Approaching Social Change as a Complex Problem in a World that Treats it as a Complicated One: The Case of Puntos de Encuentro, Nicaragua. MA Thesis. Athens, OH: Communication and Development Studies Program.

Papa, M.J., Singhal, A., & Papa, W.H. (2006). Organizing for Social Change. Newbury Park, CA: Sage.

Singhal, A. (2008). Where Social Change Scholarship and Practice Went Wrong? Might Complexity Science Provide a Way Out of this Mess? Communication for Development and Social Change, Volume 2, pp. in press.

Singhal, A., Rao, N., & Pant, S. (2006). Entertainment-Education and Possibilities for Second-Order Social Change. Journal of Creative Communications 1(3): 267-283.

Singhal, A., Sharma, D., Papa, M. J., & Witte, K. (2004). Air Cover and Ground Mobilization: Integrating Entertainment-education Broadcasts with Community Listening and Service Delivery in India. In A. Singhal, M. Cody, E. M. Rogers, & M. Sabido (Eds.), Entertainment-education and Social Change: History, Research, and Practice (pp. 351-374). Mahwah, NJ: Lawrence Erlbaum.

Stacey, R. D. (1996). Complexity and Creativity in Organizations. San Francisco, CA: Berrett-Koehler Publishers.

Wheatley, M. J. (1999). Leadership and the New Science: Discovering Order in a Chaotic World. San Francisco, CA: Berrett-Koehler Publishers.

Zimmerman, B., Lindberg, C., & Plsek, P. (1998). Edgeware: Lessons From Complexity Science for Health Care Leaders. Dallas, TX: VHA Inc.

ADOLESCENT HEALTH NEWS

Uganda: Teenage mums need to return to school
(News Article; Sub-Saharan Africa)
24 Feb 2008
Abio A, New Vision (Kampala)

Djibouti: UN-backed plan aims to boost access to education, reduce gender gap
(News Article; Sub-Saharan Africa)
25 Feb 2008
UN News Service (New York)

ADOLESCENT HEALTH RESEARCH

Factors associated with risky sexual behaviour among out-of-school youth in Kenya
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Biosocial Science. 2008;:1-13.
Khasakhala AA | Mturi AJ
This paper examines factors that may predispose unmarried and unemployed out-of-school youth to risky sexual behaviour. Data for analysis were derived from the Behaviour Surveillance Survey carried out in Kenya in late 2002. A total of 6129 male and female unmarried and unemployed out-of-school youth in the age range 15-24 years were successfully interviewed. However, for this paper only a sample of 3961 comprising sexually experienced youth in the 12 months preceding the survey was used. Methods of analysis included descriptive statistics and multinomial logistic regression. Results for males indicate that factors associated with low and high risk were whether they had fathered a child, district of residence and frequency of alcohol use, while current age and age at first sexual debut stood out for those with low risk alone. For females the district of residence and age of partner at sexual debut were the factors that predisposed them to low-risk sexual behaviour, while for high risk the district of residence, current age and ever being pregnant were significant. The results indicate that for these youth, contextual and probably social factors appear to be the main determinants of risky sexual behaviour for both males and females. The findings also support those of other studies that link risky sexual behaviour among youth, especially males, to alcohol consumption. Programmes for intervention therefore need to focus on these aspects. There is also a need for studies that can look at district-specific factors for more focused interventions.

Inconsistent reports of sexual intercourse among South African high school students
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Adolescent Health. 2008 Mar;42(3):221-227.
Palen LA | Smith EA | Caldwell LL | Flisher AJ | Wegner L
This study aims to describe patterns of inconsistent reports of sexual intercourse among a sample of South African adolescents. Consistency of reported lifetime sexual intercourse was assessed using five semiannual waves of data. Odds ratios related inconsistent reporting to demographic variables and potential indicators of general and risk-behavior-specific reliability problems. Of the sexually active participants in the sample, nearly 40% reported being virgins after sexual activity had been reported at an earlier assessment. Inconsistent reporting could not be predicted by gender or race or by general indicators of poor reliability (inconsistent reporting of gender and birth year). However individuals with inconsistent reports of sexual intercourse were more likely to be inconsistent reporters of substance use. These results suggest that researchers need to undertake efforts to deal specifically with inconsistent risk behavior data. These may include modification of data collection procedures and use of statistical methodologies that can account for response inconsistencies.

Barriers to the community support of orphans and vulnerable youth in Rwanda
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Social Science and Medicine. 2008 Apr;66(7):1557-1567.
Thurman TR | Snider LA | Boris NW | Kalisa E | Nyirazinyoye L
A consistent theme in the literature on interventions for orphans and vulnerable children is the need for community-based care. However, a number of socio-cultural factors may impede community response. In this study, mixed methods are used to elucidate community-level barriers to care for orphans and vulnerable youth in Rwanda. Data from a large survey of youth heads of household on perceptions of marginalization from the community and the factors predicting that marginalization are considered in light of additional data from a survey of adults who volunteered to mentor these youth and focus groups with both community adults and youth heads of household. Results highlight how orphans' impoverished condition, cause of parents' death, and community perceptions of orphan behavior play a role in the marginalization of orphaned youth in Rwanda. Evidence is also offered to show that targeting humanitarian assistance to vulnerable youth may inadvertently lessen the level of community support they receive and contribute to their marginalization. The implications of these data for community-based program approaches are discussed.

FAMILY PLANNING NEWS

China may scrap one-child policy, official says
(News Article; Asia)
28 Feb 2008
Reuters

India’s big population challenge
(News Article; Asia)
25 Feb 2008
Blythe N, Daily Times

FAMILY PLANNING RESEARCH

Do contraceptive choices of Turkish married adolescents differ from those of older women?
(Abstract; subscription needed for full text; Europe)
European Journal of Contraception and Reproductive Health Care. 2008 Mar;13(1):71-76.
Dilbaz B | Yildirim BA | Yildirim D | Turgal M | Cengiz H
The objective was to compare contraceptive choices of Turkish married adolescents to those of women of reproductive age and perimenopausal women. Demographic variables, fertility goals and contraceptive choices of adolescents (Group A, n = 95) were compared with those of women of reproductive age (Group B, N = 5224) and perimenopausal women (Group C, n = 2208). All women in the study group were married and had delivered at least once. A past history of voluntary terminations of pregnancy (TOPs) was reported often, although significantly less so by adolescents (43.1%) than by women belonging to the other two groups (66.5 and 77.4%, respectively). The percentage of women who applied no contraception was significantly higher in Group A (p less than 0.05). The rate of use of withdrawal, oral contraceptives and intrauterine devices did not differ significantly between the three groups. The percentage of women who were indecisive about future pregnancy or wanted to have more children was greatest in Group A (87.4, 46.9 and 25.7%, respectively; p less than 0.05). The distribution of contraceptive methods used was similar among the three age groups, but the absence of contraception was most frequent in the adolescent group. The adolescents we assessed, being married and having delivered at least once, are a highly selected group and not representative of adolescents in general. Nevertheless, their contraceptive choices did not differ from those of older women. The incidence of TOPs among them was quite high. Minimization of the frequent neglect of application of contraceptive measures by adolescents requires improvement of family planning services for this age group.

The association between oral contraceptive use and lobular and ductal breast cancer in young women
(Abstract; subscription needed for full text; Global)
International Journal of Cancer. 2008;122(4):936-941.
Nyante SJ | Gammon MD | Malone KE | Daling JR | Brinton LA
Recent reports indicate that the incidence of lobular breast cancer is increasing at a faster rate than ductal breast cancer, which may be due to the differential effects of exogenous hormones by histology. To address this issue, we examined whether the relationship between oral contraceptive use and incident breast cancer differs between lobular and ductal subtypes in young women. A population-based sample of in situ and invasive breast cancer cases between ages 20 and 44 were recruited from Atlanta, GA; Seattle-Puget Sound, WA and central New Jersey. Controls were sampled from the same areas by random-digit dialing, and were frequency matched to the expected case age distribution. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using polytomous logistic regression. Among the 100 lobular cancers, 1,164 ductal cancers, and 1,501 controls, the odds ratios for oral contraceptive ever use were 1.10 (95% CI 5 0.68-1.78) for lobular cancers and 1.21 (95% CI 5 1.01-1.45) for ductal cancers, adjusted for study site, age at diagnosis, and pap screening history. Our results suggest that the magnitude of the association between ever use of oral contraceptives and breast cancer in young women does not vary strongly by histologic subtype. These results are similar to previous studies that report little difference in the effect of oral contraceptive use on breast cancer by histology.

Hiding in plain sight: The role of contraception in preventing HIV
(Abstract; subscription needed for full text; Global)
Guttmacher Policy Review. 2008 Winter;11(1):2-5.
Cohen SA
As Congress embarks on the process of reauthorizing the U.S. program to fight HIV and AIDS, and as other global donors recalibrate levels and allocations of funding for HIV/AIDS programs, prevention seems to be making a comeback. At the inception of the President's Emergency Plan for AIDS Relief (PEPFAR) five years ago, both the funding and the programmatic emphasis titled heavily toward treatment. Yet, the rate of new HIV infection continues to outpace the world's ability to deliver antiretroviral therapy, despite recent advances in access to such medications. A public health consensus is emerging, therefore, in favor or realigning the balance between treatment and prevention efforts.

Long-term effects of a community-based program on contraceptive use among sexually active unmarried youth in Shanghai, China
(Abstract; subscription needed for full text; Asia)
Journal of Adolescent Health. 2008 Mar;42(3):249-258.
Tu X | Lou C | Gao e | Shah IH
The purpose was to evaluate the long-term (48-month) sustainable effect of a set of community-based interventions to promote contraceptive use among sexually active unmarried youth in suburban Shanghai, China. A nonrandomized community trial with one intervention and one control group was conducted in two comparable towns of a suburban area of Shanghai. The intervention program was developed and implemented to increase knowledge and access to sexual and reproductive health services among unmarried youth aged 15-24 years. Baseline surveys were conducted in both sites before implementation of the intervention, and similar surveys were conducted in both sites 20 months after the launch of the intervention and 28 months after the end of the intervention. Statistically significant differences between the respondents surveyed at baseline in 2000 and at the long-term follow up in 2004 were observed in some age categories and in some educational groups. In the postproject period, there was a major improvement in all indicators in the control group. Among the sub-set of respondents interviewed both in 2000 and 2004 who were exposed to the intervention program, the interventions were associated with a significant increase in the frequency of contraceptive use among participants initiating sexual relations over the period of the intervention (odds ratio [OR] = 6.91), as well as with significant reduction in use ever of the withdrawal method of contraception among all sexually active respondents (OR = .37) compared with the control group during long-term follow-up period. No long-term effects on contraceptive practice were observed among new respondents who were not exposed to the intervention program. Comprehensive community-based interventions appear to have limited long-term effects on contraceptive use among unmarried youth in suburban Shanghai. It is necessary to provide sex and reproductive health education and services to all unmarried young people on a regular basis.

Family planning among HIV positive and negative prevention of mother to child transmission (PMTCT) clients in a resource poor setting in South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS and Behavior. 2008 Feb 20;:[7] p..
Peltzer K | Chao LW | Dana P
The purpose of this study was to investigate family planning needs, knowledge of HIV transmission and HIV disclosure in a cohort sample that had undergone PMTCT in a resource poor setting. Five public clinics implementing PMTCT from Qaukeni Local Service Area, O.R. Tambo District in the Eastern Cape. The sample at postnatal care consisted of 758 women with known HIV status. From 116 HIV positive women 76.3% and from 642 HIV negative women 85.2% got counseling on safe sex during pregnancy but only 65.8% and 62.3% of the women respectively practiced safe sex during pregnancy, which did not differ by HIV status. Postnatally, almost all women received counseling on family planning, yet use of contraceptives and condoms were low. Among HIV positive women PMTCT knowledge and younger age of the mother were associated with pregnancy desire, and among HIV negative women HIV disclosure to the partner, younger age of the mother and having a lower number of children were associated with pregnancy desire. High pregnancy desires (yet lower than for HIV negative women); low contraceptive and condom use were found among HIV positive women. HIV prevention and family planning must acknowledge the reproductive desires of HIV positive women and men.

GENDER and HEALTH NEWS

Violence against women must stop now - UN Chief
(News Article; Global)
28 Feb 2008
Business Daily (Nairobi)

UN agencies rally to end to female genital mutilation within a generation
(News Article; Global)
27 Feb 2008
UN News Centre

Thousands fall victim to sexual violence in Central African Republic - UN
(News Article; Sub-Saharan Africa)
22 Feb 2008
UN News Centre

GENDER and HEALTH RESEARCH

Socio-cultural, psychosexual and biomedical factors associated with genital symptoms experienced by men in rural India
(Abstract; subscription needed for full text; Asia)
Tropical Medicine and International Health. 2008 Mar;13(3):1-12.
Gautham M | Singh R | Weiss H | Brugha R | Patel V
Biomedical, anthropological and psychiatric frameworks have been used to research different elements of men's sexual health - sexually transmitted infections, psychosexual concerns and psychological distress - but rarely within the same study. We combined these in a study in rural north India. In Tehri Garhwal and Agra districts, we explored male perceptions of genital and sexual symptoms through focus group discussions and then conducted a clinic-based survey of 366 symptomatic men who presented at rural private provider clinics. Men's urine specimens were tested for gonorrhoea and chlamydia infection using polymerase chain reaction techniques. Researchers screened them for probable psychological distress by administering the General Health Questionnaire (12-items). Results revealed that local and traditional notions of health influenced men's symptom perceptions, with semen loss their predominant concern. Dhat, commonly perceived as an involuntary semen loss, corresponded most closely with the symptom of urethral discharge, but was attributed mainly to non-infectious causes. It could also manifest as a syndrome with physical weakness and mental lethargy. FGD participants lacked correct and complete information on reproductive health. Around 75% of the symptomatic men presented with dhat, but only 5.5% tested positive for gonorrhoea or chlamydia. Application of syndromic sexually transmitted infection (STI) guidelines in these settings could result in over diagnosis and over treatment with antibiotics. In contrast, there was a significant association between dhat and probable psychological distress as detected by the GHQ (Adjusted OR, GHQ case positive: 2.66, 95% CI: 1.51-4.68). Our study confirms the existence of a dhat syndrome in rural India, which is culturally influenced and reflects heightened psychosexual concerns as well as mental distress states. Comprehensive health services for men should include assessments of their psychosexual needs and be supported by reproductive/sexual health education. STI treatment guidelines for urethral symptoms should be revised and be based on epidemiological data.

Engendering health sector responses to sexual violence and HIV in Kenya: Results of a qualitative study
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS Care. 2008 Feb;20(2):188-190.
Kilonzo N | Taegtmeyer M | Molyneux C | Kibaru J | Kimonji V
In Kenya many people who have been affected by sexual violence turn to the health sector for clinical treatment and preventive therapies. This interface provides a vital opportunity to impact on the dual epidemics of HIV and sexual violence. Despite this, the uptake of post-rape care services in health facilities as low and health care providers felt ill-prepared to deal with the consequences of sexual violence. A qualitative study was conducted to better understand the reasons for the low uptake of services and to establish perceptions of sexual violence in Kenya. Thirty-four key informants were interviewed and sixteen focus group discussions with women and men were held in three districts in Kenya. Blurred boundaries between forced and consensual sex emerged. Important implications for the delivery of HIV post exposure prophylaxis (PEP) after sexual violence include the need for gender-aware patient-centred training for health providers and for HIV PEP interventions to strengthen on-going HIV-prevention counselling efforts. Further research needs to determine the feasibility of on-going risk reduction measures in the context of PEP delivery.

Effects of individual and proximate educational context on intimate partner violence: A population-based study of women in India
(Abstract; subscription needed for full text; Asia)
American Journal of Public Health. 2008 Mar;98(3):507-514.
Ackerson LK | Kawachi I | Barbeau EM | Subramanian SV
We examined the role of women's education and proximate educational context on intimate partner violence (IPV). We examined a sample of 83627 married women aged 15 to 49 years from the 1998 to 1999 Indian National Family Health Survey. We used multilevel multiple logistic regression modeling to estimate the relative effect of women's and their husband's levels of education, spousal education differential, and community-level literacy on women's risk of recent and lifetime IPV. In adjusted models, odds of recent IPV among women without any education were 5.61 times (95% confidence interval [CI]=3.53, 8.92) those of college-educated women, and odds among wives of uneducated men were 1.84 times (95% CI=1.44, 2.35) those of wives of college-educated men. Women with more education than their husbands were more likely than those with educational parity to report recent IPV (odds ratio [OR]=1.18; 95% CI=1.05, 1.33). The results were similar for lifetime IPV. After we controlled for individual factors, as community male and female literacy levels increased, likelihood of IPV declined. Although increasing women's levels of education is crucial to reducing IPV for women, proximate educational context is also an important factor in reducing this public health burden.

Women's rights, domestic violence, and recourse seeking in rural Bangladesh
(Abstract; subscription needed for full text; Asia)
Violence Against Women. 2008 Mar;14(3):326-345.
Schuler SR | Bates LM | Islam F
This article seeks to deepen understanding of the reasons that abused women in a resource-poor rural setting seek recourse so seldom and with so little success. Data from in-depth interviews and group discussions are used to explore the range of responses to domestic violence and to examine barriers to recourse seeking. Findings illustrate how the combination of poverty and gender inequality, inequities in the legal framework, and patriarchal attitudes and corruption in both formal and informal institutions at the local level discourage abused women from seeking recourse and decrease the likelihood of a favorable outcome when they do.

HIV/AIDS and STIs NEWS

India: HIV drug in microbicide gel safe for use
(News Article; Global)
26 Feb 2008
HealthDay News/ Washington Post

Botswana: HIV/Aids stories must be clear, Nkala tells reporters
(News Article; Sub-Saharan Africa)
25 Feb 2008

United States: Panel approves global AIDS spending hike
(News Article; North America)
27 Feb 2008
Abrams J, Associated Press

United States: Vaccinating boys for girls' sake?
(News Article; North America)
28 Feb 2008
Hoffman J, International Herald Tribune

HIV/AIDS and STIs RESEARCH

The long-term social and economic impact of HIV on the spouses of infected individuals in northern Malawi
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Tropical Medicine and International Health. 2008 Apr;13(4):1-12.
Floyd S | Crampin AC | Glynn JR | Mwenebabu M | Mnkhondia S
The objective was to assess the social and economic impact of HIV-related illness and death on the spouses of HIV-infected individuals. From population-based surveys in the 1980s in Karonga district, northern Malawi, 197 'index individuals' were identified as HIV-positive. A total of 396 HIV-negative 'index individuals' were selected as a comparison group. These individuals, and their spouses and children, were followed up in 1998-2000, in a retrospective cohort study. All analyses compared spouses of HIV-positive indexes with those of HIV-negative indexes. By 1998-2000, most marriages involving an HIV-positive index individual had ended in widowhood. Twenty-Six percent of the wives of HIV-positive index men experienced household dissolution precipitated by widowhood, compared with 5% of the wives of HIV-negative index men. Corresponding percentages for husbands of index women were 14% and 1%. Widow inheritance was uncommon. The remarriage rate among separated or widowed wives of HIV-positive index men was half that of such wives of HIV-negative index men. About 30% of surviving wives of HIV-positive index men were household heads at the time of follow-up, compared with 5% of such wives of HIV-negative index men. Almost all these women were widows who lost their husband when greater than 35 years old, and they had relatively few household assets. The social and economic impact of HIV on the spouses of HIV-infected individuals in rural northern Malawi is substantial. Interventions that strengthen society's ability to absorb and support widows and widowers, and their dependents, without necessarily involving the traditional coping mechanism of remarriage, are essential.

The role of high-risk HPV-DNA testing in the male sexual partners of women with HPV-induced lesions
(Abstract; subscription needed for full text; South America)
European Journal of Obstetrics, Gynecology and Reproductive Biology. 2008 Mar;137(1):88-91.
Giraldo PC | Eleuterio J Jr | Cavalcante DI | Goncalves AK | Romao JA
The objectives were to assess the prevalence of high-risk HPV in the male sexual partners of women with HPV-induced lesions, and correlate it with biopsies guided by peniscopy. Fifty-four asymptomatic male sexual partners of women with low-grade squamous intra-epithelial lesions (LSIL) associated with high-risk HPV were examined between April 2003 and June 2005. The DNA-HPV was tested using a second-generation hybrid capture technique in scraped penile samples. Peniscopy identified acetowhite lesions leading to biopsy. High-risk HPV was present in 25.9% (14 out of 54) of the cases. Peniscopy led to 13 biopsies (24.07%), which resulted in two cases of condyloma, two cases of intra-epithelial neoplasia (PIN) I, one case of PIN II, and eight cases of normal tissue. The high-risk HPV test demonstrated 80% sensitivity, 100% specificity, 100% positive predictive value, and 88.9% negative predictive value for the identification of penile lesions. There was a greater chance of finding HPV lesions in the biopsy in the positive cases of high-risk HPV with abnormal peniscopy (p = 0.007); OR = 51 (CI 1.7-1527.1). Among asymptomatic male sexual partners of women with low-grade intra-epithelial squamous lesions, those infected by high-risk HPV have a higher chance of having abnormal penile tissue compared with male partners without that infection.

Treating curable sexually transmitted infections to prevent HIV in Africa. Still an effective control strategy?
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Mar;47(3):346-353.
White RG | Orroth KK | Glynn JR | Freeman EE | Bakker R
Evidence regarding the effectiveness of sexually transmitted infection (STI) treatment for HIV prevention in Africa is equivocal, leading some policy makers to question whether it should continue to be promoted for HIV control. We explore whether treating curable STIs remains a cost-effective HIV control strategy in Africa. The model STDSIM was fitted to the characteristics of 4 populations in East and West Africa. Over the simulated HIV epidemics, the population-attributable fractions (PAFs) of incident HIV attributable to STIs, the impact of syndromic STI management on HIV incidence, and the cost per HIV infection averted were evaluated and compared with an estimate of lifetime HIV treatment costs (US $3500). Throughout the HIV epidemics in all cities, the total PAF for all STIs remained high, with $50% of HIV transmission attributed to STIs. The PAF for herpes simplex virus type 2 increased during the epidemics, whereas the PAF for curable STIs and the relative impact of syndromic management decreased. The models showed that the absolute impact of syndromic management remains high in generalized epidemics, and it remained cost-saving in 3 of the 4 populations in which the cost per HIV infection averted ranged between US $321 and $1665. Curable STI interventions may remain cost-saving in populations with generalized HIV epidemics, particularly in populations with high-risk behaviors or low male circumcision rates.

MATERNAL AND CHILD HEALTH NEWS

Africa: Investing in the health of continent's mothers
(News Article; Sub-Saharan Africa)
25 Feb 2008
Kimani M, Public Agenda (Accra)

South Africa: Committee to investigate maternal, infant deaths
(News Article; Sub-Saharan Africa)
25 Feb 2008
Khumalo G, BuaNews Online

Uganda: Poor management of labour endangers mothers' lives
(Feature Article; Sub-Saharan Africa)
24 Feb 2008
Nabusoba I, New Vision (Kampala)
Related Fact Sheet: Preventing Postpartum Hemorrhage
Related Fact Sheet: Active Management of the Third Stage of Labor: A Simple Practice to Prevent Postpartum Hemorrhage

MATERNAL AND CHILD HEALTH RESEARCH

Breast-feeding patterns, time to initiation, and mortality risk among newborns in southern Nepal
(Abstract; subscription needed for full text; Asia)
Journal of Nutrition. 2008 Mar;138(3):599-603.
Mullany LC | Katz J | Li YM | Khatry SK | Le Clerq SC | Darmstadt GL | Tielsch JM
Related Report: Better breastfeeding, healthier lives
Initiation of breast-feeding within 1 h after birth has been associated with reduced neonatal mortality in a rural Ghanaian population. In South Asia, however, breast-feeding patterns and low birth weight rates differ and this relationship has not been quantified. Data were collected during a community-based randomized trial of the impact of topical chlorhexidine antisepsis interventions on neonatal mortality and morbidity in southern Nepal. In-home visits were conducted on d 1-4, 6, 8, 10, 12, 14, 21, and 28 to collect longitudinal information on timing of initiation and pattern of breast-feeding. Multivariable regression modeling was used to estimate the association between death and breast-feeding initiation time. Analysis was based on 22,838 breast-fed newborns surviving to 48 h. Within 1 h of birth, 3.4% of infants were breast-fed and 56.6% were breast-fed within 24 h of birth. Partially breast-fed infants (72.6%) were at higher mortality risk [relative risk (RR) = 1.77;95% CI = 1.32-2.39] than those exclusively breast-fed. There was a trend (P = 0.03) toward higher mortality with increasing delay in breast-feeding initiation. Mortality was higher among late (greater than or equal to 24 h) compared with early (less than 24 h) initiators (RR = 1.41; 95% CI = 1.08-1.86) after adjustment for low birth weight, preterm birth, and other covariates. Improvements in breast-feeding practices in this setting may reduce neonatal mortality substantially. Approximately 7.7 and 19.1% of all neonatal deaths may be avoided with universal initiation of breast-feeding within the first day or hour of life, respectively. Community-based breast-feeding promotion programs should remain a priority, with renewed emphasis on early initiation in addition to exclusiveness and duration of breast-feeding.

Effect of postnatal home visits on maternal / infant outcomes in Syria: A randomized controlled trial
(Abstract; subscription needed for full text; Middle East)
Public Health Nursing. 2008 Mar-Apr;25(2):115-125.
Bashour HN | Kharouf MH | Abdul Salam AA | El Asmar K | Tabbaa MA | Cheikha SA
Early postpartum home visiting is universal in many Western countries. Studies from developing countries on the effects of home visits are rare. In Syria, where the postpartum period is rather ignored, this study aimed to assess whether a community-based intervention of postnatal home visits has an effect on maternal postpartum morbidities; infant morbidity; uptake of postpartum care; use of contraceptive methods; and on selected neonatal health practices. A randomized controlled trial was carried out in Damascus. Three groups of new mothers were randomly allocated to receive either 4 postnatal home visits, one visit, or no visit. A total of 876 women were allocated and followed up. Registered midwives with special training made a one or a series of home visits providing information, educating, and supporting women. A significantly higher proportion of mothers in Groups A and B reported exclusively breastfeeding their infants (28.5% and 30%, respectively) as compared with Group C (20%), who received no visits. There were no reported differences between groups in other outcomes. While postpartum home visits significantly increased exclusive breastfeeding, other outcomes did not change. Further studies framed in a nonbiomedical context are needed. Other innovative approaches to improve postnatal care in Syria are needed.

An autopsy study of maternal mortality in Mozambique: The contribution of infectious diseases
(Research Article; Sub-Saharan Africa)
PLoS Medicine. 2008 Feb;5(2):e44.
Menendez C | Romagosa C | Ismail MR | Carrilho C | Saute F | Osman N | Machungo F | Bardaji A | Quintó L | Mayor A | Naniche D | Dobaño C | Alonoso P | Ordi J
Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policymakers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. The authors conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. HIV detection was done by virologic and serologic tests, and malaria was diagnosed by histological and parasitological examination. During 26 mo there were 179 maternal deaths, of which 139 (77.6%) had a complete autopsy and formed the basis of this analysis. Of those with test results, 65 women (52.8%) were HIV positive. Obstetric complications accounted for 38.2% of deaths; haemorrhage was the most frequent cause (16.6%). Nonobstetric conditions accounted for 56.1% of deaths; HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis were the most common causes (12.9%, 12.2%, 10.1% and 7.2% respectively). Mycobacterial infection was found in 12 (8.6%) maternal deaths. In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/ AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for HIV/AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.

POPULATION/FERTILITY/DEMOGRAPHY NEWS

Half of global population will live in cities by end of this year, predicts UN
(News Article; Global)
26 Feb 2008
UN News Centre

Taiwan: Coping with the island's declining birthrate
(News Article; Asia)
28 Feb 2008
The China Post

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Socioeconomic and behavioral determinants of mortality in posttransition Russia: A prospective population study
(Abstract; subscription needed for full text; Asia)
Annals of Epidemiology. 2008 Feb;18(2):92-100.
Perlman F | Bobak M
The purpose was to study different socioeconomic determinants of mortality in posttransition Russia and propose potential explanations. Previous research has demonstrated a widening educational mortality gradient, widespread deprivation, and harmful health behaviors. Data were from seven rounds (1994-2002) of the 38-center Russia Longitudinal Monitoring Survey. We measured associations among education, income, consumer goods, smoking, alcohol consumption, and subsequent death (reported by another household member), using univariate and multivariate Cox proportional hazards analysis. There were 11,482 adults older than 18 years, 782 deaths, and a mean follow-up of 4.2 years. Study and national mortality rates were comparable (standardized mortality ratio of 0.96 in men and 0.78 in women). Education predicted mortality strongly: the fully adjusted hazard ratios for less than secondary compared with higher education were 1.68 (1.26-2.23) in men and 3.08 (2.25-4.21) in women. Income and material measures did not predict mortality strongly. Smoking and weekly drinking independently doubled the mortality risk; however, like income, they did not explain the educational mortality gradient, of which material measures accounted for one-third in men only. Education, unlike material advantage, protected strongly against mortality. Education may better reflect lifetime health-related exposures, although other explanations (e.g., psychosocial, cardiovascular risk) deserve further research. Health behaviors exhibited strong, separate effects on mortality.

Regional fertility differences in Turkey: Persistent high fertility in the southeast
(Abstract; subscription needed for full text; Europe)
Population, Space and Place. 2008;14(2):135-158.
Yucesahin MM | Ozgur EM
The purpose of this study is to investigate regional fertility differences in Turkey at a provincial level, with a particular focus on high fertility in the eastern and southeastern regions. Furthermore, the study discusses the reasons for fertility fluctuations in eight southeastern provinces over the past two decades. This study offers maps showing the total fertility rates of the provinces between 1980 and 2000, and probes the ways in which regional fertility differences have arisen. A multiple regression analysis is also carried out in order to explain determinants of high fertility in southeastern Turkey. The study relies on population statistics issued by the State Institute of Statistics as well as Turkey Demographic and Health Surveys. The findings of this study underline that ethnicity and cultural factors are definitive of high fertility in southeastern Turkey. The use of local languages and the dominance of traditional cultural norms in the undeveloped eastern and southeastern regions with a large Kurdish (and partially Arab) population have created linguistic and cultural barriers. Thereby, unlike other regions where Turkish is the dominant language, the eastern and southeastern regions have mainly fallen outside the social interaction process that secures the adoption by individuals of modern reproductive behaviour, and these regions have persistently maintained a high level of fertility. Recent fertility fluctuations in eight provinces of southeastern Turkey are largely a consequence of the population's reduced access to family planning services due to the conflict between Turkish security forces and separatist Kurdish groups in the region.

"The Pop Reporter" (R) Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project. When you click on any link, your Internet browser will access a Web site not connected to "The Pop Reporter." Information accessed through these links and contained in this issue of "The Pop Reporter" does not necessarily state or reflect the views of the INFO Project, Johns Hopkins University, or the US Agency for International Development. All links were verified at the date of mailing. Your computer and/or network configuration regarding Java script, cookies, and other security issues may not allow you to view certain Web sites. Consult your computer technician if you are having problems.

Problems and comments can be addressed to mdadamo@jhuccp.org.

Archives available at http://www.infoforhealth.org/popreporter/.

Subscribe at http://prds.infoforhealth.org/signup.php.

Modify your account at http://prds.infoforhealth.org/modify.php.

Forward this message to a friend who could benefit from INFO project activities!

The Pop Reporter--Delivering thought-provoking global health news to your desktop.

Johns Hopkins Bloomberg School of Public Health: The INFO Project

Volume 8, Number 9 3 March 2008