Volume 8, Number 17
28 April 2008

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Guest Editorials (free with every subscription)

The continuum of care: A case for pharmacists as key members of the reproductive health care team

Author: Nicole Monastersky Maderas, Sharon Cohen Landau, and Belle Taylor-McGhee, Pharmacy Access Partnership

nmaderas@phi.org

The definition of primary care has evolved significantly in the US over the past 30 years, shifting from a model based on clearly stratified clinical specialties and disciplines to a somewhat more loosely defined provider landscape centered on principles of leadership and teamwork [1]. This trend—particularly in the US—can be ascribed to a number of factors: concerns about access to care—especially among underserved populations, growing uncertainty about insurance coverage and medical society and academic efforts to evolve health professions training and education [4]. This evolution in the US tracks the status quo in much of the rest of the world, where health care problem-solving in the face of various societal pressures and the reality of limited resources has often been creative and thoughtful [8].

US case study: The impact of state and local pharmacist partnerships on EC provision

Over the past decade, US pharmacists have had a profound effect on reproductive health in the area of EC. Many women, especially young women, are unfamiliar with EC or how it works [11]. Organizational inroads at local and state levels have made a significant impact on awareness in individual communities [13]. In the US, with the introduction of a dedicated EC product in 1998, advocates and public health professionals have increasingly been promoting improved access to the medication [14].

While the US Food and Drug Administration (FDA) regulates the status of over-the-counter and prescription medications, each state may determine the authorizing prescribers for particular medications. Forty US states allow for collaborative practice agreements in which prescribers authorize pharmacists to engage in specified activities including initiating drug therapy, although the types of agreements vary by state [16]. Many advances in EC access have occurred at the state level, allowing pharmacists to play a much more active role.

State-level policy allows for more localized advances in access, but it has also resulted in an uneven and inconsistent landscape, often confusing for the public, media and providers. Nine states have passed state laws or have regulations allowing for direct pharmacy access to EC (WA, CA, NM, AK, HI, ME, NH, MA, VT) [17].

With funding from the William and Flora Hewlett Foundation [18], Pharmacy Access Partnership, launched a year-long “States Take Action Toward Advancing EC Services” (STATES) Re-Granting Program in the fall of 2005. The program goal was to provide direct financial support to advocates and organizations working at the state level to increase access to EC in pharmacies to initiate policy and practice change. Funding available through the STATES Re-Granting Program presented a first-time opportunity for several organizations to advance access to EC in pharmacies at the state level.

Small grants (ranging from $5,000 to $20,000) were awarded to seven organizations that detailed how they could (1) effectively leverage momentum to promote increased access to EC in pharmacies achieved by current or past state-level activity, or (2) initiate new engagement among a cross-section of stakeholders if based in states where little activity had occurred.

While Plan B is now available OTC for consumers ages 18 and older, direct pharmacy access to EC remains an important option for some women, particularly teens, those without proper proof of age, and women who rely on state-funded health insurance for EC services. When Plan B was approved for OTC sales, the FDA stressed in writing that EC pharmacy access programs are an important means to ensuring access for all women [19].

The OTC decision also created an unintended barrier to EC access for low-income women: Medicaid typically does not cover the cost of OTC medications. Prior to its availability OTC, Medicaid and other state-funded health insurance programs helped make Plan B more widely accessible and in some instances recognized the benefits of the pharmacists' role in EC provision.

EC outreach and education for all health care providers and the public is still very necessary in an OTC environment [20]. EC advocates are concerned that, with Plan B now available OTC, some providers (including pharmacists) may not be as interested in participating in direct pharmacy access programs or may not want to promote EC access to adolescents [21]. Equally disconcerting is the fact that while some providers are not familiar with EC pharmacy access, there is a high level of awareness about the “pharmacist refusal” topic.

Using a Re-Granting model to invest in state-level organizations proved to be a successful approach to advance pharmacies as an important point of access for reproductive health services and supplies. The Re-Granting funds allowed grantees to provide EC trainings to pharmacists including education on new EC access administrative rules and regulations, initiate targeted public education campaigns to increase EC awareness and dispel misconceptions and provide tools to pharmacists to offer and publicize EC
pharmacy access.

Pharmacists have improved patient outcomes and reduced health care costs in states that have accommodated and supported pharmacists' involvement in patient care [22]. The clinical
role of the pharmacist continues to expand, offering more opportunities to improve reproductive health care and gain additional allies in pharmacy communities. Increased collaboration between pharmacists, the health care provider team and advocates can help achieve the common goal of improved access to reproductive health services. The STATES Re-Granting Program is one illustration of the potential to enhance reproductive health care and access through pharmacists and pharmacies. This model reinforces the importance of the entire health care team — physicians, nurse practitioners, physician assistants, nurse midwives, nurses, health educators and pharmacists — working together to provide the best possible patient-centered health care.

References:

See related article for full reference list: Maderas NM et al. The continuum of care: A case for pharmacists as key members of the reproductive health care team. Editorial. Contraception 77 (March 2008). http://www.arhp.org/editorials/march2008.cfm

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[4] Grumbach K, Hart LG, Mertz E, Coffman J, Palazzo L. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med 2003;1:97–104.
[8] Custers T, Klazinga NS, Brown AD. Increasing performance of health care services within economic constraints: working towards
improved incentive structures. Z Arztl Fortbild Qualitatssich 2007; 101:381–8.
[11] Rocca CH, Schwarz EB, Stewart FH, Darney PD, Raine TR, Harper CC. Beyond access, acceptability, use and nonuse of emergency contraception among young women. Am J Obstet Gynecol 2007;96: 29.e1–e6. 141 Editorial / Contraception 77 (2008) 139–142
[13] Schiappacasse V, Díaz S. Access to emergency contraception. IPPF Med Bull 2007;41:4.
[14] Kravitz RL, Bell RA. Direct-to-consumer advertising of prescription drugs: balancing benefits and risks, and a way forward. Clin Pharmacol Ther 2007;82:360–2.
[16] American Pharmaceutical Association. Emergency contraception, expanding access through pharmacists. Analysis of collaborative drug therapy management (CDTM) in the United States and the potential for an emergency contraception CDTM program. Presented to The Public Health Institute. January 22; 2003.
[17] State policies in brief: emergency contraception, Guttmacher Institute. www.guttmacher.org/statecenter/spibs/spib_EC.pdf [accessed October 1, 2007].
[18] TheWilliam and Flora Hewlett Foundation, 2003–2006. www.hewlett.org [accessed November 19 2007].
[19] U.S. Food and Drug Administration. Plan B (0.75 mg levonorgestrel) tablets information. August 29, 2006. www.fda.gov/cder/foi/label/2006/021045s011lbl.pdf [accessed October 26, 2007].
[20] Gee RE, Delli-Bovi LC, Chuang CH. Emergency contraception knowledge after a community education campaign. Contraception 2007;76:366–71.
[21] PharmacyAccess Partnership. Re-Granting ProgramOctober 2006.www.go2ec.org/StatesRegrantingProgram.htm [accessed December 1, 2007].
[22] Downing D. Pharmaceutical care in emergency contraception. Suppl J Am Pharm Assoc 2002;42:S38.
[23] Manasse HR, Speedie MK. Pharmacists, pharmaceuticals, and policy issues shaping the work force in pharmacy. Am J Health-Syst Pharm 2007;64(12):e30–e48.

ADOLESCENT HEALTH NEWS

Africa: 72 million children still not in school - EFA chairperson
(News Article; Sub-Saharan Africa)
23 April 2008
The Daily Observer (Banjul)

ADOLESCENT HEALTH RESEARCH

Adults' perceptions of adolescents' sexual and reproductive health: Qualitative evidence from Uganda
(Report; Sub-Saharan Africa)
New York, New York, Guttmacher Institute, 2008 Feb. [33] p. (Occasional Report No. 35)
Kibombo R | Neema S | Moore AM | Ahmed FH
Over the past 15 years, adolescent sexual and reproductive health (SRH) has increasingly received special attention in many African countries mainly due to the HIV/AIDS pandemic that has swept across the continent with devastating impact, particularly among young people (15-24 years old) who account for about half of all new HIV infections. However, adolescents frequently do not have access to appropriate sexual and reproductive health services due to a host of factors ranging from dysfunctional health care systems to stigma regarding seeking reproductive health care. While research has been done on adolescents' health-seeking behaviors, little is known about the attitudes and perceptions of adults who play a key role in adolescents' lives, adolescents' sexual behavior and access to reproductive health services. It is for this reason that the Guttmacher Institute, in collaboration with the Makerere Institute of Social Research, conducted 60 indepth interviews with parents, community leaders, teachers and health workers in one urban and one rural setting in Uganda to learn about their perceptions, attitudes and experiences of adolescents' sexual and reproductive health issues.

Trends in youth reproductive health in Ethiopia, 2000 and 2005
(Report; Sub-Saharan Africa)
Calverton, Maryland, Macro International, 2008 Apr. [110] p.
Moore Z | Govindasamy P | DaVanzo J | Bizuneh G | Themme A
The data for this study come from the 2000 and 2005 Ethiopia Demographic and Health Surveys (EDHS). The report is based on an in-depth analysis of 6,570 women and 1,008 men age 15-24 interviewed in the 2000 EDHS and 5,813 women and 2,399 men age 15-24 interviewed in the 2005 EDHS. These youth are a subgroup of a nationally representative sample of 15,367 women age 15-49 and 2,607 men age 15-59 interviewed in the year 2000 and 14,070 women age 15-49 and 6,033 men age 15-59 interviewed in the year 2005. There are many positive developments for youth in Ethiopia. Nonetheless, there remains room for substantial improvement. Overall, youth are more highly educated than their older peers. However, educational attainment among youth remains low, with half of young women and one-fourth of young men having no education. On all levels, young men are more educated than young women. The proportion of young respondents with no education decreased between 2000 and 2005, while the proportion of youth attending all levels of education increased during the period. Literacy levels among youth increased dramatically between 2000 and 2005. However, literacy levels among female youth remained substantially lower than levels among male youth. Young women are less likely to be employed than young men. Seven in ten young men were currently employed at the time of the 2005 EDHS, but only about three in ten young women were. Both young women and young men are less likely to be employed than their older counterparts. Youth in Ethiopia have more exposure to mass media than older people do. Over time, this exposure has been increasing although levels are still low-in 2005, seven in ten persons age 15-24 did not have weekly exposure to any form of mass media.

Starting young: Sexual initiation and HIV prevention in early adolescence
(Abstract; subscription needed for full text; Central America and the Caribbean)
AIDS and Behavior. 2008;:[10] p..
Dixon-Mueller R
The rising numbers of new HIV infections among young people ages 15–24 in many developing countries, especially among young women, signal an urgent need to identify and respond programmatically to behaviors and situations that contribute to the spread of HIV and other sexually transmitted infections in early adolescence. Quantitative and qualitative studies of the sexual knowledge and practices of adolescents age 14 and younger reveal that substantial numbers of boys and girls in many countries engage in unprotected heterosexual vaginal intercourse––by choice or coercion––before their 15th birthdays. Early initiation into male–male or male–female oral and/or anal sex is also documented in some populations. Educational, health, and social programs must reach 10–14-year-olds as well as older adolescents with the information, skills, services, and supplies (condoms, contraceptives) they need to negotiate their own protection from unwanted and/or unsafe sexual practices and to respect the rights of others.

FAMILY PLANNING NEWS

Dueling protests target morning-after pill distribution ban in Chile
(News Article; South America)
23 April 2008
International Herald Tribune

India: Move over, moods: The female condom is becoming a surprisingly popular birth control tool
(News Article; Asia)
26 Apr 2008
Naithani S, Tehelka

Bangladesh: Lack of fund, manpower crisis hit health sector
(News Article; Asia)
23 Apr 2008
The New Nation

FAMILY PLANNING RESEARCH

Family planning in Ghana, Burkina Faso, and Mali
(Research Article; Sub-Saharan Africa)
Washington, D.C., Population Reference Bureau, 2008. [4] p.
Gribble J
West Africa has one of the most rapidly growing populations in the world, and on average, women here have 5.7 births during their lifetimes. The 16 countries in this region represent a variety of cultural and historic backgrounds. Their residents may speak French, English, or Portuguese, in addition to one or more indigenous languages. These countries have different health systems, levels of political commitment to family planning, and numbers and types of health care providers-all of which can contribute to differences in family planning use. In West Africa, approximately 13 percent of married women use some form of family planning. Hormonal contraceptives, including the pill and injections, are the most commonly used methods. Traditional family planning methods, including periodic abstinence and withdrawal, are in second place. In addition to those women using family planning, approximately 23 percent indicate that they would like to avoid become pregnant in the near future, but are not using a family planning method. In West Africa, the wealthier a woman is, the more likely she is to use family planning. These findings, which were presented in the first article in this series, "Family Planning in West Africa," provide insight into the region as a whole. Ghana, Burkina Faso, and Mali illustrate the richness that can be found when regional numbers are teased apart.

Change in trend of contraceptive uptake -- Effect of educational leaflets and counseling
(Abstract; subscription needed for full text; Asia)
Contraception. 2008 May;77(5):377-381.
Saeed GA | Fakhar S | Rahim F | Tabassum S
The study was conducted to determine the impact of counseling and educational leaflets on contraceptive practices of couples. Randomization of 600 women was done in two groups matched for age, parity and socioeconomic status at the Department of Obstetrics and Gynaecology, Shifa Foundation Community Health Centre, Shifa International Hospital, Islamabad, Pakistan. In Group A, the intervention group was exposed to contraceptive counseling and educational leaflets in the postnatal ward after delivery, whereas in Group B, the nonintervention group was not given any formal contraceptive advice. Later on, both groups were assessed regarding their contraceptive practices. At their follow-up visit (8-12 weeks) postpartum, 19 (6.3%) women in the nonintervention group had started contraceptive use, whereas 153 (50.8%) had decided to start contraception in the next 6 months, and 129 (42.8%) women were still undecided. The main contraceptive user was the male partner (n=117, 38.8%), and the most common method used was coitus interruptus (n=62, 36.3%). In the intervention group, 170 women (56.9%) had started using contraceptives, whereas 129 (43.1%) had decided to start contraceptive use in the next 6 months. The predominant contraceptive user was the females (n=212-70.9%), and the most popular method chosen was oral contraceptive pills (n=111, 37.1%). There is a definite increase in contraceptive uptake in women provided with educational leaflets and counseling session with a shift toward use of more reliable contraceptive methods.

Fertility-limiting behavior and contraceptive choice among men in Nepal
(Research Article; Asia)
International Family Planning Perspectives. 2008 Mar;34(1):6-14.
Dahal GP | Padmadas SS | Hinde PR
Contraceptive choices among men who want no more children have been little explored in South Asia, particularly in Nepal, where fertility rates have remained high over the last few decades. Using the 2001 Nepal Demographic and Health Survey couple data set, multinomial logistic regression analyses were conducted for 1,041 married men aged 20 or older who had at least one living child and wanted no more children. Regression models examined relationships between selected characteristics and men's reported contraceptive use, and predicted probabilities were estimated to assess interactions between ecological zone, family composition and method choice. The primary goal was to determine whether the number and sex of living children influenced contraceptive use. Twenty-four percent of men who wanted no more children were not using any contraceptive method at the time of the survey, 30% reported that their wives were sterilized, 12% had had a vasectomy, 7% were using condoms and 27% used other temporary methods. The probability of relying on permanent methods was highest among men who had at least two living sons and lowest among those who had only daughters, while the probability of using no method was highest among those who had only daughters. In Nepal, men who report a desire to have no more children are likely to choose permanent methods only after they have two living sons.

As the world grows: Contraception in the 21st century
(Abstract; subscription needed for full text; Global)
Journal of Clinical Investigation. 2008 Apr;118(4):1330-1343.
Aitken RJ | Baker MA | Doncel GF | Matzuk MM | Mauck CK | Harper MJ
Contraceptives that are readily available and acceptable are required in many poorer countries to reduce population growth and in all countries to prevent maternal morbidity and mortality arising from unintended pregnancies. Most available methods use hormonal steroids or are variations of barrier methods. Reports from several fora over the last 12 years have emphasized the number of unwanted pregnancies and resultant abortions, which indicate an unmet need for safe, acceptable, and inexpensive contraceptive methods. This unmet need can be assuaged, in part, by development of new non-hormonal contraceptive methods. This Review addresses the contribution that the "omic" revolution can make to the identification of novel contraceptive targets, as well as the progress that has been made for different target molecules under development.

GENDER and HEALTH NEWS

Cameroon: Communication stakeholders decry media gender bias
(News Article; Sub-Saharan Africa)
21 Apr 2008
The Post (Buea)

South Africa: Bottom of the class in saving mothers and babies
(News Article; Sub-Saharan Africa)
17 April 2008
Health-e (Cape Town)

Actress, UN officials urge support for campaign to eliminate violence against women
(News Article; Global)
22 Apr 2008
UN News Center

GENDER and HEALTH RESEARCH

Perspectives on domestic violence: Case study from Karachi, Pakistan
(Research Article; Asia)
Eastern Mediterranean Health Journal. 2008 Mar-Apr;14(2):415-426.
Rabbani F | Qureshi F | Rizvi N
There is no adequate profile of domestic violence in Pakistan although this issue is frequently highlighted by the media. This case study used qualitative and quantitative methods to explore the nature and forms of domestic violence, circumstances, impact and coping mechanisms amongst selected women victims in Karachi. Violence was a continuum: all the women reported verbal abuse, often escalating into physical, emotional, sexual and economic abuse. The husband was the most common perpetrator. Women suffered in silence due to sociocultural norms, misinterpretation of religious beliefs, subordinate status, economic dependence and lack of legal redress. Besides short-term local measures, public policy informed by correct interpretation of religion can bring about a change in prevailing societal norms.

Environmental erectile dysfunction: Can the environment really be hazardous to your erectile health?
(Abstract; subscription needed for full text; Global)
Journal of Andrology. 2008 May-Jun;29(3):229-236.
Burnett AL
The proposal that exposures to environmental or occupational substances may affect erection ability is a tenable one and would add to a growing list of pathogenic risk factors associated with erectile dysfunction. Several lines of evidence gained by clinical epidemiologic and biomedical research investigations lend support. Several environmental toxicants to include lead, organic solvents, and pesticides have been implicated as possibly hazardous agents. Effects on the nervous and hormonal systems have been proposed as the leading mechanisms by which environmental toxicants adversely impact erectile function. Synthesis of the current evidence supports a possible risk association between environmental exposures and erectile dysfunction. However, scientific support is lacking to establish a direct causal association at this time. More scientific work is needed to identify specific environmental agents that may harm erectile function and define their exact mechanisms of action in this regard.

The prevalence and risk factors of female sexual dysfunction in young Korean women: An internet-based survey
(Abstract; subscription needed for full text; Asia)
Journal of Sexual Medicine. 2008;:[8] p..
Song SH | Jeon H | Kim SW | Paick JS | Son H
In Korea, although male sexual problems have been relatively well addressed, few surveys have been conducted on female sexual dysfunction (FSD) in the general population. In the present study, we investigated the prevalence and identified the risk factors of sexual dysfunction in young Korean women. The aim was to evaluate the prevalence and to identify the risk factors of FSD in young Korean women. A total of 47,000 women were initially approached. All received an e-mail requesting that they participate in a Web-based survey. The participants were asked to complete a questionnaire requesting detailed medical and sexual histories, which included the questions contained in the Korean version of the Female Sexual Function Index questionnaire. The prevalence of FSD in young Korean women in the different age groups and risk factors for developing FSD. A total of 504 women of average age 28.5 years (18-52 years) were evaluated during this survey. Setting the cutoff score for FSD using a receiver operating characteristic curve of our data as 25.0 points, 43.1% of women under 40 years old reported FSD. FSD was detected as a desire problem in 44.0% of women, an arousal problem in 49.0%, a lubrication problem in 37.0%, an orgasm problem in 32.0%, a satisfaction problem in 37.0%, and a pain problem in 34.6%. Risk factors for FSD as determined by logistic regression analysis were increasing age, a low frequency of sex, depression, a sexually abused history, and voiding dysfunction. The prevalence of FSD in Korean young women was common and comparable to those reported worldwide.

Domestic violence surveillance system: A model
(Abstract; subscription needed for full text; Global | South America)
Salud Publica de Mexico. 2008;50 Suppl 1:s12-s18.
Espinosa R | Gutierrez MI | Mena-Munoz JH | Cordoba P
The objective was to develop a domestic violence surveillance system. The strategies included implementation of a standard digitalized reporting and analysis system along with advocacy with community decision makers, strengthening inter-institutional attention networks, consultation for constructing internal flow charts, sensitizing and training network teams in charge of providing health care in cases of domestic violence and supporting improved public policy prevention initiatives. A total of 6 893 cases were observed using 2004 and 2005 surveillance system data. The system reports that 80% of the affected were women, followed by 36% children under 14 years. The identified aggressors were mainly females' partners. The system was useful for improving victim services. Findings indicate that significant gains were made in facilitating the attention and treatment of victims of domestic violence, improving the procedural response process and enhancing the quality of information provided to policy-making bodies.

HIV/AIDS and STIs NEWS

South Africa: Trade unions must protect workers against HIV, AIDS discrimination
(News Article; Sub-Saharan Africa)
21 April 2008
BuaNews (Tshwane)

Nigeria: Islamic council partners with committee on AIDS
(News Article; Sub-Saharan Africa)
17 April 2008
Leadership (Abuja)

Angola: HIV/Aids hinders implementation of education programme
(News Article; Sub-Saharan Africa)
22 April 2008
Angola Press Agency (Luanda)

Post-election violence in Kenya particularly hard on HIV patients
(News Article; Sub-Saharan Africa)
25 April 2008
NewsVOA.com

HIV/AIDS and STIs RESEARCH

Determinants of late disease-stage presentation at diagnosis of HIV infection in Venezuela: A case-case comparison
(Abstract; subscription needed for full text; South America)
AIDS Research and Therapy. 2008 Apr 16;5:6.
Bonjour MA | Montagne M | Zambrano M | Molina G | Lippuner C
Although Venezuela has a National Human Immunodeficiency Virus (HIV) Program offering free diagnosis and treatment, 41% of patients present for diagnosis at a later disease-stage, indicating that access to care may still be limited. Our study aimed to identify factors influencing delay in presenting for HIV-diagnosis using a case-case comparison. A cross-sectional survey was performed at the Regional HIV Reference Centre (CAI), Carabobo Region, Venezuela. Between May 2005 and October 2006 225 patients diagnosed with HIV at CAI were included and demographic, behavioural and medical characteristics collected from medical files. Socio-economic and behavioural factors were obtained from 129 eligible subjects through interviews. "Late presentation" at diagnosis was defined as patients classified with disease-stage B or C according to the 1993 Centers for Disease Control and Prevention (Atlanta, USA) classification, and "early presentation" defined as diagnosis in disease-stage A. Of 225 subjects, 91 (40%) were defined as late presenters. A similar proportion (51/129) was obtained in the interviewed sub-sample. Older age (greater than 30 years), male heterosexuality, lower socio-economic status, perceiving ones partner to be faithful and living greater than or equal to 25km from the CAI were positively associated with late diagnosis in a multivariate model. Females were less likely to present late than heterosexual males (odds ratio=0.23, P=0.06). The main barriers to HIV testing were low knowledge of HIV/AIDS, lack of awareness of the free HIV program, lack of perceived risk of HIV infection, fear for HIV-related stigma, fear for lack of confidentiality at testing site and logistic barriers. Despite the free Venezuelan HIV Program, poverty and barriers related to lack of knowledge and awareness of both HIV and the Program itself were important determinants in late presentation at HIV diagnosis. This study also indicates that women; heterosexual, bisexual and homosexual men might have different pathways to testing and different factors related to late presentation in each subgroup. Efforts must be directed to i) increase awareness of HIV/AIDS and the Program and ii) the identification of specific factors associated with delay in HIV diagnosis per subgroup, to help develop targeted public health interventions improving early diagnosis and prognosis of people living with HIV/AIDS in Venezuela and elsewhere.

Evaluating adherence to highly active antiretroviral therapy with use of pill counts and viral load measurement in the drug resources enhancement against AIDS and malnutrition program in Mozambique
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Clinical Infectious Diseases. 2008 May 15;46(10):1609?1616.
San Lio MM | Carbini R | Germano P | Guidotti G | Mancinelli S
Maintaining treatment adherence among the growing number of patients receiving antiretroviral treatment in Africa is a dramatic challenge. The objective of our study was to explore the results of a computerized pill count method and to test the validity, sensitivity, and specificity of this method with respect to viral load measurement in an African setting. We performed a prospective, observational study involving patients who received first-line highly active antiretroviral therapy in Mozambique from 1 April 2005 through 31 March 2006. Enrolled patients had received treatment for at least 3 months before the study. For defining treatment adherence levels, pill counts were used, and the results were analyzed with viral load measurements at the end of the observation period. The study involved 531 participants. During the 12 months of observation, 137 patients left the program or discontinued first-line therapy. Of the remaining 394 patients, 284 (72.1%) had greater than 95% treatment adherence; of those 284 patients, 274 (96.5%) had a final viral load less than 1000 copies/mL. A Cox proportional hazards analysis revealed that the relationship between greater than 95% treatment adherence and the final viral load was closer than that between greater than 90% treatment adherence and viral load. Treatment adherence greater than 95% maximizes the results of the nonnucleoside reverse-transcriptase inhibitor-based regimen. The pill count method appears to be a reliable and economic tool for monitoring treatment adherence in resource-limited settings.

Community health workers and the response to HIV/AIDS in South Africa: Tensions and prospects
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health Policy and Planning. 2008 May;23(3):179-187.
Schneider H | Hlophe H | van Rensburg D
After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004-06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.

Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: How will health systems adapt?
(Abstract; subscription needed for full text; Global | Sub-Saharan Africa)
Social Science and Medicine. 2008 May;66(10):2108-2121.
Van Damme W | Kober K | Kegels G
Scaling-up antiretroviral treatment (ART) to socially meaningful levels in low-income countries with a high AIDS burden is constrained by (1) the continuously growing caseload of people to be maintained on long-term ART; (2) evident problems of shortage and skewed distribution in the health workforce; and (3) the heavy workload inherent to presently used ART delivery models. If we want to imagine how health systems can react to such challenges, we need to understand better what needs to be done regarding the different types of functions ART requires, and how these can be distributed through the care supply system, knowing that different functions rely on different rationales (professional, bureaucratic, social) for which the human input need not necessarily be found in formal healthcare supply systems. Given the present realities of an increasingly pluralistic healthcare supply and highly eclectic demand, we advance three main generic requirements for ART interventions to be successful: trustworthiness, affordability and exclusiveness - and their constituting elements. We then apply this analytic model to the baseline situation (no fundamental changes) and different scenarios. In Scenario A there are no fundamental changes, but ART gets priority status and increased resources. In Scenario B the ART scale-up strengthens the overall health system: we detail a B1 technocratic variant scenario, with profoundly re-engineered ART service production, including significant task shifting, away from classical delivery models and aimed at maximum standardisation and control of all operations; while in the B2 community-based variant scenario the typology of ART functions is maximally exploited to distribute the tasks over a human potential pool that is as wide as possible, including patients and possible communities. The latter two scenarios would entail a high degree of de-medicalisation of ART.

MATERNAL AND CHILD HEALTH NEWS

Tanzania: Country gains in maternal, child survival
(News Article; Sub-Saharan Africa)
23 Apr 2008
Kidanka C, The Citizen (Dar es Salaam)

Kenya: Mother, child deaths 'high'
(News Article; Sub-Saharan Africa)
23 Apr 2008
Mosota M, The East African Standard (Nairobi)

SA child deaths increase
(News Article; Sub-Saharan Africa)
24 Apr 2008
Beresford B, Mali & Guardian

MATERNAL AND CHILD HEALTH RESEARCH

Tracking progress in maternal, newborn and child survival: Countdown to 2015 - The 2008 report
(Report; Global)
New York, NY, United Nations Children's Fund, 2008.
"Tracking progress in maternal, newborn and child survival: Countdown to 2015 - The 2008 Report" was launched at the second Countdown to 2015 Conference held in Cape Town, South Africa, 17-19 April 2008, in conjunction with the 118th Inter-Parliamentary Union Assembly. A collaboration among individuals and institutions established in 2005, the Countdown aims to stimulate country action by tracking coverage for interventions needed to attain Millennium Development Goals (MDGs) 4 and 5 – and, in addition, parts of MDGs 1, 6 and 7. Through this unified effort national and international policy makers, programme implementers, development and media partners and researchers are working together to: * Summarize, synthesize and disseminate the best and most recent information on country-level progress towards high, sustained and equitable coverage with health interventions to save women and children. * Take stock of progress in maternal, newborn and child survival. * Call on governments, development partners and the broader community to be accountable if rates of progress are not satisfactory. * Identify knowledge gaps that are hindering progress. * Propose new actions to achieve the health-related MDGs, in particular MDGs 4 and 5. The second in a series of reports, Countdown 2008 is based primarily on data drawn from national surveys and global databases. It measures coverage of basic health services proven to reduce maternal and child mortality. It also assesses the strength of health systems, the status of policies related to maternal, newborn and child health and how equitably health services are distributed.

Barriers to access prevention of mother-to-child transmission for HIV positive women in a well-resourced setting in Vietnam
(Abstract; subscription needed for full text; Asia)
AIDS Research and Therapy. 2008 Apr 17;5:7.
Nguyen TH | Oosterhoff P | Ngoc YP | Wright P | Hardon A
According to Vietnamese policy, HIV-infected women should have access at least to HIV testing and Nevirapine prophylaxis, or where available, to adequate counselling, HIV infection staging, ARV prophylaxis, and infant formula. Many studies in high HIV prevalence settings have reported low coverage of PMTCT services, but there have been few reports from low HIV prevalence settings, such as Asian countries. The authors investigated the access of HIV-infected pregnant women to PMTCT services in the well-resourced setting of the capital city, Hanoi. Fifty-two HIV positive women enrolled in a self-help group in Hanoi were consulted, through indepth interviews and bi-weekly meetings, about their experiences in accessing PMTCT services. Only 44% and 20% of the women had received minimal and comprehensive PMTCT services, respectively. Nine women did not receive any services. Twenty-two women received no counselling. The women reported being limited by lack of knowledge and information due to poor counselling, gaps in PMTCT services, and fear of stigma and discrimination. HIV testing was done too late for optimal interventions and poor quality of care by health staff was frequently mentioned. In a setting where PMTCT is available, HIV-infected women and children did not receive adequate care because of barriers to accessing those services. The results suggest key improvements would be improving quality of counselling and making PMTCT guidelines available to health services. Women should receive early HIV testing with adequate counselling, safe care and prophylaxis in a positive atmosphere towards HIV-infected women.

Correlates of low birth weight in term pregnancies: A retrospective study from Iran
(Research Article; Middle East)
BMC Pregnancy and Childbirth. 2008 Apr 19;8(12):[14] p..
Vahdaninia M | Tavafian SS | Montazeri A
Low birth weight (LBW) is considered as a major multifaceted public health concern. Seventy-two percent of LBW infants are born in Asia. An estimation of 8% LBW infants has been reported for Eastern Mediterranean region including Iran. This study investigated contributory factors of LBW in singleton term births in Tehran, Iran. Tehran is a multicultural metropolitan area and a sample from the general population in Tehran could be regarded as a representative sample of urban population in Iran. This was a retrospective study using data from 15 university maternity hospitals in Tehran, Iran. Data on all singleton term births in these hospitals were extracted from case records during a one calendar year. Study variables included: maternal age, maternal educational level, history of LBW deliveries, history of preterm labor, cigarette smoking during pregnancy, number of parities, chronic diseases and residential area (Tehran versus suburbs of Tehran). In order to examine the relationship between LBW and demographic and reproductive variables the adjusted logistic regression analysis was performed. In all, data for 3734 term pregnancies were extracted. The mean age of women was 25.7 (SD = 5.3) years and 5.2% of term births were LBW. In addition to association between LBW and maternal age, significant risk factors for LBW were: history of LBW deliveries [adjusted odds ratio (OR) = 2.53, 95% confidence interval (CI) = 1.06-6.03], smoking during pregnancy (OR = 4.64, 95% CI = 1.97-10.95) and chronic diseases (OR for hypertension = 3.70, 95% CI = 2.25-6.06, OR for others = 2.04, 95% CI = 1.09-3.83). The findings indicate that in addition to maternal age, history of LBW deliveries; smoking during pregnancy and chronic diseases are significant determinants of LBW in this population. This is consistent with national and international findings indicating that maternal variables and risk behaviors during pregnancy play important roles on LBW.

Sexual violence among pregnant women in India
(Abstract; subscription needed for full text; Asia)
Journal of Obstetrics and Gynaecology Research. 2008 Apr;34(2):238-241.
Chhabra S
The aim was to discover the extent of sexual violence during pregnancy, its correlation to various variables and effects, and to consider future possibilities for creating awareness in health providers, health seekers and communities for prevention. Two thousand pregnant women were interviewed using a semi-structured, pre-designed, pre-tested questionnaire with some open-ended questions in the local language. Of 2000 women, 1959 (97.95%) reported that they had had sex with their partners during the current pregnancy. Of the 2000, 615 (30.7%) women had not wished to have sex during the pregnancy, but had been forced to do so. Women suffer with recurrent marital rape during pregnancy with considerable after effects. This sexual violence takes place irrespective of education or socioeconomic status.

Association of maternal HIV infection with increase of infant mortality in Malawi
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Paediatrics and Child Health. 2008 May;44(5):291-296.
Hong R
The aim was to determine the association between maternal HIV infection and infant mortality in Malawi. A synthetic cohort life table based on the birth history of 2618 childbirths during 1999 and 2004, from the subsample of 2020 mothers who completed interview and were tested for HIV virus in the 2004 Malawi Demographic and Health Survey was used. The survey collected socio-demographic and health data of a natural representative sample of women aged 15 to 49; and obtained voluntary counselling tests for HIV infection from one-third of the representatives of the sample. Associations of maternal HIV status and other factors with infant mortality were estimated using survival regression analysis and the results are presented as hazard ratios (HR) with level of statistical significance (P-value). Children born to HIV-infected mothers were more than two times as likely to die during infancy as those born to uninfected mothers (HR = 2.21; P less than 0.01). Controlling for other risk factors and confounding factors for infant mortality further sharpened this relationship (HR = 2.70; P less than 0.01). Boys are more likely to die in infancy than girls. Young mothers and mothers not receiving prenatal care, and low-birthweight children and children living in rural areas, particular so in the northern region, were associated with a higher risk of infant mortality. Maternal HIV infection is strongly associated with infant mortality in Malawi independent of many other factors. Results from this study suggest that the HIV/AIDS epidemic has had an enormous impact on child well-being, child survival and infant mortality. The impact increases as the HIV/AIDS epidemic matures and infection in mothers and adults increases.

Trends in stillbirths, early and late neonatal mortality in rural Bangladesh: The role of public health interventions
(Abstract; subscription needed for full text; Asia)
Paediatric and Perinatal Epidemiology. 2008 May;22(3):269-279.
Ronsmans C | Chowdhury ME | Alam N | Koblinsky M | El Arifeen S
Trends were examined in a cohort study of stillbirths and early and late neonatal deaths in Matlab, a rural area of Bangladesh between 1975 and 2002, using routinely collected demographic surveillance data. Main outcome measures were stillbirths per 1000 births, early neonatal deaths per 1000 livebirths, and late neonatal deaths per 1000 children surviving after 1 week. The authors performed a logistic regression examining trends over time and between two areas in the three outcome measures, controlling for the effects of parental education, religion, time, geography, parity, maternal age and birth spacing. There was a marked decline in stillbirths, early and late neonatal mortality over time in both areas, though the pace of decline was somewhat faster in the ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh) service area. Stillbirths declined by 24% overall in the ICDDR,B service area (crude OR comparing 1996-2002 with 1975-81: 0.76 [95% CI 0.68, 0.84]), compared with 15% in the Government service area (crude OR comparing 1996-2002 with 1975-81: 0.85 [0.76, 0.94]). The overall reduction in early and late neonatal mortality comparing the same periods was 39% and 73%, respectively, in the ICDDR,B area, compared with 30% and 63%, respectively, in the Government service area. Adjusting for socio-economic or demographic factors did not substantially alter the time or area differentials. The dramatic decline in neonatal mortality was, in large part, due to a fall in deaths from neonatal tetanus. The pace of decline was faster in the area receiving intense maternal and child health and family planning interventions, but stillbirths, early and late neonatal deaths also declined in the area not receiving such intense attention, suggesting that factors outside the formal health sector play an important role.

POPULATION/FERTILITY/DEMOGRAPHY NEWS

Philappines: Tina's children
(News Article; Asia)
23 Apr 2008
Rodis R, Global Nation

Bangladesh: Health policy for achieving MDGs
(Commentary; Asia)
21 Apr 2008
The Daily Star

India: Dial M for Malthus
(News Article; Asia)
20 Apr 2008
Hindustan Times

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Confucian family values and childless couples in South Korea
(Abstract; subscription needed for full text; Asia)
Journal of Family Issues. 2008 May;29(5):571-591.
Yang S | Rosenblatt PC
The Korean family has long met Confucian values by producing children to maintain and support the paternal family line, but in South Korea's transition to a low birth rate, an increasing number of couples have remained childless. Have Confucian family values been abandoned? In this study, 103 young single South Koreans wrote protocols describing their thoughts about childless couples and having children. Most of them viewed childless couples negatively and said that they planned to have children of their own. Confucian values were clearly central in what students wrote about childlessness. The results suggest that the increase in voluntary childlessness does not mean that Confucian values have been abandoned by young South Koreans. Confucian family values seem to remain primary, but they may be reinterpreted or reluctantly violated because economic and other circumstances make it difficult or impossible to meet those values in the South Korean context.

Human exposure to endocrine disrupters and semen quality
(Abstract; subscription needed for full text; Global)
Journal of Toxicology and Environmental Health, Part B. 2008 Mar;11(3-4):188-220.
Phillips KP | Tanphaichitr N
Reproductive pathology in the male represents about 20% of infertility cases. Male infertility may be attributed to a number of causes, including genetic and congenital abnormalities, infection, multisystemic diseases, varicocele, and others; however, a significant number of cases are idiopathic. Global declines in semen quality were suggested to be associated with enhanced exposure to environmental chemicals that act as endocrine disrupters as a result of our increased use of pesticides, plastics, and other anthropogenic materials. A significant body of toxicology data based upon laboratory and wildlife animals studies suggests that exposure to certain endocrine disrupters is associated with reproductive toxicity, including (1) abnormalities of the male reproductive tract (cryptorchidism, hypospadias), (2) reduced semen quality, and (3) impaired fertility in the adult. There is, however, a relative paucity of studies designed to measure exposure to endocrine disrupters on semen quality parameters (sperm concentration, motility, morphology). An overview of the human semen quality literature is presented that examines the role of endocrine disrupters including organochlorines (OC), dioxins, phthalates, phytoestrogens, and chemical mixtures (pesticides and tobacco smoke).

Changing family formation in Nepal: Marriage, cohabitation and first sexual intercourse
(Research Article; Asia)
International Family Planning Perspectives. 2008 Mar;34(1):30-39.
Caltabiano M | Castiglioni M
In Nepal, marriage occurs at a relatively young age and arranged weddings are widespread. However, recent changes in the family formation process and the timing of first sexual intercourse suggest that a transformation may be underway. Data on marriage, cohabitation and first sexual intercourse from the 2001 Nepalese Demographic and Health Survey were used to describe the family formation process. The sequence of these events and the intervals between them were explored for currently married men and women. Hazard models were used to identify factors associated with behavioral changes over time. The average age at marriage among women married before age 20 increased from 13.7 years for those born in 1952-1956 to 15.6 years for those born in 1977-1981,while remaining relatively stable for men married before age 25 (17.3 years for the 1942-1946 birth cohort to 17.7 for the 1972-1976 birth cohort). After individual and couple characteristics were controlled for, younger age at interview was associated with greater odds of simultaneous marriage and cohabitation for both genders (odds ratios,1.3-1.7).Younger age at interview was also associated with premarital sex among men-those aged 39 or younger had significantly higher risks than older men of having had premarital sex, with odds ratios rising from 1.6 among those aged 35-39 to 1.8 among those aged 15-24. It is important not only to promote education as a means of delaying marriage and childbearing, but also to implement programs and services that prevent reproductive health problems for young married couples.

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Volume 8, Number 1728 April 2008