Volume 8, Number 21
26 May 2008

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ADOLESCENT HEALTH RESEARCH

Out-of-school and 'at risk'? Socio-demographic characteristics, AIDS knowledge and risk perception among young people in Northern Tanzania
(Abstract; subscription needed for full text; Sub-Saharan Africa)
International Journal of Educational Development. 2008 Jul;28(4):393-404.
Bastien S
This paper investigates the reasons why young people in urban and rural Kilimanjaro, Tanzania do not attend school, their socio-demographic characteristics, AIDS knowledge and risk perception. A structured face-to-face interview was conducted with 1007 young people between the ages of 13 and 18. Findings suggest that non-attendance is the product of a complex interaction of economic, individual, family and school-related factors. Boys have more AIDS knowledge than girls, and those from urban areas are more knowledgeable than their rural counterparts. AIDS knowledge increased significantly at each level of education. Those with the highest risk perception were male, of young age and from rural areas. Expanding access to AIDS information, particularly in rural areas, while concomitantly addressing the social and structural determinants of educational attainment is crucial to improving the health of young people.

Adolescents perception of reproductive health care services in Sri Lanka
(Research Article; Asia)
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BMC Health Services Research. 2008 May 3;8:98.
Agampodi SB | Agampodi TC | UKD P
Adolescent health needs, behaviours and expectations are unique and routine health care services are not well geared to provide these services. The purpose of this study was to explore the perceived reproductive health problems, health seeking behaviors, knowledge about available services and barriers to reach services among a group of adolescents in Sri Lanka in order to improve reproductive health service delivery. This qualitative study was conducted in a semi urban setting in Sri Lanka. A convenient sample of 32 adolescents between 17-19 years of age participated in four focus group discussions. Participants were selected from four midwife areas. A pre-tested focus group guide was used for data collection. Male and female facilitators conducted discussions separately with young males and females. All tape-recorded data was fully transcribed and thematic analysis was done. Psychological distresses due to various reasons and problems regarding menstrual cycle and masturbation were reported as the commonest health problems. Knowledge on existing services was very poor and boys were totally unaware of youth health services available through the public health system. On reproductive Health Matters, girls mainly sought help from friends whereas boys did not want to discuss their problems with anyone. Lack of availability of services was pointed out as the most important barrier in reaching the adolescent needs. Lack of access to reproductive health knowledge was an important reason for poor self-confidence among adolescents to discuss these matters. Lack of confidentiality, youth friendliness and accessibility of available services were other barriers discussed. Adolescents were happy to accept available services through public clinics and other health infrastructure for their services rather than other organizations. A demand was made for separate youth friendly services through medical practitioners. Adolescent health services are inadequate and available services are not being delivered in an acceptable manner. Proper training of health care providers on youth friendly service provision is essential. A National level integrated health care program is needed for the adolescents.

Differences of sexual behavior predictors between sexually active and nonactive female adolescents in congested communities, Bangkok metropolis
(Research Article; Asia)
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Journal of the Medical Association of Thailand. 2008 Apr;91(4):542-550.
Powwattana A | Ramasoota P
The objective was to test the differences among the predictors between sexually active and non-active female adolescents. The study design used was a descriptive research. The participants included 581 Thai female adolescents: 262 sexually non-active and 319 sexually active (average age = 19.7 years). They completed questionnaires measuring self-discrepancy, depression, power in relationships (decision making dominance and relationship control), sexual self-efficacy (ability to say no, assertiveness, precaution), cognitive strategies (gain thinking: relationship, development, curiosity; punishment avoidance thinking: negative consequence, ethical-related, fear-related), and sexual behavior. The t-test and the Hierarchical Regression were employed for data analyses. Among the sexually active, 68.8% had vaginal or anal sexual intercourse (11.7%) without using a condom. Significant enabling predictors among the sexually active included sexual self-efficacy (precaution), and gain thinking (relationship), whereas punishment avoidance thinking (negative consequence) had a negative influence: it accounted about 11.0%. Among sexually non-active, alcohol consumption, power in a relationship (decision making dominance), and gain thinking (relationship) accounted for 26.9% of the variance in explaining sexual behavior. A specific link between sexual self-efficacy and cognitive strategies will be drawn to develop a program for the sexually active. Implications for behavioral modification addressing alcohol drinking and power in a relationship should be discussed among the sexually non-active.

Severity of alcohol use and problem behaviors among school-based youths in Puerto Rico
(Research Article; Central America and the Caribbean)
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Revista Panamericana de Salud Publica / Pan American Journal of Public Health. 2008 May 20;23(5):325-332.
Latimer WW | Rojas VC | Mancha BE
The present study sought to: categorize youths into groups based on their level of alcohol use and number of symptoms of alcohol abuse and dependence defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and examine whether these categorizes were associated with other problem behaviors in which youths engage (marijuana use, sexual intercourse, and having been arrested of having trouble with the law). The study is based on a cross-sectional survey administered to 972 school-based youths from one middle school and one high school in San Juan, Puerto Rico. Youths were categorized based on their alcohol use and alcohol problems. These categories were then examined for associations with lifetime marijuana use, lifetime sexual intercourse, and having been arrested of having had trouble with the law in the past year. The original eight categories of alcohol use were collapsed into six categories based on the results. For virtually every group characterized by higher severity of alcohol use and alcohol problems, researchers found an increasing prevalence of marijuana use in their lifetimes, increasing odds of sexual intercourse in their lifetimes, and having had trouble with the law in the past year. Knowing about variations in alcohol use and alcohol problems may be instrumental in measuring the degree to which youths may also be engaging in a range of other elevated risk behaviors and a progression to more serious forms of alcohol and drug use.

Improving communication between parents and adolescents on reproductive health and HIV/AIDS. Executive summary
(Abstract; subscription needed for full text; Sub-Saharan Africa)
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In: Improving communication between parents and adolescents on reproductive health and HIV / AIDS, by Nafissatou J. Diop, Alioune Diagne. [Washington, D.C,], Population Council, Frontiers in Reproductive Health, 2008 Mar. :i-viii. (USAID Cooperative Agreement No. HRN-A-00-98-00012-)
Diop NJ | Diagne A
In 2005 the Population Council's FRONTIERS in Reproductive Health Program, in collaboration with the Centre for Development and Population Activities (CEDPA), the Ministry of Health and the Ministry of Youth in Senegal, conducted an operations research project aimed at improving parent-child (specifically parent-adolescent) communication about reproductive health and HIV/AIDS. The study was designed to focus on parents/guardians of adolescents (10-14 years and 15-19 years) and adolescent youth living in urban and rural Senegal. The overall objective was to gain a better understanding of interventions designed specifically to reduce risks to Adolescent Reproductive Health. The specific goal of the project was to develop a model of intervention and assess its effectiveness and functionality in increasing adult-youth communication around issues of adolescent well-being, sexuality and reproductive health in terms of changes in the areas of: parents' and youth's knowledge and attitudes about issues concerning adolescents, particularly reproductive health; community support for adolescent needs, particularly in communication on adolescents' reproductive health issues; the frequency, quality, and topics discussed during parent-child (parent-adolescent) communication; the protective and regulatory mechanisms used by parents to address adolescents' reproductive health.

FAMILY PLANNING RESEARCH

Injectable contraception: What should the longest interval be for reinjections?
(Abstract; subscription needed for full text; Asia | Sub-Saharan Africa)
Contraception. 2008 Jun;77(6):410-414.
Steiner MJ | Kwok C | Stanback J | Byamugisha JK | Chipato T| Magwalic T | Mmirob F | Rugpaod S | Sriplienchane S | Morrison C
Progestin-only injectable contraceptives continue to gain in popularity, but uncertainty remains about pregnancy risk among women late for reinjection. The World Health Organization (WHO) recommends a "grace period" of 2 weeks after the scheduled 13-week reinjection. Beyond 2 weeks, however, many providers send late clients home to await menses. A prospective cohort study in Uganda, Zimbabwe and Thailand followed users of depot-medroxyprogesterone acetate (DMPA) for up to 24 months. Users were tested for pregnancy at every reinjection, allowing analysis of pregnancy risk among late comers. The analysis consists of 2290 participants contributing 13,608 DMPA intervals. The pregnancy risks per 100 women-years for "on time" [0.6; 95% confidence interval (CI), 0.33-0.92], "2-week grace" (0.0; 95% CI, 0.0-1.88) and "4-week grace" (0.4; 95% CI, 0.01-2.29) injections were low and virtually identical. Extending the current WHO grace period for DMPA reinjection from 2 to 4 weeks does not increase pregnancy risk and could increase contraceptive continuation.

Isolation of human single chain variable fragment antibodies against specific sperm antigens for immunocontraceptive development
(Abstract; subscription needed for full text; Global)
Human Reproduction. 2008;23(6):1324-1337.
Samuel AS | Naz RK
Contraceptive vaccines can provide valuable alternatives to current methods of contraception. We describe here the development of sperm-reactive human single chain variable fragment (scFv) antibodies of defined sperm specificity for immunocontraception. Peripheral blood leukocytes (PBL) from antisperm antibody-positive immunoinfertile and vasectomized men were activated with human sperm antigens in vitro, and the complementary DNA prepared and PCR-amplified using primers based on all the variable regions of heavy and light chains of immunoglobulins. The scFv repertoire was cloned into pCANTAB5E vector to create a human scFv antibody library. Panning of the library against specific sperm antigens yielded several clones, and the four strongest reactive were selected for further analysis. These clones had novel sequences with unique complementarity-determining regions. ScFv antibodies were expressed, purified and analyzed for human sperm reactivity and effect on human sperm function. AFA-1 and FAB-7 scFv antibodies both reacted with fertilization antigen-1 antigen, but against different epitopes. YLP20 antibody reacted with the expected human sperm protein of 48 plus or minus 5 kDa. The fourth antibody, AS16, reacted with an 18 kDa sperm protein and seems to be a human homologue of the mouse monoclonal recombinant antisperm antibody that causes sperm agglutination. All these antibodies inhibited human sperm function. This is the first study to report the use of phage display technology to obtain antisperm scFv antibodies of defined antigen specificity. These antibodies will find clinical applications in the development of novel immunocontraceptives, and specific diagnostics for immunoinfertility.

Oral contraceptives
(Abstract; subscription needed for full text; Global)
Psychosomatics. 2008 Mar-Apr;49(2):168-175.
Oesterheld JR | Cozza K | Sandson NB
Many formulations of OCs are now available. Monophasic preparations contain the same amount of EE and progestin and are taken for 21 days of each 28-day cycle. Biphasic and triphasic preparations take the form of two or three types of pills, with varying amounts of active ingredients. Biphasic and triphasic OCs have been formulated so that the amount of progestin is reduced and the effects correspond more closely to hormonal influences during natural menstrual cycles. Recently, several formulations of continuous daily regimens of ethinylestradiol (10 microg and 30 microg) and a progestin have entered the market. These formulations allow withdrawal-bleeding periods only 4 times a year. A yearly, no-cycling version of levonorgestrel and EE (Lybrel) received FDA approval in May 2007. There are a limited number of progestin-only contraceptives. These contraceptives are the mini-pill containing norethindrone, norgestrel, or levonorgestrel; a subdermal implant of norgestrel (Norplant II); intramuscular and subcutaneous preparations of medroxyprogesterone acetate and norethindrone enanthate, administered every 3 months; and intrauterine devices that release progesterone and levonorgestrel.

Safety and efficacy of a single-rod etonogestrel implant (Implanon): Results from 11 international clinical trials
(Abstract; subscription needed for full text; Asia | North America | Europe | South America)
Fertility and Sterility. 2008;:[9] p..
Darney P | Patel A | Rosen K | Shapiro LS | Kaunitz AM
The objective was to present efficacy, safety, and bleeding profile results from the clinical trials that supported the U.S. Food and Drug Administration filing for the approval of a single-rod etonogestrel (ENG) contraceptive implant (Implanon). The design used was an integrated analysis of 11 international clinical trials. The setting was contraceptive clinics in U.S., Chile, Asia, and Europe. A total of 942 healthy women, aged 18 to 40 years were examined. Insertion of an ENG implant. Most women were enrolled in studies lasting either 2 or 3 years. Efficacy was measured by the cumulative Pearl Index in women %35 years old. Safety was primarily assessed by incidence of adverse events. Bleeding profiles were analyzed via reference period analyses. No pregnancies were reported while the ENG implants were in place. Six pregnancies occurred during the first 14 days after ENG implant removal. Including these six pregnancies, the cumulative Pearl Index was 0.38 (year 1 and 2 Pearl Indexes were 0.27 and 0.30, respectively). Common drug-related adverse events were headache, weight gain, acne, breast tenderness, emotional lability, and abdominal pain. Bleeding pattern changes were observed, but no one pattern predominated. The ENG implant is an efficacious and safe method of contraception which does not require patients' consistent action.

Contraceptive effectiveness of levonorgestrel releasing intrauterine system
(Research Article; Asia)
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Medical Journal Armed Forces India. 2008 Apr;64(2):140-142.
Kapur A | Kumar S
This study evaluated the contraceptive effectiveness of progesterone releasing intrauterine contraceptive devices (IUCD) and compared it with the Copper T device. Seventy patients were selected in each group. Menstrual charts were maintained and data recorded at one, three, six months and one year after insertion of the device. One year follow up was completed by 66 patients in the Levonorgestrel Releasing Intrauterine System (LNG-IUS) group and 62 in the Cu T group. There were age, parity and education level matched. The mean duration of menstrual flow for the LNG-IUS group was 3.6 days and that for Cu T group was 5.1 days (p greater than 0.05). Insertion of LNG-IUS was found to be significantly difficult than the Cu T 380, with increased pain at insertion (p less than 0.05). There was no pregnancy in the LNG-IUS group and expulsion rates were low. The most significant difference was scanty periods and at times amenorrhoea in the LNG-IUS group. Termination rates for various reasons were almost equal in both groups. Both devices were effective, safe, well accepted and tolerated. LNG-IUS scores high in patients with preexisting menorrhagia or dysmenorrhoea while Cu T 380 has advantages of lower cost, ease of insertion and comparable efficacy.

GENDER and HEALTH RESEARCH

Infertility and polycystic ovarian syndrome: A study of association between body mass index and intrafamily marriages
(Abstract; subscription needed for full text; Asia)
Gynecologic and Obstetric Investigation. 2008;65(4):269-274.
Haq F | Rizvi J
Polycystic ovarian syndrome (PCOS) is a common endocrine disorder which causes anovulatory infertility. Obesity is one of the factors which directly modifies the clinical, biochemical and metabolic expression of this syndrome. Recently a genetic association of PCOS with intrafamily marriages has been postulated. This study investigates the association of environmental factors such as BMI and intrafamily marriages with the clinical, biochemical and hormonal features of this syndrome. The objective was to determine the relationship of different clinical, biochemical parameters and hormonal assay with the BMI of women who are known to have PCOS, and to compare these demographic features with intrafamily marriages. From January 2005 until December 2006, patients attending the infertility clinic at Aga Khan University Hospital, Karachi, were evaluated for their clinical features. Couples were divided into 2 groups: group A had a history of first-degree intrafamily marriages, and group B had none. Complete biochemical evaluation was performed by day-2 serum FSH, LH, prolactin, testosterone and fasting serum insulin levels. The results were recorded on a data collection form. Ultrasonic evaluation was performed with transvaginal ultrasound to check the morphological appearance of the ovaries. A modified glucose tolerance test with 75 g glucose was performed and the results were recorded as normal, impaired and abnormal. Insulin resistance was calculated using the HOMA index method. During this period 203 patients were evaluated for demographic and biochemical features of PCOS. The prevalence of obesity was 70% with 59.3% women found to have hyperinsulinemia while 52.3% of patients had insulin resistance according to the HOMA index method. Univariate and multivariate analyses were used to compare the 2 groups. A linear relationship between oligomenorrhea, family history of diabetes, tonic LH, high fasting serum insulin levels, insulin resistance and an abnormal glucose tolerance test was revealed, keeping intrafamily marriage and BMI as dependent variables. In this population 48% of couples were in first-degree intrafamily marriages, suggesting the possibility of a high genetic predisposition for abnormal metabolic features beside ethnic predisposition. A linear relationship of high BMI and family marriages has been seen with insulin resistance, oligomenorrhea and impaired glycemic control. The number of obese women and the high rate of intrafamily marriages make our population genetically susceptible to metabolic complications.

A meta-analysis of human papillomavirus type-distribution in women from South Asia: Implications for vaccination
(Abstract; subscription needed for full text; Asia)
Vaccine. 2008 Jun;26(23):2811-2817.
Bhatla N | Lal N | Bao YP | Ng T | Qiao YL
The objective was to determine human papillomavirus (HPV) prevalence and type-distribution in women from South Asia, with and without cervical lesions, in order to estimate the impact of an HPV 16/18 prophylactic vaccine in this region and to assess additional types that should be incorporated in new vaccines. Ameta-analysis was conducted that included studies using polymerase chain reaction to detect HPV-16, -18, -6, -11 and at least one other HPV type, with a minimum of 20 cases in each grade of lesion. Total as well as type-specific prevalence of various HPV types were estimated, stratified by cervical lesion grade, using Stata 9.0 software package. Nine studies from India fulfilled the inclusion criteria. A total of 558, 52, 52 and 3061 women, respectively with invasive cervical cancer (ICC), high-grade squamous intraepithelial lesions (HSIL), low-grade squamous intraepithelial lesions (LSIL) and normal cytology/histology were included. Overall HPV prevalence was 94.6%, 86.5%, 65.4% and 12.0% in women with ICC, HSIL, LSIL and normal cytology/histology, respectively. In ICC, HPV-16 was the predominant type (64.8%), followed by HPV-18, -45, -33, -35, -58, -59 and -31. The estimated HPV-16/18 positive fraction was 78.9% in women with ICC (87.7% in North and 77.2% in South India), 61.5% with HSIL, 30.8% with LSIL and 3.9% in women with normal cytology/histology. There was no difference in overall HPV prevalence in cervical cancer between North and South India (P = 0.063). However, HPV-16 and -45 appeared to be more prevalent in North India (P = 0.018 and 0.013, respectively), while HPV-35 appeared to be more prevalent in South India (P = 0.033). It is estimated that HPV-16/18 vaccines will provide over 75% protection against ICC in South Asia. HPV-45, -33, -35 and -58 account for an additional 20% of cervical cancer in this region. The addition of these additional HPV types in a second-generation vaccine could provide optimal cervical cancer prevention in this region.

Wife beating in South Africa: An imbalance theory of resources and power
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Interpersonal Violence. 2008 Jun;23(6):834-852.
Choi SY | Ting KF
This article develops an imbalance theory to explain physical violence against women in intimate relationships in South Africa. The theory proposes four typologies: dependence, compensation, submission, and transgression, through which imbalances in resource contribution and power distribution between spouses are hypothesized to contribute to violence. The dependence hypothesis suggests that economic dependence of the wife will lead to more violence. The compensation hypothesis argues that the husband will use force to compensate for his inability to live up to the male-provider norm. The submission hypothesis suggests that violence will increase due to the submission of women in male-dominated families. Finally, the transgression hypothesis argues that men in female-dominated families will use force to punish their wives for supposedly transgressing the gender norm of male dominance. Empirical evidence provided some support for the dependence, submission, and transgression hypothesis.

Missing girls in India: Infanticide, feticide and made-to-order pregnancies? Insights from hospital-based sex-ratio-at-birth over the last century
(Research Article; Asia)
PLoS One. 2008 May;3(5):e2224.
Sahni M | Verma N | Narula D | Varghese RM | Sreenivas V
There are 44 million women in India. Gender bias; neglect of girls, infanticides and feticides are responsible. The sec ratio at birth can be used to examine the influence of antenatal sex selection on the sex ratio. Records from 321,991 deliveries at one hospital over 11 decades were utilized. The middle year in each decade was taken as representative of the decade. Data from 33,524 deliveries were then analyzed. Data for each decade was combined with that of previous decades and compared to the data of subsequent decades to look for any change in the trend. Sex ratio in the second children against sex of the first child was studies separately. The mean sex ratio for the 110 years examined was 910 girls to 1000 boys (95% CI; 891 to 930). The sex ratio dropped significantly from 935 (CI: 905 to 967) before 1979, to 892 (CI: 868 to 918) after 1980 (P = 0.04). The sex ratio in the second child was significantly lower if the first child was a girl [716 (CI: 672 to 762)] (P less than 0.001). On the other hand, there was an excess of girls born to mothers whose first child was boy [1140 girls per 1000 boys (CI: 1072 TO 1212 P less than 0.0001)]. The sex ratio fell significantly after 1980 when ultra sound machines for antenatal sex determination became available. The sex ratio in second children if the first was a girl was even lower. Sex selective abortions after antenatal sex determination are thus implicated. However data on second children especially the excess of girls born to mothers who have a previous boy seen in the decade before the advent of antenatal ultra sound machines, suggests that other means of sex selection are also used.

HIV/AIDS and STIs RESEARCH

High-prevalence and high-estimated incidence of HIV infection among new injecting drug users in Estonia: Need for large scale prevention programs
(Abstract; subscription needed for full text; Europe)
Journal of Public Health. 2008 Jun;30(2):119-125.
Uuskula A | Kals M | Rajaleid K | Abel K | Talu A
The objective was to examine HIV risk behavior and HIV infection among new injectors in Tallinn, Estonia. The design and methods used was data from two cross-sectional surveys of injecting drug users (IDUs) recruited from a syringe exchange program (N = 162, Study 1) or using respondent driven sampling (N = 350, Study 2). Behavioral surveys were administered; serum samples were collected for HIV testing. Subjects were categorized into new injectors (injecting less than or equal to 3 years) and long-term injectors (injecting greater than 3 years). Twenty-eight of 161 (17%, Study 1) and 73/350 (21%, Study 2) of the study subjects were new injectors. HIV infection was substantial among the newer injectors: HIV prevalence was 50% (Study 1) and 34% (Study 2), and estimated HIV incidence 31/100 PY and 21/100 PY, respectively. In Study 2, new injectors were more likely to be female and ethnic Estonian and less likely to be injecting daily compared with longterm injectors. No significant difference was found among two groups on sharing injecting equipment or reported number of sexual partners. A continuing HIV epidemic among new injectors is of critical public health concern. Interventions to prevent initiation into injecting drug use and scaling up HIV prevention programs for IDUs in Estonia are of utmost importance.

Cost-effectiveness of HIV screening of blood donations in Accra (Ghana)
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Value in Health. 2008;:[11] p..
van Hulst M | Sagoe KW | Vermande JE | van der Schaaf IP | van der Tuuk Adriani WP
Areas with high HIV-incidence rates compared to the developed world may benefit from additional testing in blood banks and may show more favorable cost-effectiveness ratios. We evaluated the cost-effectiveness of adding p24 antigen, mini pool nucleic acid amplification testing (MPNAT), or individual donation NAT (ID-NAT) to the HIV-antibody screening at the Korle Bu Teaching Hospital (Accra, Ghana), where currently only HIV-antibody screening is undertaken. The residual risk of HIV transmission was derived from blood donations to the blood bank of the Korle Bu Teaching Hospital in 2004. Remaining life expectancies of patients receiving blood transfusion were estimated using the World Health Organization life expectancies. Cost-effectiveness ratios for adding the tests to HIV-antibody screening only were determined using a decision tree model and a Markov model for HIV. The prevalence of HIV was estimated at 1.51% in 18,714 donations during 2004. The incremental cost per disability-adjusted life-year (DALY) averted was US$1237 for p24 antigen, US$3142 for MP-NAT and US$7695 compared to the next least expensive strategy. HIV-antibody screening itself was cost-saving compared to no screening at all, gaining US$73.85 and averting 0.86 DALY per transfused patient. Up to a willingness-to-pay of US$2736 per DALY averted, HIV-antibody screening without additional testing was the most cost-effective strategy. Over a willingness-to-pay of US$11,828 per DALY averted, ID-NAT was significantly more cost-effective than the other strategies. Adding p24 antigen, MP-NAT, or ID-NAT to the current antibody screening cannot be regarded as a cost-effective health-care intervention for Ghana.

HIV/AIDS prevention in the Nepalese context
(Abstract; subscription needed for full text; Asia)
Evaluation and the Health Professions. 2008 Jun;31(2):198-210.
Pokhrel P | Regmi S | Piedade E
With their numbers now approaching almost 30 million, Nepalese feature importantly in the South Asian demography. Yet, it has been only 60 years since Nepal gained international recognition as a nation-state. Nepal at present is one of the world's poorest countries and is in dire need of development, especially in the area of health. Given the current civil instability coupled with rapid modernization, the health and well-being of the Nepalese people have been increasingly affected by newer threats, such as HIV/AIDS. The present study discusses the uniqueness of the Nepalese context in relation to HIV/AIDS prevention. The authors suggest that HIV/AIDS prevention programs in Nepal should now focus more on adolescents from rural regions. The authors also suggest the ways one may approach the task of developing a prevention program targeting rural youths.

MATERNAL AND CHILD HEALTH RESEARCH

Exclusive breastfeeding in Vietnam: An attainable goal
(Abstract; subscription needed for full text; Asia)
Acta Paediatrica. 2008;:[3] p..
Almroth S | Arts M | Quang ND | Hoa PT | Williams C
The aim was to explore community views on the feasibility of exclusive breastfeeding in Vietnam. A total of 118 interviews were conducted with mothers, grandmothers, fathers, health workers and 'oldest women' in rural and urban areas in the north and south of Vietnam. Special issues were further examined through 12 'strategic interviews'. Exclusive breastfeeding was rare because it was poorly understood and little appreciated, by health professionals as well as lay persons, as the best way to feed an infant during the first 6 months. Early fluid supplementation was the rule and most infants received water and milk in addition to breast milk. While a majority of the women worked, they had found ways to manage their work so that it did not need to interfere with exclusive breastfeeding. Family members expressed a readiness to support exclusive breastfeeding when it was explained to them. Exclusive breastfeeding in Vietnam, while currently uncommon, is an attainable goal. Establishing exclusive breastfeeding as the norm in the general population would make it easier for HIV-infected women, for whom replacement feeding is not acceptable, feasible, affordable, sustainable and safe, to breastfeed exclusively.

A population-based survey of women's traditional postpartum behaviours in Northern China
(Abstract; subscription needed for full text; Asia)
Midwifery. 2008 Jun;24(2):238-245.
Wang X | Wang Y | Zanzhou S | Wang J | Wang J
The objective was to describe patterns of women's postpartum behaviour in the period of 'doing the month' in a Northern rural area in China; and to determine the degree of difference between postpartum behaviour and daily behaviour. A retrospective cross-sectional survey was conducted in May 2004, using a questionnaire previously developed in pilot studies. The setting was the Laishui County, Hebei Province, China. The participants in the study were a random sample of 1813 rural women. Women's traditional postpartum behaviours assessed by our postpartum behaviour questionnaire showed that most women adhered to traditional customs, drastically changing their practices in eating, sanitation, dress, activity, and household chores during the period of 'doing the month.' The analysis of variance analysis indicated that a woman's age had no effect on the change of behavioural patterns, and that a women's education had no significant effect. Traditional postpartum behaviours are still very popular in rural areas of Northern China. Fearful of suffering illness in later years, many women closely adhere to traditional postpartum practices.

Community-based health insurance and access to maternal health services: Evidence from three West African countries
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Social Science and Medicine. 2008 Jun;66(12):2460-2473.
Smith KV | Sulzbach S
Community-based health insurance (CBHI) has been incorporated into the health financing strategies of governments and communities in several Sub-Saharan African countries. Despite the support for and proliferation of CBHI schemes in this region, empirical evidence on how CBHI impacts access to health care, particularly maternal health services, is very limited. The authors use recent household surveys in three West African countries - Senegal, Mali, and Ghana - to examine the relationship between CBHI membership and access to formal sector maternal health care. The authors find that membership in a CBHI scheme is positively associated with the use of maternal health services, particularly in areas where utilization rates are very low and for more expensive delivery-related care. The findings suggest, however, that membership in a CBHI scheme is not sufficient to influence maternal health behaviors - it is the inclusion of maternal health care in the benefits package that makes a difference. While many questions remain about CBHI, this study provides preliminary evidence suggesting that CBHI is a potential demand-side mechanism to increase maternal health care access. However, complementary supply-side interventions to improve quality of and geographic access to health care are also critical for improving health outcomes in this region.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Growing old and staying young: Population policy in an ageing closed economy
(Abstract; subscription needed for full text; Europe)
Journal of Population Economics. 2008 Jul;21(3):573-588.
van Groezen B | Meijdam L
This paper analyses the relation between public pensions, fertility and child care in a closed-economy overlapping generations model with endogenous fertility. It is shown that raising a child involves two social externalities and that it is optimal to introduce child allowances if the government redistributes income from the young to the old. The optimal child allowance rises when longevity increases. If the costs of raising children depend positively on the wage, a third externality arises and the returns to savings should be taxed.

Avoidable mortality risks and measurement of wellbeing and inequality
(Abstract; subscription needed for full text; Global)
Journal of Health Economics. 2008 May;27(3):624-641.
Tang KK | Chin JT | Rao DS
This paper proposes a data envelopment method to separate avoidable and unavoidable mortality risks. As unavoidable mortality is either beyond the control of humanity or likely to be very cost-ineffective to reduce in the short to medium term, avoidable mortality is of much greater practical relevance in measuring wellbeing and inequality. The new method is applied to a dataset consisting of life tables for 191 countries in the year 2000 to obtain a reference distribution of unavoidable mortality risks. The reference distribution is used to improve on the standard age-at-death measure to obtain an age-at-avoidable-death measure. Compared with the standard measure, age-at-avoidable-death provides a very different picture of wellbeing, and more so when it comes to inequality measures.

Birth spacing, fertility selection and child survival: Analysis using a correlated hazard model
(Abstract; subscription needed for full text; Asia)
Journal of Health Economics. 2008 May;27(3):690-705.
Maitra P | Pal S
If fertility reflects the choice of households, results of their choice (duration between successive births and health of the children) cannot be considered to be determined randomly. Most existing studies of child health, however, tend to overlook the effects of fertility selection on child health. This paper argues that not accounting for this selection issue yields biased estimates and it is difficult a priori to predict the direction of this bias. We find that the estimates of birth spacing on child mortality are different when we do not account for fertility selection. Additionally, the correlated hazard estimates that we present here better fit our samples than the corresponding bivariate probit estimates used in the literature. A comparison of the fertility behaviour of households in the Indian and the Pakistani Punjab highlights the differential nature of institutions on demographic transition in these neighbouring regions.

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Johns Hopkins Bloomberg School of Public Health: The INFO Project

Volume 8, Number 2126 May 2008