Volume 8, Number 24
16 June 2008

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ADOLESCENT HEALTH RESEARCH

School-based drama interventions in health promotion for children and adolescents: Systematic review
(Abstract; subscription needed for full text; Global)
Journal of Advanced Nursing. 2008;:[16] p.
Joronen K | Rankin SH | Astedt-Kurki P
The paper is a report of a review of the literature on the effects of school-based drama interventions in health promotion for school-aged children and adolescents. Drama, theatre and role-playing methods are commonly used in health promotion programmes, but evidence of their effectiveness is limited. The educational drama approach and social cognitive theory is share the assumption that learning is based on self-reflection and interaction between environment and person. However, educational drama also emphasizes learning through the dialectics between actual and fictional contexts. A search was carried out using 10 databases and hand searching for the period January 1990 to October 2006. A Cochrane systematic review was conducted. Nine studies met the criteria for inclusion. Their topics included health behaviour (five studies), mental health (two) and social health (two). Actor-performed drama or theatre play followed by group activities was the intervention in five studies, and classroom drama in four studies. Four of the studies were randomized controlled trials and five were non-randomized controlled studies. Four reports gave the theory on which the intervention was based, and in eight studies at least some positive effects or changes were reported, mostly concerning knowledge and attitudes related to health behaviour. The diversity of designs and instruments limited comparisons. There is a need for well-designed and theory-based studies that address drama interventions in health promotion for children and families. The challenge is to find or develop a theory, which combines educational, drama and health theories with valid and reliable measurements to examine the effects of the intervention.

Effectiveness of weekly supplementation of iron to control anaemia among adolescent girls of Nashik, Maharashtra, India
(Abstract; subscription needed for full text; Asia)
Journal of Health, Population and Nutrition. 2008 Mar;26(1):74-78.
Deshmukh PR | Garg BS | Bharambe MS
A national nutritional anaemia-control programme in India, focusing on supplementation of iron to pregnant women after the first trimester of pregnancy, failed to make an impact. It is prudent to recommend the correction of iron stores before the woman becomes pregnant. 'Efficacy' of weekly supplementation of iron has been proved to improve iron stores in adolescence in many studies abroad and in India. The objective was to study the 'effectiveness' of a weekly iron-supplementation regimen among urban-slum, rural, and tribal girls of Nashik district, Maharashtra, India. A baseline and the mid-term assessments were done using the cluster-sampling techniques. In each stratum, 30 clusters were identified. Twelve and 10 adolescent girls from each cluster were identified in the baseline and mid-term surveys respectively. The haemoglobin estimation was done using the HemoCue system. Data were analyzed using the Epi Info software (version 6.04). The overall prevalence of anaemia came down significantly to 54.3% from 65.3%. The decline was statistically significant (p less than 0.001) in tribal girls (48.6% from 68.9%) and among rural girls (51.6% from 62.8%). But the decline was not statistically significant among urban slum girls. Similarly, a significant rise in the mean haemoglobin levels was seen among tribal and rural girls. However, it did not increase significantly among urban slum girls. The programme had performed poorly in urban-slum areas, as the mean number of tablets consumed in urban-slum areas was only 5.6 plus or minus 3.3, as against 6.7 plus or minus 2.6 tablets in tribal girls and 7.2 plus or minus 2.2 tablets in rural girls. Considering the biological and operational feasibility and the effectiveness of the intervention, weekly supplementation of iron to adolescent girls should be universally started to correct the iron stores of a woman before she becomes pregnant.

Using drama for school-based adolescent sexuality education in Zaria, Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Reproductive Health Matters. 2008 May;16(31):202-210.
Kafewo SA
This paper describes the use of drama and participatory methods in a girls-only secondary school in Zaria, Nigeria, as a means of sexuality education, carried out by the Nigerian Popular Theatre Alliance and the Second Chance Organization of Nigeria. The issues addressed had to come from the students, to allow them to develop critical thinking and learn useful lessons. The topics that concerned the group of 15 girls who participated from the school included abortion, premarital sex and pregnancy, teacher-student relationships and lesbianism. Participants developed a play about teacher-student relationships and presented it to the whole school. The presentation was stopped several times in order to involve the audience in discussing the choices available to the protagonist and what they would do in her place. This allowed all the students to explore the problem, generate and assess alternative solutions and communicate their learning to others. It also started a process of change in how the school dealt with girls who were forced to drop out due to sexuality-related problems, including pregnancy. Our long-term aim is advocacy to support the introduction of sexuality education as a permanent element in the curriculum throughout the school system.

FAMILY PLANNING RESEARCH

Effect of low dose oral pill on haemostatic parameters in a set of Pakistani population
(Research Article; Asia)
Journal of Pakistan Medical Association. 2008 May;58(5):229-233.
Afsar NA | Barakzai Q | Adil SN
The purpose of this study was to observe the adverse effects of low dose combination contraceptive pills on blood coagulation in a set of local population. Between December 2002 to December 2003 a comparative cross-sectional study was conducted at the Department of Pharmacology, Ziauddin Medical University, Karachi and Aga Khan University Hospital, Karachi. Fifty women of reproductive age were divided in two equal groups; one being the users of combination oral contraceptive pills (ethinyl estradiol and levonorgestrel) and the other being matching controls not taking any hormonal contraceptives. We studied, CBC, PT and INR, APTT, BT and platelet aggregation against ADP, collagen, epinephrine and ristocetin. PT, INR, and platelet aggregation response to ADP, collagen, epinephrine, and ristocetin were not significantly different among the groups. However, APTT was shortened in users of contraceptives (p = 0.003). The referred oral contraceptive is associated with enhanced activity of intrinsic pathway of secondary haemostasis.

Meta-analysis of intrauterine device use and risk of endometrial cancer
(Abstract; subscription needed for full text; Global)
Annals of Epidemiology. 2008 Jun;18(6):492-499.
Beining RM | Dennis LK | Smith EM | Dokras A
We sought to study the association between intrauterine device (IUD) use and endometrial cancer. A comprehensive search of literature published through April 2007 was conducted, studies reviewed, and data abstracted. Data from ten studies were pooled and analyzed using both fixed- and random-effects models to examine the association of ever use of an IUD and endometrial cancer. Based on the random effects model, a protective crude association between IUD use and endometrial cancer was observed (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.29-0.51; heterogeneity p less than 0.001) with a pooled adjusted risk of OR = 0.54 (95% CI, 0.47-0.63; heterogeneity p = 0.40). A decreased risk of endometrial cancer also was seen for increased years of IUD use (OR for 5 years of use 0.88; 95% CI = 0.84-0.92; n = 5; heterogeneity p = 0.14), increased years since last IUD use (OR for 5 years of use 0.91; 95% CI, 0.86-0.95; n = 4; heterogeneity p = 0.02), and increased years since first IUD use (OR for 5 years of use 0.89; 95% CI, 0.83-0.95; n = 4; heterogeneity p = 0.04). Our results suggest that nonhormonal IUD use may be associated with a decreased risk for endometrial cancer; however, the exact mechanism for this association is unclear. Future investigations should address the difference in the proposed association by specific type of IUDs.

Global knowledge / local bodies: Family planning service providers? interpretations of contraceptive knowledge(s)
(Research Article; Sub-Saharan Africa)
Demographic Research. 2008 Jun 10;18(17):469-498.
Richey LA
Contraceptive technologies and the knowledges that are constructed around them are simultaneously global and local. Family planning methods in the context of international development interventions are interpreted and understood as part of the relationship between meanings that are at once embodied and remote. While quality of care issues have been raised over nearly two decades, the interactive relationship between policy/program, supply, and interpersonal relations in forming identities has not been analyzed. This paper is based on two years of qualitative fieldwork conducted in Tanzania over a period between the mid-1990s and the mid-2000s. It examines Tanzanian service providers' perceptions of contraceptives to shed light on questions of local level dissemination of population knowledge(s) and shaping of identities. The findings suggest that the family planning program serves in a process of differentiation between two groups of "local" women: the service providers and their clients. This differentiation subsequently shapes the implementation of the family planning program.

Evaluation of the potential of synthetic peptides of 80 kDa human sperm antigen (80 kDaHSA) for the development of contraceptive vaccine for male
(Abstract; subscription needed for full text; Global)
Vaccine. 2008;:[8] p.
Khobarekar BG | Vernekar V | Raghavan V | Kamada M | Maegawa M
80 kDaHSA has been demonstrated to be responsible for inducing immunoinfertility. Synthetic peptides NT, 1, 2 and 4 of 80 kDaHSA are immunogenic and immunobiologically mimic the native protein. Peptides 1 and NT being highly immunogenic their potential for contraceptive vaccine developmentwas evaluated. Active immunization of male rabbits with peptide-1 and -NT induced reversible infertility in 100% and 60% of animals, respectively and subsequently active immunization of non-human primate model, male marmosets with peptide-1 induced reversible infertility in six out of seven high antibody titer animals. The present study suggests the potential of peptide-1 of 80 kDaHSA for the development of contraceptive vaccine.

Breast-feeding and lactational amenorrhea in the United Arab Emirates
(Abstract; subscription needed for full text; Middle East)
Journal of Pediatric Nursing. 2008;:[7] p.
Radwan H | Mussaiger AO | Hachem F
This study was designed to investigate the relation of breast-feeding and weaning practices with the duration of lactational amenorrhea among breast-feeding mothers in the United Arab Emirates. A total of 593 mothers were interviewed in the Maternal and Child Health Centers in three areas: Abu Dhabi, Dubai, and Al Ain. The total mean duration of lactational amenorrhea in this study was 6.1 months, and there was a direct relation with the length of exclusive breast-feeding. The duration of postpartum amenorrhea was the longest in Al Ain (7.2 months), as compared with Dubai (6.9 months) and Abu Dhabi (4.3 months). The age of the infant when formula milk and solid supplements were introduced was significantly related to the duration of lactational amenorrhea. This study confirms the results of other studies concerning the effectiveness of the lactational amenorrhea method as a natural method of contraception for the first 6 months postpartum, especially for mothers who breast-feed exclusively and more frequently and who delay the introduction of food supplements.

GENDER and HEALTH RESEARCH

Male reproductive proteins and reproductive outcomes
(Abstract; subscription needed for full text; Global)
American Journal of Obstetrics and Gynecology. 2008 Jun;198(6):620.e1-620.e4.
Ness RB | Grainger DA
Male reproductive proteins (MRPs), associated with sperm and semen, are the moieties responsible for carrying male genes into the next generation. Evolutionary biologists have focused on their capacity to control conception. Immunologists have shown that MRPs cause female genital tract inflammation as preparatory for embryo implantation and placentation. These observations argue that MRPs are critically important to reproductive success. Yet the impact of male reproductive proteins on obstetrical outcomes in women is largely unstudied. Epidemiologic and clinical observations suggest that shorter-duration exposure to MRPs prior to conception may elevate the risk for preeclampsia. A limited literature has also linked sexual behavior to bacterial vaginosis and preterm birth. We offer a clinical opinion that MRPs may have broad implications for successful reproduction, potentially involved in the composition of vaginal microflora, risks of preterm birth and preeclampsia, and success of assisted reproduction.

Economic violence to women and girls: Is it receiving the necessary attention?
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Trauma, Violence, and Abuse. 2008 Jul;9(3):167-177.
Fawole OI
Most studies on gender-based violence (GBV) have focused on its physical, sexual, and psychological manifestations. This paper seeks to draw attention to the types of economic violence experienced by women, and describes its consequences on health and development. Economic violence experienced included limited access to funds and credit; controlling access to health care, employment, education, including agricultural resources; excluding from financial decision making; and discriminatory traditional laws on inheritance, property rights, and use of communal land. At work women experienced receiving unequal remuneration for work done equal in value to the men's, were overworked and underpaid, and used for unpaid work outside the contractual agreement. Some experienced fraud and theft from some men, illegal confiscation of goods for sale, and unlawful closing down of worksites. At home, some were barred from working by partners; while other men totally abandoned family maintenance to the women. Unfortunately, economic violence results in deepening poverty and compromises educational attainment and developmental opportunities for women. It leads to physical violence, promotes sexual exploitation and the risk of contracting HIV infection, maternal morbidity and mortality, and trafficking of women and girls. Economic abuse may continue even after the woman has left the abusive relationship. There is need for further large-scale studies on economic violence to women. Multi-strategy interventions that promote equity between women and men, provide economic opportunities for women, inform them of their rights, reach out to men and change societal beliefs and attitudes that permit exploitative behavior are urgently required.

Detecting intimate partner violence during pregnancy: Awareness-raising indicators for use by primary healthcare professionals
(Abstract; subscription needed for full text; South America)
Public Health. 2008 Jul;122(7):716-724.
Reichenheim ME | Patricio TF | Moraes CL
Given the deleterious consequences of intimate partner violence (IPV) for gestation, it is important to promote a more effective and amicable approach that engenders greater receptiveness, stimulates more open communication and, ultimately, facilitates addressing the problem. In this regard, active primary care professionals need to be educated about the different profiles of violence found in domestic environments. The aim of this study is to make the identification of those subgroups of pregnant women most likely to be living in IPV situations both practical and simple. Its ultimate goal is to give healthcare professionals who work directly with the public the tools to anticipate such events. To this end, this study presents a profile of IPV during pregnancy according to different characteristics observed among primary health service users. Five hundred and twenty-seven women who carried children to term in Rio de Janeiro were interviewed. A Portuguese version of the Revised Conflict Tactics Scale (CTS2) was used to detect IPV. Several sociodemographic factors, life habits and reproductive health characteristics of pregnant women and their partners were scrutinized. Prevalence projections by subgroup were obtained using a multinomial logit model. The projected prevalences for negotiation, psychological violence, minor physical violence and severe physical violence were, respectively, 0.1% [95% confidence interval (CI) 0.0-0.6], 2.6% (95%CI 0.7-6.9), 7.0% (95%CI 1.7-18.5) and 90.3% (95%CI 77.2-96.8) for the extreme scenario, i.e. women o20 years of age, non-White, living in house with inadequate garbage disposal, previous history of abortion, reporting fear of someone, reporting lack of affective social support, and reporting drug use by woman or spouse. In the absence of these characteristics, the projected prevalences were 51.3% (95%CI 38.5-64.6), 40.0% (95%CI 28.5-51.9), 7.6% (95%CI 4.2-12.7) and 1.1% (95%CI 0.3-2.4), respectively. This study found that knowledge of certain characteristics of pregnant women who attend health services can alert professionals to the high probability of IPV, facilitating early identification of the problem and subsequent implementation of proactive measures.

HIV/AIDS AND SEXUAL AND REPRODUCTIVE HEALTH INTEGRATION

Burkina Faso: Young, positive and sexually active
(News Article; Sub-Saharan Africa)
5 Jun 2008
IRIN HIV/AIDS (Plus News)

HIV/AIDS and STIs RESEARCH

Geographic prevalence and multilevel determination of community-level factors associated with herpes simplex virus type 2 infection in Chennai, India
(Abstract; subscription needed for full text; Asia)
American Journal of Epidemiology. 2008;167(12):1495?1503.
Jennings JM | Louis TA | Ellen JM | Srikrishnan AK | Sivaram S
Herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections, and it increases the risk of transmission of human immunodeficiency virus type 1 at least twofold. Individual-level factors are insufficient to explain geographic and population variation in HSV-2, suggesting the need to identify ecologic factors. The authors sought to determine the geographic prevalence and community-level factors associated with HSV-2 after controlling for individual-level factors among slums in Chennai, India. From March to June 2001, participants aged 18-40 years voluntarily completed a survey and were tested for HSV-2. Community characteristics were assessed through interviews with key informants and other secondary data sources. Multilevel nonlinear analysis was conducted. Eighty-five percent of eligible persons completed the survey; of these, 98% underwent HSV-2 testing, producing a final sample of 1,275. Participants were of Tamil ethnicity, were predominantly female and married, and were on average 30 years old. Fifteen percent were infected with HSV-2, and there was significant variation in HSV-2 prevalence among communities. After controlling for individual-level factors, the authors identified community-level factors, including socioeconomic status and the presence of injection drug users, that were independently associated with HSV-2 and explained 11% of the variance in prevalence. Future studies are needed to test mechanisms through which these community-level factors may be operating.

The role of HIV / AIDS committees in effective workplace governance of HIV / AIDS in South African small and medium-sized enterprises (SMEs)
(Abstract; subscription needed for full text; Sub-Saharan Africa)
SAHARA J: Journal of Social Aspects of HIV / AIDS. 2008 Apr;5(1):2-10.
Vass JR
The primary purpose of this study was to assess the role, status and scope of workplace HIV/AIDS committees as a means of effective workplace governance of the HIV/AIDS impact, and their role in extending social protective HIV/AIDS-related rights to employees. In-depth qualitative case studies were conducted in five South African small and medium-sized enterprises (SMEs) that were actively implementing HIV/AIDS policies and programmes. Companies commonly implemented HIV/AIDS policies and programmes through a workplace committee dedicated to HIV/AIDS or a generic committee dealing with issues other than HIV/ AIDS. Management, through the human resources department and the occupational health practitioner often drove initial policy formulation, and had virtually sole control of the HIV/AIDS budget. Employee members of committees were mostly volunteers, and were often production or blue collar employees, while there was a notable lack of participation by white-collar employees, line management and trade unions. While the powers of workplace committees were largely consultative, employee committee members often managed in an indirect manner to secure and extend social protective rights on HIV/AIDS to employees, and monitor their effective implementation in practice. In the interim, workplace committees represented one of the best means to facilitate more effective workplace HIV/AIDS governance. However, the increased demands on collective bargaining as a result of an anticipated rises in AIDS-related morbidity and mortality might prove to be beyond the scope of such voluntary committees in the longer term.

Human papillomavirus infection and cervical disease in human immunodeficiency virus-1-infected women
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Obstetrics and Gynecology. 2008 Jun;111(6):1380-1387.
Denny L | Boa R | Williamson AL | Allan B | Hardie D
The objective was to report on the natural history of high-risk human papillomavirus (HPV) infection and cervical disease in human immunodeficiency virus (HIV)-1-infected women living in Cape Town, South Africa. This was a prospective study of 400 untreated, HIV-1-infected women who underwent high-risk HPV DNA testing, cytology, colposcopy, histology, and CD4 count testing every 6 months for 36 months. Human immunodeficiency virus viral loads and HPV type distribution were determined at entry and after 18 months. Sixty-eight percent of the women were highrisk HPV DNA positive at entry, 35% had a cytologic diagnosis of low-grade squamous intraepithelial lesion (LSIL), and 13% had high-grade squamous intraepithelial lesion (HSIL). There were no cancers. Abnormal cytology and high-risk HPV positivity were strongly correlated with low CD4 counts and high HIV viral loads. The most prevalent types of HPV were HPV-16, -52, -53, -35, and -18. Incident high-risk HPV infection occurred in 22%, and of those infected with high-risk HPV, 94% of infections persisted over an 18-month period, and 6% cleared their infections. Cytologic progression to SIL from normal/ atypical squamous cells of undetermined significance cytology occurred in 17% of cases, but only 4% of cases of LSIL progressed to HSIL. There is a high level of high-risk HPV infection in HIV-1 infected women, but progression to HSIL over 36 months occurred in the minority of cases. We recommend an initial colposcopy for an abnormal test, and if no high-grade lesion is identified, triennial screening would be appropriate. Human papillomavirus type 16 was the commonest, and HPV-18 was the fifth commonest, suggesting that vaccination against these two types would have a significant effect.

Changes in prevalence and incidence of HIV-1, HIV-2 and dual infections in urban areas of Bissau, Guinea-Bissau: Is HIV-2 disappearing?
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS. 2008 Jun 19;22(10):1195-1202.
da Silva ZJ | Oliveira I | Andersen A | Dias F | Rodrigues A
The objective of this study was to assess the changes in HIV prevalence and incidence between 1996 and 2006 in urban areas of Bissau. The design was a cross-sectional survey of 384 randomly selected houses within a community-based follow-up study of HIV-1 and HIV-2. A total of 3242 individuals aged at least 15 years were eligible for inclusion. Participants were interviewed about behavioral and socio-economic factors and had a blood sample drawn. A total of 2548 individuals were tested for antibodies to HIV-1 and HIV-2, of whom 649 had taken part in a similar survey in 1996. With 0.5% HIV dual reactions included, the overall HIV-1 prevalence was 4.6% (118 out of 2548) and the HIV-2 prevalence was 4.4% (112 out of 2548). The prevalence of HIV-1 increased more for women than men especially in the 25-34-year age group. HIV-2 prevalence decreased below 45 years of age but not for individuals more than 45 years old. The incidence rate between 1996 and 2006 was 0.5 per 100 person-years for HIV-1 and 0.24 per 100 person-years for HIV-2. Compared with a previous period from 1987 to 1996, the incidence of HIV-2 is declining whereas no significant increase in the incidence of HIV-1 was observed. The present study shows an increasing prevalence of HIV-1 and a decreasing prevalence of HIV-2 in Guinea-Bissau. HIV is generally a bigger problem for women. Despite the general decline in prevalence, HIV-2 may continue as an infection in older people, especially women.

Integrated AIDS program, Thika, Kenya. A case study
(Case Study; Sub-Saharan Africa)
Chapel Hill, North Carolina, University of North Carolina at Chapel Hill, Carolina Population Center, MEASURE Evaluation, 2008 May. 41 p. (Array)
Thurman TR | Neudorf K
The purpose of this case study is to gain a better understanding of one of the programs selected for the evaluation - Integrated AIDS Program-Thika (IAPThika) supported by Pathfinder International - as well as identify lessons learned that could be applied to other initiatives. The case study is based upon program document review; program site visits, including discussions with local staff, volunteers, beneficiaries, and community members; and observations of program activities. The primary audience for this case study includes OVC program implementers in Kenya and elsewhere in Africa, as well as relevant policy makers, funding agencies addressing OVC needs, and other local and international stakeholders.

The relationship of acceptance or denial of HIV-status to antiretroviral adherence among adult HIV patients in urban Botswana
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Social Science and Medicine. 2008 Jul;67(2):301-310.
Nam SL | Fielding K | Avalos A | Dickinson D | Gaolathe T
Adherence to antiretroviral therapy among HIV patients is the most important patient-enabled factor related to virological failure and can lead to drug resistance. It is important to avoid virological failure, especially in resource-limited settings where treatment options are limited and the effects of treatment failure are profound. This qualitative study aimed to identify the psycho-social factors related to adherence behaviour in Gaborone, Botswana, a high prevalence setting in southern Africa. One-to-one, in-depth interviews were conducted with adult antiretroviral patients in the private and public health sectors who had been on antiretroviral therapy for a minimum of 6 months. A grounded theory approach was adopted and patients were selected purposively and theoretical sampling determined the final sample size. Thirty-two patients were interviewed, 22 from the public-sector, the mean age was 9.5 years and 53% were women. We found that acceptance of HIV-status, the ability to avoid internalising stigmatising attitudes and identification of an encouraging confidante were key factors related to good adherence. Encouraging confidantes (including clinicians) and contributed to promoting hope and acceptance of HIV-status, enabling patients to develop a positive therapeutic relationship with their antiretrovirals and make lifestyle changes that promoted adherence. Active participation in a social network and a desire to avoid being thin and visibly identifiable as HIV-positive were also adherence-motivating factors. Conversely, participants who expressed some degree of denial about their HIV-status tended to express emotions associated with depression, and internalised stigma that inhibited the development of a relationship with a confidante. We feel it is important to identify individuals with HIV who are still in some degree of denial about their status and to identify depression among patients on antiretrovirals. This will enable more targeted, individualised support in the management of individuals' HIV disease.

MATERNAL AND CHILD HEALTH RESEARCH

Health and survival of young children in southern Tanzania
(Research Article; Sub-Saharan Africa)
BMC Public Health. 2008;8(194):[33] p..
Schellenberg JR | Mrisho M | Manzi F | Shirima K | Mbuya C
With a view to developing health systems strategies to improve reach to high-risk groups, we present information on health and survival from household and health facility perspectives in five districts of southern Tanzania. We documented availability of health workers, vaccines, drugs, supplies and services essential for child health through a survey of all health facilities in the area. We did a representative cluster sample survey of 21,600 households using a modular questionnaire including household assets, birth histories, and antenatal care in currently pregnant women. In a subsample of households we asked about health of all children under two years, including breastfeeding, mosquito net use, vaccination, vitamin A, and care-seeking for recent illness, and measured haemoglobin and malaria parasitaemia. In the health facility survey, a prescriber or nurse was present on the day of the survey in about 40% of 114 dispensaries. Less than half of health facilities had all seven 'essential oral treatments', and water was available in only 22%. In the household survey, antenatal attendance (88%) and DPT-HepB3 vaccine coverage in children (81%) were high. Neonatal and infant mortality were 43.2 and 76.4 per 1000 live births respectively. Infant mortality was 40% higher for teenage mothers than older women (RR 1.4, 95% confidence interval (CI) 1.1-1.7), and 20% higher for mothers with no formal education than those who had been to school (RR 1.2, CI 1.0-1.4). The benefits of education on survival were apparently restricted to post-neonatal infants. There was no evidence of inequality in infant mortality by socio-economic status. Vaccine coverage, net use, anaemia and parasitaemia were inequitable: the least poor had a consistent advantage over children from the poorest families. Infant mortality was higher in families living over 5km from their nearest health facility compared to those living closer (RR 1.25, CI 1.0-1.5): 75% of households live within this distance. Relatively short distances to health facilities, high antenatal and vaccine coverage show that peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources.

Maternal herpes simplex virus type 2 coinfection increases the risk of perinatal HIV transmission: Possibility to further decrease transmission?
(Abstract; subscription needed for full text; Asia)
AIDS. 2008 Jun 18;22(10):1169?1176.
Bollen LJ | Whitehead SJ | Mock PA | Leelawiwat W | Asavapiriyanont S
The objectives were to evaluate the association between maternal herpes simplex virus type 2 seropositivity and genital herpes simplex virus type 2 shedding with perinatal HIV transmission. Evaluation of women who participated in a 1996-1997 perinatal HIV transmission prevention trial in Thailand. In this nonbreastfeeding population, women were randomized to zidovudine or placebo from 36 weeks gestation through delivery; maternal plasma and cervicovaginal HIV viral load and infant HIV status were determined for the original study. Stored maternal plasma and cervicovaginal samples were tested for herpes simplex virus type 2 antibodies by enzyme-linked immunoassay and for herpes simplex virus type 2 DNA by real-time PCR, respectively. Among 307 HIV-positive women with available samples, 228 (74.3%) were herpes simplex virus type 2 seropositive and 24 (7.8%) were shedding herpes simplex virus type 2. Herpes simplex virus type 2 seropositivity was associated with overall perinatal HIV transmission [adjusted odds ratio, 2.6; 95% confidence interval, 1.0-6.7)], and herpes simplex virus type 2 shedding was associated with intrapartum transmission (adjusted odds ratio, 2.9; 95% confidence interval, 1.0-8.5) independent of plasma and cervicovaginal HIV viral load, and zidovudine treatment. Median plasma HIV viral load was higher among herpes simplex virus type 2 shedders (4.2 vs. 4.1 log10 copies/ml; P = 0.05), and more shedders had quantifiable levels of HIV in cervicovaginal samples, compared with women not shedding herpes simplex virus type 2 (62.5 vs. 34.3%; P = 0.005). We found an increased risk of perinatal HIV transmission among herpes simplex virus type 2 seropositive women and an increased risk of intrapartum HIV transmission among women shedding herpes simplex virus type 2. These novel findings suggest that interventions to control herpes simplex virus type 2 infection could further reduce perinatal HIV transmission.

Risk factors for low birthweight in the public-hospitals at Peshawar, NWFP Pakistan
(Research Article; Asia)
BMC Public Health. 2008;8(197):[24] p..
Badshah S | Mason L | McKelvie K | Payne R | Lisboa PJ
Low birthweight is a widely used indicator of newborn health. This study investigates the association of birthweight less than 2.5kg (LBW) with a wide range of factors related to geodemographics, maternal health and pregnancy history in public hospitals at Peshawar, North West Frontier Province (NWFP) Pakistan. It is noted that that Low birthweight may arise for two different reasons, one related to gestational age and the other corresponding to births that are small for gestational age (SGA). Data on geo-demographics, maternal health indicators, pregnancy history and outcome scores for newborn babies and their families (n=1039) were collected prospectively between August and November 2003 in a cross-sectional survey of four public hospitals in Peshawar, NWFP-Pakistan. Crude and adjusted odds ratios were used to investigate the factors affecting incidence of LBW, by multivariate logistic regression. Gestational age was included as an explanatory variable therefore the additional covariates identified by model selection are expected to account for SGA. The main geo-demographic risk factors for SGA identified in this study, controlling for gestational age of less than 37 weeks, are maternal age, nationality and consanguinity. Presentation with anaemia and the history of previous abortion/miscarriage were also found to be significant independent factors. The adjusted odds ratio for gestational age showed the largest effect in explaining the incidence of LBW. The next highest odds ratio was for maternal age below 20 years. The explanatory model included two pairwise interactions, for which the predicted incidence figures for LBW show an increase among the Tribal area with presentation of anaemia, and among full term babies with their mothers having a previous history of abortion/miscarriage. In addition to gestational age, specific factors related to geo-demographics (maternal age, consanguinity and nationality), maternal health (anaemia) and pregnancy history (abortion/miscarriage) were significantly associated with the incidence of LBW observed at the four hospitals surveyed in Peshawar. These results indicate that cultural factors can adversely affect the incidence of SGA in this area of Pakistan.

Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: A cluster-randomised controlled trial
(Abstract; subscription needed for full text; Asia)
Lancet. 2008 Jun 7-13;371(9628):1936-1944.
Baqui AH | El-Arifeen S | Darmstadt GL | Ahmed S | Williams EK
Neonatal mortality accounts for a high proportion of deaths in children under the age of 5 years in Bangladesh. Therefore the project for advancing the health of newborns and mothers (Projahnmo) implemented a community-based intervention package through government and non-government organisation infrastructures to reduce neonatal mortality. In Sylhet district, 24 clusters (with a population of about 20 000 each) were randomly assigned in equal numbers to one of two intervention arms or to the comparison arm. Because of the study design, masking was not feasible. All married women of reproductive age (15-49 years) were eligible to participate. In the home-care arm, female community health workers (one per 4000 population) identified pregnant women, made two antenatal home visits to promote birth and newborn-care preparedness, made postnatal home visits to assess newborns on the first, third, and seventh days of birth, and referred or treated sick neonates. In the community-care arm, birth and newborn-care preparedness and careseeking from qualified providers were promoted solely through group sessions held by female and male community mobilisers. The primary outcome was reduction in neonatal mortality. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number 00198705. The number of clusters per arm was eight. The number of participants was 36059, 40159, and 37598 in the home-care, community-care, and comparison arms, respectively, with 14 769, 16 325, and 15 350 livebirths, respectively. In the last 6 months of the 30-month intervention, neonatal mortality rates were 29.2 per 1000, 45.2 per 1000, and 43.5 per 1000 in the home-care, community-care, and comparison arms, respectively. Neonatal mortality was reduced in the home-care arm by 34% (adjusted relative risk 0.66; 95% CI 0.47-0.93) during the last 6 months versus that in the comparison arm. No mortality reduction was noted in the community-care arm (0.95; 0.69-1.31). A home-care strategy to promote an integrated package of preventive and curative newborn care is effective in reducing neonatal mortality in communities with a weak health system, low health-care use, and high neonatal mortality. United States Agency for International Development and saving newborn lives programme by Save the Children (US) with a grant from Bill and Melinda Gates Foundation.

Extended antiretroviral prophylaxis to reduce breast-milk HIV-1 transmission
(Abstract; subscription needed for full text; Sub-Saharan Africa)
New England Journal of Medicine. 2008;:[11] p.
Kumwenda NI | Hoover DR | Mofenson LM | Thigpen MC | Kafulafula G
Effective strategies are urgently needed to reduce mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) through breast-feeding in resource-limited settings. Women with HIV-1 infection who were breast-feeding infants were enrolled in a randomized, phase 3 trial in Blantyre, Malawi. At birth, the infants were randomly assigned to one of three regimens: single-dose nevirapine plus 1 week of zidovudine (control regimen) or the control regimen plus daily extended prophylaxis either with nevirapine (extended nevirapine) or with nevirapine plus zidovudine (extended dual prophylaxis) until the age of 14 weeks. Using Kaplan-Meier analyses, we assessed the risk of HIV-1 infection among infants who were HIV-1-negative on DNA polymerase-chain-reaction assay at birth. Among 3016 infants in the study, the control group had consistently higher rates of HIV-1 infection from the age of 6 weeks through 18 months. At 9 months, the estimated rate of HIV-1 infection (the primary end point) was 10.6% in the control group, as compared with 5.2% in the extended-nevirapine group (P less than 0.001) and 6.4% in the extended-dual-prophylaxis group (P = 0.002). There were no significant differences between the two extended-prophylaxis groups. The frequency of breastfeeding did not differ significantly among the study groups. Infants receiving extended dual prophylaxis had a significant increase in the number of adverse events (primarily neutropenia) that were deemed to be possibly related to a study drug. Extended prophylaxis with nevirapine or with nevirapine and zidovudine for the first 14 weeks of life significantly reduced postnatal HIV-1 infection in 9-month-old infants.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

An assessment of China's fertility level using the variable-r method
(Abstract; subscription needed for full text; Asia)
Demography. 2008 May;45(2):271-281.
Cai Y
The fertility level in China is a matter of uncertainty and controversy. This paper applies Preston and Coale's (1982) variable-r method to assess the fertility level in China. By using data from China's 1990 and 2000 censuses as well as annual population change surveys, the variable-r method confirms that Chinese fertility has reached a level well below replacement.

Does female schooling reduce fertility? Evidence from Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Development Economics. 2008 Aug;87(1):57-75.
Osili UO | Long BT
The literature generally points to a negative relationship between female education and fertility. Citing this pattern, policymakers have advocated educating girls and young women as a means to reduce population growth and foster sustained economic and social welfare in developing countries. This paper tests whether the relationship between fertility and education is indeed causal by investigating the introduction of universal primary education in Nigeria. Exploiting differences in program exposure by region and age, the paper presents reduced form and instrumental variables estimates of the impact of female education on fertility. The analysis suggests that increasing female education by one year reduces early fertility by 0.26 births.

Household bargaining over fertility: Theory and evidence from Malaysia
(Abstract; subscription needed for full text; Asia)
Journal of Development Economics. 2008 Jun;86(2):215-241.
Rasul I
We develop and test a model of household bargaining over fertility when transfers between spouses are possible. The model makes precise how the fertility preferences of each spouse translate into fertility outcomes. We show this depends on whether or not spouses can commit to their future actions within marriage. If couples bargain with commitment, fertility outcomes take account of both spouses' fertility preferences and do not depend on the threat point in marital bargaining. If couples bargain without commitment, the influence of each spouse's fertility preference on fertility outcomes depends on the relevant threat point in marital bargaining, and the distribution of bargaining power. We test the models using household data from the Malaysia Family Life Survey. This data set contains information on each spouse's desired fertility level, as well as fertility outcomes. We exploit differences in threat points in marital bargaining across ethnic groups to help identify the underlying bargaining model. The evidence suggests couples bargain without commitment.

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Volume 8, Number 2416 June 2008