Volume 8, Number 25
23 June 2008

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ADOLESCENT HEALTH RESEARCH

Monitoring HIV risk and evaluating interventions among young people in urban West Africa: Development and validation of an instrument
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS Education and Prevention. 2008 Jun;20(3):203-219.
Boileau C | Rashed S | Sylla M | Zunzunegui MV
We developed an instrument for HIV/AIDS behavioral surveillance applicable to youth living in urban West Africa. The instrument includes a comprehensive set of constructs borrowed from the sociocognitive theory of planned behavior as well as measures of parental and peer communication. An exploratory (n = 189) and validation sample (n = 342) of young men and women living in Bamako were interviewed. Scale construct validity was assessed via factor analysis and multiple linear regressions and internal consistency was assessed using Cronbach's coefficient. All constructs had high internal consistency, scales' structure was relatively stable, and associations between different components of the questionnaire were in the predicted directions. Gender, sexual experience and education were significantly associated with attitudes and perception of control. Furthermore, attitudes, perceived behavioral control, perceived norms, and peer communication significantly predicted condom use. This questionnaire offers a valid and reliable tool for assessing young people's sexual behavior in an urban West African setting.

Sex education via computer-aided instruction for early secondary school students
(Research Article; Asia)
Journal of the Medical Association of Thailand. 2008 May;91(5):759-763.
Eamratsameekool W
Development and utilization of computer-aided instruction (CAI) on sex education may facilitate learning and provide an additional education channel to early secondary school students. Randomized control-group pretest-posttest design was used and was applied to four student groups from different schools within Roi Et Municipality as 1) CAI, 2) CAI control, 3) Teacher, and 4) Teacher control groups. The CAI were developed and organized in accordance with new sex education concepts. Questionnaires were also developed accordingly. Analysis of covariance (ANCOVA) was employed. One hundred and eighty three students from four rooms from four different schools were enrolled. The pretest scores were 24.65, 27.44, 31.51, and 33.66; and posttest scores were 25.00, 25.74, 33.80, and 34.77 for CAI, CAI control, Teacher, and Teacher control groups, respectively. The ANCOVA revealed there was no significant difference between the CAI and the CAI control groups (F = 0.399; p = 0.529) and between the Teacher and the Teacher control groups (F = 0.307; p = 0.581). Sexual knowledge of CAI group did not differ from the control group. Computer competency of the students underlined CAI usage.

Adolescent and adult participation in an HIV vaccine trial preparedness cohort in South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Adolescent Health. 2008 Jul;43(1):8-14.
Middelkoop K | Myer L | Mark D | Mthimunye SP | Smit J
The importance of involving adolescents in HIV prevention trials has been recognized, but there have been few experiences reported from sub-Saharan Africa. We analyzed adult and adolescent data from a cohort study conducted to assess the feasibility of involving adolescents and adults in HIV vaccine-related studies. Two hundred HIV-negative participants aged 16 to 40 years were enrolled, including 86 (43%) adolescents. At baseline, sexual risk behavior and willingness to participate (WTP) in future HIV vaccine trials questionnaires were administered. Three monthly HIV counseling, pregnancy, HIV and syphilis tests were performed. Risk questionnaires were repeated at 6 months and WTP at 12 months. No significant difference in retention between adults (83%) and adolescents (87%) was noted (p = .58). Initially, more adults (40%) reported WTP compared to adolescents (13%) (p less than .001). At the end of the study both groups reported higher levels of WTP; increasing to 40% among adolescents. HIV incidence during the study was 9.2 infections per 100 person-years (95% confidence interval [CI]: 4.4-19.2) among adolescents compared to 5.8 (95% CI 2.6-12.9) in adults (p = .42). Retention of high-risk HIV-negative adolescents in a cohort study is feasible. Following education, adolescents reported improved WTP. The high HIV incidence rate in adolescents highlights the importance of including this group in prevention trials.

Relative contribution of intrapersonal and partner factors to contraceptive behavior among Taiwanese female adolescents
(Abstract; subscription needed for full text; Asia)
Journal of Nursing Scholarship. 2008 Jun;40(2):131-136.
Wang RH | Chiou CJ
The purpose of this study was to explore the relative contribution of intrapersonal factors (demographic data, sexual history, and self-efficacy for contraception) and partner factors (perceptions of support from sexual partners for contraception, and relationship power) to contraceptive behaviors among sexually active female adolescents in Taiwan. Using a cross-sectional design, we recruited female adolescents who have had a steady male sexual partner in the past 3 months (N = 375 ) as participants. Questionnaires including demographic data, sexual history, contraceptive behavior, self-efficacy for contraception, perceptions of support from sexual partner for contraception, and perceptions of relationship power were submitted anonymously for this study. Participants who had their first sexual experience at less than 14 years of age and were from one-parent families had the least comprehensive contraceptive behavior than did other participants. Number of steady sexual partners was significantly negatively correlated with contraceptive behavior. Self-efficacy, perceptions of support from sexual partner for contraception, and relationship power all were positively correlated with contraceptive behavior. The important explanatory variables of contraceptive behavior were self-efficacy, age of first sexual intercourse, intervals between sexual intercourse, and perceptions of support from sexual partner for contraception. These accounted for 39.1% of variance in contraceptive behavior. Intrapersonal factors (self-efficacy, age of first sexual intercourse, and intervals between sexual intercourse) were more important than were partner factors (perceptions of support from sexual partners for contraception and relationship power) in influencing contraceptive behavior among sexually active female adolescents in Taiwan. Intervention to increase contraceptive behavior among female adolescents should be focused more on intrapersonal factors than on partner factors.

FAMILY PLANNING RESEARCH

Inverse association of NSAID use and ovarian cancer in relation to oral contraceptive use and parity
(Abstract; subscription needed for full text; Global | Global)
British Journal of Cancer. 2008 June 3;98(11):1781-1783.
Wernli KJ | Newcomb PA | Hampton JM | Trentham-Dietz A | Egan KM
We examined the association between non-steroidal anti-inflammatory drug (NSAID) use and ovarian cancer by potential effect modifiers, parity and oral contraceptive use, in a population-based case-control study conducted in Wisconsin and Massachusetts. Women reported prior use of NSAIDs and information on risk factors in a telephone interview. A total of 487 invasive ovarian cancer cases and 2653 control women aged 20-74 years were included in the analysis. After adjustment for age, state of residence and other covariates, ever use of NSAIDs was inversely associated with ovarian cancer in never users of oral contraceptives (odds ratio (OR=0.58, 95% confidence interval (CI) 0.42-0.80) but not for ever users (OR=0.98, 95% CI 0.71-1.35) (P-interaction = 0.03). A reduced risk with NSAID use was also noted in nulliparous women (OR=0.47, 95% CI 0.27-0.82) but not among parous women (OR=0.81, 95% CI 0.64-1.04) (P-interaction=0.05). These results suggest that use of NSAIDs were beneficial to women at greatest risk for ovarian cancer.

Spermicidal bacteriocins: Lacticin 3147 and subtilosin A
(Abstract; subscription needed for full text; Global)
Bioorganic and Medicinal Chemistry Letters. 2008 May 15;18(10):3103-3106.
Silkin L | Hamza S | Kaufman S | Cobb SL | Vederas JC
Spermicidal compounds that also exhibit antimicrobial properties would be extremely attractive agents as they could be used to not only prevent unwanted pregnancy but also to combat the growing prevalence of sexually transmitted infections (STI). One class of compounds that are potential candidates for development of dual-acting contraceptive products are antimicrobial peptides (AMPs). Herein, we report preliminary studies carried out to investigate the spermicidal activity of two bacteriocins, lacticin 3147 and subtilosin A, on bovine, horse/pony, boar and rat sperm.

Use of emergency contraceptive pills and condoms by college students: A survey
(Abstract; subscription needed for full text; Asia)
International Journal of Nursing Studies. 2008 May;45(5):775-783.
Kang HS | Moneyham L
This study examined the intentions, knowledge, and attitudes of college students regarding the use of emergency contraceptive pills (ECPs) and condoms. A cross-sectional descriptive study was conducted at 16 Korean colleges. Data were collected from March 15 to June 10, 2006 from a convenience sample of 1046 college students using a survey questionnaire. The survey included measures of demographic variables, intention to use ECPs (one item) and condoms (one item), knowledge about ECPs (12 items), and attitudes toward using ECPs (12 items) and condoms (16 items). All items except knowledge were rated on a 5-point Likert-type response format, with higher scores indicating greater intentions, more positive attitudes, and greater knowledge. Of the 1046 participants, 76.3% had heard of ECPs and 13.2% of the sexually active participants (n = 190) had used them. Participants showed a general lack of knowledge about ECPs and misconceptions about their safety. The intentions of using ECPs and condoms were positively correlated with each other and with attitude such that the more positive the attitude, the greater their intention to use both ECPs and condoms. There were significant gender differences on many of the variables, in that female students had higher knowledge about ECPs, intention of using ECPs and condoms, and more positive attitude toward condoms than male students who had more positive attitudes toward ECPs. Females had more concerns about the safety of ECPs than males. The findings suggest that college students must be better informed about ECPs, and reassured about their safety. Additionally, promoting ECPs would not negatively affect condom use. Efforts are needed to disseminate up-todate information to the general public and to develop educational and awareness programs to empower young people to make informed decisions about the use of ECPs and condoms.

GENDER and HEALTH RESEARCH

Empowerment and physical violence throughout women's reproductive life in Mexico
(Abstract; subscription needed for full text; North America)
Violence Against Women. 2008 Jun;14(6):655-677.
Castro R | Casique I | Brindis CD
This article analyzes intimate partner violence (IPV) against women aged 15 to 21, 30 to 34, and 45 to 49, based on the 2003 National Survey on the Dynamics of Household Relationships (in Spanish, ENDIREH) in Mexico. The authors examined the degree of women's empowerment and autonomy in relation to their partners. Logit regression analyses showed that variables significantly associated with physical violence varied between the three age groups, suggesting that women followed specific trajectories throughout their reproductive lives. Some dimensions of empowerment reduced the risk of violence (women's ability to decide whether to work, when to have sexual relations, and the extent of their partners' participation in household chores). Other dimensions (women's decision making regarding reproductive matters) increased such risk. Thus, access to resources meant to empower women did not automatically decrease the risk of violence. The authors recommend specific interventions tailored to each age group, aimed at breaking the cycle of violence.

Use of modern medical care for pregnancy and childbirth care: Does female schooling matter?
(Research Article; Asia)
[Washington, D.C.], World Bank, East Asia and Pacific Region, Human Development Sector Department, Health, Nutrition and Population, 2008 May. 66 p. (Policy Research Working Paper No. 4625)
Somanathan A
Controversy exists over whether the estimated effects of schooling on health care use reflect the influence of unobserved factors. Existing estimates may overstate the schooling effect because of the failure to control for unobserved variables or may be downwardly biased due to measurement error. This paper contributes to the resolution of this debate by adopting an instrumental variable approach to estimate the impact of female schooling on maternal health care use. A school construction program in Indonesia in the 1970s is used to construct an instrumental variable for education. The choice between use and non-use of maternal health services is estimated as a function of schooling and other variables. Data from the Indonesia Family Life Survey are used for this paper. Standard regression models estimated in the paper indicate that each additional year of schooling does indeed have a significant, positive effect on maternal health care use. Instrumental variable estimates of the schooling effect are larger. The results suggest that schooling has a positive impact on maternal health care use even after eliminating the effect of unobserved variables and measurement error. This paper moves beyond previous work on the impact of education on health care use by adopting an IV approach to address the problem of endogeneity and measurement error. IV methods have been used widely in the labour economics literature to examine the impact of schooling on wages and other labour market outcomes but rarely to estimate the effect of schooling on health outcomes.

Psychiatric morbidity following hysterectomy in Egypt
(Abstract; subscription needed for full text; North Africa)
International Journal of Gynecology and Obstetrics. 2008 Jul;102(1):60-64.
Helmy YA | Hassanin IM | Elraheem TA | Bedaiwy AA | Peterson RS
The objective of this study was to evaluate psychiatric morbidity in Egyptian women before and after hysterectomy for benign indications. This was a 2-year prospective observational study at Sohag University Hospital, Egypt, in which 96 women scheduled for hysterectomy were assessed for psychiatric comorbidity before and after the operation using the General Health Questionnaire (GHQ-28), Beck Depression Inventory, and Hamilton Anxiety Scale. Of these, 35 (36.5%) had scores of 4 or higher, signifying psychiatric comorbidity (group 1), and 61 (63.5%) had scores less than 4, suggesting no psychiatric comorbidity (group 2). Postoperatively, severe anxiety and depressive symptoms were common in group 1. In group 2, 48 (78.7%) of the 61 women had scores of 4 or higher. In that subgroup, depressive and anxiety symptoms were more common among nulliparas whereas women with a high parity experienced the least psychiatric comorbidity. As women undergoing hysterectomy risk psychiatric morbidity, gynecologists should consider less invasive interventions to treat benign conditions.

Priorities for women's health from the Global Burden of Disease study
(Abstract; subscription needed for full text; Global)
International Journal of Gynecology and Obstetrics. 2008 Jul;102(1):82-90.
Ribeiro PS | Jacobsen KH | Mathers CD | Garcia-Moreno C
Women's health is increasingly recognized as a global health priority. It is essential to address not only sexual and reproductive health, but also other health issues that occur throughout life. This paper uses the 2005 estimates of morbidity and mortality from the WHO Global Burden of Disease study and a review of the literature to identify key areas of concern for women by age group and world region. The leading causes of death in women aged between 15 and 44 years include infectious diseases such as HIV/AIDS, tuberculosis, maternal health conditions, and injuries. The leading causes of death in women aged 45 years and older include cardiovascular diseases, chronic obstructive pulmonary disease, and other noncommunicable conditions. Neuropsychiatric and sensory disorders are a major cause of disability for both age groups. An understanding of the key regional and age-specific priorities for women's health will facilitate the development of appropriate interventions and policies to reduce disease burden.

Postnatal depression and the experience of South Asian marriage migrant women in Taiwan: Survey and semi-structured interview study
(Abstract; subscription needed for full text; Asia)
International Journal of Nursing Studies. 2008 Jun;45(6):924-931.
Huang YC | Mathers NJ
The objective of this study was to investigate the experience of South Asian marriage migrant women in Taiwan by (1) determining their experiences and health beliefs during the postnatal period and their uptake of health care and determining the number of women with positive screening scores for postnatal depression during this period. South Asian marriage migrant women were recruited using the following criteria: (1) Vietnamese and Indonesian women living in Taiwan for more than 1 year; (2) 6 months post-uncomplicated delivery; (3) conversational ability in Taiwanese and/or Mandarin Chinese and (4) a semi-structured interview and translated versions of the Edinburgh Postnatal Depression Scale (EPDS) investigated their experiences and health beliefs and identified the women with positive screens for postnatal depression. A total of 106 migrant women agreed to take part. Ninety-two women were from Vietnam (86.7%) and 14 from Indonesia (13.3%). More than half (56.6%) were aged between 19 and 24 (66% primigravida). The husbands of the women were mainly unskilled workers (80%). The frequency of a positive screen for postnatal depression was 25.5% (EPDS score greater than 13). There was a statistically significant association between a score of 13 or more on the EPDS and self-reported 'emotional distress' following birth (p less than 0.01 ANOVA). Thematic analysis derived four key themes related to their experience and health beliefs: (1) Self-reported health: Although the main concern of the migrant women was the health of their baby and their families, some of them found their new families were unsupportive when they themselves were unwell. (2) Health beliefs: Dietary beliefs were important with a number of issues arising from a difference in health beliefs between themselves and their new families. (3) Access to health care: Communication problems and difficulties arising from their relationships with their new families affected 1/3 of women's access to health care and available health information. (4) Adaptation to a new environment: Many of the women described how difficult it was to adapt to their new environment and how they coped with the difficulties. South Asian migrant women in Taiwan face considerable challenges. If the health needs of these women are to be met, interventions which are 'culturally competent' at the level of the individual, family and organisation need to be developed.

HIV/AIDS and STIs RESEARCH

The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda
(Abstract; subscription needed for full text; Sub-Saharan Africa)
PLoS Medicine. 2008 Jun;5(6):e116.
Kigozi G | Gray RH | Wawer MJ | Serwadda D | Makumbi F
The objective of the study was to compare rates of adverse events (AEs) related to male circumcision (MC) in HIV-positive and HIV-negative men in order to provide guidance for MC programs that may provide services to HIV-infected and uninfected men. A total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization [WHO] stage I or II and CD4 counts greater than 350 cells/mm3) were circumcised in two separate but procedurally identical trials of MC for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1-2 d and 5-9 d, and at 4-6 wk, to assess surgery-related AEs, wound healing, and resumption of intercourse. AE risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios (AdjORs) were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrollment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe AEs were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (AdjOR 0.91, 95% confidence interval [CI] 0.47-1.74). Infections were the most common AEs (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 wk postsurgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). AEs were more common in men who resumed intercourse before wound healing compared to those who waited (AdjOR 1.56, 95% CI 1.05-2.33). Overall, the safety of MC was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counseled to refrain from intercourse until full wound healing is achieved.

Efavirenz replacement by immediate full-dose nevirapine is safe in HIV-1-infected patients in Cambodia
(Abstract; subscription needed for full text; Asia)
HIV Medicine. :[5] p..
Laureillard D | Prak N | Fernandez M | Ngeth C | Moeung S
Efavirenz is used for the antiretroviral treatment of HIV/tuberculosis-coinfected patients in developing countries. A switch to nevirapine is regularly carried out because of the cost and side effects of efavirenz. Pharmacokinetic studies suggested that nevirapine should be initiated at full dose when used as a substitute for efavirenz. The aim of this study was to measure the cumulative incidence of adverse events (AEs) related to nevirapine in patients switched from efavirenz to immediate full-dose nevirapine (FDN). In 2001 an antiretroviral treatment programme was initiated with the first-line regimen stavudine, lamivudine and efavirenz. In 2003, the fixed-dose combination of stavudine, lamivudine and nevirapine was recommended. Thus, first-line therapy was changed and FDN was initiated when patients were switched from efavirenz to nevirapine. Between April and December 2004, 394 patients were switched from efavirenz to FDN. The cumulative incidence of AEs related to nevirapine was 13.2% [95% confidence interval (CI) 10.2-16.7] and that of severe AEs was 8.9% (95% CI 6.5-11.9). In women the incidence of AEs was 17.6% (95% CI 12.1-24.3) and that of severe AEs was 12.2% (95% CI 7.7-18.2). Our results indicate that an FDN switch from efavirenz does not appear to result in more AEs than when nevirapine is initiated with escalating doses. These data are particularly relevant in resource-limited settings.

HIV and sexual risk behaviors among recognized high-risk groups in Bangladesh: Need for a comprehensive prevention program
(Abstract; subscription needed for full text; Asia)
International Journal of Infectious Diseases. 2008 Jul;12(4):363-370.
Islam MM | Conigrave KM
The objective of this study was to examine trends in HIV and related risk behaviors among recognized high-risk groups in Bangladesh, the types and extent of prevention initiatives that have been undertaken, and highlight the immediate needs. Journal publications and conference abstracts and proceedings were reviewed. Experts involved in the development and evaluation of current programs or policy were contacted for official reports and policy documents. The trends in sexual risk behaviors over five rounds of national surveillance were tabulated. Gaps in the ongoing prevention interventions have been assessed in the light of the Anderson-May equation. Periodic surveillance on recognized high-risk groups shows that HIV prevalence has been increasing steadily. In the capital city, HIV prevalence in one subset of a high-risk group is close to the level of a concentrated epidemic (4.9%). The high prevalence of sexual risk behaviors among drug users and sex workers and their clients is alarming. Although a small increase in condom use and a reduction of syphilis have been noted among subsets of high-risk groups in recent years, this is clearly not enough to curb the threat of a possible HIV epidemic. There is an urgent need for a comprehensive prevention program that should include more efforts on education and condom promotion, effective management of all sexually transmitted infections, a screening program for migrant workers, the continuation of both behavioral and serological components of HIV surveillance, and the expansion of surveillance to cover the remaining high-risk groups, with due consideration to the consistency of surveillance indicators.

Prevalence of sexually transmitted infections among sexually active Jordanian females
(Abstract; subscription needed for full text; Middle East)
Sexually Transmitted Diseases. 2008 Jun;35(6):607-610.
Mahafzah AM | Al-Ramahi MQ | Asa'd AM | El-Khateeb MS
The objective of this study was to determine the prevalence of the most important sexually transmitted infections among women of child bearing age in Jordan. The goal was to assess the need for screening programs to detect sexually transmitted infections. This is a cross-sectional study wherein consecutive symptomatic and asymptomatic women presenting to gynecology and family planning clinics from different areas in Jordan were tested for reproductive tract infections caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, and Trichomonas vaginalis. The prevalence of C. trachomatis infection was 0.6% and 0.5%, among symptomatic and asymptomatic women respectively, that of N. gonorrhoeae was 0.9% and 2.2%, that of T. pallidum 0.0% and 0.0%, and that of Tr. vaginalis was 0.7% and 0.5%. These prevalence rates did not differ significantly between symptomatic and asymptomatic women. Based on the low prevalence of sexually transmitted infections detected in this study among Jordanian women, the need for screening programs for such infections is questioned.

Consistent condom use in married Zimbabwean women after a condom intervention
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Sexually Transmitted Diseases. 2008 Jun;35(6):624-630.
Callegari L | Harper CC | Van der Straten A | Kamba M | Chipato T
Condom use to prevent HIV in Africa has increased in nonmarital sexual encounters but remains low within marriage. Married women of reproductive age, however, are at high risk of HIV. This study investigated factors associated with consistent condom use after a brief intervention. We conducted an HIV prevention condom intervention with a cohort of 394 married women, aged 17 to 47, recruited from clinics in Zimbabwe. Consistent condom users were ineligible. At enrollment, participants received education and were offered free male and female condoms and HIV testing. Women completed a follow-up questionnaire at 2-months. We used logistic regression analysis to measure the association of protected sex (i.e., 100% use of male or female condoms) at follow-up with condom attitudes, negotiation skills, HIV risk perception and testing. At follow-up, 179 (48.5%) women reported consistent condom use throughout the study, and 318 (87%) reported condom use at last sexual episode; 72 women tested HIV-positive, only 4 of whom reported at enrollment that it was likely that they were infected. Results showed that women who tested positive were more likely to report consistent condom use (OR 2.9, 95% CI 1.7-5.2). HIV risk perceptions and condom negotiation self-efficacy increased postintervention, and were significantly associated with consistent condom use. Hormonal contraception was negatively associated with consistent condom use (OR 0.3, 95% CI 0.19-0.65). Married women reported significant increases in consistent condom use in response to a brief intervention, especially if HIV-positive.

Barriers to access to antiretroviral treatment in developing countries: A review
(Abstract; subscription needed for full text; Global)
Tropical Medicine and International Health. 2008 Jul;13(7):904-913.
Posse M | Meheus F | van Asten H | van der Ven A | Baltussen R
The objective of this study was to present a review of barriers impeding people living with HIV / AIDS in developing countries from accessing treatment, and to make recommendations for further studies. Electronic databases, websites of main global agencies and international AIDS conferences were searched for relevant articles published between 1996 and 2007. Articles were reviewed using the Andersen and May framework of access to health services and barriers were categorized as either population-level or health system-level barriers. A total of 19 studies (7 articles and 12 abstracts) in English were reviewed. The barriers most frequently cited at the population level were lack of information about antiretroviral therapy (ART), perceived high costs for ART and stigma. Barriers most frequently cited at the health system level were long distance from home to the health facility, lack of co-ordination across services and limited involvement of the community in the programme planning process. Dissemination of information about HIV / AIDS and alternative related care, and alternative health financing policies seem to be the most relevant policy measures to remove barriers. In view of the paucity of evidence on barriers to access to ART, research should address the relative importance of barriers, include a mix of qualitative and quantitative research methods and evaluate barriers in different settings.

MATERNAL AND CHILD HEALTH RESEARCH

Developing evidence-based maternity care in Iran: A quality improvement study
(Research Article; Middle East)
BMC Pregnancy and Childbirth. 2008 Jun 13;8:20.
Aghlmand S | Akbari F | Lameei A | Mohammad K | Small R
Current Iranian perinatal statistics indicate that maternity care continues to need improvement. In response, we implemented a multi-faceted intervention to improve the quality of maternity care at an Iranian Social Security Hospital. Using a before-and-after design our aim was to improve the uptake of selected evidence based practices and more closely attend to identified women?s needs and preferences. The major steps of the study were to (1) identify women?s needs, values and preferences via interviews, (2) select through a process of professional consensus the top evidence-based clinical recommendations requiring local implementation (3) redesign care based on the selected evidence-based recommendations and women?s views, and (4) implement the new care model. We measured the impact of the new care model on maternal satisfaction and caesarean birth rates utilising maternal surveys and medical record audit before and after implementation of the new care model. Twenty women?s needs and requirements as well as ten evidence-based clinical recommendations were selected as a basis for improving care. Following the introduction of the new model of care, women?s satisfaction levels improved significantly on 16 of 20 items (p less than 0.0001) compared with baseline. Seventy-eight percent of studied women experienced care consistent with the new model and fewer women had a caesarean birth (30% compared with 42% previously). The introduction of a quality improvement care model improved compliance with evidence-based guidelines and was associated with an improvement in women?s satisfaction levels and a reduction in rates of caesarean birth.

Social costs of skilled attendance at birth in rural Ghana
(Abstract; subscription needed for full text; Sub-Saharan Africa)
International Journal of Gynecology and Obstetrics. 2008 Jul;102(1):91-94.
Bazzano AN | Kirkwood B | Tawiah-Agyemang C | Owusu-Agyei S | Adongo P
The objective of this study was to examine the social costs to women of skilled attendance at birth in rural Ghana. Ethnographic data were obtained through participant observation, interviews, case histories, and focus groups and were analyzed alongside data from a birth cohort of 2878 singletons born in the Kintampo study district between July 2003 and June 2004. Most women delivered at home. Home delivery raises a woman's status in her community, while seeking skilled attendance lowers it. Women feel that seeking assistance in childbirth wastes other people's time and they value secrecy in labor. Negative treatment by health providers and expensive supplies needed for delivery also act as barriers. The social costs of obtaining skilled attendance at birth must be offset by community level strategies such as mobilization of older women and husbands, and ensuring health providers extend professional, humane care to laboring women.

Practices of rural Egyptian birth attendants during the antenatal, intrapartum and early neonatal periods
(Report; North Africa)
Journal of Health, Population and Nutrition. 2008 Mar;26(1):36-45.
Darmstadt GL | Hussein MH | Winch PJ | Haws RA | Gipson R
Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Two-thirds of neonatal deaths occur during the first week of life, usually at home. While previous Egyptian studies have identified provider practices contributing to maternal mortality, none has focused on neonatal care. A survey of reported practices of birth attendants was administered. Chi-square tests were used for measuring the statistical significance of inter-regional differences. In total, 217 recently-delivered mothers in rural areas of three governorates were interviewed about antenatal, intrapartum and postnatal care they received. This study identified antenatal advice of birth attendants to mothers about neonatal care and routine intrapartum and postpartum practices. While mothers usually received antenatal care from physicians, traditional birth attendants (dayas) conducted most deliveries. Advice was rare, except for breastfeeding. Routine practices included hand-washing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns, and lack of administration of eye prophylaxis or vitamin K. One-third of complicated deliveries occurred at home, commonly attended by relatives, and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities, mothers reported frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported. Priority areas for behaviour change and future research to improve neonatal health outcomes were identified, specific to type of provider (physician, nurse, or daya) and regional variations in practices.

Undertaking a complex evaluation of safe motherhood in rural Burkina Faso
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Tropical Medicine and International Health. 2008 Jul;13 Suppl 1:1-5.
Graham WJ | Conombo SG | Zombre DS | Meda N | Byass P
Evaluations of composite health interventions, such as those attempting to make motherhood safer, are by definition complex, but nevertheless regarded as essential to informing progress in global health. This paper introduces a series of reports which set out the basis of Family Care International's Skilled Care Initiative in rural Burkina Faso, go on to describe strategies and methods for evaluating it, and present evaluation findings in terms of pregnancy outcomes, utilisation and effects of the intervention and economics. Although there were encouraging findings, no 'magic bullets' emerged from these studies, illustrating the reality that sustained and increasing resources are needed to achieve safe motherhood for all. There is no cheap or short-cut solution.

Understanding home-based neonatal care practice in rural southern Tanzania
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008 Jul;102(7):669-678.
Mrisho M | Schellenberg JA | Mushi AK | Obrist B | Mshinda H
In order to understand home-based neonatal care practices in rural Tanzania, with the aim of providing a basis for the development of strategies for improving neonatal survival, we conducted a qualitative study in southern Tanzania. In-depth interviews, focus group discussions and case studies were used through a network of female community-based informants in eight villages of Lindi Rural and Tandahimba districts. Data collection took place between March 2005 and April 2007. The results show that although women and families do make efforts to prepare for childbirth, most home births are assisted by unskilled attendants, which contributes to a lack of immediate appropriate care for both mother and baby. The umbilical cord is thought to make the baby vulnerable to witchcraft and great care is taken to shield both mother and baby from bad spirits until the cord stump falls off. Some neonates are denied colostrum, which is perceived as dirty. Behaviour-change communication efforts are needed to improve early newborn care practices.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

The legacies of context: Past and present influences on contraceptive choice in Nang Rong, Thailand
(Abstract; subscription needed for full text; Asia)
Demography. 2008 May;45(2):283-302.
Edmeades J
This study explores the ways in which women's contraceptive behavior in a rural area of Thailand is shaped by both past and present context, based on the life course framework. Although the importance of contextual influences for contraceptive behavior is well established in the literature, relatively little research has been conducted that explores how behavior is influenced by historical and contemporaneous contextual factors and by individual life experiences. In addition, much of this research has neglected the role of the normative environment within which contraceptive use takes place. The focus of this paper centers on the effect of contraceptive environment at both early and late stages of the life course and on how this effect is shaped by individual experience with migration to urban areas. This study takes advantage of a unique, prospective longitudinal data set with detailed information on community context at multiple points in time, an important improvement upon prior research. The results show that contraceptive behavior is particularly responsive to current community context, with past context primarily exerting an indirect effect on behavior through shaping current contextual influences.

Birth-spacing, fertility and neonatal mortality in India: Dynamics, frailty, and fecundity
(Abstract; subscription needed for full text; Asia)
Journal of Econometrics. 2008 Apr;143(2):274-290.
Bhalotra S | van Soest A
Using microdata on 30,000 childbirths in India and dynamic panel data models, we analyse causal effects of birth spacing on subsequent neonatal mortality and of mortality on subsequent birth intervals, controlling for unobserved heterogeneity. Right censoring is accounted for by jointly estimating a fertility equation, identified by using data on sterilization. We find evidence of frailty, fecundity, and causal effects in both directions. Birth intervals explain only a limited share of the correlation between neonatal mortality of successive children in a family. We predict that for every neonatal death, 0.37 additional children are born, of whom 0.30 survive.

The relationship between rainfall and human density and its implications for future water stress in Sub-Saharan Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Ecological Economics. 2008 Jun 15;66(2-3):319-336.
le Blanc D | Perez R
This paper estimates the relationship between average rainfall and population density in Sub-Saharan Africa in order to assess the consequences of climate and demographic changes in terms of future water stress in that region. Geographic Information System (GIS) data on density and rainfall and climate change scenarios are combined in order to identify areas which will be subject to increased pressures stemming from excessive population, given their precipitation levels. We first describe the empirical relationship existing between average yearly rainfall and density over sub-Saharan Africa. The limit of 900 mm of annual rainfall appears to define the threshold below which water constitutes a binding constraint to higher densities. Above that threshold, density and rainfall are not spatially correlated. In a second stage, we identify areas subject to water stress. In our framework, those are defined as zones belonging to the right end of the distribution of densities conditional on average rainfall. In a last step, localized population projections and changes in rainfall predicted by two mainstream climate change scenarios are utilized to assess the respective impacts of those two factors on the changes in extent and distribution of high-stress zones over the continent between 2000 and 2050. If population growth follows projected trends, density increases across the continent should lead to a significant increase in the extent of such zones, especially around the Sahel belt and in Eastern Africa. The impact of changes in rainfall is more difficult to assess, because climate models differ locally as regards projections of yearly rainfall, especially in intermediate zones such as the Sahel. If, according to the predictions of most climate models, the Sahel were to experience average rainfall increases, these would ease, though not offset totally, the pressure stemming from demographic growth in that region. In contrast, in most of Eastern Africa, predicted drops in average rainfall would work in the same direction as demographic changes to increase the pressure on significant parts of the territory. In Southern Africa, demographic stagnation is likely to mitigate significantly the impact of climate change.

Population growth and natural-resources pressures in the Mekong River Basin
(Abstract; subscription needed for full text; Asia)
AMBIO. 2008 May 1;37(3):219-224.
Pech S | Sunada K
The main purpose of this paper is to stimulate policy debate over the current national focus on food self-sufficiency and a broader national and regional development agenda in the Mekong River Basin. We provide the context, empirical evidence, and an analysis of the demand (real or perceived) associated with population growth. We also present a comparison of demand forecasts with the sustainable potential of the natural-resources base of the Mekong River Basin in order to contribute to a better understanding of this immense and complex Mekong River Basin environment.

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