Maternal versus paternal orphans and HIV/STI risk among adolescent girls in Zimbabwe.

The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Orphans (whether orphaned by AIDS or other causes) have been shown to have economic and educational disadvantages as well as poor reproductive health outcomes. We recruited a convenience sample of 200 girls in a peri-urban area of Zimbabwe to examine the impact of orphan status (compared to non-orphans) on household composition, education, risk behaviour, pregnancy and prevalent HIV and HSV-2 infection. In our population, maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had an STI, to have been pregnant and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school. Our findings suggest that maternal care and support is important for HIV prevention. This finding corroborates previous research in Zimbabwe and has implications for intervention strategies among orphan girls.

Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database.

Using a retrospective analysis of the Intensive Care National Audit and Research Centre Case Mix Programme Database (ICNARC CMPD), we have summarised the characteristics and outcomes for mechanically ventilated patients admitted to UK intensive care units (ICUs) after cardiac arrest. Descriptive statistics on case mix, physiology, treatment, service delivery, outcome and activity were described separately for community cardiac arrest, in-hospital cardiac arrest (peri-operative) and in-hospital cardiac arrest (not peri-operative). The impact on outcome of several patient characteristics and physiological values were analysed using multivariable logistic regression. Mechanically ventilated survivors of cardiac arrest accounted for 24,132 (5.8%) of all admissions to the 174 ICUs in the ICNARC CMP. Of these, 10,347 (42.9%) survived to leave the ICU and 6778 (28.6%) survived to acute hospital discharge. The ICNARC model gives much better discrimination than APACHE II for predicting hospital mortality after admission to ICU following cardiac arrest: the predicted hospital mortality based on the APACHE II and ICNARC model was 41.9% and 79.7%, respectively.

Therapeutic hypothermia after cardiac arrest: a survey of practice in intensive care units in the United Kingdom.

A telephone survey was carried out on the use of hypothermia as part of the management of unconscious patients following cardiac arrest admitted to United Kingdom (UK) intensive care units (ICUs). All 256 UK ICUs listed in the Critical Care Services Manual 2004 were contacted to determine how many units have implemented therapeutic hypothermia for unconscious patients admitted following cardiac arrest, how it is implemented, and the reasons for non-implementation. Two hundred and forty-six (98.4%) ICUs agreed to participate. Sixty-seven (28.4%) ICUs have cooled patients after cardiac arrest, although the majority of these have treated fewer than 10 patients. The commonest reasons given for not using therapeutic hypothermia in this situation are logistical or resource issues, or the perceived lack of evidence or consensus within individual ICU teams.

Implementing intensive insulin therapy: development and audit of the Bath insulin protocol.

Intensive insulin therapy to control blood glucose has been found to reduce mortality among critically ill patients in a surgical intensive care unit, though a simple prescriptive insulin infusion protocol to achieve this has not been published previously. This study documents the development and routine use of a simple prescriptive intravenous insulin infusion protocol for critically ill patients and compares the results with previous practice. During development the protocol was optimized and practical issues of implementation addressed. The optimized protocol was then used for all ICU admissions, and a prospectively defined retrospective chart audit performed for the first month of use. Results were compared with a similar time period the previous year. In September 2002, 27 admissions were started on the protocol. Blood glucose for the time on the protocol had a median value of 6.2 (IQR 5.9-7.1) mmol/l compared with 9.2 (IQR 8.1-10.2) mmol/l for those on insulin in 2001. Blood glucose for the whole ICU stay for those on the protocol in 2002 had a median value of 6.6 (IQR 6.0-7.4) mmol/l compared with 8.6 (IQR 8.0-9.4) mmol/l in 2001. Blood glucose for all ICU patients in 2002 had a median value of 6.5 (IQR 6.0-7.3) mmol/l compared with 7.2 (IQR 6.3-8.3) mmol/l in 2001. Three blood glucose recordings were less than 2.2 mmol/l in September 2002. This study provides initial effectiveness and safety data for the Bath Insulin Protocol Further audits in a larger patient population are now needed.

Knowledge of malaria, risk perception, and compliance with prophylaxis and personal and environmental preventive measures in travelers exiting Zimbabwe from Harare and Victoria Falls International airport.

BACKGROUND: Travel associated malaria is a major health risk for visitors to malaria endemic destinations. To examine the knowledge of malaria prevention, risk perception, current prophylactic behavior, and compliance with chemoprophylaxis and personal and environmental protection measures we conducted a study in a cohort of travelers exiting Zimbabwe from two international airports during a peak malaria transmission period. METHODS: Data were collected by pretested self-administered questionnaires from 595 adults in the departure lounges of Harare and Victoria Falls International airports. Excluded were children and travelers from the African continent. A multilingual research assistant supervised data collection. RESULTS: The majority of travelers obtained health advice prior to travel. Patterns of protective behavior and compliance with prophylaxis were inconsistent with a high perception of malaria threat and good knowledge. About 23% of travelers failed to use chemoprophylaxis during their visit. In the group of travelers who used chemoprophylaxis, 18% were noncompliant. Fifteen drug combinations were in use. Full compliance with medication plus use of personal preventive measures always was estimated as 13%. Forgetfulness was the main cause of noncompliance, followed by deliberate omission due to side effects. Of 57 travelers who reported side effects from current medication, over half used mefloquine. CONCLUSIONS: There is a need to examine how people process personal risk and communications about risk. We must recognize the competition between precautionary measures against malaria and other life demands that are imposed by travel, especially in young long stay travelers and persons visiting primarily for business purposes. Mediating a protective response will also depend on judgments about the effectiveness of the action, strengthening travelers intentions toward adherence, and increasing efficacy perception by individuals and their peers. Conflicts in prophylactic recommendations need to be resolved. As ecotourism develops in Zimbabwe and other malaria regions, stakeholders in this rapidly growing industry must be made aware of the important role they can play in protecting clients from malaria.

Voluntary testing and counselling for HIV. "Are adults in rural communities ready to test?" A descriptive survey.

OBJECTIVE: To describe rural adult preparedness to test for HIV, perceived susceptibility, response to peer group opinion, perceived positive and negative outcome expectations of testing. DESIGN: Cross sectional descriptive study. SETTING: Mashonaland West Province, Zimbabwe. SUBJECTS: Purposive convenience sample; 204 adults, 102 females, aged 18 to 50. MAIN OUTCOME MEASURES: Stage of preparedness to test for HIV, perceptions of susceptibility, response to peer group opinion, negative and positive expectations about testing. RESULTS: None of the 204 participants had knowingly been tested for HIV prior to the study; 55.8% had heard about Voluntary Counselling and Testing (VCT) and 21.0% had thought about testing. Of these, 15 (34.8%) had already talked to somebody about testing. When compared with married respondents, significantly more singles expressed preparedness to test for HIV in the next six months (p = 0.040). Only 14.2% of respondents expressed willingness to pay for a test. Females worried more than males about "getting HIV in the future" (p = 0.019). Singles were more likely to worry about their partners' current HIV status than married and once married respondents (p < 0.001). When compared with women, men showed more likelihood of responding to pressure from friends to test for HIV (p = 0.039). Strongly articulated fears about testing included being seen by friends at a VCT centre, stigmatisation, violence and stress. Significantly more women than men were fearful that an HIV test would be painful (p = 0.006). Similarly, women were more fearful than men about taking an HIV test (p = 0.007), the possibility of waiting for the result (p = 0.022) and returning for results (p = 0.020). Anticipated positive outcomes of testing included getting assistance in the early stage of the disease. CONCLUSION: Knowledge of HIV status acquired voluntarily in a psychologically and socially supportive environment will be a significant motivator for individuals and their partners to initiate and maintain safer sexual behaviour. Our study showed some preparedness among adults from two rural communities to test for HIV. While current strategies to promote VCT in urban areas reflect sensitivity to many of the fears of adults expressed in this study, the initiative must be expanded to embrace rural communities. There is a need to build on positive perceptions about testing and embrace a strategy that disables fear, particularly among women. The initiative must go beyond the individual as the primary target and be promoted within the broader context of the community with the assistance of credible opinion leaders. It should also link closely with other services that offer primary prevention, pilot treatment and support activities.

Country watch: Zimbabwe.

PIP: Tsungirirai is a counseling and information service developed during 1994 in response to the growing problem of HIV/AIDS in the small town of Norton, southwest of Harare, Zimbabwe. The objectives of the project include identification of key leaders in the area, determination of the setting in which HIV was spreading, and community consultation in program design and implementation. Tsungirirai's initial activities included a series of workshops on participatory techniques particularly the LADA (Listening-Appraisal-Dialogue-Action) method for key leaders, community men, women, and adolescents. Workshop participants demonstrated different views concerning HIV/AIDS problems. Key leaders viewed the HIV/AIDS problem within the context of existing laws that contradict traditional mores, while the youth linked the problem of HIV to the issue of unemployment and lack of recreation. Lessons learned include the following: 1) stop talking and listen; 2) start where people are at instead of telling them what they already know; 3) let the people decide; 4) turn a dream into reality; and 5) facilitate awareness process instead of leading it.^ieng

A pre-intervention survey to determine understanding of HIV and AIDS in farm worker communities in Zimbabwe.

A cumulative total of 41,298 AIDS cases have been reported in Zimbabwe as of March 1995. Of concern is the growing evidence of high levels of seroprevalence among rural farm workers. A pre-intervention survey was conducted by interview in one district to examine behavioral factors likely to place farm workers in marginalized rural communities at risk for sexually transmitted diseases (STD) and HIV infection. Seven hundred seventy commercial farm workers from 17 randomly selected commercial farm participated in the study. We found that farm worker communities, which are characterized by educationally disadvantaged women when compared with men (p < .001), have had little exposure to AIDS prevention activities. Beliefs that AIDS is brought about by divine or ancestral retribution were upheld by less education women (p < .001). A significant association was found with respect to perceived risk to HIV and low self-efficacy among uneducated women who articulated helplessness and an inability to protect themselves from HIV infection. Among more educated men, we found acknowledgment about multipartnering and that changes in behavior are more likely to develop as a result of changes in normative values (p = .075). Condom use among men, which is probably the most effective barrier against STD infection, was shown to be associated with age (p < .01) and education (p < .01). The study concludes with recommendations for an appropriate intervention.

Was the intervention implemented as intended?: a process evaluation of an AIDS prevention intervention in rural zimbabwe.

End-point evaluations are still the most commonly used method of assessing the success or failure of interventions. This article describes how a process evaluation was used to measure "what happened" during an HIV/AIDS prevention program for farm workers in Zimbabwe. The intervention was developed according to the Paulo Freirian theory of Social Change and the Ecological Model for health promotion. The stages of the intervention were cyclical; in the first stage innovative methods were used to encourage appraisal of vulnerability to HIV/AIDS through activities which raised critical thinking and dialogue. In the next phase, emphasis was placed on developing cognitive and attitude change in the target group. Self-protective behavior was encouraged through condom use and an increase in self-efficacy with respect to negotiating safe sex, especially among women. In the last stage of the intervention, efforts were made to create a climate for maintenance of behavior and socially responsible action within the community. The process evaluation provided valuable insight into factors which, when aggregated, provided an overview of a program whose successes and failures may well have been determined by issues outside the scope of the intervention. The effect of seasonal fluctuations of labor, income, and farming activity on program activity, patterns of STD, and condom demand were marked. This leads back to the researchers' initial question: "Was the intervention implemented as planned?" and the answer-only partially.

Fragile-X syndrome in North East Essex: towards systematic screening: clinical selection.

A systematic screening for fragile-X syndrome, using various clinical criteria to preselect for cytogenetic testing, was performed throughout the North East Essex Health District on 1100 people attending three different local services for people with learning disability. The selection procedure used varied from a gestalt impression to head, ear and testis measurement depending on the setting. Fifty-nine males and five females who met the selection criteria went on to have chromosome studies. Of these, 23 males and one female were positive (more than 4% positive cells). They came from 19 families. Whilst the true prevalence of fragile-X syndrome is not known in the district, at a minimum, it contributed 3.2% of the institutionalized males (health authority care), 4.4% of the boys and 2.1% of the girls attending special schools for severe learning disability, 7.9% of the boys attending schools for mild learning disability (Local Education Authority), and 3.5% of men attending the two adult training centres within the district (social services). These figures compare well with the yield from reported surveys in which all individuals without a known diagnosis were tested cytogenetically.

Picture codes as discussion starters in AIDS education.

PIP: Picture codes, poster-size collections of drawings that present a real-life problem, are being used in Zimbabwe to stimulate discussion on acquired immunodeficiency syndrome (AIDS). Unlike posters, which are intended for pubic display and present a solution to a problem, picture codes are used in small-group discussions and have no captions. Group members describe what they think is occurring in the picture code, seek a reason for the problem depicted, link the problem to real-life issues, identify the underlying causes of the problem, and then propose solutions. The effectiveness of this technique in stimulating discussion and identifying community problems was illustrated by pretesting of a picture code depicting a wealthy middle-aged man sexually propositioning a young schoolgirl. The code was shown separately to 20 mothers and 30 adolescent girls in Harare. The mothers focused on the need for the formal education system to assume a greater role in sex education given erosion of the traditional extended family. The adolescents also expressed a need for sex education in the schools and acknowledged their difficulties in rejecting sexual advances.^ieng

Using Theory to Design an Intervention for HIV/AIDS Prevention in Farm Workers in Rural Zimbabwe.

A variety of primary prevention strategies are used in HIV prevention programs in Africa. However, these are often developed through intuition and the theoretical basis for many interventions is limited to the knowledge/attitude model. This article illustrates how research findings from a base-line survey are combined with Paulo Freire's social change theory and the Ecological Model for Health Promotion to develop a participatory intervention for HIV/AIDS prevention in farm workers in Zimbabwe. The article addresses the need to focus attention on the process of change at the interpersonal level, organizational and policy levels of the community. Dialogue is central to the range of strategies proposed for the intervention. The effect will be measured through process and outcome evaluation.

AIDS education is more than telling people what not to do.

PIP: Education is only one of may approaches which may be used to bring about behavioral change. While it is clear that awareness in Africa about AIDS has grown since education campaigns were launched in the late 1980s, significant misunderstandings and misconceptions remain. The author invited seventeen nongovernmental organizations to participate in a review workshop in 1992 with the goal of learning about which communication methods are currently being used in AIDS education programs in Zimbabwe. Talks, lectures, leader controlled discussions, focus groups, drama/role play, posters, stories, and client counseling are being used to teach about AIDS. Little evidence, however, indicates that sexually active individuals within targeted risk groups have changed their behaviors to reduce the risk of HIV transmission. The denial of risk due to traditional beliefs about disease causation stemming from God or other external forces and the tendency to shift the blame for infection to women are cited as causal factors for the lack of behavior modification. Program planners and administrators must reach beyond the vague and diffuse education campaigns implemented thus far. AIDS workers must instead by trained to focus their attention upon the development of effective, targeted interventions involving communities and at-risk subpopulations.^ieng

African communities in the struggle against AIDS : the need for a new approach

The problem of AIDS in Africa not only lies in the dimensions of its transmission but it is also fraught with political and cultural sensitivity compounded by economic and social problems. Community participation is essential if any meaningful mobilisation for development is to be achieved. Information sharing; support activities against AIDS are emphasised in the article