Impact of an integrated adolescent reproductive health program in Brazil.

An impact evaluation of an integrated school- and health-clinic-based adolescent reproductive health initiative was undertaken by the State Secretariats of Health and Education in Bahia, Brazil during 1997-99. The project was initiated in response to continued high pregnancy rates among adolescents and growing numbers of new HIV infections among young adults. It sought to promote responsible sexual and health-seeking behaviors among public secondary-school students, including the use of public health clinics. The study design included a matched control group used to measure project impact. The findings indicate that the project was successful in increasing the flow of sexual and reproductive health information to secondary-school students and that it had an impact on adolescents' intentions to use public health clinics in the future. No effects on sexual or contraceptive-use behaviors or on use of public clinics were observed, however. Client exit-interview data from a subset of project clinics indicate that adolescents who use clinic-based services are overwhelmingly female and considerably older on average and much more likely ever to have been pregnant than are adolescents in the target population for the project.

Correlates of sexual activity and condom use among secondary-school students in urban Peru.

Recent data indicate that adolescent fertility rates in Peru remain high and that Peruvian adolescents and young adults account for a disproportionate share of new HIV infections. The present study was undertaken to identify key risk and protective factors for early sexual activity and unprotected sex among secondary-school students in nine large cities in Peru. Survey data from 6,962 students aged 13-18 are consistent with existing research in indicating that behaviors of Peruvian youth are influenced in important ways by many factors. In the present study, these included region of residence, family economic position, family structure, working for pay, peer behaviors, and self-esteem. Knowledge of pregnancy and of the risks of acquiring sexually transmitted diseases and of the means of avoiding both did not, however, differentiate risk-takers from non-risk-takers. The study findings suggest a need for adolescent health programs to broaden their focus beyond the immediate proximate determinants of behavior, such as sexual and reproductive health knowledge and access to contraceptives, and also to target some of the key contextual factors influencing adolescent behavior.

The effects of maternal-child health service utilization on subsequent contraceptive use in Morocco.

There are a number of reasons for anticipating that contact by women in developing country settings with modern maternal-child health (MCH) services will lead to increased use of family planning services. Indeed, the expectation of such a relationship underlies the integrated service delivery strategy that has been adopted on a more or less global basis. However, the available empirical evidence in support of this proposition is inconclusive. This study re-examines this issue in Morocco. Household survey data and data on the supply environment for health and family planning services gathered in 1992 are analysed in the study. A full-information maximum likelihood estimator is used to control for the possible endogeneity of health care and contraceptive choices. The findings indicate a substantial and apparently causal relationship between the intensity of MCH service use and subsequent contraceptive use. Policy simulations indicate that sizeable increases in contraceptive prevalence might be realized by increasing the coverage and intensity of use of MCH services.

PIP: This study examined the association between frequency of use of maternal and child health (MCH) services and subsequent contraceptive use (CU) in Morocco. Data were obtained from a 1992 Moroccan Health Survey among 3267 married women with at least 1 live birth and the 1992 Service Availability Module. Analysis was based on full information maximum likelihood estimates and nonparametric, discrete factor strategies. The analysis ignored the possibility that CU can lead to increase MCH use, because few women use contraception before a first birth. Findings indicate that intensity of MCH service use was a statistically significant determinant of subsequent CU. The magnitude of the effect was large. For example, an increase in MCH service use from 2 to 4 would result in an increase of over 71% in contraceptive prevalence, from 32% to 55%. Modern CU would increase from 55% to 65%. Traditional CU would increase from 7% to 19%. Increases were more likely despite controls for individual and household characteristics. Findings do not explain the role of integrated services. Since there are numerous sources of supply, it is likely that counseling and promotion by health facility staff were significant factors. Evidence supports the need to include community-level factors in the analysis, but key community factors remain unmeasured.

Vasectomy in the United States, 1991 and 1995.

OBJECTIVES: This study sought to assess whether the controversy surrounding publications linking vasectomy and prostate cancer has had an effect on vasectomy acceptance and practice in the United States. METHODS: National probability surveys of urology, general surgery, and family practices were undertaken in 1992 and 1996. RESULTS: Estimates of the total number of vasectomies performed, population rate, and proportion of practices performing vasectomy were not significantly different in 1991 and 1995. CONCLUSIONS: This study provides no solid evidence that the recent controversy over prostate cancer has influenced vasectomy acceptance or practice in the United States. However, the use of vasectomy appears to have leveled off in the 1990s.

The impact of the family planning supply environment on contraceptive intentions and use in Morocco.

Although the extent to which organized family planning programs influence reproductive preferences remains a subject of debate, most observers would grant that such programs play a key role in helping individuals to realize their contraceptive and reproductive intentions. However, few prior studies have quantified the magnitude of this facilitating or enabling effect of family planning services, given existing demand for contraception. This study takes advantage of panel survey data and linked information on the supply environment for family planning services in Morocco in order to bridge this research gap. In the analysis, contraceptive use during the 1992-95 period is related to contraceptive intentions in 1992; individual-, household-, and community-level determinants of contraceptive behavior; and family planning supply factors. Estimation procedures are used that control for unobserved joint determinants of contraceptive intentions and use. Evidence of a significant enabling or facilitating role of family planning services is found, and the results also suggest that family planning program factors influence contraceptive intentions in important ways.

Clinical aspects of vasectomies performed in the United States in 1995.

OBJECTIVES: Currently, no surveillance system collects data on the numbers and characteristics of vasectomies performed annually in the United States. This study provides nationwide data on the numbers of vasectomies and the use of no-scalpel vasectomy, various occlusion methods, fascial interposition, and protocols for analyzing semen after vasectomy. METHODS: A retrospective mail survey (with telephone follow-up) was conducted of 1800 urology, family practice, and general surgery practices drawn from the American Medical Association's Physician Master File and stratified by specialty and census region. Mail survey and telephone follow-up yielded an 88% response rate. RESULTS: In 1995, approximately 494,000 vasectomies are estimated to have been performed by 15,800 physicians in the United States. Urologists performed 76% of all vasectomies, and nearly all (93%) urology practices performed vasectomies in 1995. Nearly one third (29%) of vasectomies in 1995 were no-scalpel vasectomies, and 37% of physicians performing no-scalpel vasectomies taught themselves the procedure. The most common occlusion method in 1995 (used for 38% of all vasectomies) was concurrent use of ligation and cautery. In 1995, slightly less than half (48%) of all physicians surveyed interposed the fascial sheath over one end of the vas when performing a vasectomy. Protocols for ensuring azoospermia varied: 56% of physicians required one postvasectomy semen specimen; 39% required two, and 5%, three or more. CONCLUSIONS: No-scalpel vasectomy, used by nearly one third of U.S. physicians, has become an accepted part of urologic care. Physicians' variations in occlusion methods, use of fascial interposition, and postvasectomy protocols underscore the need for large scale, controlled, and statistically valid studies to determine the efficacy of occlusion methods and fascial interposition, as well as whether azoospermia is the only determination of a successful vasectomy.

The reliability of reporting of contraceptive behavior in DHS calendar data: evidence from Morocco.

This report addresses the consistency of reporting in the contraceptive calendar in the 1992 and 1995 Morocco Demographic and Health Surveys. Because a panel design was used in these surveys, the same women were interviewed in both years, providing a unique opportunity to examine the reliability of responses. Measures of reliability for various aspects of contraceptive-use dynamics are computed, and the impact of reporting errors on contraceptive failure, discontinuation, and switching rates is estimated. Results suggest that reporting of contraceptive behavior in Moroccan DHS calendar data appears to be relatively reliable at the aggregate level. Individual respondents, particularly those whose contraceptive patterns have been complex, have a lower level of reliability. The observed inconsistencies do not appear to affect aggregate-level estimates of contraceptive prevalence; however, measures of contraceptive-use dynamics are less stable.

The impact of primary health care services on under-five mortality in rural Niger.

BACKGROUND: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period. METHODS: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects. RESULTS: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources. CONCLUSIONS: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

PIP: The phased implementation of Niger's Rural Health Improvement Program, in conjunction with a 1985 Ministry of Health survey, facilitated quantification of the contribution of primary health care interventions to the reduction of infant and child mortality. During 1978-84, over 8000 health workers were trained and deployed to unserved villages; in addition, 45% of rural villages were provided with primary care services through dispensaries or village health teams. The 35 rural clusters covered in the survey were grouped into three categories: 1) villages located 5 km or less from a dispensary; 2) those located over 5 km from a dispensary, but with a village health team; and 3) villages located more than 5 km from a dispensary and with no health team. Mothers residing near a dispensary were two to five times more likely than their counterparts in the other two groups to have received prenatal care for the most recent birth, had the delivery attended by trained health personnel, received nutrition and health education, and know how to prepare oral rehydration solution. Children in the dispensary-proximate villages were three times more likely to have been at least partially immunized and to have a health card and twice as likely to have had their most recent diarrhea episode treated by a health worker. The unadjusted proportions of infants and children who died in the five years preceding the survey were 0.191 in villages served by a dispensary, 0.203 in villages served by a health team, and 0.267 in villages with neither resource. Multivariate analyses indicated that significantly lower mortality was associated with the presence of a dispensary, maternal literacy, and the existence in the community of farm machinery or access to seeds to plant the next crop. Overall, these findings confirm the significance of primary health care services, especially treatment of infantile diarrhea and tetanus, to reducing under-five mortality in sub-Saharan Africa.

A not quite as quick but much cleaner alternative to the Expanded Programme on Immunization (EPI) Cluster Survey design.

BACKGROUND: Although the Expanded Programme on Immunization (EPI) cluster survey methodology has been successfully used for assessing levels of immunization programme coverage in developing country settings, certain features of the methodology, as it is usually carried out, make it less-than-optimal choice for large, national surveys and/or surveys with multiple measurement objectives. What is needed is a 'middle ground' between rigorous cluster sampling methods, which are seen as unfeasible for routine use in many developing country settings, and the EPI cluster survey approach. METHODS: This article suggests some fairly straightforward modifications to the basic EPI cluster survey design that put it on a solid probability footing and render it easily adaptable to differing and/or multiple measurement objectives, without incurring prohibitive costs or adding appreciably to the complexity of survey operations. The proposed modifications concern primarily the manner in which households are chosen at the second stage of sample selection. CONCLUSIONS: Because the modified sampling strategy maintains the scientific rigor of conventional cluster sampling methods while retaining many of the desirable features of the EPI survey methodology, the methodology is likely to be a preferred 'middle ground' survey design, relevant for many applications, particularly surveys designed to monitor multiple health indicators over time. The fieldwork burden in the modified design is only marginally higher than in EPI cluster surveys, and considerably lower than in conventional cluster surveys.

Detecting induced abortions from reports of pregnancy terminations in DHS calendar data.

This study considers whether pregnancy terminations reported in Demographic and Health Survey (DHS) calendar data can be classified accurately as having been spontaneous or induced based upon other information collected in the survey interview. A classification scheme is proposed that is an adaptation of the method developed by the World Health Organization for categorizing cases in which women admitted to hospitals experienced complications of pregnancy termination. The scheme is evaluated using data from the 1993 Turkey DHS. Evaluation results indicate that the method identifies true cases of induced abortion accurately, but tends to classify a relatively large number of reported spontaneous terminations as induced abortions. However, when it is corrected for likely respondent misreporting of induced abortions as spontaneous terminations, both the sensitivity and specificity of the method appear to be acceptable.

PIP: The World Health Organization (WHO) classification scheme for pregnancy terminations was modified to evaluate the accuracy of pregnancy terminations as spontaneous or induced abortion in Demographic and Health Survey (DHS) calendar data. The decision algorithm considered length of gestation at time of termination, whether contraception was used during the period before termination and, if so, reason for discontinuation, whether the pregnancy was wanted or unwanted, and age, parity, and marital status at the time of the pregnancy termination. 1993 DHS calendar data on 1539 pregnancy terminations from Turkey were applied to the classification method. The algorithm classified 1413 (92%) of the terminations. It classified 71.8% (1015) as probably induced compared to 63% as reported by survey respondents. The algorithm classified 28.2% (398) as probably spontaneous compared to 37% as reported by survey respondents. The ratio of test positive to true positive (i.e., sensitivity of the method) was 92.5%, showing that the algorithm does a good job at identifying true cases of induced abortions. On the other hand, the ratio of test negatives to true negatives (i.e., specificity of the method) was only 65%, suggesting that the algorithm yields a relatively large number of false positives. When the investigators considered the effects of errors caused by misreporting of classification on the efficacy of the proposed scheme, both sensitivity and specificity increased (assuming 10% error, 92.7% and 67.3%; 25% error, 92.9% and 71.4%; and 50% error, 93.3% and 79.1%, respectively).

Prevalence and differentials of low birth weight in Niamey, Niger.

This study provides population representative data on live births occurring in Niamey, Niger during the period 1980 to 1985. A total of 5097 live births were systematically sampled from maternity registers over the study period. Due to legislation and incentives to register all live births, between 90 and 95 per cent of all live births are represented in this study. The data here suggest that low birth weight (LBW) prevalence may be lower in this urban area than it is in the region as a whole; and that the demographic risk factors are similar to those found in other developing countries. Finally, in many developing countries, maternity coverage of attended births may be quite high, suggesting that record or prospective studies examining trends in LBW and risk factors for perinatal outcomes might be convenient and implemented at very low cost.

Intra-household correlations in maternal-child nutritional status in rural Guinea: implications for programme-screening strategies.

It is commonly assumed in public health practice that households in developing country settings are relatively homogeneous with respect to nutritional status. To the extent that this assumption is valid, nutritional assessments of mothers or individual children would provide an effective screening mechanism for household-level maternal-child nutritional risk. However, there has been no confirmation of the strength of intra-household correlations in nutritional status among women and children. Using data from a cross-sectional survey undertaken in 1990 in rural central Guinea, the present study investigates the nature of within-household relationships in maternal and child nutritional status and considers the implications for programme screening strategies. Mothers and their surviving children under 5 years of age are the focus of the analysis. Correlations between maternal and child nutritional levels are assessed and the performance of maternal-child nutritional indicators as screening tools for household nutritional risk are formally evaluated by analysing the sensitivity, specificity, and positive-negative predictive values of various indicators.

PIP: The authors explore to what extent households may be identified as being at risk of maternal-childhood malnutrition on the basis of a nutritional assessment of one household member. Cross-sectional survey data collected in 1990 from the central Guinean provinces of Labe, Tougue, Lelouma, Dolaba, and Pita, on 780 mothers and their 1118 surviving children under 5 years of age are the focus of the analysis. The survey had been conducted to obtain baseline data on nutrition and health problems in the region. Investigators assessed correlations between maternal and child nutrition, and formally evaluated the performance of maternal-child nutritional indicators as screening tools for household nutrition risk. Although significant intra-households correlations were found with regard to nutritional status among women and children, the data clearly indicate the inefficiency of screening for household-level maternal-child nutritional risk on the basis of anthropometric indicators for mothers and/or individual children under age five years.

Breast-feeding, water and sanitation, and childhood malnutrition in the Philippines.

This study examines effects and interactions of socioeconomic status, access to water supply and sanitation, and breast-feeding practices in relation to child growth in two provincial cities in the Philippines. Multivariate analysis identified food expenditure per head, education of the household head and gender of the child as significant predictors of nutritional status. The duration of partial and full breast-feeding was negatively (though non-significantly) associated with growth. Sanitation facilities and breast-feeding are, however, important determinants during the first year of life. Among children over 1 year of age, socioeconomic variables and gender are the most important predictors. Breast-feeding is shown to provide more important health benefits for children in lower income households. The need for further studies on the causes of gender differences in nutritional status was apparent.

Costs of rearing children in agricultural economies: an alternative estimation approach and findings from rural Bangladesh.

PIP: There are changes in child costs during demographic transition. This study examines household time allocation from 66 agricultural households in 3 villages in Tangail District in rural north central Bangladesh in 1984-85 (371 days). Component and total child-rearing costs are estimated in alternative ways. Conventional "opportunity wage" measures are considered overestimated. The methodological shortcomings of direct cost accounting procedures and consumer demand methods in computing time cost and monetary cost of child rearing are pointed out. In this study's alternative computation, age standardized equivalent costs are generated. Child food consumption costs were generated from a large national survey conducted in 1983. Nonfood expenditures were estimated by food to nonfood expenditure ratios taken from the aforementioned survey. For estimating breast-feeding costs, an estimate was produced based on the assumption that costs for infant food consumption were a fixed proportion of food costs for older children. Land ownership groups were set up to reflect socioeconomic status: 1) landless households, 2) marginal farm households with 1 acre or .4 hectares of land, 3) middle income households with 1-2 acres of land, 4) upper middle income households with 2-4 acres of land, and 5) upper income or rich households with over 4 acres of land. The nonmarket wage rate for hired household help was used to determine the value of cooking, fetching water, and household cleaning and repairing. The results confirm the low costs of child rearing in high fertility societies. Productive nonmarket activities are effective in subsidizing the costs of children. The addition of a child into households already with children has a low impact on time costs of children; "this economies of scale effect is estimated ... at 20%." The highest relative costs were found in the lowest income households, and the lowest costs were in the highest income households. 5% of total household income is devoted to child rearing in the lowest income households compared to 1% of income in the highest income households. The implications are that fertility decline is more directly related to structural changes in the economy, satisfaction of existing demand for family planning, and the producing additional demand for fertility control.^ieng