[Patellar dislocation in children and adolescents : Current developments in diagnostics and treatment]. / Patellaluxation im Kindes- und Jugendalter : Aktuelle Entwicklung bei Diagnostik und Therapie.

BACKGROUND: The latest results concerning patellar instability in children and adolescents lead to a better understanding of the underlying pathology. OBJECTIVES: Determination of necessary diagnostic procedures and treatment of patellar instability in children and adolescents. MATERIAL AND METHODS: Analysis of available literature based on a systematic MEDLINE analysis. RESULTS: Diagnostics, risk factors und treatment of adult patellar instability are applicable in the treatment of children. A trend towards early surgical stabilization after primary dislocation was identified. Growth plate-preserving methods for autologous MPFL reconstruction can safely be used in children. CONCLUSIONS: For children with a high risk of redislocation, primary surgical intervention should be performed. The necessary method must be determined by individual risk factor analysis.

[Campaigns for HIV testing, an effective strategy for universal access to prevention and treatment? The experience of Burkina Faso]. / Les campagnes de dépistage du VIH, une stratégie efficace pour l'accès universel à la prévention et au traitement ? L'expérience du Burkina Faso.

OBJECTIVES: Increasing the rate of people who know their HIV status is imperative, particularly in sub Saharan Africa, and this requires an assessment of strategies for increasing the utilization of testing services. This article discusses the relevance, feasibility, and effectiveness of national screening campaigns conducted between 2006 and 2010 in Burkina Faso. METHODOLOGY: An analysis of all data regarding testing uptake from 2006 to 2010 was conducted, along with interviews of key participants in the process. RESULTS: The results show that the 8 screening campaigns led to HIV testing of 487,727 people, that is, 50% of the total number of people tested and 24.6 % of HIV+ people diagnosed during this period. Campaigns succeeded in testing populations that are difficult to reach (especially young people), at a low cost. CONCLUSIONS: This strategy is relevant and useful for identifying HIV+ people. Its utility for HIV prevention campaigns requires further study. Campaigns are effective and cost-effective even in this country with a low disease prevalence. These results underline the importance of the synergy between community-based organizations and health services in the provision of counseling and testing.

The social and gender context of HIV disclosure in sub-saharan Africa: a review of policies and practices

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa; as well as what is known about rates; consequences and social context of disclosure; with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical; public health and human rights questions about how to protect the medical confidentiality; health and well-being of people living with HIV on the one hand; and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region; a spate of recent laws; policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit; there is less clarity about the ethics of third party notification; especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa; health workers continue to grapple with difficult challenges in the face of nondisclosure; and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region; and must be considered within policies and programmes. Taken as a whole; this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected

Correlates of the age at natural menopause in Morocco.

PRIMARY OBJECTIVE: To determine the median age of natural menopause and factors associated with the timing of menopause in Morocco. RESEARCH DESIGN: A population-based sample of 299 women from Rabat, Morocco were interviewed using a semi-structured questionnaire. METHODS AND PROCEDURES: Logit analysis and logistic regression were used to estimate the median age and identify factors associated with the age at menopause. MAIN OUTCOMES AND RESULTS: The median age of natural menopause in Morocco is estimated to be 48.4 years (95% CI: 36.9, 70.3). Women who reported the onset of menstruation at age 11 or younger (OR = 2.84, 95% CI: 1.00, 8.10) had an earlier age at menopause than women who started menstruating at age 12 or older. Women who had ever used oral contraceptives were more likely to have a later age at menopause (OR = 0.55, 95% CI: 0.30, 1.00). The length of time a woman used oral contraceptives influenced the timing of the menopause in unadjusted models but after adjusting for the age at menarche the effect was no longer statistically significant. Marital status, parity, education level, and social class were not statistically associated with the age at menopause. CONCLUSIONS: The estimated age at natural menopause in Morocco is 1-3 years earlier than the median ages reported in industrialized countries and some developing countries. Factors that alter the frequency of ovulation or rate of follicular atresia appear to be important in determining the age at menopause.

Discontinuation of postmenopausal hormone therapy in a Massachusetts HMO.

Long-term postmenopausal hormone therapy alleviates menopausal symptoms, decreases women's risk of osteoporosis and has been shown to reduce cardiovascular morbidity and mortality in more than 30 observational studies. However, nearly half of all women initiating hormone therapy discontinue within the first year. This study was conducted to determine the rate and predictors of hormone therapy discontinuation in a clinical practice setting. We identified 992 women aged 45-59 who began hormone therapy between 1993 and 1995 in a Massachusetts health maintenance organization. Women were followed 2 years from the day they filled a prescription for estrogen. 53% discontinued hormone therapy by the end of the first year and one-fifth stopped after the first prescription. A prescription from a gynecologist (RR = 0.82, 95% CI: 0.68, 0.99) and a mammogram a year prior to initiation (RR = 0.75, 95% CI: 0.63, 0.89) were associated with a lower rate of discontinuation. Women who were using monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRI) antidepressants 3 months prior to initiation (RR = 2.07, 95% CI: 1.26, 3.39) or who had been enrolled in the health plan for less than 3 years (RR = 1.33, 95% CI: 1.10, 1.62) had an increased risk of discontinuing hormone therapy. The year a woman entered the cohort was also associated with a higher rate of discontinuation (RR = 1.40, 95% CI: 1.14, 1.74 for 1994 and RR = 1.95, 95% CI: 1.52, 2.50 for 1995). The results indicate that long-term hormone therapy use is uncommon in clinical practice, particularly when a woman or her physician attempts to use hormone therapy as an alternative to antidepressant therapy, and that the rates of discontinuation of hormone therapy were rising rapidly in the mid-1990s.

Side effects and sociobehavioral factors associated with the discontinuation of hormone therapy in a Massachusetts health maintenance organization.

OBJECTIVE: To identify sociobehavioral factors and side effects associated with the discontinuation of postmenopausal hormone therapy in a clinical practice setting DESIGN: A total of 816 women aged 45-59 who began hormone therapy between July 1993 and June 1995 in a Massachusetts health maintenance organization were followed for 2 years from the day they received a prescription for estrogen. This cohort has been previously studied for health, treatment, and demographic determinants of hormone therapy discontinuation. In March 1999, these women were mailed a questionnaire containing closed and open-ended questions. A total of 449 women (55%) completed the survey. Discrete-time hazards models were used to identify determinants of discontinuation, controlling for medical predictors of survey nonresponse. RESULTS: Women separated from their partners when they initiated hormone therapy (relative risk [RR] of discontinuation = 3.42; 95% confidence interval [CI] = 1.09, 10.73) and women with a body mass index greater than 29.0 (RR = 1.62; 95% CI = 1.18, 2.23) were more likely to discontinue. Women who had ever used oral contraceptives were less likely to discontinue hormone therapy (RR = 0.70; 95% CI = 0.51, 0.98). After women began using hormone therapy, those who experienced irregular bleeding (RR = 1.58; 95% CI = 1.08, 2.31), edema (RR = 2.18; 95% CI = 1.42, 3.34), or abdominal cramps and pelvic pain (RR = 2.42; 95% CI = 1.46, 4.02) while using hormones were more likely to discontinue. The effect of edema and abdominal cramps on the rate of discontinuation was greatest during the first 6 months of use. Women who adjusted their progestin schedule on their own were four times more likely than other women to discontinue hormones (RR = 4.18; 95% CI = 2.20, 7.94). The use of alternative therapies was not statistically associated with discontinuation. CONCLUSIONS: Women who report therapeutic benefits from hormone therapy are more likely to continue using hormones long-term. The experience of certain side effects, especially during the first few months of hormone use, strongly affects whether women continue using hormone therapy.

Physicians' perceptions of menopause and prescribing practices in Morocco.

OBJECTIVE: To investigate the prescribing practices of Moroccan physicians around menopause. METHODS: A survey was carried out on a representative sample of physicians in the capital city Rabat. The sample included general practitioners, gynecologists, cardiologists and rheumatologists, practicing in both public and private facilities. The instrument consisted of close- and open-ended questions about the socio-demographic characteristics of physicians, their patient population, their prescribing practices, and their perceptions of menopause and the different medical approaches to managing the symptoms and risks associated with it. RESULTS: Most of the physicians interviewed are positively inclined towards the notion of prevention and in favor of hormonal treatment, and approximately half report that they have prescribed hormone therapy. Gynecologists and male physicians prescribe hormones more frequently, as well as physicians who are at private facilities. These findings are discussed in relation to the physicians' perceptions of the menopause transition. CONCLUSION: There are considerable variations in prescribing practices and perceptions of menopause among Moroccan physicians.

Age at natural menopause in Beirut, Lebanon: the role of reproductive and lifestyle factors.

PRIMARY OBJECTIVE: To determine the median age of natural menopause and factors associated with the timing of menopause in Beirut, Lebanon. RESEARCH DESGIN: A population-based sample of 298 women were interviewed using a semi-structured questionnaire. METHODS AND PROCEDURES: Logit analysis and logistic regression were used to estimate the median age and identify correlates of menopausal status. MAIN OUTCOMES AND RESULTS: The median age of natural menopause in Beirut, Lebanon is estimated to be 49.3 years. Not being currently married (odds ratio (OR)=4.19, 95% CI: 1.53, 11.51) and smoking (OR = 1.02 for each year of smoking, 95% CI: 1.00, 1.05) are significantly associated with an earlier age at menopause. Women with menstrual bleeding longer than 5 days have later ages at menopause (OR = 0.50, 95% CI: 0.26, 0.97). Age at menarche, parity, education and socio-economic status are not statistically associated with the age at menopause. CONCLUSIONS: The age at natural menopause in Lebanon is comparable to median ages reported for women in industrialized countries (49.3-51.4). Our results emphasize the role of smoking in determining an earlier age at menopause and indicate that reproductive characteristics affect the timing of menopause.

Pluralism and pragmatism: knowledge and practice of birth in Morocco.

This article examines knowledge and practice surrounding birth in Morocco, using women's narratives of their recent birth experiences, observations of medical encounters, and statements about prescribed behaviors during pregnancy and birth, as well as the vocabulary used to refer to physiological processes, disease conditions, and social relationships. The analysis shows that the three major themes that define the traditional Moroccan ethnophysiology of birth--conceptions of hot and cold, the symbolism of blood, and the metaphors of openness and obstruction--are not inconsistent with the precepts of biomedicine and public health and do not in themselves constitute obstacles either to safe home births or the use of formal health services. Women integrate biomedical and local knowledge and practices and simultaneously seek care from "traditional" and "modern" practitioners, creatively combining elements in accordance with their situations and the means at their disposal. Birth narratives show the eclecticism and flexibility that characterize women's attitudes and behaviors regarding pregnancy and birth. Women's decisions are shaped by two overriding considerations: incertitude about what can happen during the last phase of a pregnancy and ambivalence toward the available alternatives for care, both of which reflect a realistic assessment of their situations. By showing how women make decisions in response to these considerations, this article seeks to clarify some of the links between beliefs and practices and to contribute to ongoing discussions regarding the relevance of local knowledge for patterns of health care.

Menopause across cultures: a review of the evidence.

OBJECTIVE: To review the cross-cultural evidence on menopausal symptoms to assess the extent of variability in symptomatology and the relative weight of hormonal and social factors. DESIGN: Literature review and critical summaries of available studies. RESULTS: Symptoms related to menopause are found in all regions of the world, although everywhere large proportions of women go through menopause uneventfully. The evidence does not support that women in developing countries report fewer symptoms than in industrialized countries. There is a great diversity in symptom frequencies across countries, and the association of symptoms with menopausal status is weak. A number of symptoms thought to be part of menopause are in fact not specific to it, although the evidence does support the narrow estrogen hypothesis of a core of symptoms associated with estrogen decline, namely vasomotor and vaginal symptoms. CONCLUSIONS: The association between hormonal changes and menopause symptomatology is complex and mediated by sociocultural factors.

[A socio-anthropological study of birth in Morocco]. / Une analyse socioanthropologique de la naissance au Maroc.

BACKGROUND: To understand the role of beliefs, notions of risk and local practices in explaining the low utilization of maternal health services in Morocco. METHODS: Ethnographic research in three sites in Morocco, including interviews with 126 women and observation of medical encounters at health facilities. RESULTS: Local practices are not incompatible a priori with the use of health services, and women manifest a relatively pragmatic and flexible attitude towards the decisions they make regarding birth. The different factors that influence women's choices are analyzed, in particular those related to obstacles of accessibility and quality of services. CONCLUSION: The pluralism and eclecticism that characterize beliefs and behaviors related to birth in Morocco suggest that an improvement in the quality of care would encourage more women to seek care from health facilities.

Risk, uncertainty, and agency: culture and safe motherhood in Morocco.

This article critically examines the notion that Moroccan women's infrequent use of health facilities during pregnancy and birth results from their lack of awareness of the risks of childbirth. It argues that while ethnographic data appear at first to lend support to this hypothesis, a closer examination of the customs surrounding birth shows that ideas about risk are found in local constructions of childbirth. The choices women make regarding birth and the flexibility that characterizes their decisions reflect the uncertain circumstances of labor and problems in the accessibility and quality of health services. Differences in the notions of risk that women hold and express are a function, not of an inability to conceive of risks, but rather of the real alternatives they have for controlling these risks.

Female genital surgeries: the known, the unknown, and the unknowable.

This article reviews the literature on female genital surgeries and examines the extent to which available research supports commonly accepted "facts" about the prevalence and harmful effects of these practices, in particular their possible health complications, and their effect on sexuality. While information regarding the prevalence of female genital surgeries is becoming increasingly available, the powerful discourse that depicts these practices as inevitably causing death and serious ill health, and as unequivocally destroying sexual pleasure, is not sufficiently supported by the evidence. The article discusses some of the implications of research on female genital surgeries for the societies that are involved--not merely those where the practices are found, but also those whose gaze has been so intensely focused on the customs of others.

Symptom reporting around the menopause in Beirut, Lebanon.

OBJECTIVES: to assess the extent to which women in Beirut suffer from symptoms in the course of the menopause transition, and to measure the medical management of menopause. METHODS: a survey was carried out on a representative sample of 298 women; the questionnaire collected information on respondents' sociodemographic characteristics, life circumstances, general health, and reproductive health; it also included a symptom checklist, questions on the management of menopausal symptoms, and lifestyle questions. RESULTS: the article documents the frequencies of various symptoms associated with aging and menopause; the number of symptoms reported by respondents is negatively associated with employment, but other associations with sociodemographic variables are not significant; smoking is found to be high in the study population and is associated with the occurrence of hot flashes, but its association with other menopausal symptoms is not significant; over a third of the women seek help in dealing with the symptoms they experience, 15% use hormone replacement therapy, and 20% use calcium supplements.

Son preference and differential treatment in Morocco and Tunisia.

This report investigates the links between son preference and differential treatment of children by analyzing data from the Demographic and Health Surveys of Morocco and Tunisia, two countries that are thought to vary considerably regarding indicators of gender. The analyses find no significant differences in either country in the duration and intensity of breastfeeding and small differences in favor of boys in Tunisia regarding immunization and the treatment of diarrhea. These findings, which are, to some degree, unexpected, are discussed in light of other research relevant to son preference in the two countries.

PIP: An analysis of Demographic and Health Survey data from Morocco (1987) and Tunisia (1988) failed to document the expected link between son preference and differential treatment of children. Although excess female child mortality and morbidity have been declining in the Middle East, gender-based differentials persist in selected health and nutrition variables. The present analysis used data on breast feeding, immunization, and the treatment of diarrhea for the sample of children in both countries born 5 years before the surveys. A slightly higher proportion of boys than girls breast fed for durations exceeding 18 months in Tunisia, but no pattern of difference by gender was observed for Morocco. In both countries, boys were slightly more likely to be fully immunized than girls (67% versus 64% in Morocco and 88% versus 85% in Tunisia). In Morocco, the proportion of children with diarrhea not receiving either home or medical treatment was slightly higher among girls than boys (46% versus 42%); in Tunisia, 35% of girls but only 31% of boys were untreated. The unexpectedly small magnitude of the sex differences found in this analysis contradicts the social science literature, which emphasizes a pattern of sex discrimination in both these countries. Also surprising was the finding that Tunisia, considered the more egalitarian of the two countries, had stronger son preference than Morocco for indicators of both fertility and health behavior. This calls into question simplistic explanations of the effect of women's status on demographic behavior.

Urbanisation, household composition and the reproductive health of women in a South African city.

Post-apartheid South Africa is faced with the effects of a distorted urbanisation process. A coherent response to urbanisation includes the mitigation of the adverse health effects of urbanisation. Women, by virtue of the stringent control of their movements to urban areas under apartheid, have migrated to the urban areas at an increasing rate recently. One consequence has been the transformation of traditional household structures consonant with changing patterns of fertility and infertility in the urban areas. This paper describes the composition of households in Khayelitsha, South Africa, a suburb that has seen an explosive increase in population over a 5-year period, from 5000 to an estimated 250,000 people. A survey of 659 households revealed the woman-headed households increased from 11% in those women who had been in the urban areas for fewer than 5 years, to 35% in those who had been in the urban areas for more than 20 years. This was not a function of widowhood or divorce, but appears to be an adaptive strategy adopted by women in the face of gender oppression in a harsh urban environment. The study also revealed the phenomenon of "alliance" household formation, in which atypical households made up of a variety of non-descript combinations of people provide support for women from remote rural areas, another adaptive strategy. Fertility was related to age, income, education and urbanisation. Women who had been in the urban areas for longer than 10 years had a total fertility rate (TFR) of 2.5, while those who had been in the urban areas for less than 10 years had a TFR of 5.8. Reported infertility was related to marital status, education, gynaecological illness and urbanisation, with recently urbanised women reporting more infertility. This probably reflects the different expectations of rural women and changes the mix of attitudes to fertility in the urban areas substantially. These findings have major implications for population policies in South Africa and an eclectic mix of approaches, including small area-specific approaches, to family spacing is recommended.

Back to nature? Historical and cross-cultural perspectives on barriers to optimal breastfeeding.

This article examines the discrepancy between the recommendations of international authorities concerning breastfeeding and the practices of a significant proportion of women all over the world who discontinue breastfeeding because of the reported insufficiency of their milk. Our review of the evidence on the insufficient milk syndrome suggests that the phenomenon is inextricably linked to the construction of family, gender and motherhood at different historical times and in different parts of the world, and that the prevention of early discontinuation of breastfeeding requires a better understanding of these issues in their historical and cultural context.

Fertility norms and son preference in Morocco and Tunisia: does women's status matter?

This paper investigates the normative and behavioural dimensions of son preference in Morocco and Tunisia, using data from the Demographic and Health Surveys of the two countries. It considers three measures of son preference: (1) mothers' ideal number of children, and any preference for having more sons than daughters; (2) the desire for additional children, given their existing family; (3) reported use of contraception in relation to the existing number of children of each sex. The analyses indicate a moderate preference for sons in both countries, and suggest that this preference is somewhat stronger in Tunisia. These findings are interpreted within the cultural context of the two countries, and in particular societal notions of women's status.

Reproductive choice in Islam: gender and state in Iran and Tunisia.

This report examines the extent to which reproductive choice is compatible with Islamic principles. It presents the argument that the impact of Islam on reproductive choice is largely a function of the political context in which gender issues are defined. Indicators of reproductive health in countries of the Middle East are reviewed and the way these relate to constraints on reproductive choice is assessed. The examples of Tunisia and Iran are used to illustrate the way in which Islam is invoked to legitimate conflicting positions concerning women and their reproductive options.

PIP: A population and international health specialist examines the circumstances that affect different interpretations of reproductive choice in Muslim countries. She uses Iran and Tunisia as cases to show how the state develops reproductive options for women. In both countries, one uses Islamic doctrine to legitimate conflicting positions in regards to women's place and reproduction. For example, in Tunisia, President Bourguiba (1957-1984) justified abolition of polygyny by referring to a Koranic verse that says a man cannot be fair to all wives. He claimed this verse negated polygyny, because the verse which allows men to have up to 4 wives requires that all wives be treated equally. After the 1979 Iranian revolution, Ayatollah Khomeini sought religious justifications from the Koran and Hadith for the retraditionalization of women's roles. It urged them to marry and have children. Yet, the theocratic government mobilized women on a massive scale to vote, recruited them into paramilitary forces, and hired them as government employees. Therefore, the effect of Islam on gender and reproduction is basically a function of the political setting in which these issues are interpreted. Changes in the economic, political, and social arenas influence the means by which people in power interpret the ethical code of religion into policies affecting women's status. Contrary views of the social order are played out in women and reproduction issues. For example, the veiling of Muslim women expresses various groups' dramatic opposition to the state, colonial powers, or to Western influence. They use the veiling to represent their call for a return to true Islam. One cannot assume that all groups referred to as fundamentalist support reduced women's freedoms, and modernization does not lead to greater reproductive choice. These contradictions allow individual women to identify their own strategies, e.g., manipulating the rules or resisting them.