The decline of FGM in Egypt since 1987: a cohort analysis of the Egypt Demographic and Health Surveys.

BACKGROUND: Female genital mutilation (FGM) has been a longstanding tradition in Egypt and until recently the practice was quasi-universal. Nevertheless, there are indications that the practice has been losing support and that fewer girls are getting cut. This study analyzes the prevalence of FGM in different birth cohorts, to test whether the prevalence declined over time. The study also examines whether such a decline is occurring in all segments of society or whether it is limited mostly to certain more modernized segments of society. METHODS: This study pooled data from the 2005, 2008 and 2014 waves of the Egypt Demographic and Health Surveys (EDHS). The women participating in the EDHS provided data on 62,507 girls born to them between 1987 and 2014, including whether they were cut and at what age. Kaplan-Meier and Weibull proportional hazard survival analyses were used to examine trends in the prevalence and hazards of FGM across birth cohorts. Controls for region, religion and socioeconomic status of the parents were included in the Weibull regression. RESULTS: The results show a steady decline in FGM across the birth cohorts studied. The base hazard for the 2010 birth cohort is only 30% that of the 1987 one. Further analyses show that the decline in FGM occurred in all segments of Egyptian society in a fairly similar manner although differences by region, religion and socioeconomic status persisted. CONCLUSIONS: This study confirms that FGM is declining in Egypt. The proportion of girls getting cut has declined rapidly over the past few decades. This decline is not limited to the more modernized segments of society, but has spread to the more traditional segments as well. The latter increases prospects for the eventual eradication of the practice.

Poverty and a child's height development during early childhood: A double disadvantage? A study of the 2006-2009 birth cohorts in Flanders.

INTRODUCTION: Poverty is a well-known risk factor for a child's health and development. This paper aimed to establish whether poverty negatively affected both intra-uterine growth and early childhood growth, i.e., whether children facing poverty were at a double disadvantage. METHODS: For this study, we made use of routinely collected data on child development throughout early childhood from the 2006-2009 birth cohorts in Kind & Gezin's Ikaros database collected during 2,605,975 consultations with 273,935 children from birth to 730 days old. Indicators for child development at birth were gestational age and height-at-birth. A standardized height-for-age indicator captured height development throughout early childhood. A multidimensional indicator measured the risk of poverty. For the analysis of development at birth, we used linear and logistic regression; for the analysis of height development during early childhood, we estimated linear and logistic growth curve models. RESULTS: The risk of poverty negatively affected both gestational age and height-at-birth. Throughout early childhood, we observed a negative relation between the risk of poverty and height-for-age indicators. However, the effect varied throughout childhood. Children at risk of poverty (over)compensated for their smaller stature at birth, and between ages 6 and 18 months, approximately, the negative effects of risk of poverty decreased substantially or disappeared. However, towards the end of the period studied, children born in households at risk of poverty started to lag again in height development. CONCLUSION: This study found that the risk of poverty indeed negatively affected a child's growth, both in utero and in early childhood. However, the results suggest that developmental lags later in childhood were not merely an extension of such lags at birth.

Trends in attitudes towards female genital mutilation among ever-married Egyptian women, evidence from the Demographic and Health Surveys, 1995-2014: paths of change.

BACKGROUND: Over the past few decades Egypt has attempted to limit and control female genital mutilation (FGM). However, these efforts have not succeeded in curbing the practice, which maintains wide popular support and is firmly embedded in local traditions and structures. An attitudinal change is therefore a prerequisite for any successful campaign against FGM. This paper charts the evolution of beliefs that the practice of FGM in Egypt should be stopped. METHOD: This paper examines trends in opposition to FGM among ever-married women in Egypt between 1995 and 2014, using six waves of the Egypt Demographic and Health Surveys. RESULTS: The results show that the percentage of ever-married women who think the practice of FGM should be stopped rose from 13.9 % in 1995 to 31.3 % in 2014. The central question here is whether this trend exists because new cohorts of young married women are more modern and more opposed to the practice, or because opposition to FGM has spread through multiple segments of society. Our results show that back in 1995 opposition to FGM was concentrated in two groups: non-circumcised women, and wealthy, highly educated urban women. Between 1995 and 2014 opposition to FGM increased considerably among other groups of women. CONCLUSION: Our results show that the observed increases in opposition to FGM are not caused by younger cohorts of married women who oppose FGM, nor by the expansion of the groups most likely to oppose FGM. Rather, the results imply that the belief that FGM should be stopped spread to all walks of life, although poorly educated rural women remain least likely to oppose FGM.

Women's position and attitudes towards female genital mutilation in Egypt: A secondary analysis of the Egypt demographic and health surveys, 1995-2014.

BACKGROUND: Female genital mutilation (FGM) is still widespread in Egyptian society. It is strongly entrenched in local tradition and culture and has a strong link to the position of women. To eradicate the practice a major attitudinal change is a required for which an improvement in the social position of women is a prerequisite. This study examines the relationship between Egyptian women's social positions and their attitudes towards FGM, and investigates whether the spread of anti-FGM attitudes is related to the observed improvements in the position of women over time. METHODS: Changes in attitudes towards FGM are tracked using data from the Egypt Demographic and Health Surveys from 1995 to 2014. Multilevel logistic regressions are used to estimate 1) the effects of indicators of a woman's social position on her attitude towards FGM, and 2) whether these effects change over time. RESULTS: Literate, better educated and employed women are more likely to oppose FGM. Initially growing opposition to FGM was related to the expansion of women's education, but lately opposition to FGM also seems to have spread to other segments of Egyptian society. CONCLUSIONS: The improvement of women's social position has certainly contributed to the spread of anti-FGM attitudes in Egyptian society. Better educated and less traditional women were at the heart of this change, and formed the basis from where anti-FGM sentiment has spread over wider segments of Egyptian society.

Breastfeeding or bottled milk? Poverty and feeding choices in the native and immigrant population in Belgium.

In many European countries, mothers in poverty show a preference for bottled milk over breastfeeding. What remains unknown is whether the impact of poverty on feeding choices differs between immigrants and natives. We first assessed whether being born into poverty indicates a higher chance of being bottle-fed, then evaluated whether region of origin of the mother moderates the impact of poverty on feeding choice. Based on population data from nearly all newborns in Belgium in 2004 (N = 34,314), we performed several binary logistic analyses to answer these research questions. Analyses showed a strong difference in feeding choices between native and migrant mothers in poverty: for Belgian mothers, the choice to breastfeed significantly decreased; no such effect was observed for migrant women. Southern European mothers living in poverty have an even higher chance of breastfeeding than those who are better off. We suggest possible explanations and set a direction for future research regarding breastfeeding choices for migrant mothers.

Depression in Europe: does migrant integration have mental health payoffs? A cross-national comparison of 20 European countries.

Objectives. Depression is a leading cause of ill health and disability. As migrants form an increasing group in Europe, already making up about 8.7% of the population in 2010, knowledge on migrant-related inequalities in depression is of main public health interest. In this study, we first assess whether migrants in Europe are at higher risk for depression compared to the native population. Second, we assess whether the association between migration and depression is dependent on different forms of migrant integration. Migrant integration is looked at both from the individual and from the national level. Design. Hierarchical linear regression analyses based on data for 20 countries in the European Social Survey 2006/2007 (N = 37,076 individuals aged 15 or more). Depression is measured using the center for Epidemiologic Depression Scale. We consider migrant integration over time (first- and second-generation migrants, differentiated according to European Union (EU) or non-EU origin), barriers to integration (low educational level, financial difficulties, being out of the labor market, ethnic minority status, discrimination), and the host country environment (national migrant integration policy). Controls are gender, age, partner relationship, social support, and welfare state regime. Results. Natives and second-generation migrants do not differ significantly in their risk profile for depression. First-generation migrants show higher levels of depression, with those born outside of Europe to be the worst off. This higher risk for depression is not attributable to ethnic minority status but is mainly due to experienced barriers to socioeconomic integration and processes of discrimination. A country's national policy on migrant integration shows not to soften the depressing effect of being a first-generation migrant nor does it have indirect beneficial health effects by reducing barriers to integration. Conclusion. In Europe, first-generation EU and non-EU migrants experience higher levels of depression. Second-generation migrants and natives show similar risk profiles.

Do welfare regimes influence the association between disability and self-perceived health? A multilevel analysis of 57 countries.

Disability is usually associated with poorer self-rated health. However, as many people with disabilities do not consider themselves unhealthy, the association may not be as straightforward as it appears. This study examines whether the relationship between disability and self-rated health is dependent on a country's welfare regime. Welfare regimes can play a significant role in securing the needs of disabled people and lessening their social exclusion. However, welfare regimes also label disabled people accordingly, before they become entitled to specific provisions and services. Being given a low status label and being dependent on welfare provisions might trigger a negative self-evaluation of health. Using data from 57 countries of the World Health Survey of 2002-2004, the multilevel regression analyses show that people with a disability tend to rate their health worse than people without any disability. Moreover, the strength of this negative association varies significantly across countries and is affected by a country's welfare regime. The association is the strongest in the various Welfare State regimes (mostly European countries) and the weakest in Informal-Security regimes (Latin-American and Asian countries) and in Insecurity regimes (African countries). Disabled people living in Welfare States regimes tend to rate their health worse than people in other regimes. These findings confirm that welfare regimes play a role in shaping the health perception of disabled people and that processes of labeling may result in unintended and negative consequences of welfare programs. Research on the nexus between disability and self-rated health that neglects this macro-social context of welfare regimes may lead to undifferentiated and even incorrect conclusions.

Rwandan young people's perceptions on sexuality and relationships: results from a qualitative study using the 'mailbox technique'.

This study aimed to gain more insight into young Rwandans' perceptions on sex and relationships, which is essential for formulating effective sexual and reproductive health (SRH) promotion interventions. Using a 'mailbox technique', this paper studies the spontaneous thoughts of Rwandan young people on sexuality. Mailboxes were installed in five secondary schools in the Bugesera district and students were invited to write about their ideas, secrets, wishes, desires and fears on sexuality and relationships. Of the 186 letters collected, 154 addressed SRH topics. The letters were analysed in NVivo 9 using a theoretical model on vulnerability. Two stereotypical sexual interactions co-exist: experimental sex, taking place unprepared, driven by desire among young people of the same age, and transactional sex, occurring after negotiation between older men/women and younger girls/boys in exchange for money or goods. Both types expose young people to poor, though different, SRH outcomes. Young people have little capacity to manage their vulnerability in these relationships: they have limited knowledge on SRH topics, lack adult guidance or support and have difficult access to condoms. They apply seemingly contradictory norms and behaviours concerning sexuality. In conclusion, we have formulated several recommendations for SRH interventions.

Information Processing from Infancy to 11 Years: Continuities and Prediction of IQ.

This study provides the first direct evidence of cognitive continuity for multiple specific information processing abilities from infancy and toddlerhood to pre-adolescence, and provides support for the view that infant abilities and form the basis of later childhood abilities. Data from a large sample of children (N = 131) were obtained at five different time points (7, 12, 24, 36 months, and 11 years) for a large battery of tasks representing four cognitive domains (attention, processing speed, memory, and representational competence). Structural equation models of continuity were assessed for each domain, in which it was assumed that infant abilities → toddler abilities → 11-year abilities. Abilities at each age were represented by latent variables, which minimize task-specific variance and measurement error. The model for each domain fit the data. Moreover, abilities from the three age periods predicted global outcome, with infant, toddler, and contemporaneous 11-year measures, respectively, accounting for 12.3%, 18.5%, and 45.2% of the variance in 11-year IQ. These findings strengthen contentions that specific cognitive abilities that can be identified in infancy show long-term continuity and contribute importantly to later cognitive competence.

Effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a non-randomized controlled trial.

BACKGROUND: While the HIV epidemic is levelling off in sub-Saharan Africa, it remains at an unacceptably high level. Young people aged 15-24 years remain particularly vulnerable, resulting in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. This study assesses the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people's sexual behavior, HIV knowledge and attitudes. METHODS: In a non-randomized longitudinal controlled trial, fourteen schools were selected in two neighboring districts in Rwanda Bugesera (intervention) and Rwamagana (control). Students (n = 1950) in eight intervention and six control schools participated in three surveys (baseline, six and twelve months in the intervention). Analysis was done using linear and logistic regression using generalized estimation equations adjusted for propensity score. RESULTS: The overall retention rate was 72%. Time trends in sexual risk behavior (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. It did significantly reduce reported stigma. CONCLUSIONS: Analyzing this and other interventions, we identified several reasons for the observed limited effectiveness of peer education: 1) intervention activities (spreading information) are not tuned to objectives (changing behavior); 2) young people prefer receiving HIV information from other sources than peers; 3) outcome indicators are not adequate and the context of the relationship in which sex occurs and the context in which sex occurs is ignored. Effectiveness of peer education may increase through integration in holistic interventions and redefining peer educators' role as focal points for sensitization and referral to experts and services. Finally, we argue that a narrow focus on sexual risks will never significantly turn the tide.

Nothing as Practical as a Good Theory? The Theoretical Basis of HIV Prevention Interventions for Young People in Sub-Saharan Africa: A Systematic Review.

This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV prevention interventions for youth. Additional articles were identified on websites of international organisations and through searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent (n = 13), followed by Health Belief Model (n = 7), and Theory of Reasoned Action/Planned Behaviour (n = 6). These cognitive behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three articles provided information about why a particular theory was selected. Interventions used theory to inform content (n = 13), for evaluation purposes (n = 4) or both (n = 7). No patterns of differential effectiveness could be detected between studies using and not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual factors.

Sexual coercion among in-school adolescents in Rwanda: prevalence and correlates of victimization and normative acceptance.

Adolescents are particularly vulnerable to sexual coercion, as victim as well as perpetrator. This paper aims to adapt sexual and reproductive health interventions to the reality of young people's sexuality and relationships. This study assesses the prevalence of forced sex, characteristics of victims and norms regarding sexual coercion among Rwandan adolescents. A survey was completed by 285 senior secondary school students and four focus groups were conducted. Of sexually active respondents, 15.5% (95% CI = [15.1 - 15.9]) reported forced sexual intercourse. Sexual victimization was associated with being female and having (had) a concurrent sexual relationship. Acceptance of sexual coercion was associated with importance attached to Rwandan traditions and an interaction term between sex (being male) and alcohol use. Respondents linked concurrency and age-disparate relationships to transactional sex, increasing the risk of sexual coercion. Various risk factors were identified. The findings suggest the need for moving towards comprehensive sex education.

Differences in working conditions and employment arrangements among migrant and non-migrant workers in Europe.

OBJECTIVE: To determine migrant workers' exposure to select occupational risks and compare it with that of non-migrant workers in Europe. DESIGN: Based on the European Working Conditions Survey (EWCS-2005, n=29,654 workers, 31 countries) we examined differential prevalence amongst migrant and non-migrant workers' primary paid jobs in terms of employment arrangements (working >10 hours/day, working >5 days/week, on Sundays, without a contract, changes in the work schedule and not free to decide when to take holidays or days off) and working conditions (exposure to hazards including chemical, physical agents, physical load and psychological conditions). For the purpose of this study, a migrant is defined as a person without nationality of the country of residence (n=926). Adjusted prevalence ratios (aPRs) for age, economic sector and education were calculated. RESULTS: Differences in employment arrangements and working conditions were noted by migration status, gender and occupational status. Among non-manual workers, migrant males are more exposed than non-migrant males to negative psychosocial conditions--working at a very high speed (aPR 1.23; 95% CI 1.07-1.42) and shift work (aPR 1.66; 95% CI 1.27-2.17)--and adverse employment arrangements: working on Sundays (aPR 1.91; 95% CI 1.42-2.55), variable starting/finishing times (aPR 1.17; 95% CI 1.04-1.32) and changes in work schedule (aPR 1.56; 95% CI 1.30-1.88). Compared with non-migrant males, male migrant manual workers are the group with a greater number of disparities in terms of exposure to negative working conditions. Female migrant non-manual workers are more exposed to psychosocial conditions - working at very high speed (aPR 1.26; 95% CI 1.10-1.44) and shift work (aPR 1.61; 95% CI 1.29-2.01) while female manual migrant workers were more likely to report standing or walking (aPR 2.43; 95% CI 1.98-2.97), not having a contract (aPR 2.94; 95% CI 2.07-4.10) and not being free to decide days off and holidays (aPR 1.25; 95% CI 1.07-1.48) than non-migrants. CONCLUSION: Migrant workers across Europe are more likely to be exposed to certain working and employment arrangements that may place them at higher risk of future health problems.

Perceived social approval and condom use with casual partners among youth in urban Cameroon.

BACKGROUND: HIV prevention programs targeting youth often emphasize the role of peers, and assume that youths will model their behavior after their peers'. We challenge this view; we argue that adopting a given behavior requires social approval, and that youths do not necessarily turn to peers for such approval. This study analyzes survey data on youths in urban Cameroon to 1) identify which type of persons youths look to for social approval, and 2) establish how important social approval by these persons is for condom use among youths. METHODS: We analyzed data from three survey waves (2000, 2002, and 2003) of a reproductive health survey conducted among urban Cameroonian youth (aged 15-24). Only respondents who reported having at least one casual partner in the past year were retained for the analysis. Bivariate analyses and structural equation modeling were used to examine relationships among perceived social approval, attitudes towards condoms and condom use. RESULTS: The data show that only 3% of youths named their friends as people whose opinion they valued, while 93% mentioned family members. The perceived approval of condom use by these persons had a significant positive effect on the frequency of condom use among youths. The frequency of condom use was also affected by the respondents' attitudes toward condom use, the range of persons with whom they discussed reproductive health matters, whether they were enrolled in school, socioeconomic status, their self-efficacy, perceived severity of AIDS, risk perception and sexual risk behavior. The perceived social approval of condom use and the respondents' own condom attitudes were correlated. CONCLUSIONS: Our analysis demonstrates that perceived social approval facilitates the adoption of condom use among urban Cameroonian youth. However, youths tend to value the opinions of family members much more than the opinions of their peers. These results suggest that interventions targeting youths should not focus exclusively on peers but should also include other groups, such as parents and community leaders.

Basic Information Processing Abilities at 11 years Account for Deficits in IQ Associated with Preterm Birth.

Although it is well established that preterms as a group do poorly relative to their full-term peers on tests of global cognitive functioning, the basis for this relative deficiency is less understood. The present paper examines preterm deficits in core cognitive abilities and determines their role in mediating preterm/full-term differences in IQ. The performance of 11-year-old children born preterm (birth weight <1750g) and their full-term controls were compared on a large battery of 15 tasks, covering four basic cognitive domains -- memory, attention, speed of processing and representational competence. The validity of these four domains was established using latent variables and confirmatory factor analysis (CFA). Preterms showed pervasive deficits within and across domains. Additionally, preterm deficits in IQ were completely mediated by these four cognitive domains in a structural equation model involving a cascade from elementary abilities (attention and speed), to more complex abilities (memory and representational competence), to IQ. The similarity of findings to those obtained with this cohort in infancy and toddlerhood suggest that preterm deficits persist - across time, across task, and from the non-verbal to the verbal period.

Economic hardship and depression across the life course: the impact of welfare state regimes.

Previous research in the United States suggests that depression related to economic hardship decreases with age. We test whether this pattern can be generalized to other developed nations. Based on data from 23 countries in the European Social Survey (2006--2007), multilevel analyses show that the moderating role of age depends on the socio-political context. While the hardship--depression link is not significantly different across the life course in Nordic and Bismarckian regimes, the hardship--depression link increases with age in Southern and Eastern European countries and decreases with age in strength in Anglo-Saxon welfare states. Our findings suggest that welfare state regimes play a significant role in attenuating, boosting, or even reversing the health effects of social experiences such as economic hardship on aging. Health knowledge gained through research that ignores the socio-political context may be limited in terms of generalization.

The structure of memory in infants and toddlers: an SEM study with full-terms and preterms.

There is considerable dispute about the nature of infant memory. Using SEM models, we examined whether popular characterizations of the structure of adult memory, including the two-process theory of recognition, are applicable in the infant and toddler years. The participants were a cohort of preterms and full-terms assessed longitudinally--at 1, 2, and 3 years--on a battery containing tasks of immediate and delayed recognition, recall, and memory span (a measure of short-term capacity). Results were in accord with adult models which assume that short- and long-term memory are distinct, and that two processes--familiarity and recollection--underlie recognition memory, while one alone--recollection--supports recall. The finding that prematurity, which entails risk of hippocampal compromise, affected recollection, but not familiarity, accords well with adult findings that hippocampal damage selectively affects recollection. These findings reveal striking similarity between the structure and theoretical underpinnings of infant and adult memory.

Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic review and meta-analysis of randomized and nonrandomized trials.

OBJECTIVE: Systematically assess the effectiveness of HIV-prevention interventions in changing sexual behaviour of young people (10-25 years) in sub-Saharan Africa. METHODS: Three online databases were searched using prespecified terms. Additional articles were identified on websites of international organizations and by searching bibliographies. Randomized and nonrandomized trials of interventions aiming to reduce risk behaviour were included as well as single-arm studies reporting effects of differential exposure to an intervention. Data were extracted independently in duplicate using predefined data fields. RESULTS: Thirty-one studies on 28 interventions met the inclusion criteria, including 11 randomized trials. Difficulties with implementing planned activities were reportedly common and differential exposure to intervention was high. Two hundred and seventeen outcome measures were extracted: 88 early (within 1 year of intervention) and 129 late outcomes (more than 1 year after the end of the intervention). Sex education and condom promotion among youth did not increase sexual behaviour as well as risky sexual behaviour. No positive effects on sexual behaviour were detected either and condom use at last sex only increased among males [relative risk = 1.46; 95% confidence interval = 1.31-1.64]. One study reported a reduction of herpes simplex virus-2, but not HIV incidence. CONCLUSION: There remains a stark mismatch between the HIV burden in youth and the number of attempts to design and test prevention interventions - only two trials report biological outcomes. More effective interventions targeting youth are needed. Attention should go to studying implementation difficulties, sex differences in responses to interventions, determinants of exposure to interventions and perhaps inclusion of other factors apart from HIV/AIDS which influence sexual behaviour.

AIDS knowledge and sexual activity among Flemish secondary school students: a multilevel analysis of the effects of type of education.

BACKGROUND: The behavior of adolescents puts them at an increased risk for HIV and other STIs, and their knowledge about HIV/AIDS is often inadequate. An understanding of how AIDS knowledge and sexual activity co-vary among Flemish secondary school students and of how education type, specifically, affects these students is limited. This study addresses the question of whether the effects of education type on HIV/AIDS knowledge and sexual activity are independent of the socio-demographic characteristics of the students. METHODS: Data from the Flemish Educational Assessment survey, which collected data from a large representative sample of third- and fifth-grade high school students (N = 11,872), were used. Data were analyzed using multilevel logistic and Poisson regression techniques. RESULTS: There is an indication that type of education affects both an adolescent's sexual activity and his/her AIDS knowledge; these effects prove robust for differences in socio-economic backgrounds. Students in lower status education types are more likely to be sexually active and to have poorer AIDS knowledge. The relationship between AIDS knowledge and sexual activity is, however, more complex. Although students in education types with poorer AIDS knowledge are more sexually active, within each of these groups the sexually active have better AIDS knowledge than the non-sexually active. There is also evidence of active information seeking by sexually active students, which leads to improved AIDS knowledge. CONCLUSION: These findings are consistent with the literature on the role of the educational system in the reproduction of social inequalities. Students from lower status education types are at increased sexual risk compared to those from higher status types. There is also evidence of active information seeking by sexually active students, which leads to improved AIDS knowledge.