Rapid ethnographic assessment of breastfeeding practices in periurban Mexico City.

Before carrying out a breastfeeding promotion programme in a periurban area of Mexico City, we conducted a rapid ethnographic study to determine the factors associated with absence of exclusive breastfeeding. The responses to pilot interviews were used to develop a standardized questionnaire regarding reasons for infant feeding choice, sources of advice, and barriers to breastfeeding. We interviewed a random sample of 150 mothers with a child < 5 years of age; 136 (91%) of them had initiated breastfeeding; but only 2% exclusively breastfed up to 4 months. The mothers consistently stated that the child's nutrition, health, growth, and hygiene were the main reasons for the type of feeding selected; cost, comfort, and the husband's opinion were less important. Physicians were ranked as the most important source of advice. Reduction or cessation of breastfeeding occurred on the doctor's advice (68%); or when the mothers encountered local folk illnesses such as "coraje" (52%) or "susto" (54%), which are associated with anger or fright; or had "not enough milk" (62%) or "bad milk" (56%); or because of illness of the mother (56%) or child (43%). During childhood illnesses and conditions, breastfeeding was reduced and the use of supplementary foods was increased. This study emphasizes the importance of cultural values in infant feeding choices, defines specific barriers to breastfeeding, and provides a basis for interventions to promote exclusive breastfeeding in the study population.

PIP: Prior to initiating a community-based intervention program to promote exclusive breast feeding in San Pedro Martir, Mexico, a 2-month (1994) rapid ethnographic assessment was conducted. 150 mothers whose youngest child was under 5 years of age were interviewed. 136 mothers (91%) had breast-fed their infant, for a median duration of 6 months, but only 2% exclusively breast-fed for up to 4 months. Mothers consistently described breast feeding as the best nutrition for their infant. However, the dominant feeding pattern was mixed breast and bottle-feeding. Formula, tea, and water were introduced during the first postpartum day. By the end of the third month, 63% of mothers had introduced solid food to promote growth. It was common practice to reduce breast feeding and increase feeding of supplementary foods when a child was ill. Physicians were the most respected source of knowledge on breast feeding. 42% of mothers reported that, at some point when they were breast feeding, a doctor had advised them to stop and half these mothers complied. The data collected in this rapid survey were used to guide a peer counseling program to promote exclusive breast feeding in the community.

Emergency contraception in Mexico City: what do health care providers and potential users know and think about it?

Emergency contraception promises to reduce Mexico's high unwanted pregnancy and unsafe abortion rates. Because oral contraceptives are sold over-the-counter, several emergency contraceptive regimens are already potentially available to those women who know about the method. Soon, specially packaged emergency contraceptives may also arrive in Mexico. To initiate campaigns promoting emergency contraception, we interviewed health care providers and clients at health clinics in Mexico City, ascertaining knowledge, attitudes, and practices concerning the method. We found limited knowledge, but nevertheless cautious support for emergency contraception in Mexico. Health care providers and clients greatly overestimated the negative health effects of emergency contraception, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believed emergency contraception should be more widely available, including in schools and vending machines with information prevalent in the mass media and elsewhere.

PIP: An interview was conducted to ascertain knowledge, attitudes, and practices concerning emergency contraception (EC) among health care providers and potential EC users in metropolitan Mexico. Findings showed that there was a limited knowledge about EC per se and its method, but nevertheless, most of the participants were cautious to support EC in Mexico. Health care providers and clients greatly overestimated the negative health effects of EC, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believe EC should be more widely available, including in schools and vending machines, with information prevalent in the mass media and elsewhere.

Getting the word out in Guatemala.

PIP: In Guatemala, a 1997 KAP (knowledge, attitude, practice) survey conducted in three areas of the country revealed that 88% of the people knew about the family planning (FP) program conducted by the Family Welfare Association of Guatemala (APROFAM), but only a few respondents understood modern contraceptive methods. The survey results were used by participants in a national workshop to create a work plan for 1998. The KAP survey also revealed that, while traditional birth attendants may recommend that a pregnant woman be referred to a hospital, husbands usually make the final decision. Meanwhile, a Japanese "Overseas Cooperation Volunteer" public health nurse based at a clinic in Solola State (a referral center for APROFAM clinics) has been providing counseling and FP guidance to local people. This nurse has uncovered an urgent need to treat and prevent reproductive tract infections and to delivery high-quality, low-cost reproductive health care in the area.^ieng

AIDS and condoms in Brasilia: a telephone survey.

A telephone survey was conducted to measure AIDS knowledge, media usage and condom attitudes and behaviors among 500 adults aged 18 to 49 in Brasilia, as well as to evaluate the feasibility of the telephone survey method in a developing country. The response rate was 91.6%. Respondents had good knowledge about correct modes of HIV transmission and prevention but also believed HIV was transmitted through blood donation, public toilets, swimming pools, and mosquito bites. TV and newspapers were the most important sources of information on health matters and AIDS, though health workers were considered the most credible sources of such information. Only 19% of sexual encounters in the 4 weeks prior to the survey included condoms. Single and younger respondents and those with more positive attitudes used condoms more frequently. More work is needed to identify appropriate messages to motivate people to use condoms. Telephone surveys regarding AIDS and sexual attitudes and behaviors are feasible in Brasilia, a planned community with universal telephone coverage.

PIP: This study examines the knowledge, attitudes, and behavior of AIDS and condom use in Brazil. Data were obtained during March-April 1994 from 500 completed telephone interviews among a sample of adults 18-49 years old living in the Plano Piloto sector of Brasilia, Brazil. The survey was conducted about 2 months after a national television and radio campaign on AIDS prevention, use of condoms, and avoidance of sharing syringes or needles. The questionnaire was based on questions from the Global Program on AIDS protocol. 99% of the sample reported that AIDS was one of the most important health problems facing Brazil today. The other health problems mentioned were cancer, famine, and cholera. 27% did not consider themselves at risk of AIDS. 2% considered themselves at great risk. The rest believed they had a small to moderate risk. 93% were aware that people with AIDS might appear healthy looking. 95% indicated sexual contact as a mode of transmission. 34% reported condom use as a means of avoiding AIDS transmission. 19% reported sexual abstinence as a preventive measure. 15% reported that people should inform others of their AIDS status as a way to avoid transmitting AIDS. 41% knew someone with AIDS. Less educated respondents held more inaccurate beliefs about the general means of transmission, but there were no educational differences about safe activities involving specific contact with persons infected with AIDS. Most misinformation pertained to public toilets, blood donations, use of swimming pools, and mosquito bites. 89% believed in a high risk at dental clinics used by AIDS patients. 72% were regular television users. Television and newspapers were the most important sources of information on AIDS and health. Only 19% used condoms in sexual activity occurring in the prior 4 weeks. Psychosocial factors were more important than demographic factors in predicting condom use.

Using a knowledge, attitudes and practices survey to supplement findings of an outbreak investigation: cholera prevention measures during the 1991 epidemic in Peru.

BACKGROUND: To assess the effectiveness of the cholera prevention activities of the Peruvian Ministry of Health, we conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the cholera epidemic in 1991. METHODS: We surveyed heads of 67 urban and 61 rural households to determine diarrhoea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding ten cholera prevention measures. RESULTS: Twenty-five per cent of 482 urban and 11% of 454 rural household members had diarrhoea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, and education through interpersonal communication was more prevalent in rural villages. Ninety-three per cent of rural and 67% of urban respondents believed they could prevent cholera. The mean numbers of correct responses to ten knowledge questions were 7.8 for urban and 8.2 for rural respondents. Practices lagged behind knowledge and attitudes (mean correct response to ten possible: urban 4.9, rural 4.6). Seventy-five per cent of respondents drank untreated water and 91% ate unwashed produce, both of which were identified as cholera risk factors in a concurrently conducted case-control study. CONCLUSIONS: The cholera prevention campaign successfully educated respondents, but did not cause many to adopt preventive behaviours. Direct interpersonal education by community-based personnel may enhance the likelihood of translating education into changes in health behaviours. Knowledge, attitudes, and practices surveys conducted with case-control studies during an epidemic can be an effective method of refining education/control programmes.

PIP: The authors conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the 1991 cholera epidemic to assess the effectiveness of the Peruvian Ministry of Health's cholera prevention activities. Diarrhea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding 10 cholera prevention measures were determined by surveying the heads of 67 urban and 61 rural households. 25% of 482 urban and 11% of 454 rural household members had diarrhea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, while education through interpersonal communication prevailed in rural villages. 93% of rural and 67% of urban respondents believed they could prevent cholera. Rural respondents were slightly more knowledgeable than urban respondents about cholera. Overall, however, practices did not reflect their knowledge and attitudes; 75% of respondents drank untreated water and 91% ate unwashed produce.

AIDS and condom-related knowledge, beliefs, and behaviors in Mexican migrant laborers.

PIP: A survey of 87 Mexican migrants (55 males and 32 females) who have lived and worked in the US since 1982 assessed AIDS and condom-related knowledge, beliefs, and sexual practices. Although respondents were highly knowledgeable about major modes of HIV transmission, one-third to one-half believed that HIV could be contracted from mosquito bites, public bathrooms, kissing, and the HIV test. Only 15% knew someone with AIDS. Ever-use of condoms was reported by 70.9% of men and 41.9% of women. Of the 68 subjects who had been sexually active in the year preceding the survey, 20 reported two or more partners. Among sexually active respondents, 16.2% always used condoms with their primary partner, while 43.0% used condoms consistently with occasional partners. 48.9% of men and 57.1% of women never used condoms with their primary partner; with casual partners, these rates were 30.8% and 44.4%, respectively. Worry about contracting AIDS, self-rated on a scale from 1 (very often) to 4 (never), averaged 2.84, with higher worry scores among those 18-31 years of age and with multiple partners. Respondents did not anticipate negative consequences of condom use (e.g., reduced sexual pleasure), but females expressed concern that carrying condoms would cause them to be viewed as promiscuous.^ieng

[Vaginal citology. Prevention and good health. Survey]. / Citologia vaginal. Prevencion y buena salud. Encuesta.

PIP: A 1993 survey of knowledge, attitudes and practices related to sexually transmitted diseases and other conditions included a series of questions for women on vaginal cytology. The survey was based on a subsample of the PROFAMILIA master sample. 15,080 persons were interviewed, including 6949 women 18-69 years old. The section on vaginal cytology began with a description of the procedure before the questions were asked. Among the total sample, 66.2% reported having undergone cervical cytology while 33.8% had not. 4.8% did not request the results. For the 61.4% of the sample that requested the results, 49.4% were normal, 11.1% were abnormal, and 0.9% did not know or were not given their results. Of those with abnormal results, 9.3% returned for another consultation and 1.8% did not. The proportion of women having cervical cytology exceeded 80% for women 30-49 years old. 69.9% of urban and 54.2% of rural women had been tested. 28.9% underwent the most recent test due to a personal decision, 24.7% on medical recommendation, 23.2% because of symptoms, 12.0% to prevent cancer, 3.2% for safety, 2.0% because a year had passed since the last test, 2.0% in response to a campaign, 1.6% because a friend suggested it, and 1.1% because they had never had it done. The symptoms that motivated the test were a discharge for 31.4%, pain for 30.0%, bleeding for 11.8%, itching for 5.5%, postpartum problems for 2.8%, burning for 2.5%, and cyst for 1.9%. Abnormal results were obtained in 40% of the women who had the test because of symptoms. The average number of times in the past 5 years that the test was done was 2.8. 9% of respondents had not had a test in the past 5 years, 26% had 1, 18% had 2, 12% had 3, 7% had 4, 16% had 5, and 11% had 6 or more. 64.4% of women under 25 and 39% over 60 had never had vaginal cytology. Rural women and the less educated were less likely to have had the procedure.^ieng

Domestic violence: an educational imperative?

OBJECTIVE: Domestic violence is the most common cause of injury to women. Obstetrician-gynecologists, who most women consider their primary care physicians, have a unique role in identifying battered women. This study was designed to assess the extent and nature of current training curricula regarding domestic violence education in obstetrics and gynecology residencies. STUDY DESIGN: A survey sent to all obstetrics and gynecology residencies requested demographic data, the curriculum in respect to domestic violence, availability of interested faculty, the prevalence of battering among patients, satisfaction with the current teaching, and knowledge of pending legislation. Respondents were also asked which of 10 common clinical presentations would prompt their faculty to discuss the possibility the patient was being battered. RESULTS: Eighty-three percent of programs responded. The "typical" program was urban, had five residents per year, and had faculties of full-time academicians and part-time private practitioners. Twenty-eight percent reported having at least one faculty member with expertise in domestic violence. One third reported a prevalence of battering of < or = 1% with 6% estimating fewer than 1 in 1000. Seventy-five percent did not recognize at least one clinical scenario as suggestive of battering. The majority were dissatisfied with their teaching and wanted help in curriculum development. Forty percent were unaware of pending legislation linking federal support of medical education to including domestic violence in curricula. CONCLUSIONS: The results of this survey highlight deficiencies in the education of obstetrics and gynecology residents about domestic violence. Programs report limited faculty interest, underestimate prevalence, fail to recognize common presentations, and are dissatisfied with their current curriculum. We are not preparing obstetrics and gynecology residents to care for patients with a common problem--domestic violence.

PIP: In the US, domestic violence is the most common cause of injury to women, and, because they are women's primary care physicians, obstetrician-gynecologists (OB-GYNs) are in a position to identify battered women. With legislation pending that would require federally-funded medical education to include domestic violence in its curriculum, a survey was conducted of all OB-GYN residencies to determine their current status in the provision of domestic violence education. With 83% of the programs responding (n = 264), it was found that 28% had at least one faculty member with expertise in domestic violence, that the incidence of domestic violence among clients was underestimated, and that 75% of respondents did not recognize at least 1 of the 10 common clinical scenarios as suggestive of battering (at least 44% failed to recognize the risk factors of no prenatal care, preterm labor, emergency room visits, and psychiatric diagnoses). Only 28% of respondents reported that they teach residents to ask all or almost all patients about battering. Most respondents expressed dissatisfaction with their coverage of this topic and asked for help in curriculum development. In addition, 40% were unaware of the pending federal legislation. This study concluded that there is a strong need to develop an OB-GYN curriculum that deals with domestic violence but that further study is needed to determine the optimal teaching methods.

[Street children and AIDS in Haiti]. / Enfants de la rue et SIDA en Haïti.

This study is a qualitative inquiry KAP about sexuality, and adoption and preservation of safe sexual behaviors, among the children of the street in Port-au-Prince, Haiti. Three groups of participating children of the street were observed in Port-au-Prince for three months, during June through August 1991. The information was collected with the use of pre-tested charts for each theme chosen. Then, individual interviews were conducted with leaders identified among the educators and children of the street. One of the main goals of Aids educational programs of street children should be to make them believe in the existence of the disease, and the real risk it poses for death. The strategies that we will use to convince them should deal with the different social, psychological, economical, and environmental factors that characterized the children as follows: 1) their adherence to a peer group and the relationship of power between the older and younger children; 2) the fundamental importance of money in their life, and that all relationships that they have are based on the capacity of people to give them something, such as money; 3) the role of their social appearance and their need to behave like other children for even one day; 4) their low self-esteem; 5) their feeling of powerlessness and resignation related to their living conditions; 6) the influence of the street culture; and 7) their understanding of sexuality as an immediate pleasure.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: In Haiti, observations of 70 boys, 6-17 years old, living in the streets of Port-au-Prince and interviews with 10 key informants were conducted so researchers could learn the knowledge, attitude, and practices of the boys concerning sexuality and sex behaviors. The street children were observed at the airport parking lot, the Madankolo bus station, and the market in the rich quarter of Port-au-Prince. They did not use condoms. They did not feel that they would develop AIDS or any illness. They perceived AIDS as only a long-term fatal disease less dangerous than other daily events. Sexually transmitted diseases (STDs) indicated sex with prostitutes, which elevated their social stature among street children. They had insufficient knowledge of the cause, transmission modes, and prevention of HIV infection. They had poor self-esteem. They did not value or protect their bodies. They perceived the condom as being imposed by the outside. The group was unstable, transient, and without a charismatic leader. It had an authoritarian leader who was not well respected. A boy with whom another boy feels comfortable may be a vehicle for HIV prevention messages. The link unifying two friends is greater than the link to the group. Sex with men was a quick way for the boys to earn money. The boys preferred heterosexual relationships. The boys have adopted a street mentality to survive in the street where life is always dangerous, violent, and geared towards acquisition of goods or money. When designing an AIDS/STD education program, one must address the following: the importance of money as a tool for social validation, the emotional forces of the street child which made him grow up quickly, his very developed survival instinct, and violence of which he is a victim and which he practices.

Congratulations to the mothers. Breastfeeding.

PIP: In Lima, Peru, a study was conducted that evaluated the influences on mothers' decisions regarding breastfeeding. Local views and health professional advice was ascertained. A follow-up study of a group of pregnant women was conducted to assess knowledge, attitude, and practice in regard to the early feeding of their children. The women were interviewed in their homes before delivery, as soon as possible after delivery, and twice a week until their babies were 1 month old. The experience of the mother was the key factor, but advice from relatives, neighbors, and health professionals was also important. A lack of information about exclusive breast feeding was common. Although the women knew breast feeding was good, they were unaware that exclusive breast feeding was best. Health workers knew to advise against other milks, but failed to advise mothers against the use of herbal teas and sweetened water as supplements. The women commonly believed they were unable to produce enough milk to feed their children because of their own undernourishment. Others believed exclusive breast feeding would worsen their own health, while some experienced difficulties breast feeding. This led to supplementation with other milks; herbal teas were given to cure colic and to quench infants' thirst. Based on these findings, the project focused educational efforts on providing better information to mothers. Messages stressed the thirst quenching property of breast milk and its similar benefits to herbal tea, which should be consumed by the mother, rather than the infant. Since breast feeding practices were closely linked to mothers' beliefs about their own needs, the project emphasized the value and needs of the mother and the benefits of breast feeding for her. Educational activities, which continued for 12 months, included videos shown to small groups of mothers, posters, distribution of pamphlets, and messages broadcast over loudspeakers. A significant increase in the number of children aged 0-4 months being exclusively breast fed was observed; however, the increase only occurred in the second, third, and fourth month. This seemed to be a direct result of the decrease in use of herbal teas and sweetened waters. The number of women using other milks as supplements did not decrease significantly.^ieng

Cutaneous leishmaniasis in subtropical Ecuador: popular perceptions, knowledge, and treatment.

Popular perceptions and knowledge about cutaneous leishmaniasis and its treatment were studied in an endemic area of subtropical Northwest Ecuador. Although most of the adults surveyed were familiar with the disease, the vector, and traditional treatments, many showed a lack of knowledge about transmission of the disease, ulcer healing, and conventional treatment. Gender was found to have a significant impact on disease risk, perceptions, and treatment knowledge. Males experienced a risk of contracting cutaneous leishmaniasis that was almost triple that of women. Men were also more likely to perceive that the disease seriously diminished the victim's capacity to work. Women, on the other hand, were more prone to perceive that cutaneous leishmaniasis was a serious disease that significantly decreased self-esteem. Although 80% of the subjects knew at least one method of treating the disease, women tended to know more methods than men. Most of 150 different therapies reported involved the use of indigenous plants, chemicals, acids, antibiotics, heat treatments, or petroleum by-products. Some of these treatments could have clinical value. However, only 7% of the subjects knew about pentavalent antimonials. Almost 70% of the subjects with a past or present infection history were treated solely by traditional methods; only 12% received a full course of Glucantime, while 7.5% got an incomplete course. The findings indicate that it will be important to consider the identified gaps in knowledge and gender perceptions regarding the disease and its treatment when planning future control programs.

PIP: In 1989-1991, a study of 466 children and adults (i.e., = or 18 years) living in 26 small agricultural villages in the remote subtropical forest of Northwest Pichincha Province on the western slope of the Andes Mountains in Ecuador examined perceptions and knowledge of cutaneous leishmaniasis and local methods used to treat it. 13% of all adult subjects had active cutaneous leishmaniasis. Men were 2.83 times more likely to have cutaneous leishmaniasis than women (p = .037), perhaps due to increased occupational exposure (i.e., agricultural work in the rain forest) and social exposure (i.e., outside during times of maximum vector activity). They were more likely to consider it to have a negative effect on the affected person's capacity to work (77.3% vs. 61.2%; p = .025). Women were more likely than men to perceive it as a severe disease (85.2% vs. 68%; p = .015) that reduced the victim's self- esteem (89.9% vs.75.7%; p = .017). 97.3% of subjects were familiar with the sandfly vector, yet less than 10% knew it was responsible for cutaneous leishmaniasis. 80% of adults knew at least 1 treatment option. Women could name more treatment methods than men (1.6 vs. 1.2; p .05). The adults named more than 150 treatment options, most of which were traditional methods involving the application of topical preparations or objects to the ulcers (e.g., herbs, trees, or other plants and homemade rum, wood alcohol, iodine, menthol, methiolate, and sulfur). Just 7% were familiar with antimonial drugs. Most adults and children who had either active cutaneous leishmaniasis or a history of past infection (68%) had been treated with traditional methods. 8.5% received both traditional treatments and Glucantime. Just 12% received the full course of Glucantime therapy. 7.5% received an incomplete course of glucantime therapy. These results show that public health officials need to consider the gaps in knowledge and gender perceptions of cutaneous leishmaniasis and in its treatment when they plan control programs.

Patterns of contraceptive use and pregnancy among young Hispanic women on the Texas-Mexico border.

Our objective was to identify significant family planning and health access problems of young Hispanic women on the Texas-Mexico border. Samples of 300 young Hispanic women living in each of the twin cities of El Paso and Juarez were interviewed regarding their knowledge, attitudes, and experiences with respect to birth control, pregnancy, maternal and child health, and health-care services. Knowledge and attitudes of the women about birth control technology were assessed along with their beliefs regarding the use of such technology. Results showed that contraceptive knowledge and usage patterns for young Hispanic women in Juarez and El Paso were significantly different. They relied on different types of birth control methods and also differed with respect to confidence in these methods and related medical services. Both groups reflected positive attitudes toward both child bearing and use of birth control although Juarez women were significantly more favorable toward child bearing. Both groups overwhelmingly favored female doctors. The young women studied have accepted the need for birth control, prefer fewer children, and have some degree of confidence in medical services. Their knowledge and use of reliable versus unreliable birth control devices appear to be major areas requiring culturally sensitive intervention.

PIP: Social work students administered a questionnaire to 600 randomly selected adolescent females from El Paso, Texas, and Juarez, Mexico, to examine their knowledge and use of contraceptive methods and their attitudes about pregnancy, contraception, and child care. 11.7% of the El Paso respondents and 16.7% of the Juarez respondents had been pregnant at some time. Oral contraceptives (OCs) were the most known contraceptive method. Women in El Paso were more likely to be familiar with OCs (98% vs. 91.3%), condoms (93.7% vs. 74.7%), vaginal methods (79.7% vs. 67.8%), and withdrawal (65.3% vs. 44.5%) than were those in Juarez (p = .001). On the other hand, more Juarez women than El Paso women knew about injectables (79.8% vs. 34.1%), sterility or tubal ligation (89.9% vs. 63.3%), vasectomy (73.2% vs. 69%), Billing's method (19.2% vs. 5.3%), and the rhythm method (73.6% vs. 36.4%) (= = .001). Many women from both cities used ineffective methods. Women in Juarez were much more likely to use the rhythm method than those in El Paso (26.4% vs. 3.4%; p = .001). Women from both cities, particularly those in Juarez (p = .001), believed more information on contraception was needed. They felt strongly that men should also be responsible for family planning and approve of women using contraceptives. They believed that couples should have fewer children. Juarez women has a more positive view of pregnancy and childbearing than did El Paso women. El Paso women were more likely to visit a physician in the last year for reasons other than check-ups (mean number of visits, 1.88 vs. 1.25; p = .005). Most women preferred to receive maternal and child health/family planning services from a female physician (56% in Juarez and 64.3% in El Paso). These findings indicated that cultural differences in contraceptive knowledge and usage as well as confidence in various methods and related medical services existed. They emphasized the need for culturally relevant education, research, and service programs concerning adolescents in the Texas-Mexico border region.

On the limited utility of KAP-style survey data in the practical epidemiology of AIDS, with reference to the AIDS epidemic in Chile.

Population surveys concerning 'risk behaviours' thought to be related to the AIDS epidemic are many. Nevertheless, unfocused inquiry into diffuse behaviours in undifferentiated populations is not productive in low-seroprevalence populations, especially when the point is to design some form of intervention that might actually avert further infection. This is because of a failure to distinguish conceptually between the relevance of AIDS-related behavioural data for individuals and for populations. An illustration is drawn from the AIDS epidemic in Santiago, Chile, and an alternative perspective, based on extensive interviews with persons with AIDS and a survey of current HIV-surveillance and blood-screening programs, is described.

PIP: The AIDS epidemic and the associated discovery of HIV brought attention to the dearth of knowledge among social scientists about homosexuality, bisexuality, injectable drug use, and other behaviors which may place participating individuals at risk of contracting and/or transmitting HIV. To redress these gaps in their knowledge, researchers have recently tended to gather attitudinal and behavioral data through population-based KAP-style surveys and to make inferences from such data to the current prevalence and future course of the AIDS epidemic. While survey data may help expand our knowledge on the distribution of practices in a variety of populations, it is not clear that they help us understand the epidemiology of AIDS in a given population. The author argues that these unfocused inquiries into diffuse behaviors in undifferentiated populations are not productive in low-seroprevalence populations, especially when the objective is to design interventions to avert further infection. The failure of KAP surveys to distinguish conceptually between the relevance of AIDS-related behavioral data for individuals and for populations makes them fundamentally flawed for such purposes. An illustration of the AIDS epidemic in Santiago, Chile, is used to substantiate this argument and an alternative perspective is presented based upon interviews with people with AIDS and a survey of current HIV-surveillance and blood screening programs. KAP survey findings generally lead to prescriptions for mass behavior modification. Individuals infected with HIV who remain sexually active and their partners should instead be targeted by interventions to change their behavior. This approach would focus on actual social and sexual networks and the true etiology of viral contagion. In closing, the author acknowledges that his proposed approach may unjustly stigmatize or blame certain groups; contribute to a lack of unity in the fight against the virus and jeopardize supportive funding and legislation; and create a false sense of security for individuals not in the targeted risk groups.

Social norms for condom use: implications for HIV prevention interventions of a KABP survey with heterosexuals in the Eastern Caribbean.

PIP: A knowledge, attitude, belief, and practices survey was given to a sample of 591 residents of St. Lucia in the fall of 1990. The survey posed a host of questions relating to whether respondents were inclined to use condoms when having sex. Respondents were sexually experienced, aged 15-60 years, and interviewed in their homes. Questions were posed and viewed as possible indicators of AIDS knowledge, cues to action, perceived susceptibility, perceived severity, perceived locus of control, normative pressure, and condom use outcome expectancies. Statistical analysis suggests that each variable is related to condom use. Analysis also indicates that perceived normative pressure to use condoms was by far the single most important determinant of condom use among the sample. The author closes by discussing the implications of these findings for designing mass media campaigns to increase condom use and strongly recommends a normative campaign.^ieng

Research on AIDS: knowledge, attitudes and practices among street youth.

PIP: CHILDHOPE (with funding from the United Nations Children's Fund and the aid of nongovernmental organizations in the Philippines, Thailand, Colombia, and Kenya) conducted surveys of street youth in order to ascertain their knowledge, attitudes, and practices in regard to sex and the prevention of human immunodeficiency virus (HIV) infections and other sexually transmitted diseases (STDs). The youth also participated in acquired immunodeficiency syndrome (AIDS) prevention and sex education activities. Youth from all 4 sites reported early sexual activity and multiple partners. Sex was used in all 4 sites to obtain pleasure (recreation), income (prostitution), food or shelter (survival sex), and power (gang rape). Philippine youth reported prostitution and survival sex, including homosexual sex, with foreigners and locals. Kenyan girls reported both prostitution (their main occupation) and survival sex. Kenyan males reported prostitution with foreigners and locals, and rapes of girls. In Bogota, males reported rapes of girls, and gang rapes of females for punishment or initiation. They also reported using sex workers and exchanging sex with men or women for food and shelter. Females from Bogota reported that their "friends" sometimes used survival sex to support their children; nearly all had been previously involved in survival sex on the street. Sexual abuse was common in Kenya and the Philippines; some youth in Manila were abused at shelters. In all 4 sites, there was a high awareness of AIDS and STDs, but information was often incorrect, especially in regard to transmission and treatment of STDs. Although nearly all of the youth knew about modes of transmission of HIV, those from the Philippines and Colombia did not have a personal realization or fear that they could contract it, while those from Kenya and Thailand believed they were at high risk and wanted assistance. 20/21 Kenyan girls were tested by the Undugu Society for HIV after detection of current STD infections in 7 of them; 4 were HIV positive. 2 of these have returned home, and 2 are being provided shelter, counseling and support by the Society. Without changing the problems that create a need for survival sex among youth, little can be done about promoting safe sex and healthy lifestyles.^ieng

Planning for life in Latin America.

PIP: The Instituto Mexicano de Investigacion de Familia y Poblacion conducted a study of 12-19 year old girls from lower middle to lower socioeconomic classes in Mexico City to determine knowledge level of sexuality and current sexual and contraceptive practices. Researchers wanted to use the information to create a sex education program and then evaluate the program's effect. The findings showed a need to obliterate false beliefs, to provide detailed and practical information about sexual behavior, and to expand sex education by stressing clarification of values, assertiveness, decision making, support networks among peers, and communication with family, partner, and peers. They developed a program called Planning Your Life. It was designed to make the best use of adolescents' cognitive abilities and to involve parents, teachers, and the community in the process by reinforcing newly learned attitudes and behaviors. Students rendered the new concepts into action by participating in group and individual exercises. They were also to leave the classes daily and practice their new skills and abilities. Knowledge increased significantly in students who attended the course. Further adolescents, particularly boys, who took part in the course before beginning sexual relations were more likely to use contraceptives than those who had already begun sexual relations. Thus children should receive sex education before they begin sexual activity. Effective sex education should equip children with skills to communicate with others in constructive and healthy ways, to make decisions which match their knowledge, to recognize traditional sexual roles and values, to pursue higher education, to strengthen family ties, to plan for the future, and to be cognizant of the likely effect of their present behavior.^ieng

Evaluation of clinical management training programme for diarrhoea.

We report the evaluation of a training programme on clinical management of infantile diarrhoea. The training programme was delivered through a series of on-site clinical courses offered to a selected group of physicians and nurses from 16 health units in Peru and a series of local workshops conducted in their own health units. The outcome of this training programme was assessed by pre- and post-tests, knowledge, attitude, and practice (KAP) questionnaires, and observational surveys. A significant improvement in medical knowledge about diarrhoea, in particular about the use of ORT and drug therapy, was observed. Although the observational surveys showed significant improvement in the use of ORT at health facilities (2.9% to 23.6%, p = 0.007) the rate observed was still low compared to the high level of knowledge on ORT that was demonstrated by the KAP questionnaires. A reduction of antibiotic prescription for inpatients with diarrhoea (85.7% to 64.8%, p = 0.025) was observed. The training programme was also effective in promoting the establishment of Oral Rehydration Units in the participants' health facilities.

PIP: Physicians designed a training program on clinical management of diarrhea which consisted of 11 clinical training courses at the Cayetano Heredia University Hospital in Lima, Peru for 37 physicians and 37 nurses from 16 hospitals in 20 various cities in Peru; a number of local workshops on overall features of clinical management of diarrhea cases; and supervisory pre- and posttraining visits to the hospitals. Health workers treated only 2.9% of dehydration cases and 25.7% of inpatient diarrhea cases before dehydration set in and 7.7% of similar outpatients with oral rehydration therapy (ORT) during the pretraining observational survey. After the training, these corresponding figures increased to 23.6% (p=.007), 57.6% (p=.002), and 88.9% (p.0001). The 23.6% rate was still low compared with the high level of knowledge about diarrhea treatment, however. Before training, they prescribed antibiotics to 85.7% of inpatients and 50% of outpatients. After the training, health workers still prescribed antibiotics to 50% of outpatients even though 95% knew correct drug prescription practices. On the other hand, they prescribed antibiotics to a lower percentage of inpatients (64.8%; p=.025). Before the course, they recommended breast feeding and weaning foods in 25.7% and 28.6% of inpatients, respectively, and in 47.1% and 41.2% of outpatients, respectively. Following the course, health workers were more likely to advise breast feeding and weaning foods for outpatients (p=.015 and p=.001, respectively), but tended not do so for inpatients. They were less likely to recommend breast feeding (25.7% vs. 19.4%). This evaluation helped promote creation of rehydration units in 12 of the participating hospitals. The results showed a need for continuous medical education for the health workers in the new units.

Early sexual experience and traditional values in Colombia.

PIP: Results on adolescent's knowledge, attitude, and practice in sexuality and reproductive health are presented from 2 surveys of 1199 middle-class youths aged 13-18 years in main cities of Colombia. Survey populations were selected from high schools and users of Family Compensation Fund. While traditional values and customs prevail among these youths, they nonetheless tend to begin sex between ages 15-18, and have little concern over the consequences of their sexual behavior. They are, moreover, quite ignorant about reproductive health. Sexuality is not thought of as part of marriage, women are expected to be virgins at marriage, and a resounding 87% of the study population rejected abortion legislation. 90% of the young men had their 1st sexual encounter with either a prostitute or domestic servant, while 90% of the young women had their 1st encounters with friends from within their social groups. Sexual relations from adolescence on were supported by 35% of the girls and 60% of the boys, 72% of the girls and 38% of the boys supported virginity, yet less than 10% were in favor of the notion of open relationships. 20% of the girls and 25% of the boys had active sex lives, with homosexuality representing 1.6% and 3.1% of the two sex groupings, respectively. Sex education is practically non-existent. Most young women know little of contraception, and fail to use it out of misconceptions regarding method safety, and fear of one's parents finding out. The young men, on the other hand, cite forgetfulness and inability to obtain contraception as reasons for use failure. Accordingly, 5% of the girls fell pregnant between ages 15-17, with 66% ending in abortion, and 18.6% of the girls and 12.3% of the boys admitted to having had a sexually transmitted disease. 55% indicated that they would not use contraceptives.^ieng

Birth control and low-income Mexican-American women: the impact of three values.

PIP: This study examines how 3 particular sociocultural values affect Mexican-American women's attitude, knowledge, and use of birth control. Researchers interviewed 99 low-income married Mexican-American women, 48 of whom had a low level of acculturation and 51 of whom had a high level, focusing on the values of motherhood, male dominance, and sexual expression. While the low acculturation group showed a significant linear relationship between attitudes towards birth control and the 3 values, the high acculturation group failed to exhibit a similar relationship. The study also found that no significant relationship exists between knowledge of birth control and the aforementioned values. The sociocultural values, however, do explain a 30% variability in attitudes towards birth control among the women with low acculturation, as well as a 22% variability in birth control use. Although significant, the results do not fully account for the variability. The study suggests several possible explanations for the unaccounted variance: considering the complexity of the values involved, the instruments involved may have failed to fully uncover their effects; because they were normed on Anglo-Americans, the instruments may not have sensitive enough of Mexican-American attitudes; and finally, the study may have overlooked other important values. Nonetheless, the study points out definite differences in attitudes between high and low acculturation groups. Considering that Hispanic women -- particularly Mexican-American women -- experience a very high birthrate (double that of non-Hispanics), examining sociocultural values may give insights into better family planning methods for this group.^ieng

Survey report: Bolivia.

PIP: This article is a summary of the National Demographic and Health Survey in Bolivia (ENDSA-1989). Bolivia has one of America's lowest population densities and one of its highest fertility rates. During a Bolivian woman's lifetime she will have 5.1 children. 61% of women in union want no more children, and surprisingly 41% of women age 15-19 want no more children. 30% of women are using contraception, yet 75% of women recognize at least 1 contraceptive method and 70% know where to obtain a method. 53% of women with a middle or higher education use contraception, while 12% of uneducated women use contraception. ENDSA-1989's assessment of Bolivia's infant and child health care describes a need for oral rehydration therapy (ORT) and preventive immunizations (e.g. few children with diarrhea receive ORT and 20% of children under age 5 have documented immunization records). There is also little maternal health care. More than 1/2 of the mothers interviewed received no prenatal health care and only 40% received medical assistance during delivery.^ieng