Breastfeeding and breastmilk substitute use and feeding motivations among mothers in Bandung City, Indonesia.

Suboptimal breastfeeding is common in Indonesia, with only half of infants 0-5 months of age exclusively breastfed and feeding of breastmilk substitutes (BMS) highly prevalent among infants and toddlers. Various factors influence these feeding practices, including social norms, limited health system support and BMS manufacturer marketing practices. This cross-sectional survey aimed to identify the prevalence of breastfeeding and BMS feeding among children aged 0-35 months, explore socio-demographic characteristics and motivating factors associated with these feeding behaviours and identify the prevalence of mothers' exposure to BMS promotions. Indonesian mothers of children <3 years of age (n = 595) were interviewed in Bandung City health facilities using structured questionnaires. Although all children were ever breastfed, half of children across all age groups received BMS in the previous day. Maternal employment outside the home and insufficient breastmilk production were associated with BMS use. The most important motivational factors for feeding BMS were perceived benefits for growth, intelligence and immunity. Despite Indonesian legislation restricting some BMS marketing, 93% of mothers reported observing a BMS promotion outside the health system, with television, social media and newspapers as the most common sources. Half of mothers (43%) reported observing a BMS promotion within the health system, and half (46%) reported receiving recommendations from health workers to use BMS. Such high prevalence of BMS marketing may be influencing caregivers' feeding choices; stronger national legislation and implementation of laws are needed to ensure mothers' ability to make feeding choices free from manufacturer influence.

Promotions of breastmilk substitutes, commercial complementary foods and commercial snack products commonly fed to young children are frequently found in points-of-sale in Bandung City, Indonesia.

Few studies have documented the marketing of commercial foods and beverages for infants and young children in West Java, Indonesia. To assess the prevalence of promotions at points-of-sale for commercially produced products commonly fed to young children in Bandung City, 43 small and large stores were visited in 2017. Promotions for breastmilk substitutes (BMS), commercially produced complementary foods (CPCF), and select types of commercial snack products were photographed and information recorded on promotion characteristics. There were 402 and 206 promotions observed with BMS and CPCF products, respectively. Sixteen promotions with BMS products for infants under 12 months were found in 42.9% of stores selling BMS, violating national regulations. Almost all BMS promotions (98.3%) included BMS products for ages 1 year and above ("growing-up milks"). Of all BMS products available for sale, half of all infant/follow-up formula and 77.2% of growing-up milks were promoted. CPCF were found in 97.7% of stores, and 81.0% of these stores had promotions; 70.5% of all available CPCF products were promoted. Of the 2,451 promotions observed for commercial snack products, 17.3% used promotional techniques targeting young children or caregivers. Joint-promotions were common, with BMS and CPCF marketed in combination with commercial snack products; 49.0% of BMS promotions were joint BMS-snack promotions, and 80.0% or more of infant/follow-up formula promotions included a commercial snack. Revising and enforcing infant food and beverage marketing regulations to ensure consistency with global standards are necessary to protect and promote optimal infant and young child feeding in Indonesia.

High proportions of children under 3 years of age consume commercially produced snack foods and sugar-sweetened beverages in Bandung City, Indonesia.

Child undernutrition continues to be a national concern in Indonesia, whereas childhood overweight/obesity rises. Economic development has led to wide availability of highly processed foods and beverages, with growing evidence that children are consuming commercial snack products during the critical complementary feeding period. This study assessed the prevalence and patterns of consumption of commercially produced snack foods and sugar-sweetened beverages among Indonesian children. A cross-sectional survey was conducted with 495 mothers of children aged 6-35 months living in Bandung City, Indonesia. Among all children, 81.6% consumed a commercial snack food and 40.0% consumed a sugar-sweetened beverage in the day preceding the interview. At 6-11 months, 46.5% of children consumed a snack food and 2.0% consumed a sugar-sweetened beverage. Snack foods were consumed 3 or more times a day by 60.0% of children 24-35 months of age. Sweet biscuits and savory snacks were the most commonly consumed snack foods; sweetened milks and sweetened teas were the most common beverages. Maternal education, child age, and consumption of a commercially produced complementary food were associated with snack food consumption. Factors associated with sugar-sweetened beverage consumption were child age and consumption of a commercially produced complementary food or breastmilk substitute. These findings reflect a high presence of processed, high-sugar/salt commercial snack products in the diets of children 6-35 months. National attention should focus on interventions to reduce reliance on processed snack products and increase consumption of nutrient-rich, locally available foods during the complementary feeding period.

Commercially produced complementary foods in Bandung City, Indonesia, are often reported to be iron fortified but with less than recommended amounts or suboptimal forms of iron.

Commercially produced complementary foods (CPCF) that are iron fortified can help improve iron status of young children. We conducted a review of 217 CPCF sold in 42 stores in Bandung, Indonesia, in 2017. There were 95 (44%) infant cereals, 71 (33%) snacks or finger foods (biscuits or cookies, puffs, and noodles or crackers), 35 (16%) purees, and 16 (7%) other foods for which we obtained label information. Nearly 70% of CPCF reported iron content on their labels, but only 58% of products were reported to be fortified with iron according to ingredient lists. Among iron-fortified products, only one fifth indicated a specific type of iron used as the fortificant, but all of these were recommended by the World Health Organization for fortifying complementary foods. Infant cereal was more likely to contain added iron (81%) compared with snacks or finger food (58%) and purees (14%) and had higher iron content per median serving size (cereal = 3.8 mg, snacks or finger food = 1.3 mg, mixed meals = 2.7 mg, and purees = 0.9 mg). Infant cereal was most likely to meet the recommended daily intakes for iron (41% for infants 6-12 months of age and 66% for children 12-36 months) compared with snacks or finger food (infants = 14%, children = 22%), mixed meals (infants = 28%, children = 46%), or purees (infants = 9%, children = 15%). Regulations on fortification of complementary foods need to specify minimum levels and forms of iron and require reporting in relation to requirements by child age and serving size. Monitoring and enforcement of regulations will be essential to ensure compliance.

Pilot implementation of a monitoring and enforcement system for the International Code of Marketing of Breast-milk Substitutes in Cambodia.

Globally, monitoring and enforcement mechanisms for the World Health Organization's International Code of Marketing of Breast-milk Substitutes are often lacking. The Cambodian government adopted the Code as the national standard in Sub-Decree 133 on Marketing of Products for Infant and Young Child Feeding. Following the formation of a multisectoral Oversight Board and development of detailed guidance documents for the implementation and enforcement of Sub-Decree 133, a 7-month pilot was conducted in 2017 to trial a monitoring system in four urban areas of Cambodia. The pilot included training of monitors from the Ministries of Health and Commerce, screening for violations at retail locations and health facilities, testing reporting mechanisms, and taking actions against violators. During the pilot, 85 national- and subnational-level monitors were trained, 392 site visits were made, 2,377 monitoring checklists were completed, and 11 warning letters were issued to violators. Half of the completed checklists (52.9%) indicated Code violations, yet monitors submitted zero violation reports. The pilot revealed modifications needed to the monitoring system: integrate monitor trainings into existing ministry training curricula for sustainability; enhance targeting of monitors for Sub-Decree training; delineate clear roles and responsibilities for the national and subnational levels; simplify monitoring checklists and violation reports; and improve integration of monitoring activities into routine ministry operations. Before the Sub-Decree 133 monitoring and enforcement system is implemented throughout Cambodia, revisions must be made to ensure the viability of this system. Challenges and lessons learned can also guide Code monitoring efforts being undertaken by other countries.

Expanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa.

BACKGROUND: Clients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods. METHODS: We examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients. RESULTS: Following the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects. CONCLUSIONS: The intervention failed to improve PMTCT clients' knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally.

Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study.

BACKGROUND: The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa. METHODS: A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined. RESULTS: The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods. CONCLUSIONS: Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.

Gender, Alcohol Consumption Patterns, and Engagement in Sexually Intimate Behaviors Among Adolescents and Young Adults in Nha Trang, Viet Nam.

A randomly selected cross-sectional survey was conducted with 880 youth (16 to 24 years) in Nha Trang City to assess relationships between alcohol consumption and sexual behaviors. A timeline followback method was employed. Chi-square, generalized logit modeling and logistic regression analyses were performed. Of the sample, 78.2% male and 56.1% female respondents ever consumed alcohol. Males reporting sexual behaviors (vaginal, anal, oral sex) had a significantly higher calculated peak BAC of 0.151 compared to 0.082 for males reporting no sexual intimacy (p < .0001). Females reporting sexual behaviors had a peak BAC of 0.072 compared to 0.027 for those reporting no sexual intimacy (p = .016). Fifty percent of (33/66) males and 30.4% (7/23) females report event specific drinking and engagement in sexual behaviors. Males reporting 11+ drinks in 30 days had more sexual partners than those reporting 1 to 10 drinks (p = .037). Data suggest different physical and psychosocial mediators between alcohol consumption and sexual behaviors by gender.

Meta-analysis of changes in the levels of catecholamines and blood pressure with continuous positive airway pressure therapy in obstructive sleep apnea.

Stress from obstructive sleep apnea (OSA) stimulates catecholamine release consequently exacerbating hypertension. However, different studies have shown a conflicting impact of continuous positive airway pressure (CPAP) treatment in patients with OSA on catecholamine levels and blood pressure. We aimed to examine changes to catecholamine levels and blood pressure in response to CPAP treatment. We conducted a meta-analysis of data published up to May 2020. The quality of the studies was evaluated using standard tools for assessing the risk of bias. Meta-analysis was conducted using RevMan (v5.3) and expressed in standardized mean difference (SMD) for catecholamines and mean difference (MD) for systolic (SBP) and diastolic blood pressure (DBP). A total of 38 studies met our search criteria; they consisted of 14 randomized control trials (RCT) totaling 576 participants and 24 prospective cohort studies (PCS) of 547 participants. Mean age ranged between 41 and 62 year and body mass index between 27.2 and 35.1 kg/m2 . CPAP treatment reduced 24-hour urinary noradrenaline levels both in RCT (SMD = -1.1; 95% confidence interval (CI): -1.63 to - 0.56) and in PCS (SMD = 0.38 (CI: 0.24 to 0.53). SBP was also reduced by CPAP treatment in RCT (4.8 mmHg; CI: 2.0-7.7) and in PCS (7.5 mmHg; CI: 3.3-11.7). DBP was similarly reduced (3.0 mmHg; CI: 1.4-4.6) and in PCS (5.1 mmHg; CI: 2.3-8.0). In conclusion, CPAP treatment in patients with OSA reduces catecholamine levels and blood pressure. This suggests that sympathetic activity plays an intermediary role in hypertension associated with OSA-related stress.

Non-genetic and genetic risk factors for adult cerebral venous thrombosis.

INTRODUCTION: A wide variety of non-genetic and genetic factors have been shown to associate with increased risk for cerebral venous thrombosis (CVT). However, there is a paucity of risk factor data and conclusions about their impact are often conflicting. Herein, we quantified the associations of non-genetic and genetic risk factors for CVT in adults. MATERIALS AND METHODS: Electronic databases were searched up to January 2017. Meta-analyses were performed (RevMan v5.3) to determine pooled odds ratios (ORs and 95% CIs) for risk factors, interstudy heterogeneity and publication bias. RESULTS: Twenty non-genetic (n = 2314) and 33 genetic (n = 2117) studies up to January 2017 met the selection criteria. For non-genetic factors, CVT risk increased in the presence of glucocorticosteroid therapy by 18.3-fold (3.3-102.6), alcohol consumption 2.7-fold (1.8-3.9), infection 7.5-fold (2.6-21.6), surgery 9.6-fold (1.1-83.5), hypercholesterolaemia 2.4-fold (1.3-4.4), hyperhomocysteinaemia 3.1-fold (2.1-4.6), antiphospholipid antibodies 7.0-fold (2.1-23.6), autoimmune diseases 5.6-fold (2.3-13.6), anaemia 4.0-fold (2.1-7.9), malignancy 3.2-fold (1.4-7.1) and pregnancy/puerperium 11.4-fold (5.7-24.3). Smoking, hypertension and diabetes did not associate with CVT risk. For genetic factors, CVT risk increased in the presence of factor V Leiden (G1691A) by 2.5-fold (1.9-3.3), protein C deficiency 10.7-fold (3.1-37.7), protein S deficiency 5.7-fold (1.4-22.4), antithrombin deficiency 3.8-fold (1.0-13.8), prothrombin (G20210A) 5.5-fold (4.0-7.27) and TAFI gene variant (C1040T) 1.6-fold (1.0-2.4). Prothrombin G20210A and factor V Leiden polymorphisms tended to have higher ORs for CVT than for ischaemic stroke. CONCLUSIONS: We provide quantitative data supporting a strong basis for genetic and non-genetic risk factors in CVT. Its genetic liability seems higher when compared with sporadic ischaemic stroke.

Sexual stigma, sexual behaviors, and abstinence among Vietnamese adolescents: implications for risk and protective behaviors for HIV, sexually transmitted infections, and unwanted pregnancy.

As rates of HIV increase in Vietnam, there is a need for data on social relations and sexual risk and protective behaviors among Vietnamese adolescents in a context of rapid social and economic changes. The authors report results from qualitative interviews with 159 Vietnamese adolescents living in Hanoi, Nha Trang City, and Ninh Hoa District and a survey of 886 adolescents in these same three sites. In the qualitative interviews, youths report a strong adherence to ideals and values regarding abstinence outside of marriage. Youths reported low rates of engagement in vaginal, anal, and/or oral sex with a significant difference in reported behaviors between males (29/469, 6.2%) and females (7/416, 1.7%; p = .000). A total of 15 of 32 (46.9%) sexually active youths reported rarely or never using condoms. Females had significantly higher scores for perceived sexual stigma than males (t = -10.22 [95% confidence interval (CI); -3.72 to -2.52; p = .000) whereas males scored significantly lower than females on a scale of perceived self-efficacy for abstinence (t = 5.31 [95% CI; .27 to .59]; p = .000). The stigmatization of sexual relations outside of marriage particularly for young women reinforces abstinence; however, these same values decrease adolescents' ability to obtain accurate information about sexuality and HIV and sexually transmitted infections and engage in safer sex.

Understanding the Broader Sexual and Reproductive Health Needs of Female Sex Workers in Dhaka, Bangladesh.

CONTEXT: Little is known about the sexual and reproductive health care needs of female sex workers in Dhaka, Bangladesh. METHODS: Survey data were collected from 354 hotel-based and 323 street-based female sex workers using a venue-based stratified cluster sampling approach. In addition, in-depth interviews were conducted with 20 female sex workers recruited from drop-in centers. We calculated unmet need for family planning and examined fertility desires, use of condoms and other contraceptive methods, experiences with gender-based violence, sexual and reproductive health service needs, and preferences on where to receive services. RESULTS: The prevalence of unmet need was 25% among hotel-based female sex workers and 36% among street-based female sex workers. Almost all participants reported having used condoms in the past 30 days, and 44% of hotel-based sex workers and 30% of street-based sex workers reported dual method use during that period. Condom use was inconsistent, however, and condom breakage and nonuse for extra money were common. Many women reported experiencing gender-based violence. Sexual and reproductive health services had been obtained by 64% of hotel-based and 89% of street-based sex workers in the past six months; drop-in centers were their preferred site for receiving health services. CONCLUSIONS: Female sex workers in Dhaka need family planning and other sexual and reproductive health services and prefer receiving them from drop-in centers.

Age Differences in Prefrontal Surface Area and Thickness in Middle Aged to Older Adults.

Age is associated with reductions in surface area and cortical thickness, particularly in prefrontal regions. There is also evidence of greater thickness in some regions at older ages. Non-linear age effects in some studies suggest that age may continue to impact brain structure in later decades of life, but relatively few studies have examined the impact of age on brain structure within middle-aged to older adults. We investigated age differences in prefrontal surface area and cortical thickness in healthy adults between the ages of 51 and 81 years. Participants received a structural 3-Tesla magnetic resonance imaging scan. Based on a priori hypotheses, primary analyses focused on surface area and cortical thickness in the dorsolateral prefrontal cortex, anterior cingulate cortex, and orbitofrontal cortex. We also performed exploratory vertex-wise analyses of surface area and cortical thickness across the entire cortex. We found that older age was associated with smaller surface area in the dorsolateral prefrontal and orbitofrontal cortices but greater cortical thickness in the dorsolateral prefrontal and anterior cingulate cortices. Vertex-wise analyses revealed smaller surface area in primarily frontal regions at older ages, but no age effects were found for cortical thickness. Results suggest age is associated with reduced surface area but greater cortical thickness in prefrontal regions during later decades of life, and highlight the differential effects age has on regional surface area and cortical thickness.

Unique and interactive effect of anxiety and depressive symptoms on cognitive and brain function in young and older adults.

OBJECTIVE: Depression and anxiety and are associated with cognitive deficits and brain changes, especially in older adults. Despite the frequent co-occurrence of these conditions, cognitive neuroscience studies examining comorbid depression and anxiety are limited. The goal of the present study was to examine the unique and combined effect of depressive and anxiety symptoms on cognitive and brain functioning in young and older adults. METHODS: Seventy-one healthy, community-dwelling adults between the ages of 18 and 81 were administered a neuropsychological battery and completed the Center for Epidemiologic Studies Depression Scale (CES-D) and the trait form of the State-Trait Anxiety Inventory (STAI-T). A subset of 25 participants also underwent functional magnetic resonance imaging (fMRI) scanning while completing the n-back working memory task. RESULTS: Total depressive symptoms, depressed mood symptoms, and somatic symptoms were associated with deficits in speed, working memory and executive functions, especially in older adults. Symptoms of lack of well-being were not associated with any neuropsychological test. Anxiety was associated with better attention and working memory. Moreover, anxiety modified the relationship between depressive symptoms and executive functioning in older adults, as elevated depressive symptoms were associated with worse performance at low levels of anxiety, but not at higher anxiety levels. Similarly, analysis of fMRI data showed that total depressive symptoms and depressed mood symptoms were associated with decreased activity in the superior frontal gyrus at low anxiety levels, but not at high anxiety levels. CONCLUSION: Results confirm previous reports that subthreshold depression and anxiety impact cognitive and brain functioning and suggest that the interaction of depression and anxiety results in distinct cognitive and brain changes. Findings highlight the importance of assessing and controlling for symptoms of depression and anxiety in research studies of either condition.

Integrating family planning services into HIV care and treatment clinics in Tanzania: evaluation of a facilitated referral model.

BACKGROUND: Many clients of HIV care and treatment services have unmet contraceptive needs. Integrating family planning (FP) services into HIV services is an increasingly utilized strategy for meeting those unmet needs. However, numerous models for services integration are potentially applicable for clients with diverse health needs. This study developed and tested a 'facilitated referral' model for integrating FP into HIV care and treatment in Tanzania with the primary outcome being a reduction in unmet need for contraception among female clients. METHODS: The facilitated referral model included seven distinct steps for service providers. A quasi-experimental, pre- and post-test, repeated cross-sectional study was conducted to evaluate the impact of the model. Female clients at 12 HIV care and treatment clinics (CTCs) were interviewed pre- and post-intervention and CTC providers were interviewed post-intervention. RESULTS: A total of 323 CTC clients were interviewed pre-intervention and 299 were interviewed post-intervention. Among all clients, the adjusted decrease in proportion with unmet need (3%) was not significant (P = 0.103) but among only sexually active clients, the adjusted decrease (8%) approached significance (P = 0.052). Furthermore, the proportion of sexually active clients using a contraceptive method post-intervention increased by an estimated 12% (P = 0.013). Dual method use increased by 16% (P = 0.004). Increases were observed for all seven steps of the model from pre- to post-intervention. All providers (n = 45) stated that FP integration was a good addition although there were implementation challenges. CONCLUSION: This study demonstrated that the facilitated referral model is a feasible strategy for integrating FP into HIV care and treatment services. The findings show that this model resulted in increased contraceptive use among HIV-positive female clients. By highlighting the distinct steps necessary for facilitated referrals, this study can help inform both programmes and future research efforts in services integration.

Community-based provision of injectable contraceptives in Madagascar: 'task shifting' to expand access to injectable contraceptives.

INTRODUCTION: Injectable contraceptives are now the most popular contraceptive methods in sub-Saharan Africa. Injectables have not been an option for African women lacking convenient access to health facilities, however, since very few family planning programmes permit community-based distribution (CBD) of injectables by non-medically trained workers. Committed to reducing unmet contraceptive need among remote, rural populations, the Ministry of Health and Family Planning (MOHFP) of Madagascar sought evidence regarding the safety, effectiveness and acceptability of CBD of injectables. METHODS: The MOHFP joined implementing partners in training 61 experienced CBD agents from 13 communities in provision of injectables. Management mechanisms for injectables were added to the CBD programme's pre-existing systems for record keeping, commodity management and supervision. After 7 months of service provision, an evaluation team reviewed service records and interviewed CBD workers and their supervisors and clients. RESULTS: CBD workers demonstrated competence in injection technique, counselling and management of clients' re-injection schedule. CBD of injectables appeared to increase contraceptive use, with 1662 women accepting injectables from a CBD worker. Of these, 41% were new family planning users. All CBD agents wished to continue providing this service, and most supervisors indicated the programme should continue. Nearly all clients interviewed said they intended to return to the CBD worker for re-injection and would recommend this service to a friend. CONCLUSIONS: This experience from Madagascar is among the first evidence from sub-Saharan Africa documenting the feasibility, effectiveness and acceptability of CBD services for injectable contraceptives. This evidence influenced national and global policy makers to recommend expansion of the practice. CBD of injectables is an example of effective task shifting of a clinical practice as a means of extending services to underserved populations without further burdening clinicians.

Evaluation of three adolescent sexual health programs in ha noi and khanh hoa province, Vietnam.

With an increase in sexual activity among young adults in Vietnam and associated risks, there is a need for evidence-based sexual health interventions. This evaluation of three sexual health programs based on the Protection Motivation Theory (PMT) was conducted in 12 communes in Ha Noi, Nha Trang City, and Ninh Hoa District. Inclusion criteria included unmarried youth 15-20 years residing in selected communes. Communes were randomly allocated to an intervention, and participants were randomly selected within each commune. The intervention programs included Vietnamese Focus on Kids (VFOK), the gender-based program Exploring the World of Adolescents (EWA), and EWA plus parental and health provider education (EWA+). Programs were delivered over a ten-week period in the communities by locally trained facilitators. The gender-based EWA program with parental involvement (EWA+) compared to VFOK showed significantly greater increase in knowledge. EWA+ in comparison to VFOK also showed significant decrease at immediate postintervention for intention to have sex. Sustained changes are observed in all three interventions for self-efficacy condom use, self-efficacy abstinence, response efficacy for condoms, extrinsic rewards, and perceived vulnerability for HIV. These findings suggest that theory-based community programs contribute to sustained changes in knowledge and attitudes regarding sexual risk among Vietnamese adolescents.

Parent-youth communication and concordance between parents and adolescents on reported engagement in social relationships and sexually intimate behaviors in Hanoi and Khanh Hoa Province, Vietnam.

PURPOSE: Parent-child communication is associated with positive outcomes for youths' engagement in sexual behaviors. Limited data are available regarding parent-child communication in transitional countries. We present data from Vietnamese parent-youth dyads on parent reproductive health (RH) knowledge, comfort of communication, frequency of talk, and discordancy between youths' reported and parents' perceptions for engagement in relationships and sexually intimate behaviors. METHODS: The cohort included 185 randomly selected parent-youth dyads in four communes in Hanoi and Khanh Hoa Province. Descriptive and comparative analysis included chi-squared tests, independent samples t-tests, and ANOVA. Linear regression analysis was used to assess relationships between parental knowledge, level of comfort, frequency of talk, and discordancy. RESULTS: Seventy-six percent of parents and 44% of youth were female. The mean age of youth was 17.2 years. The mean score for parental "RH knowledge" was 24.74 (SD, 3.84; range, 15-34). Lower parental RH knowledge was positively associated with lower levels of education (F = 2.983; df, 184; p = .014). Data indicate a linear model in which knowledge is related to "comfort" (ß = .17; p = .048), and "comfort" to frequency of "talk" (ß = .6; p < .0001). Frequency of "talk" is not related to parents' discordant perceptions regarding their child's reported involvement in relationships (ß = .002; p = .79) or sexual touching (ß = .57; p = .60). CONCLUSIONS: Parent and youth in Vietnam are engaged in limited communication about RH. There is a need for more data to assess the effect of these communication patterns on youths' engagement in sexual behaviors and for development of family-centered interventions to increase parental knowledge and skills for positive communication.

Strategies for developing gender-specific HIV prevention for adolescents in Vietnam.

In Vietnam, between 2000 and 2006, HIV rates among 15- to 49-year-olds in the general population have increased from 27% to 53%. The HIV epidemic is occuring in a context of rapid socioeconomic changes, which have brought about conflicting ideals and norms between "traditional" and "modern" gender roles. We discuss the processes for developing the Exploring the World of Adolescents gender-specific HIV prevention curricula for 15- to 21-year-old adolescents living in both rural and urban Vietnam. The curricula are modeled after an existing HIV prevention program previously adapted and evaluated in Vietnam (Vietnamese Focus on Kids) and based in social learning theory (prevention motivation theory) contextualized within socioeconomic changes. The overall capacity building and participatory strategies for program development included (a) review of the HIV/AIDS and socioeconomic conditions in Vietnam, (b) review of the Vietnamese Focus on Kids curriculum themes and the theoretical constructs from the protection motivation theory, () analysis of qualitative and quantitative needs assessment data to incorporate culturally significant issues of gender and sexuality, and (d) a review of themes and activities from existing evidence-based adolescent reproductive health curricula.