Exames laboratoriais da Pesquisa Nacional de Saúde: metodologia de amostragem, coleta e análise dos dados / Laboratory exams of the National Health Survey: methodology of sampling, data collection and analysis

RESUMO: Introdução: O artigo teve o objetivo de descrever a metodologia de coleta dos dados dos exames laboratoriais da Pesquisa Nacional de Saúde (PNS). Metodologia: Foi selecionada uma subamostra de 25% dos setores censitários, obedecendo à estratificação da amostra da PNS, com probabilidade inversamente proporcional à dificuldade de coleta. A coleta de sangue e urina dos moradores selecionados para entrevista individual foi realizada nos domicílios por um agente de laboratório. Por conta das dificuldades encontradas no trabalho de campo,a amostra não atingiu número suficiente em alguns estratos da pesquisa, então para a análise dos dados foi proposto procedimento de pós-estratificação. Resultados: A coleta de material biológico foi realizada em 8.952 indivíduos. Os exames realizados foram: hemoglobina glicada; colesterol total; colesterol LDL; colesterol HDL; sorologia para dengue; hemograma série vermelha (eritograma) e série branca (leucograma); cromatografia líquida de alta eficiência (HPLC) para diagnóstico de hemoglobinopatias; e creatinina. Na urina, estimativa de excreção de potássio, sal, sódio e creatinina. A base de dados dos exames laboratoriais foi ponderada e disponibilizada para os usuários no site da PNS da Fundação Oswaldo Cruz, sem necessidade de autorização prévia para uso. Conclusão: A subamostra total coletada é de grande valia, pois permitiu estabelecer parâmetros de referência nacionais adequados às características sociodemográficas e geográficas da população brasileira, fornecendo informações relevantes e complementares para a análise da situação de saúde do Brasil.

ABSTRACT: Introduction: This article aims at describing the National Health Survey (Pesquisa Nacional de Saúde- PNS) methodology of collecting laboratory exams data. Methodology: A subsample of 25% of the census tracts was selected, according to the stratification of the PNS sample, with a probability inversely proportional to the difficulty of collection. The collection of blood and urine was done in the households by a laboratory agent, among residents selected for individual interview. Due to the difficulties found in the field work, the sample did not reach the minimum expected number in some strata, and a post-stratification procedure was proposed for the data analysis. Results: The collection of biospecimens was performed in 8,952 individuals. Laboratory tests were: glycated hemoglobin; total cholesterol; LDL cholesterol; HDL cholesterol; serology for dengue; red blood cell count (erythrogram) and white series count (leukogram); high performance liquid chromatography (HPLC) for diagnosis of hemoglobinopathies; creatinine. Theexcretion of potassium, salt and sodium and creatinine was estimated in the urine. The database of laboratory exams was weighed and made publicly available on the Oswaldo Cruz Foundation's PNS website and can be accessed without prior authorization. Conclusion: The total subsample of laboratory exams is of great value, since it allowed us to establish national reference parameters adequate to sociodemographic and geographic characteristics of the Brazilian population, providing relevant and complementary information for the analysis of the health situation of Brazil.

The impact of traditional birth attendant training on delivery complications in Ghana.

OBJECTIVES: In their efforts to reduce maternal and neonatal morbidity and mortality, many national and international agencies make considerable investments in training traditional birth attendants (TBAs). The value of TBA training is controversial, and plausible arguments are made both for and against. Numerous process evaluations are reported in the literature and the results are mixed, though generally positive. Outcome evaluations, however, are scarce. This article describes an outcome evaluation of TBA training conducted in two districts of Brong-Ahafo Region, Ghana, during 1996. DESIGN AND METHODS: Data from a random sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes, controlling for other independent variables. RESULTS: Of eight outcomes modelled, three were associated with training and five were not. Three additional outcomes were not modelled, primarily due to low prevalence. CONCLUSIONS: Despite some inherent design limitations, this study found that the evidence for a beneficial impact of TBA training was not compelling. Training sponsors should consider alternative health investments and, where TBA training remains the intervention of choice, be realistic about expectations of impact.

Contraceptives and teens: what are the options?

PIP: This article focuses on the contraceptive options of adolescents to prevent unintended pregnancy. Based on the Contraceptive Technology Update 2000 Contraceptive Survey involving health care providers, 90% of the respondents will provide injectable depot medroxyprogesterone acetate (Depo-Provera or DMPA) to young teens. Meanwhile, in surveying providers¿ practices with regard to the possible link between DMPA use and diminishing bone mass, about half of the providers inform patients of such an effect and about 30% use other methods, such as counseling on calcium supplementation and weight-bearing exercise. However, just-released research revealed that DMPA's impact on bone density might be a short-term or current-user effect, apparently without long-term implications. On the other hand, when providers were asked for the treatment of severe dysmenorrhea in women who are not sexually active and have no plans to engage in such activity, 45% of respondents said they would prescribe an oral contraceptive and a prostaglandin inhibitor.^ieng

Alternative methods in the investigation of adolescents' sexual life.

PURPOSE: To describe two methodological approaches to surveying adolescents' sexual life which were combined within a national survey. METHODS: The questionnaire was designed during a 5-day workshop. Ten adolescents played the roles of imaginary adolescents involved in different situations related to sexual life. The information obtained through the analysis of these role-plays was used to establish the sequence of the questions, their content, and wording. The questionnaire was computerized so that it could be completed by the adolescents using laptop computers. Its arborescent structure, leading each respondent from one module to another, made possible the adjustment of the questions to each respondent's stage of development and type of sexual experience. RESULTS: A total of 4283 teenagers (2075 girls and 2208 boys, and 4 refusals) 16-20 years were included. Only 7.6% did not fill in the whole questionnaire. By the age of 18 years, more than 50% of boys and girls were sexually active. Half of sexually active teenagers have discussed contraception issue before engaging in their first intercourse, but much fewer (14-35%) have discussed issues related to HIV transmission. During their first sexual intercourse, the majority of the respondents used a condom (girls, 63%; boys, 58%) or condom plus oral contraception (girls, 11%; boys, 17%). CONCLUSION: Youth participation and role-play decrease the conceptual biases often associated with professionals' perceptions and bring tools enabling a better exploration of circumstances and negotiations surrounding the sexual encounter. The computerized questionnaire increases confidentiality, attractiveness, easy data collection, and, above all, adjustment of the questions to the respondent's level of experience. These methods could be more systematically used in surveys targeting sensitive issues related to adolescents' health.

PIP: This is a study, conducted among 4283 teenagers aged 16-20 years, describing two methodological approaches in surveying adolescents' sexual life, which were combined within a national survey. A computerized questionnaire was used. The sequence, contents, and wordings of the questions were based on the analysis of role-playing by 10 adolescents in a 5-day workshop. The tree-like structure of the questionnaire led each respondent from one module to another as questions were adjusted according to respondent's stage of development and type of sexual experiences. 2075 of the respondents were girls; 2208 were boys. 7.6% did not finish the questionnaire due to its length. It was found that by age 18 more than 50% of the sample were sexually active. Half of this segment discussed contraception before engaging in their first act of sexual intercourse, and a majority of them used condoms. However, only 14-35% discussed issues concerning HIV transmission. The participation of young people in the design of the questionnaire produced an enormous amount of usable information and increased the acceptability of the survey to the respondents. Moreover, it reduced the influence of professionals' perceptions, which tends to bias the concept of the survey as well as the sequence and wording of the questions. Role-playing produced more creative and spontaneous materials for the survey. This kind questionnaire is advantageous as a general model. Firstly, it strengthens the feeling of confidentiality; secondly, the focus group and role-playing approach in association with computerization favors a qualitative, flexible, and contextual approach to adolescents' sexuality.

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.

Prevalence of anaemia during pregnancy in district Burdwan, West Bengal.

A total of 653 women in third trimester of pregnancy were examined for the presence of anaemia in Kanksha and Ausgram II blocks of Burdwan. 80% of them were found anaemic (haemoglobin level < 11 gm%). 67% of the pregnant women took iron folates till varied periods. Iron deficiency was the commonest cause for the anaemia.

PIP: This article presents the prevalence of anemia during pregnancy in District Burdwan, West Bengal, India. 653 women in Kanksha (experimental block) and Ausgram II (control block) in the third trimester of pregnancy were examined for the presence of anemia. Results showed that 80% of the pregnant women in Kanksha and Ausgram II were found to be anemic and 67% took iron folates till varied periods. The habit of iron folate consumption improved with increasing duration of pregnancy: At 6 months only 18.8% consumed 50-100 tablets of iron and folic acid (IFA), while 43% consumed the same quantity at 9 months. Only 4.2% of women in the 9th month were anemic in the category of those taking more than 100 IFA tablets compared to 50% among those taking less than 50 tablets at the same point in pregnancy. The occurrence of moderate anemia declined significantly with increasing duration of pregnancy. The similar trend of IFA consumption in connection with women having normal levels of hemoglobin indicates a high prevalence of iron deficiency maternal anemia in Kanksha and Ausgram II.

Postpartum contraceptive use in Bangladesh: understanding users' perspectives.

Qualitative and quantitative data are used to explore postpartum contraceptive use in two populations in Bangladesh. Findings from in-depth interviews with contraceptive users illustrate that women are primarily concerned with their own and their newborn child's health and well-being in the period following childbirth. In addition, women are aware of a diminished risk of pregnancy during the period of postpartum amenorrhea. These perceptions, plus a belief that modern methods of contraception are "strong" and potentially damaging to health, mean that the majority of women are reluctant to adopt family planning methods soon after birth, despite a desire to avoid closely spaced pregnancies. Supplementation of the child's diet is also shown to be an important factor determining the timing of postpartum contraceptive initiation. The findings suggest that current policies promoting contraception to women in the immediate postpartum period are inappropriate for many Bangladeshi women.

PIP: This study examined female contraceptive users' understandings, preferences, and behaviors during the postpartum period in Bangladesh. Qualitative and quantitative data focused on the vulnerability of mother and child, the risk of conception, breast feeding's protection against pregnancy, modern method use, postpartum use, and use during breast feeding. Two cohorts were used to examine the relationship between the timing of contraceptive use and resumption of menses, contraceptive use during postpartum amenorrhea, delays in adoption, and contraceptive use during breast feeding. Data were obtained from a range of qualitative data sources in the rural Matlab maternal health and family planning treatment area and in a Dhaka slum study area of the Urban Health Extension Project. Quantitative data were obtained from the Record Keeping System of Matlab and the Urban Surveillance System among a 2-year cohort of 5483 women who had given birth in Matlab in 1990-91. Findings indicate that family planning services should be integrated within maternal and child health care for women in the postpartum period. After childbirth, women are preoccupied with their and their child's health. This preoccupation influences women's priorities and behavior. Bangladeshi women seldom begin contraception soon after birth. Most breast feed for an extended period. The current policy that promotes contraception immediately after birth is inappropriate. Postpartum strategies should incorporate lactational amenorrhea and teach women about breast feeding's impact on fertility. Providers should be sensitive to women's fears and concerns.

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

Evaluation of awareness and utilization of an autologous blood transfusion programme.

Autologous blood transfusion (ABT) has an important role in transfusion practice in the developing world due to increasing incidence of HIV and hepatitis C virus infection. Our study was done to evaluate the level of awareness and utilization of an autologous blood transfusion programme in a teaching hospital in Delhi. We assessed the level of awareness of preoperative ABT amongst treating physicians from different specialties in a teaching hospital through an anonymous questionnaire. The utilization of this methodology in transfusion practice was estimated from records of the Blood Transfusion Service. Of the 150 doctors contacted 96 (64%) responded. Although 67.7% of them were aware of the technique and its advantages, only 21.8% used it for the patients under their care. In the preceding 24 months 133 (1.1%) of 12,090 blood collections in the transfusion service were from autologous donor-patients. Only one unit of blood was collected from each patient, although 41.8% of them received > or = 2 units of blood. Of the 11,123 patients transfused, 55 (0.49%) received the ABT. Thus only 55 (41.3%) of 133 total ABT collections were utilized. The study highlights that there is a general lack of awareness about ABT amongst physicians. This transfusion practice is rarely and inadequately used. The study was repeated the following year after an intensive intervention strategy was adopted. The results show a trend towards improvement in the practice of ABT. This study emphasizes the need for proper organization, planning and communication between clinicians and blood transfusion personnel for effective implementation of an ABT programme, especially in countries with a high incidence of transfusion-transmitted infections and acute shortages of blood for transfusion.

Impact of dengue virus infection and its control.

Dengue virus infection has been counted among emerging and re-emerging diseases because of (1) the increasing number of patients, (2) the expansion of epidemic areas, and (3) the appearance of severe clinical manifestation of dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS), which is often fatal if not properly treated. In the meantime, there are no effective dengue control measures: a dengue vaccine is still under development and vector control does not provide a long-lasting effect. In order to obtain direct evidence for the virulent virus theory concerning the pathogenesis of DHF/DSS, type 2 dengue virus strains isolated from patients with different clinical severities in the same epidemic area in northeast Thailand, during the same season, were comparatively sequenced. The result revealed a DF strain specific amino acid substitution from I to R in the PrM, and a DSS strain specific amino acid substitution from D to G in the NS1 gene regions, which could significantly alter the nature of these proteins. Moreover, DF strain specific nucleotide substitutions in the 3' noncoding region were predicted to alter its secondary structure. These amino acid and nucleotide substitutions in other strains isolated in different epidemic areas during other seasons, together with their biological significance, remain to be confirmed. In order to innovate dengue vector control, field tests were carried out in dengue epidemic areas in Vietnam to examine the efficacy of Olyset Net screen, which is a wide-mesh net made of polyethylene thread impregnated with permethrin. The results show that Olyset Net (1) reduced the number of principal dengue vector species, Aedes aegypti, (2) interrupted the silent transmission of dengue viruses and (3) was highly appreciated by the local people as a convenient and comfortable vector control method. This encouraging evaluation of the Olyset Net screen should be confirmed further by other tests under different settings.

PIP: The number of dengue hemorrhagic fever cases reported to the World Health Organization increased sharply in the 1985-90 period. This expansion was associated with socioeconomic growth in tropical countries and increases in the importance of migration as a mode of dengue transmission. To find direct evidence for the virulent virus theory, the author investigated dengue virus infection in northeastern Thailand and performed comparative sequence analysis of virus strains collected from individuals with different clinical manifestations. The four dengue type 2 strains possessed the highest homology to the New Guinea C strain. As the sequences diverged from the standard, the clinical severity of the disease was reduced. The biologic significance of the amino acid and nucleotide substitutions observed requires further analysis. In another study, the author evaluated the impact of vector control with the permethrin-impregnated Olyset mesh screen in northern Viet Nam's Hai Hung Province in 1994. The net provided significant protection against the principal dengue vector mosquito, Aedes aegypti, and the antibody rate remained low (6.4%) during the epidemic rainy season. Net acceptors agreed that this method of vector control is simple, convenient, and effective.

The family planning aspects of the practice of traditional healers in Ibadan, Nigeria.

The family planning aspects of the practice of traditional healers in Ibadan, a large city in south west Nigeria, was investigated by means of a questionnaire survey of 193 traditional healers. The findings revealed that between 13% and 53% agreed with certain cultural beliefs which tend to increase fertility and that their perceptions of ideal child spacing is most commonly 2-3 years. Only 13% think a couple should have a specified number of children; a large proportion think the number should be "as God wills" (42%) or as many as the couple has resources to cope with (42%). Nearly all think that traditional healers and orthodox health professional should work together in the area of family planning. While most of them recommend traditional methods of contraception (such as beads and herbs) to their clients, up to 22% recommend modern family planning methods such as condoms and oral contraceptive pills. The implications of these findings for family planning programmes and the possibility of the involvement of traditional healers in the promotion of modern family planning methods are discussed.

PIP: The family planning aspects of the practice of traditional healers in Ibadan, a large city in southwest Nigeria, was investigated by means of a questionnaire survey of 193 traditional healers. The findings revealed that between 13% and 53% agreed with certain cultural beliefs that tend to increase fertility and that their perceptions of ideal child spacing is most commonly 2-3 years. Only 13% thought a couple should have a specified number of children; a large proportion thought the number should be "as God wills" (42%) or as many as the couple has resources to support (42%). Nearly all thought that traditional healers and orthodox health professionals should work together in the area of family planning. While most of them recommend traditional methods of contraception (such as beads and herbs) to their clients, up to 22% recommend modern family planning methods such as condoms and oral contraceptives. The implications of these findings for family planning programs and the possibility of the involvement of traditional healers in the promotion of modern family planning methods are discussed.

The use of traditional herbal medication during pregnancy.

PIP: A survey of 577 pregnant women attending their first antenatal visit at King Edward VIII Hospital in Durban, South Africa, in 1995 revealed widespread use of herbal medications. 60% of these women had a secondary or tertiary education. 498 women (86.3%) knew about Isihlambezo (herbs taken during pregnancy for cleansing) and 252 women (43.7%) were currently taking medicinal herbs. The two most common sources of knowledge about these medicines were parents/relatives (69.8%) and traditional birth attendants/herbalists (22.6%). 28.5% of non-users indicated they had been advised by doctors not to take the herbs. In most cases, herbal medicine use--generally a daily oral dose--was initiated in the second trimester of pregnancy. Most commonly, such remedies were ingested to improve fetal conditions (45.2%) or make labor easier (16.7%). Conditions such as childhood malnutrition, congenital malformations, tumors, and acute renal failure have been linked to toxic or carcinogenic constituents present in herbal medicines taken during pregnancy. Further research is needed to determine the side effects of Isihlambezo on the pregnant woman, the fetus, the labor process, and the outcome of pregnancy. Moreover, there is a need to identify the active chemical substance in herbal medications, establish their pharmacokinetics, determine whether their use can be clinically identified without reliance on patient self-report, and to develop antidotes. The antagonistic stance of medical practitioners toward herbalism tends to exacerbate the distance between traditional and modern medicine in Africa.^ieng

The importance of traditional midwives in the delivery of health care in the Republic of South Africa.

From the data collected during qualitative research, in 1995, to determine the possibility of collaboration with traditional healers a number of themes were highlighted. The different types of traditional healers, the way in which they operate as well as the importance of collaboration was identified. In this article the contributions of traditional midwives in rendering health care, especially in the rural areas in the Northern Cape and the Free State will be discussed. The data was collected during interviews and observations, done over a period of seven months. When the respondents could not speak English or Afrikaans an interpreter was used. Interviews were also conducted with health care staff and patients. The contributions of the traditional midwives are of utmost importance and should not be discouraged. With the necessary training the traditional midwives could help in providing an effective and efficient health service to pregnant women. Traditional midwives have been an integral part of African medicine for centuries. This is not only because African people still love and fear the spirits, but also because a great number of the South African population do not have access to existing health services. This is especially so in the rural areas and informal settlements. According to the Reconstruction and Development Programme (RDP) of the Government of National Unity it is important that everyone who could make a contribution towards the provision of health care should be involved. This view is supported in the ANC Health Plan and a Policy Document for the Development of a District Health System for South Africa, where it is stated that traditional healers (traditional midwives are included in this category) could play a role in the delivery of health care. The research on which the article is based was done to determine the role traditional healers could play in collaboration with primary health care services. In this article only the role of the traditional midwife will be discussed.

PIP: This study determined the feasibility of traditional healers as health care workers in primary health care (PHC) in South Africa. The research was designed to question PHC clinic nurses and traditional healers about their attitudes toward collaboration and working together within PHC services. Patients were questioned about their acceptance of joint collaboration. Traditional healers are identified as "isangoma," "nganga," "inyanga," "umprofeti" or faith healers and traditional midwifes. Researchers visited 24 PHC clinics and met with 257 traditional healers in groups, 33 individual healers, 3 staff nurses, 35 professional nurses, a group of 11 health advisors, 36 patients, 1 research officer, and 1 district medical officer of health. During 1995, researchers conducted 123 interviews. Findings were presented on 1) the reasons for collaboration, 2) the training of traditional midwives, 3) the role of the traditional midwife in the community, 4) the treatment provided by traditional midwives, 5) the problems of traditional midwives, and 6) recommendations. Findings confirm the guidelines generated by Isaacs (1995) on how to approach the training of traditional healers in PHC and the identification of the difficulties in training. Tactful persuasion is needed to convince traditional healers who are set in they ways to change. Trainers need to understand the traditional healers' approach to problem solving. Healers view asking questions as showing doubt and an inability to diagnose. A requirement of successful collaboration is to show respect and a positive attitude toward traditional healers and to explain the aims of the project. Programs used in the Free State and the former Transvaal might be used for training traditional healers. It is concluded that the role of the traditional healer is an important one, one not likely to be changed, and one amenable to training.

Characteristics of traditional birth attendants and their beliefs and practices in the Offot Clan, Nigeria.

This article presents the findings of a survey of a group of 52 traditional birth attendants (TBAs) in a clan in south-eastern Nigeria. The purpose of the study was to develop a database from which to design an effective programme for TBAs in the safe delivery and early referral of women with complications to hospital. The study showed that the majority of TBAs were illiterate and had no previous experience or training, even informal training, when they took on the TBA role. Ignorance about maternal complications during childbirth and the appropriate treatment was evident for most of the group. A small number of the group relied solely on divine revelation for guidance in the management of child-bearing women. The results of the survey clearly showed that educational programmes for TBAs and better integration into the health care system are essential for lowering maternal mortality and morbidity rates in areas where most mothers are not open to nor have access to professional care in childbirth.

PIP: To develop a database for the design of a traditional birth attendant (TBA) training program, a survey was conducted of the 52 Offot Clan TBAs in 21 villages in southeastern Nigeria's rain forest belt (Akwa Ibom State). The ultimate goal of the training program is to identify and correct risky practices that impede safe motherhood. The average age of TBAs was 45.3 years (range, 28-70 years); 46.2% were married and 46.2% were widowed. 67.3% were illiterate. All claimed they were supernaturally endowed to practice their profession. After starting practice, 10 of the 19 TBAs with some previous training (generally by close relatives) and 7 of the 34 untrained TBAs participated in continuing education, primarily a Ministry of Health workshop. 51 of the 52 TBAs accepted that there is a need for training before commencing practice and 50 supported regular monitoring to ensure acceptable practice standards. TBAs reported that they managed problems in pregnancy primarily with fasting, prayers, herbal medicines, or enema. They were generally uninformed about the causes and management of antepartum and postpartum hemorrhage--a major cause of maternal mortality. An educational program has been designed to upgrade TBA knowledge and practices and a need has been identified to register, retrain, and monitor all practicing TBAs. Obstetricians and trained midwives in the area are being encouraged to offer support and leadership to TBAs rather than continue to shut them out of the health care system.

Socio-economic and other variables affecting maternal mortality in Sierra Leone.

PIP: This study identifies socioeconomic and health care variables affecting maternal mortality in 12 villages in Gbendembu Ngowahun Chiefdom in Sierra Leone. Data were obtained from Bombali district in the Northern Province. The villages include about 245,000 people. Analysis is based on interviews, participant observation, and health records from primary health care (PHC) centers and peripheral health units (PHUs). Interviews were conducted among 400 households and among 31 traditional birth attendants (TBAs) and PHC staff during November 1989 to February 1990. Findings indicate that high parity was related to early marriage. Over 40% of women were married by the age of 15 years. About 85% of women aged 45-49 years had 6 or more children. 55.1% had 9 or more children. Localized areas within the Chiefdom had even higher fertility. Fertility was somewhat lower among women living beyond a 3-mile radius of the PHUs. Most of the women had never had any formal primary education, particularly older women. More people were Christians than Muslims. About 80-90% of the population was composed of very poor subsistence farmers. During the rainy season people went hungry. Few could afford health care. About 69.5% of deliveries in the prior 24 months occurred at home, 21.5% were performed at a health center, and about 9% occurred in the hospital. The health units were located in Gbendembu and Kalangba. One aide per unit was assigned to maternal and child health services. The program aim--to reduce maternal mortality by 30% by the year 2000--is unattainable. Many factors are constraints to quality health care. Facilities were inadequate, prices were high, and nurses were unfriendly. Over 70% of deliveries within 3 miles of PHUs and over 90% of outside deliveries were performed by TBAs. Over 60% of TBAs were untrained and did not use sterile supplies.^ieng

Knowledge, attitudes and practices on breast cancer and breast examination of nurses and midwives in Metro Manila.

This cross-sectional panel study determined the baseline knowledge about breast cancer and the attitudes on breast examination of nurses and midwives assigned at the different health centers in Metro Manila, and determined their sensitivity in detecting breast lumps after teaching them the Mamma-Care technique of breast examination, before they began to implement breast examination in the field. 225 nurses and midwives from a randomly selected 101 health centers in Metro Manila participated in a training seminar regarding breast cancer screening. They were given questionnaires to determine their baseline knowledge (multiple choice objective questionnaires) and attitudes (Liker-scale questionnaire) regarding their implementation of breast exam in the field. During the seminar, they were taught the Mamma-Care technique of breast examination with the aid of a videotape and lecture demonstration. They were then asked to examine silicone breast models which contain lumps of varying sizes (2 cm), mobility and hardness. Their sensitivity (through positive lumps detected by examination/total number of lumps in the breast model) in detecting lumps was then evaluated. Correct pretest knowledge on breast cancer symptoms, risk factors, treatment and screening were 83%, 64%, 86%, and 82%, respectively, which improved after training for 93%, 75%, 93%, and 92%, respectively. Trends in attitudes regarding implementation of breast exam were favorable. Sensitivity rates were 100% (33 nurses/midwives), 80% (48 n/m), 60% (n/m), 20% (17 n/m), and 0% (2 n/m). Overall sensitivity rate was 62%. Training and practice of skills among health center workers would enhance the Department of Health program on early detection of breast cancer in the Philippines.

Old skills and new knowledge: midwifery in contemporary Zimbabwe.

Sixty-one traditional birth attendants residing in the southern sector of Zimbabwe were interviewed concerning their midwifery practice. Traditional midwives were interviewed individually to gather information concerning: (a) the development of traditional midwifery skills, (b) the nature of traditional birthing patterns, (c) the features of the one-week midwifery training program provided to upgrade traditional midwives, and (d) traditional midwifery as practiced today, post the one-week training program. In describing past and present traditional midwifery, they reported a change in the use of sanitation practices, a heightened understanding of at-risk pregnancies and the need for formal medical intervention, and the adoption of mechanisms to record new births.

PIP: Since the early 1980s, midwives in Zimbabwe have been enrolled in a 1-week training program focused on normal and high-risk childbirth. In 1992, 61 trained rural midwives (mean age, 59.9 years) from the Ndebele ethnic group in southern Zimbabwe were interviewed about changes in their practice resulting from the training. The majority of respondents (96.7%) indicated they had learned midwifery skills from their mother, grandmother, or grandmother-in-law. Training-related changes reported included increased understanding of the importance of a hygienic environment for delivery, attempts to work with pregnant women early in their pregnancies rather than only after labor had started, referral of potential high-risk births to the clinic, collaboration with clinic nurses, and institution of record keeping. The training program has enabled midwives to maintain harmless traditional practices (e.g., the ritual burying of the placenta) while abandoning those that are unhygienic (e.g., placing cow dung around the mother and newborn). About 50-60% of all practicing traditional midwives in Zimbabwe have participated in this training.

Grandma ahead of her time: traditional ways of diarrhoea management in Lesotho.

The study was aimed at learning about home management of infant and young child diarrhoea in Lesotho. Focus groups and individual interviews were conducted with mothers, grandmothers and nurses during two phases of field work in three geographically different locations. It was found that home management of diarrhoea traditionally had emphasised feeding. While medical advice in the past recommended that, except for breast feeding, food should be withheld during diarrhoea, mothers, grandmothers and even nurses had been reluctant to follow this advice. Mothers and grandmothers saw feeding during diarrhoea as so essential that they would make special efforts to feed a child with diarrhoea. Since most foods contain protein and carbohydrates which stimulate intestinal fluid absorption, feeding during diarrhoea, besides maintaining nutrition, will help maintain hydration. When such beneficial feeding practices are protected and supported there is less need to promote new practices and less risk of producing harmful effects.

Knowledge and misconceptions about malaria among secondary school students and teachers in Kassala, eastern Sudan.

This study reports the responses of high secondary school students and teachers to a questionnaire on their knowledge and misconceptions about malaria. Knowledge about symptoms and cause of malaria seems to be adequate. However, there were deficiencies regarding knowledge of the seriousness of malaria in primigravidas and children. There was an exaggerated belief that chloroquine may cause abortion. There were also important misconceptions regarding the causation of malaria by the plant Unkoleeb (sorghum saccharatum), the belief that the local beverage Aradaib (Tramindus indica) cures malaria, as well as beliefs that chloroquine injections are more effective than tablets, that intravenous fluids are essential for treatment of every attack, and that multi-vitamins may prevent the disease. The study throws light on areas where health education should be focused.

PIP: A cross-sectional study conducted in Kassala, Sudan, investigated knowledge about malaria among 333 students and 38 teachers at 5 secondary schools in this malaria-endemic town. The overall malaria knowledge score was 13.9 (+or- 1.7) out of a possible maximum of 18. There were no significant differences in scores between students and teachers or males and females. Of concern, however, was the high frequency of incorrect responses for the following items: malaria is caused by eating unripe sweet sorghum (33.7%); one is predisposed to malaria by attacks of common cold (56.6%); chloroquine injections are more effective for treatment than are tablets (28.6%); malaria can be treated with the beverage Aradaib (22.6%); iv fluids are essential for treatment of a malaria attack (36.7%); and malaria can be prevented by taking multivitamins (48.0%). In addition, 28.3% of respondents believed that chloroquine can cause abortion, and only 47.4% of students and teachers were aware that malaria is more serious in primigravidas than multigravidas. These findings indicate an urgent need for health education campaigns in the schools and community to modify misconceptions about malaria.

Indigenous healers in the North West Province: a survey of their clinical activities in health care in the rural areas.

The purpose of this study was to explore the clinical conditions brought to indigenous healers by people in the rural areas in search of health care. The demographic variables and preventive, promotive, curative and follow-up activities of indigenous healers were investigated. Data were collected from a simple random sample of 35 indigenous healers. A questionnaire designed by Mogoba (1984) for investigation of training and functioning of traditional doctors in Southern Africa was modified and used to collect data. Findings showed that indigenous healers deal with the same health problems confronting formal health workers, especially in the paediatric field. Infertility, mental illness problems and sexually transmitted diseases ranked high in the adult conditions brought to the healers. There seem to be conditions that can be handled only by the indigenous healers due to their cultural nature. Findings also show that the services of indigenous healers are not confined to any specific group or social class within black population.

PIP: This study describes the medical practice among a sample of indigenous healers from Thaba Nchu, Ganyesa, Kurumane, Mankwe, and Molopo regions of the North West province of South Africa. Data were obtained from interviews conducted among 35 indigenous healers recommended by heads from a sample of 40 villages. Findings indicate that 60% were Botswanan. 51% were female. 85.7% were aged 30-59 years. 77% were married, and 5.7% were divorced. 31% had a lower primary education, and 25.7% finished high primary schooling. 22.4% had no formal schooling. 60% were bone throwers, and 34.2% were bone throwers and sangomas. 54% received their training "by their ancestors through dreams." 31% received formal training in indigenous healing. 14% served an apprenticeship with an experienced healer. 94% had a period of training from 2-5 years. 57% were registered with an association for indigenous healers. 77% relied on bone throwing for diagnosis of health problems. Other treatment methods included scarification, enema, induced vomiting, ritual performance, and prevention of witchcraft. Healers treated infertility, septic sores, impotence, sexually transmitted diseases, deliveries, makgome or boswagade, asthma, mental illness, high blood pressure, palpitations, tuberculosis, alcoholism, diabetes, and cancer. Pediatric diseases that were treated included tlhogwana, ditantanyane, measles, Kwashiorkor, and whooping cough. Healers relied on the following methods for disease prevention and health promotion: home fortifying, home cleansing, personal cleansing, scarification, and cultural education in taboos. 74% made referrals to either a western trained physician (17 out of 26) or other healers. All were generalists. Clients included professionals, such as nurses, teachers, and religious ministers. Although there is potential danger in some treatment methods, healers serve an important role in health prevention and treatment.