Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners.

BACKGROUND: Among mental health staff, burnout has been associated with undesirable outcomes, such as physical and mental ill-health, high levels of staff turnover and poorer patient care. AIMS: To estimate the prevalence and predictors of burnout amongst Improving Access to Psychological Therapist (IAPT) practitioners. METHODS: IAPT practitioners (N = 201) completed an on-line survey measuring time spent per week on different types of work related activity. These were investigated as predictors of burnout (measured using the Oldenburg Burnout Inventory). RESULTS: The prevalence of burnout was 68.6% (95% confidence interval (CI) 58.8-77.3%) among psychological wellbeing practitioners (PWP) and 50.0% (95% CI 39.6-60.4%) among high intensity (HI) therapists. Among PWPs hours of overtime-predicted higher odds of burnout and hours of clinical supervision predicted lower odds of burnout. The odds of burnout increased with telephone hours of patient contact among PWPs who had worked in the service for two or more years. None of the job characteristics significantly predicted burnout among HI therapists. CONCLUSIONS: Our results suggest a high prevalence of burnout among IAPT practitioners. Strategies to reduce burnout among PWPs involving reductions in workload, particularly telephone contact and increases in clinical supervision need to be evaluated.

Effectiveness of creative arts-based interventions for treating children and adolescents exposed to traumatic events: a systematic review of the quantitative evidence and meta-analysis.

BACKGROUND: The effect of interventions based on the creative arts for children and adolescents exposed to traumatic events was estimated for measures of post-traumatic stress disorder (PTSD) and other psychological symptoms. METHOD: Using a pre-registered protocol, relevant journal articles were identified through searches of: PsycInfo; Psychology and Behavioural Sciences Collection; CINAHL and PsycArticles. Data were pooled using a random effects model, and effect estimates were reported as Hedges' g. RESULTS: Pooled effect estimates indicated that arts-based interventions significantly reduced PTSD symptom scores compared to pre-intervention (15 studies, g = -.67, p < .001) and a control group (7 studies, g = -.50, p < .001). Significant reductions were also found for measures of negative mood, but results were mixed for externalizing problems and anxiety. CONCLUSIONS: Despite variations in study quality, intervention approaches and types of trauma experience, the results tentatively suggest that creative arts-based interventions may be effective in reducing symptoms of trauma and negative mood.

Promoting critical consciousness and social mobilization in HIV/AIDS programmes: lessons and curricular tools from a South African intervention.

The development of critical consciousness is seen as a key stage in communities increasing levels of dialogue about priority problems and effecting structural change for health. However, relatively little research identifies concrete methods for programmes to build critical consciousness. We examined how a South African structural intervention used critical consciousness as a tool for prevention of intimate partner violence and HIV infection. We collected qualitative data in the form of in-depth interviews with managers, trainers, and participants of the Intervention with Microfinance for AIDS and Gender Equity intervention (IMAGE) in rural South Africa. The data were analysed through a coding structure developed in QSR NVivo. We draw practical lessons from IMAGE to guide other HIV programmes aiming to promoting critical consciousness and social mobilization. This research suggests that specific curricular tools can work towards critical consciousness and that mobilization efforts in future programmes can be strengthened by including individual and collective efforts by participants.

Process evaluation of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in rural South Africa.

The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) combines microfinance, gender/HIV training and community mobilization (CM) in South Africa. A trial found reduced intimate partner violence among clients but less evidence for impact on sexual behaviour among clients' households or communities. This process evaluation examined how feasible IMAGE was to deliver and how accessible and acceptable it was to intended beneficiaries during a trial and subsequent scale-up. Data came from attendance registers, financial records, observations, structured questionnaires (378) and focus group discussions and interviews (128) with clients and staff. Gender/HIV training and CM were managed initially by an academic unit ('linked' model) and later by the microfinance institution (MFI) ('parallel' model). Microfinance and gender/HIV training were feasible to deliver and accessible and acceptable to most clients. Though participation in CM was high for some clients, others experienced barriers to collective action, a finding which may help explain lack of intervention effects among household/community members. Delivery was feasible in the short term but both models were considered unsustainable in the longer term. A linked model involving a MFI and a non-academic partner agency may be more sustainable and is being tried. Feasible models for delivering microfinance and health promotion require further investigation.

Temporal perspective and parental intention to accept the human papillomavirus vaccination for their daughter.

OBJECTIVE: A school-based vaccination programme to prevent infection with the human papillomavirus (HPV), the virus that causes cervical cancer, began in October 2008 in England. The present study evaluated the role of temporal perspective in the formation of attitudes and intentions towards the vaccine. DESIGN: A cross-sectional correlational survey of 245 parents of 11-12-year-old girls. METHODS: Parents read a passage about the HPV vaccine containing information about benefits and concerns parents might have about the vaccine. They then completed a thought listing task and measures of attitude, vaccine efficacy, anticipated regret, intention, and consideration of future consequences. RESULTS: Parents with higher consideration of future consequences generated more positive relative to negative thoughts, held more positive attitudes, higher response efficacy, reported higher anticipated regret about not vaccinating their daughters and held more positive intentions. Mediation analyses suggested that the influence of thoughts generated on intention to vaccinate was partially mediated by attitude, perceived vaccine efficacy, and anticipated regret if the vaccine were not taken up. CONCLUSION: Messages emphasizing efficacy of vaccination and anticipated regret are likely to promote vaccination uptake.

Assessing the incremental effects of combining economic and health interventions: the IMAGE study in South Africa.

OBJECTIVE: To explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone. METHODS: Cross-sectional data were derived from three randomly selected matched clusters in rural South Africa: (i) four villages with 2-year exposure to the Intervention with Microfinance for AIDS and Gender Equity (IMAGE), a combined microfinance-health training intervention; (ii) four villages with 2-year exposure to microfinance services alone; and (iii) four control villages not targeted by any intervention. Adjusted risk ratios (aRRs) employing village-level summaries compared associations between groups in relation to indicators of economic well-being, empowerment, intimate partner violence (IPV) and HIV risk behaviour. The magnitude and consistency of aRRs allowed for an estimate of incremental effects. FINDINGS: A total of 1409 participants were enrolled, all female, with a median age of 45. After 2 years, both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group. However, only the IMAGE group demonstrated consistent associations across all domains with regard to women's empowerment, intimate partner violence and HIV risk behaviour. CONCLUSION: The addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits. Donor agencies should encourage intersectoral partnerships that can foster synergy and broaden the health and social effects of economic interventions such as microfinance.

Factors associated with the sexual behavior of Canadian Aboriginal young people and their implications for health promotion.

OBJECTIVES: We examined factors associated with having ever had sex, having more than 1 lifetime sexual partner, and condom nonuse at last incident of sexual intercourse among Canadian Aboriginal young people. METHODS: We conducted a secondary analysis of data from the 2003 British Columbia Adolescent Health Survey, a cross-sectional survey of young people in grades 7 through 12. RESULTS: Of 1140 young Aboriginal men, 34% had ever had sex; of these, 63% had had more than 1 sexual partner, and 21% had not used a condom at their last incident of sexual intercourse. Of 1336 young Aboriginal women, 35% had ever had sex; of these, 56% had had more than 1 sexual partner, and 41% had not used a condom at their last incident of sexual intercourse. Frequent substance use, having been sexually abused, and having lived on a land reservation were strongly associated with sexual behavior outcomes. Feeling connected to family was strongly associated with increased condom use. CONCLUSIONS: Sexual behavior change interventions for Aboriginal young people must move beyond the individual and incorporate interpersonal and structural dimensions. Interventions to reduce substance use and sexual abuse and promote feelings of family connectedness in this population should be explored. Young people living on land reserves need special attention.

Characteristics of sexual partnerships, not just of individuals, are associated with condom use and recent HIV infection in rural South Africa.

Characteristics of sexual partnerships, as well as those of the individuals involved, might influence the use of condoms and risk of HIV transmission. We set out to identify characteristics of non-spousal sexual partnerships associated with condom use at last sex in the previous year and HIV infection in the previous three years among sexually active young people in rural South Africa. We conducted an analysis of follow-up data (collected in 2004) from a cohort of 14-35-year old men and women recruited to a cluster-randomised trial. Data on 1647 non-spousal sexual partnerships during the previous year were reported in 2004 and analysed alongside new HIV infections over the previous three years among 762 individuals who were HIV-negative in 2001. Structured interviews elicited information on sexual behaviour. HIV serostatus was assessed through oral-fluid ELISA. Condom use at last sex was reported for 615/1647 non-spousal sexual partnerships (37.3%) and was more commonly reported by individuals who were younger, more educated and aware of their HIV status. Condom use was more common in casual partnerships, those where the male partner was younger, where sex was less frequent and where the respondent believed the partner to have other sexual contacts. New HIV infection in the last three years was identified for 87/762 individuals (11.4%) and was more common among females and those out of school. Infection risk was associated with the age of the partners and was less common among individuals reporting less frequent intercourse in the previous year. Characteristics of sexual partnerships, as well as those of individuals, are important determinants of condom use and risk of HIV infection. Male characteristics may be particularly important because of their greater capacity to make decisions about HIV prevention. Established non-spousal sexual partnerships are an increasingly important context for HIV transmission in this setting.

Factors associated with pregnancy and STI among Aboriginal students in British Columbia.

BACKGROUND: Aboriginal adolescents are more likely to become pregnant and contract an STI than other Canadian adolescents. This study provides some of the first data on factors associated with these outcomes among Aboriginal adolescents. METHODS: A secondary analysis was conducted using 2003 data from a large cross-sectional survey of British Columbia secondary school students. 445 young women and 360 young men who identified as Aboriginal and reported ever having sex were included in analyses. Associations between self-reported pregnancy and STI and 11 exposure variables were examined using logistic regression. RESULTS: Of young women, 10.6% reported a pregnancy; 10.5% of young men reported causing a pregnancy. An STI diagnosis was reported by 4.2% of young women and 3.9% of young men. In multivariate analyses for young men, ever having been sexually abused was the strongest consistent risk factor for causing a pregnancy (AOR = 4.30, 95% CI 1.64-11.25) and STI diagnosis (AOR = 5.58, 95% CI 1.61-19.37). For young women, abuse was associated with increased odds of pregnancy (AOR = 10.37, 95% CI 4.04-26.60) but not STI. Among young women, substance use was the strongest consistent risk factor for both pregnancy (AOR = 3.36, 95% CI 1.25-9.08) and STI (AOR = 5.27, 95% CI 1.50-18.42); for young men, substance use was associated with higher odds of STI (AOR = 4.60, 95% CI 1.11-19.14). Factors associated with decreased risk included community, school and family involvement. CONCLUSIONS: Health care professionals, communities and policy-makers must urgently address sexual abuse and substance use. Exploring promotion of school and community involvement and family cohesion may be useful for sexual health interventions with Aboriginal students.

The health of trafficked women: a survey of women entering posttrafficking services in Europe.

Trained counselors interviewed 192 women who had been trafficked and sexually exploited about abuse and evaluated their physical and mental health status within 14 days of entry into posttrafficking services. Most reported physical or sexual violence while trafficked (95%), pre-trafficking abuse (59%), and multiple posttrafficking physical and psychological problems. Newly identified trafficked women require immediate attention to address posttrauma symptoms and adequate recovery time before making decisions about participating in prosecutorial or immigration proceedings or returning home.

Can social capital be intentionally generated? a randomized trial from rural South Africa.

While much descriptive research has documented positive associations between social capital and a range of economic, social and health outcomes, there have been few intervention studies to assess whether social capital can be intentionally generated. We conducted an intervention in rural South Africa that combined group-based microfinance with participatory gender and HIV training in an attempt to catalyze changes in solidarity, reciprocity and social group membership as a means to reduce women's vulnerability to intimate partner violence and HIV. A cluster randomized trial was used to assess intervention effects among eight study villages. In this paper, we examined effects on structural and cognitive social capital among 845 participants and age and wealth matched women from households in comparison villages. This was supported by a diverse portfolio of qualitative research. After two years, adjusted effect estimates indicated higher levels of structural and cognitive social capital in the intervention group than the comparison group, although confidence intervals were wide. Qualitative research illustrated the ways in which economic and social gains enhanced participation in social groups, and the positive and negative dynamics that emerged within the program. There were numerous instances where individuals and village loan centres worked to address community concerns, both working through existing social networks, and through the establishment of new partnerships with local leadership structures, police, the health sector and NGOs. This is among the first experimental trials suggesting that social capital can be exogenously strengthened. The implications for community interventions in public health are further explored.

Is social capital associated with HIV risk in rural South Africa?

The role of social capital in promoting health is now widely debated within international public health. In relation to HIV, the results of previous observational and cross-sectional studies have been mixed. In some settings it has been suggested that high levels of social capital and community cohesion might be protective and facilitate more effective collective responses to the epidemic. In others, group membership has been a risk factor for HIV infection. There have been few attempts to strengthen social capital, particularly in developing countries, and examine its effect on vulnerability to HIV. Employing data from an intervention study, we examined associations between social capital and HIV risk among 1063 14 to 35-year-old male and female residents of 750 poor households from 8 villages in rural Limpopo province, South Africa. We assessed cognitive social capital (CSC) and structural social capital (SSC) separately, and examined associations with numerous aspects of HIV-related psycho-social attributes, risk behavior, prevalence and incidence. Among males, after adjusting for potential confounders, residing in households with greater levels of CSC was linked to lower HIV prevalence and higher levels of condom use. Among females, similar patterns of relationships with CSC were observed. However, while greater SSC was associated with protective psychosocial attributes and risk behavior, it was also associated with higher rates of HIV infection. This work underscores the complex and nuanced relationship between social capital and HIV risk in a rural African context. We suggest that not all social capital is protective or health promotive, and that getting the balance right is critical to informing HIV prevention efforts.

HIV incidence and recent injections among adults in rural southwestern Uganda.

Thirty-six incident HIV cases were matched for age, sex and time period with 36 controls to examine associations with recent injections. A significant association between HIV incidence and a history of injections was detected that was not reduced after adjusting for available sexual behaviour variables. This association could either be the result of injections causing HIV infection or, more likely, injections for seroconversion illnesses or other consequences of unsafe sex.

Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial.

BACKGROUND: HIV infection and intimate-partner violence share a common risk environment in much of southern Africa. The aim of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum. METHODS: Villages in the rural Limpopo province of South Africa were pair-matched and randomly allocated to receive the intervention at study onset (intervention group, n=4) or 3 years later (comparison group, n=4). Loans were provided to poor women who enrolled in the intervention group. A participatory learning and action curriculum was integrated into loan meetings, which took place every 2 weeks. Both arms of the trial were divided into three groups: direct programme participants or matched controls (cohort one), randomly selected 14-35-year-old household co-residents (cohort two), and randomly selected community members (cohort three). Primary outcomes were experience of intimate-partner violence--either physical or sexual--in the past 12 months by a spouse or other sexual intimate (cohort one), unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months (cohorts two and three), and HIV incidence (cohort three). Analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00242957. FINDINGS: In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0.45, 95% CI 0.23-0.91; adjusted risk difference -7.3%, -16.2 to 1.5). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1.02, 0.85-1.23), and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner (0.89, 0.66-1.19) or HIV incidence (1.06, 0.66-1.69) in cohort three. INTERPRETATION: A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants. Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa.

Understanding the impact of a microfinance-based intervention on women's empowerment and the reduction of intimate partner violence in South Africa.

OBJECTIVES: We sought to obtain evidence about the scope of women's empowerment and the mechanisms underlying the significant reduction in intimate partner violence documented by the Intervention With Microfinance for AIDS and Gender Equity (IMAGE) cluster-randomized trial in rural South Africa. METHODS: The IMAGE intervention combined a microfinance program with participatory training on understanding HIV infection, gender norms, domestic violence, and sexuality. Outcome measures included past year's experience of intimate partner violence and 9 indicators of women's empowerment. Qualitative data about changes occurring within intimate relationships, loan groups, and the community were also collected. RESULTS: After 2 years, the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half (adjusted risk ratio=0.45; 95% confidence interval=0.23, 0.91). Improvements in all 9 indicators of empowerment were observed. Reductions in violence resulted from a range of responses enabling women to challenge the acceptability of violence, expect and receive better treatment from partners, leave abusive relationships, and raise public awareness about intimate partner violence. CONCLUSIONS: Our findings, both qualitative and quantitative, indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence.

Associations between mild-to-moderate anaemia in pregnancy and helminth, malaria and HIV infection in Entebbe, Uganda.

It is suggested that helminths, particularly hookworm and schistosomiasis, may be important causes of anaemia in pregnancy. We assessed the associations between mild-to-moderate anaemia (haemoglobin >8.0 g/dl and <11.2 g/dl) and helminths, malaria and HIV among 2507 otherwise healthy pregnant women at enrolment to a trial of deworming in pregnancy in Entebbe, Uganda. The prevalence of anaemia was 39.7%. The prevalence of hookworm was 44.5%, Mansonella perstans 21.3%, Schistosoma mansoni 18.3%, Strongyloides 12.3%, Trichuris 9.1%, Ascaris 2.3%, asymptomatic Plasmodium falciparum parasitaemia 10.9% and HIV 11.9%. Anaemia showed little association with the presence of any helminth, but showed a strong association with malaria (adjusted odds ratio (AOR) 3.22, 95% CI 2.43-4.26) and HIV (AOR 2.46, 95% CI 1.90-3.19). There was a weak association between anaemia and increasing hookworm infection intensity. Thus, although highly prevalent, helminths showed little association with mild-to-moderate anaemia in this population, but HIV and malaria both showed a strong association. This result may relate to relatively good nutrition and low helminth infection intensity. These findings are pertinent to estimating the disease burden of helminths and other infections in pregnancy. [Clinical Trial No. ISRCTN32849447].

Assessing household wealth in health studies in developing countries: a comparison of participatory wealth ranking and survey techniques from rural South Africa.

BACKGROUND: Accurate tools for assessing household wealth are essential for many health studies in developing countries. Household survey and participatory wealth ranking (PWR) are two approaches to generate data for this purpose. METHODS: A household survey and PWR were conducted among eight villages in rural South Africa. We developed three indicators of household wealth using the data. One indicator used PWR data only, one used principal components analysis to combine data from the survey, while the final indicator used survey data combined in a manner informed by the PWR. We assessed internal consistency of the indices and assessed their level of agreement in ranking household wealth. RESULTS: Food security, asset ownership, housing quality and employment were important indicators of household wealth. PWR, consisting of three independent rankings of 9671 households, showed a high level of internal consistency (intraclass correlation coefficient 0.81, 95% CI 0.79-0.82). Data on 1429 households were available from all three techniques. There was moderate agreement in ranking households into wealth tertiles between the two indicators based on survey data (spearman rho = 0.69, kappa = 0.43), but only limited agreement between these techniques and the PWR data (spearman rho = 0.38 and 0.31, kappa = 0.20 and 0.17). CONCLUSION: Both PWR and household survey can provide a rapid assessment of household wealth. Each technique had strengths and weaknesses. Reasons for differences might include data inaccuracies or limitations in the methods by which information was weighted. Alternatively, the techniques may measure different things. More research is needed to increase the validity of measures of socioeconomic position used in health studies in developing countries.

Use of antenatal services and delivery care in Entebbe, Uganda: a community survey.

BACKGROUND: Disparities in perinatal health care occur worldwide. If the UN Millennium Development Goals in maternal and child health are to be met, this needs to be addressed. This study was conducted to facilitate our understanding of the changing use of maternity care services in a semi-urban community in Entebbe Uganda and to examine the range of antenatal and delivery services received in health care facilities and at home. METHODS: We conducted a retrospective community survey among women using structured questionnaires to describe the use of antenatal services and delivery care. RESULTS: In total 413 women reported on their most recent pregnancy. Antenatal care attendance was high with 96% attending once, and 69% the recommended four times. Blood pressure monitoring (95%) and tetanus vaccination (91%) were the services most frequently reported and HIV testing (47%), haematinics (58%) and presumptive treatment for malaria (66%) least frequently. Hospital clinics significantly outperformed public clinics in the quality of antenatal service. A significant improvement in the reported quality of antenatal services received was observed by year (p < 0.001). Improvement in the range and consistency of services at Entebbe Hospital over time was associated with an increase in the numbers who sought care there (p = 0.038). Although 63% delivered their newborn at a local hospital, 11% still delivered at home with no skilled assistance and just under half of these women reported financial/transportation difficulties as the primary reason. Less educated, poorer mothers were more likely to have unskilled/no assistance. Simple newborn care practices were commonly neglected. Only 35% of newborns were breastfed within the first hour and delayed wrapping of newborn infants occurred after 27% of deliveries. CONCLUSION: Although antenatal services were well utilised, the quality of services varied. Women were able and willing to travel to a facility providing a good service. Access to essential skilled birth attendants remains difficult especially for less educated, poorer women, commonly mediated by financial and transport difficulties and several simple post delivery practices were commonly neglected. These factors need to be addressed to ensure that high quality care reaches the most vulnerable women and infants.

Bacterial vaginosis, vaginal flora patterns and vaginal hygiene practices in patients presenting with vaginal discharge syndrome in The Gambia, West Africa.

BACKGROUND: Bacterial vaginosis (BV) - a syndrome characterised by a shift in vaginal flora - appears to be particularly common in sub-Saharan Africa, but little is known of the pattern of vaginal flora associated with BV in Africa. We conducted a study aimed at determining the prevalence of BV and patterns of BV-associated vaginal micro-flora among women with vaginal discharge syndrome (VDS) in The Gambia, West Africa. METHODS: We enrolled 227 women with VDS from a large genito-urinary medicine clinic in Fajara, The Gambia. BV was diagnosed by the Nugent's score and Amsel's clinical criteria. Vaginal swabs were collected for T vaginalis and vaginal flora microscopy, and for Lactobacillus spp, aerobic organisms, Candida spp and BV-associated bacteria (Gardnerella vaginalis, anaerobic bacteria, and Mycoplasma spp) cultures; and cervical swabs were collected for N gonorrhoeae culture and C trachomatis PCR. Sera were tested for HIV-1 and HIV-2 antibodies. Sexual health history including details on sexual hygiene were obtained by standardised questionnaire. RESULTS: BV prevalence was 47.6% by Nugent's score and 30.8% by Amsel's clinical criteria. Lactobacillus spp were isolated in 37.8% of women, and 70% of the isolates were hydrogen-peroxide (H202)-producing strains. Prevalence of BV-associated bacteria were: G vaginalis 44.4%; Bacteroides 16.7%; Prevotella 15.2%; Peptostretococcus 1.5%; Mobiluncus 0%; other anaerobes 3.1%; and Mycoplasma hominis 21.4%. BV was positively associated with isolation of G vaginalis (odds-ratio [OR] 19.42, 95%CI 7.91 - 47.6) and anaerobes (P = 0.001 [OR] could not be calculated), but not with M hominis. BV was negatively associated with presence of Lactobacillus (OR 0.07, 95%CI 0.03 - 0.15), and H2O2-producing lactobacilli (OR 0.12, 95% CI 0.05 - 0.28). Presence of H2O2-producing lactobacilli was associated with significantly lower prevalence of G vaginalis, anaerobes and C trachomatis. HIV prevalence was 12.8%. Overall, there was no association between BV and HIV, and among micro-organisms associated with BV, only Bacteroides spp. and Prevotella spp. were associated with HIV. BV or vaginal flora patterns were not associated with any of the factors relating to sexual hygiene practices (vaginal douching, menstrual hygiene, female genital cutting). CONCLUSION: In this population, BV prevalence was higher than in corresponding populations in industrialised countries, but the pattern of vaginal micro-flora associated with BV was similar. BV or vaginal flora patterns were not associated with HIV nor with any of the vaginal hygiene characteristics.

Herpes simplex 2 risk among women in a polygynous setting in rural West Africa.

OBJECTIVES: To determine risk factors for herpes simplex 2 (HSV2) infection in women in a polygynous rural Gambian population. METHODS: Data from women who participated in a cross-sectional survey of reproductive health were matched to their own and, for women who had been or were married (ever-married), their spouses' data collected in a cross-sectional survey of fertility interests, including information on marital histories. RESULTS: Data were available on 150 never-married and 525 ever-married women. HSV2 prevalence was 16% amongst never-married women and 36% amongst ever-married women. For ever-married women, their own personal characteristics (age, ethnicity and genital cutting status) and events from their husbands' marriage history were important determinants of HSV2 infection. Women whose husbands married for the first time over age 35 were at greater risk than women whose husbands married by age 24 [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.20-6.10]. Women whose husband reported interest in a new marriage were more likely to be HSV2 positive (OR 1.91, 95% CI 1.18-3.09). Women whose husbands were currently monogamous but had had previous marriages (OR 2.76, 95% CI 1.30-5.88) and women in currently polygynous marriages (OR 2.88, 95% CI 1.66-5.01) were three times as likely to be HSV2 positive as women who were their husband's only wife ever. CONCLUSION: Much transmission of HSV2 in this setting occurs within marriage where opportunity for personal protection is limited. High levels of transmission within marriage may undermine the impact of sexual behaviour change programmes aiming to reduce HSV2 and HIV incidence and complicate their evaluation.