Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study.

BACKGROUND: In rural Nepal, where women face financial and geographic barriers in accessing ultrasound scans, the government initiated a Rural Obstetric Ultrasound Program (ROUSG) to train skilled birth attendants (SBAs) in rural birthing centers and expand access to routine ultrasound scans for local pregnant women. This study explores the perceived benefits and limitations of the training and implementation of this program. METHODS: A qualitative study was conducted in 15 primary care facilities in Bhojpur and Dhading, two rural districts of Nepal. The research team conducted in-depth interviews with 15 trained SBAs and focus group discussions with 48 service recipients and 30 FCHVs to gain insight into their perceptions. All interviews and focus group discussions were recorded, reviewed, and manually coded into MS Excel. RESULTS: Overall, our findings indicated that the ROUSG program was very well received among all our study participants, though critical gaps were identified, mostly during the training of the SBAs. These included insufficient guidance or practice opportunities during training and the challenges of implementing the mobile obstetric ultrasound service. Most importantly, though, our results suggest that the implementation of the ROUSG program increased access to prenatal care, earlier identification and referrals for abnormal scans, as well as reduced pregnancy-related stress. There was also a notable anecdotal increase in antenatal care utilization and institutional deliveries, as well as high satisfaction in both service providers and recipients. CONCLUSION: Our findings highlighted that while the training component could use some strengthening with increased opportunities for supervised practice sessions and periodic refresher training after the initial 21-days, the program itself had the potential to fill crucial gaps in maternal and newborn care in rural Nepal, by expanding access not only to ROUSG services but also to other MNH services such as ANC and institutional deliveries. Our findings also support the use of ultrasound in areas with limited resources as a solution to identify potential complications at earlier stages of pregnancy and improve timely referrals, indicating the potential for reducing maternal and neonatal morbidities. This initial study supports further research into the role ROUSG can play in expanding critical MNH services in underserved areas and improving broader health outcomes through earlier identification of potential obstetric complications.

Socio-culturally adapted educational videos increase maternal and newborn health knowledge in pregnant women and female community health volunteers in Nepal's Khotang district.

OBJECTIVES: While Nepal has made significant improvements in maternal and newborn health overall, the lack of maternal and newborn health-related knowledge in the more rural parts of the country has led to significant disparities in terms of both maternal and newborn health service utilization and maternal and newborn health outcomes. This study aimed to assess whether viewing culturally adapted maternal and newborn health educational films had a positive impact on (1) the maternal and newborn health knowledge levels among pregnant women and (2) the postpartum hemorrhage-related knowledge levels among Female Community Health Volunteers in rural Nepal. METHODS: Four locations were selected for their remoteness and comparatively high number of pregnancies. A convenience sample of 101 pregnant women and 39 Female Community Health Volunteers were enrolled in the study. A pre- and post-test design was employed to assess this intervention. Paired t-tests were used to analyze the change in number of correct responses by knowledge domain for multi-film participants, producing a numeric "mean knowledge score," and McNemar's tests were used to calculate the change and significance among select questions grouped into distinct themes, domains, and points of "maternal and newborn health-related knowledge" based on the priorities outlined in Nepal's maternal and newborn health 2030 goals. RESULTS: There was a significant improvement in knowledge scores on maternal and newborn health issues after watching the educational films for both types of participants. The mean knowledge score for pregnant women improved from 10 to 15 (P < 0.001) for the Understanding Antenatal Care (ANC) film, 3 to 10 (P < 0.001) for the Warning Sign in Pregnancy film, and 6 to 14 (P < 0.001) for the Newborn Care film. For the Female Community Health Volunteers, knowledge also significantly improved (P < 0.05) in all except one category after watching the postpartum hemorrhage film. The percent that correctly answered when to administer misoprostol (80%-95%) was the only variable in which knowledge improvement was not significant (P < 0.057). CONCLUSION: Using culturally adapted educational films is an effective intervention to improve short-term maternal and newborn health-related knowledge among rural populations with low educational levels. The authors recommend additional larger-scale trials of this type of intervention in Nepal and other low- and middle-income countries to determine the impact on long-term maternal and newborn health knowledge and behaviors among rural populations.

Non-surgical interventions for pelvic organ prolapse in rural Nepal: a prospective monitoring and evaluation study.

OBJECTIVES: Pelvic organ prolapse (POP) is a major cause of morbidity in Nepal, particularly affecting women in the rural communities. Women with POP in Nepal may suffer from symptoms for decades. At present, the Government of Nepal advocates surgical intervention but access to surgical care is inadequate. This report evaluated the feasibility of a non-surgical public health programme in rural Nepal, and describes risk factors associated with POP in this setting. DESIGN: Prospective monitoring and evaluation study of a new public health programme. SETTING: Baglung district, rural Nepal. PARTICIPANTS: Women with gynaecological symptoms of POP. MAIN OUTCOME MEASURES: Risk factors for disease progression were assessed using Fisher's exact test, Pearson's χ(2)-test and logistic regression analysis. RESULTS: Of the 74 women included in this analysis, 70.8% were diagnosed with stage 2 POP or greater. The majority of women did not have any further children following the onset of POP symptoms (63.5%). Duration of symptoms ranged from 2 months to 60 years, with 73.4% of women suffering for over 5 years and 28.4% suffering for over 20 years. Univariate analyses identified age at screening, age at onset of symptoms, the duration of symptoms and an associated rectocele as factors associated with increasing POP severity (p < 0.05). Kegel exercises were taught to 25 (33.8%) women with POP and ring pessaries were offered to 47 (63.5%) women with POP. CONCLUSIONS: Non-surgical interventions may provide an opportunity to address the significant burden of POP in rural Nepal.

Knowledge and skills for management of sexually transmitted infections among rural medical practitioners in Bangladesh.

Sexually transmitted infection (STI) management is considered rudimentary among rural medical practitioners (RMPs) in Bangladesh. We sought to understand the level of knowledge and skills in STI management and to assess the impact of a two-day training orientation among RMPs in Tangail district. Data were collected through a baseline survey of 225 practicing RMPs in the study area and a three-month follow-up survey of 99 RMPs who participated in a two-day STI/HIV orientation training. The level of formal training among RMPs ranged from none (22.7%), to paramedical training (14.7%) and local medical assistant training (62.6%). The baseline survey revealed a low level of STI/HIV knowledge and misconceptions about the transmission of STI/HIV among RMPs. RMPs mostly prescribed first line antibiotics for treatment of common reproductive tract infections (RTIs) including STIs, but they rarely prescribed the correct dosages according to the national RTI/STI management guidelines. Only 3% of RMPs were able to correctly answer all four HIV transmission (unprotected sexual intercourse, blood transfusion, needle sharing and mother to child transmission) questions at baseline, while 94.9% of RMPs answered all four correctly at three months following the training (p=0.001). Only 10% of RMPs reported suggesting the recommended drug (azithromycin) and only 2% mentioned about the recommended dosage (2gm single dose) for the treatment of urethritis/cervicitis; compared to 49.5% suggested azithromycin at follow-up with 39.4% mentioned the recommended 2gm single dose (p=0.001). Our study found low level of knowledge and poor practices related RTI/STI management among RMPs. Short orientation training and education intervention shown promise to increase knowledge and management skills for RTIs/STIs.

Attitudes and practices towards micronutrient supplementation among pregnant women in rural Tibet.

The objective of this study was to identify trends and change in micronutrient supplementation (MNS) knowledge across pregnancy and post-partum and to assess the impact of MNS knowledge (MNS-k) on practice in pregnancy in rural Tibet, an area with endemic micronutrient deficiency. A prospective cohort with repeated measures at early, late and after pregnancy in a rural area in the Tibetan Autonomous Region included women receiving care by community workers. Key messages about MNS-k and optimal MNS practice were communicated through health worker encounters with pregnant women. Outcomes included MNS consumption practice, knowledge and attitudes. The proportion of women in the highest MNS-k category increased by 35% from early to late pregnancy (37.5-50.7%, respectively; p < .005). MNS-k was associated with MNS consumption in a dose-response manner over pregnancy (trend X2 p-value < .0001), with increasing knowledge associated with increased MNS consumption. By late pregnancy, 32.5% of women had never consumed an MNS in this pregnancy, and 51.5% had not consumed an MNS on the assessed day or the day before. Sustained knowledge of MNS improved in pregnancy and post-partum. Best practice around MNS consumption increased though remained sub-optimal.

Wuchereria bancrofti transmission pattern in southern Mali prior to and following the institution of mass drug administration.

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000 with the goal of stopping transmission of lymphatic filariasis (LF) through yearly mass drug administration (MDA). Although preliminary surveys of the human population in Mali suggested that Wuchereria bancrofti infection was highly endemic in the Sikasso district, baseline entomological data were required to confirm high levels of transmission prior to the selection of villages in this region for a study of the impact of MDA on transmission of LF by anopheline vectors. METHODS: W. bancrofti transmission was assessed in 2001 (pre-MDA) and 2002 (post-MDA) in the Central District of Sikasso in southern Mali by dissection of Anopheles mosquitoes caught using the human landing catch (HLC) method. The relative frequencies and molecular forms of An. gambiae complex were determined. RESULTS: The majority (86%) of the anopheline vectors captured were identified as An. gambiae complex, and these accounted for >90% of the entomological inoculation rate (EIR) during both years of the study. There was a dramatic decrease in the number of An. gambiae complex mosquitoes captured and in the An. gambiae complex infectivity rates following MDA, accounting for the observed decrease in EIR in 2002 (from 12.55 to 3.79 infective bites per person during the transmission season). An. funestus complex mosquitoes were responsible for a low level of transmission, which was similar during both years of the study (1.2 infective bites per person during the transmission season in 2001 and 1.03 in 2002). CONCLUSIONS: Based on the entomological data from this study, the district of Sikasso was confirmed as an area of high W. bancrofti transmission. This led to the selection of this area for a multi-national study on the effects of MDA on LF transmission by anopheline vectors. Comparison of vector transmission parameters prior to and immediately following the first round of MDA demonstrated a significant decrease in overall transmission. Importantly, the dramatic variability in EIR over the transmission season suggests that the efficacy of MDA can be maximized by delivering drug at the beginning of the rainy season (just prior to the peak of transmission).

First report of HIV-related oral manifestations in Mali.

INTRODUCTION: In 2004, the sudden availability of free antiretroviral therapy (ART in Mali, within the context of an already overburdened health care system created gaps in individual patient quality of care. The objective of this study was to determine the prevalence of HIV-related oral manifestations (OM) during the first month of ART therapy in a Malian health facility. METHODS: Medical records of adult patients who initiated ART regimens at the Gabriel Touré Hospital, Mali (2001 to 2008) were randomly identified. Multiple logistic regression models were used to evaluate the relationship between the presence of OM during the first month of ART and selected variables, including CD4 counts and WHO clinical staging at ART initiation. RESULTS: Out of 205 patients on ART (mean age 39 ± 10 years), 71.0% were females and 36.1% had no formal education. 40.6% were in WHO clinical stage III. OM prevalence during the first month of HIV care was 31.4%, being oral candidiasis the commonest lesion. 73.2% and 82.5% of the patients with OM had CD4 count < 200 cells/mm3 and were classified as WHO clinical stage III or IV. WHO clinical stage III and VI patients had 5.4-fold increased odds of having any OM (both p< 0.01) when controlling for age, ethnicity, gender, marital status, and CD4 counts. CONCLUSION: OM detected in people with low CD4 count and WHO clinical stage III and IV at ART initiation suggested that they were very immune-compromised when initiating HIV care. Early identification of OM could improve the quality of care and guarantee the benefits of ART.

Sexual mixing patterns among social networks of HIV-positive and HIV-negative Beijing men who have sex with men: a multilevel comparison using roundtable network mapping.

Men who have sex with men (MSM) are of immediate concern in China's HIV epidemic. In 2008, approximately 2.5-6.5% of China's eight million MSM were HIV positive, while MSM represented 11% of all new HIV cases. Two factors that will in-part determine HIV-transmission dynamics among MSM, are sexual mixing patterns and the social networks which shape them. Sexual mixing patterns and social networks of Chinese MSM, however, remain poorly understood with little refined data available. One reason is that stigma discourages disclosure of names and identifiers to researchers. Using an alternative network-mapping approach, matched case-control design, and snowball sampling, this pilot study sought to compare characteristics of social networks of HIV-positive and HIV-negative Beijing MSM at the individual, dyad, and network levels. First, HIV-negative MSM controls were matched to HIV-positive MSM cases based on age, education, residency, and ethnicity. Then, each case or control and their MSM social network convened at a specific time and location with study investigators. Venues included health clinics, karaoke clubs, brothels, and community centers. Then, using arbitrarily assigned numbers in lieu of actual names, all participants simultaneously completed self-administered surveys regarding their sexual relationships with other participants of the same social network. These new findings indicate that cross-generational sex (anal or oral sex between men with ≥10 years age difference) was more prevalent among social networks of HIV-positive MSM, and was due to older age structure of the social network, rather than behavioral differences in sex-partner selection. Members of social networks of HIV-positive MSM were also less likely to have ever disclosed their MSM identity to non-MSM. Future studies should partner with MSM advocacy groups to explore behavioral and structural interventions as possible means of reducing the cross-generational sex and sexual identity-development issues elevating HIV risk for young Chinese MSM.

Temporal analysis of feeding patterns of Culex erraticus in central Alabama.

Host blood meals in seven mosquito species previously shown to be infected with eastern equine encephalitis virus at a site in the Tuskegee National Forest in southcentral Alabama were investigated. Of 1374 blood meals derived from 88 different host species collected over 6 years from these seven mosquito species, 1099 were derived from Culex erraticus. Analysis of the temporal pattern of Cx. erraticus meals using a Runs test revealed that the patterns of feeding upon avian and mammalian hosts from March to September of each year were not randomly distributed over time. Similarly, meals taken from the three most commonly targeted host species (yellow-crowned night heron, great blue heron, and white-tailed deer) were not randomly distributed. A Tukey's two-way analysis of variance test demonstrated that although the temporal pattern of meals taken from avian hosts were consistent over the years, the patterns of meals taken from the individual host species were not consistent from year to year.

Association between tobacco use in pregnancy and placenta-associated syndromes: a population-based study.

INTRODUCTION: Cigarette smoking is an established risk factor for adverse perinatal outcomes. The purpose of this study is to examine the association between maternal smoking in pregnancy and the occurrence of placental-associated syndromes (PAS). METHODS: We analyzed data from a population-based retrospective cohort of singleton deliveries that occurred in the state of Missouri from 1989 through 2005 (N = 1,224,133). The main outcome was PAS, a composite outcome defined as the occurrence of placental abruption, placenta previa, preeclampsia, small for gestational age, preterm or stillbirth. We used logistic regression models to generate adjusted odd ratios and their 95 percent confidence intervals. Non-smoking gravidas served as the referent category. RESULTS: The overall prevalence of prenatal smoking was 19.6%. Cigarette smoking in pregnancy was associated with the composite outcome of placental syndromes (odds ratio, 95% confidence interval = 1.59, 1.57-1.60). This association showed a dose-response relationship, with the risk of PAS increasing with increased quantity of cigarettes smoked. Similar results were observed between smoking in pregnancy and independent risks for abruption, previa, SGA, stillbirth, and preterm delivery. CONCLUSION: Maternal smoking in pregnancy is a risk factor for the development of placenta-associated syndrome. Smoking cessation interventions in pregnancy should continue to be encouraged in all maternity care settings.

Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education.

OBJECTIVE: A substantial dropout from the first dose of diphtheria-tetanus-pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing a substantially redesigned immunization card, centre-based education, or both interventions together on DTP3 completion at six rural expanded programme on immunization (EPI) centres in Pakistan. METHODS: Mother-child pairs were enrolled at DTP1 and randomized to four study groups: redesigned card, centre-based education, combined intervention and standard care. Each child was followed up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow-up period in each study group. RESULTS: We enrolled 378 mother-child pairs in redesigned card group, 376 in centre-based education group, 374 in combined intervention group and 378 in standard care group. By the end of follow-up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (66%) (crude risk ratio [RR] = 1.7; 95% CI = 1.5, 2.0), centre-based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8) and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0). CONCLUSIONS: Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow-up immunization visits. The study underscores the potential of study interventions' public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system.

Effect of single session counselling on partner referral for sexually transmitted infections management in Bangladesh.

OBJECTIVES: This study evaluated the role of single session counselling on partner referral among index cases diagnosed as having sexually transmitted infections (STIs) in Bangladesh. METHODS: A quasirandomised trial was conducted in 1339 index cases with symptomatic STIs in 3 public and 3 non-government organisation operated clinics. RESULTS: Out of 1339 index cases, partner referral was achieved by 37% in the counselling group and 27% in the non-counselling group. Index cases in the counselling group and non-counselling group were similar in terms of condom use rates, STI symptoms and duration of disease. A quarter of the index cases reported having more than one sex partner in last 3 months, and 39% reported having commercial sex partners. Only 8% of the index cases reported using condoms during their last sex act. Partner referral rates were higher among index clients with higher age, higher income, those who attended NGO clinics, those who had only one partner and among those who had no commercial partners, but counselling had significantly positive impact in all of these subgroups. In multivariate analysis, the probability of partner referral was 1.3 times higher among index cases in the counselling group (prevalence ratio 1.3; 95% CI 1.1 to 1.6) as compared to index cases in the non-counselling group. CONCLUSIONS: Patient-oriented single session counselling was found to have a modest but significant effect in increasing partner referral for STIs in Bangladesh, greater emphasis should be placed on examining further development and dissemination of partner referral counselling in STI care facilities.

Prevalence of syphilis among antenatal clinic attendees in Karachi: imperative to begin universal screening in Pakistan.

OBJECTIVES: To assess the prevalence and associated risk factors of syphilis among antenatal clinic attendees by a multi-center cross-sectional study in Karachi, Pakistan. METHODS: We administered a structured questionnaire and obtained a blood sample for syphilis serology (rapid plasma reagin test with Treponema pallidum hemagglutination assay confirmation) from all women giving informed consent over six weeks in 2007. Prevalence was calculated at 95% confidence intervals. Multivariate analysis was adapted to assess risk factors. RESULTS: There were seven (0.9%) confirmed cases of syphilis (95% CI: 0.4, 1.8) in a sample size of 800 women recruited from three urban sites (-1% refusal rate). Women who lived in an area where male drug use is prevalent had 1.5% higher prevalence rates than women from the other two sites 0.5%. CONCLUSIONS: We documented higher-than-expected syphilis seroprevalence rates in a low risk population of antenatal clinic attendees in Pakistan. Bridge populations for syphilis may include drug users, who are usually married, and Hijras or their clients. In accordance with our results, the national policy for syphilis control in Pakistan should be modified to include universal syphilis screening in antenatal clinics with subsequent partner notification.

Factors associated with partner referral among patients with sexually transmitted infections in Bangladesh.

Understanding the demographic, behavioural and psychosocial factors associated with partner referral for patients with sexually transmitted infections (STIs) is important for designing appropriate intervention strategies. A survey was conducted among STI clients in three government and three non-governmental organization-operated clinics in Dhaka and Chittagong city in Bangladesh. Demographic and psychosocial information was collected using a questionnaire guided by the Attitude-Social Influence-Self Efficacy model. Partner referral data were collected by verification of referral cards when partners appeared at the clinics within one month of interviewing the STI clients. Of the 1339 clients interviewed, 81% accepted partner referral cards but only 32% actually referred their partners; 37% of these referrals were done by clients randomly assigned to a single counselling session vs. 27% by clients not assigned to a counselling session (p < 0.0001). Among psychosocial factors, partner referral intention was best predicted by attitudes and perceived social norms of the STI clients. Actual partner referral was significantly associated with intention to refer partner and attitudes of the index clients. Married clients were significantly more likely to refer their partners, and clients with low income were less likely to refer partners. Intervention programmes must address psychosocial and socio-economic issues to improve partner referral for STIs in Bangladesh.

Are treatments for cervical precancerous lesions in less-developed countries safe enough to promote scaling-up of cervical screening programs? A systematic review.

BACKGROUND: Since the mid-1990 s, there have been growing efforts to prevent cervical cancer in less-developed countries through the development of innovative screening approaches such as visual inspection of the cervix associated with same day management of cervical lesions with cryotherapy or loop electrosurgical excision procedure (LEEP). In the past, promising cancer screening interventions have been widely promoted despite incomplete evidence, only to become the subject of intense controversies about ensuing net health benefit. Because the efficacy and effectiveness of the new protocols for global cervical cancer screening have not been well characterized yet, and as a contribution to the evaluation of the balance between the benefits and risks of these protocols, we reviewed the literature on the safety of cryotherapy and LEEP for cervical intraepithelial neoplasia (CIN) in low- and middle-income countries. METHODS: We searched 12 databases (Medline, Google Scholar, Scopus, Cochrane Library, Web of Science, OCLC, PAIS International Database, WHO Global Health Library, CINAHL, Science.gov, NYAM Grey Literature Report, and POPLINE) for original research published between January 1995 and April 2009. Both peer-reviewed publications and items of "grey" literature were retrieved; no language restriction was applied. We calculated the median (minimum, maximum) reported rate for each harm considered. Because of limitations and heterogeneity in the data, no formal meta-analysis was performed. RESULTS: The search identified 32 articles that reported safety data from 24 cryotherapy and LEEP studies. The combined sample consisted of 6,902 women treated by cryotherapy and 4,524 women treated by LEEP. Most studies were conducted in reference or research settings in Asia and Africa. Short-term harms of cryotherapy and LEEP appeared to be similar to those described in the literature from high-income countries. Information was sparse on HIV-related harms and long-term reproductive outcomes of treatment. CONCLUSIONS: When performed in resource-limited settings by qualified providers, cryotherapy and LEEP are not associated with excess harm. However, available data are insufficient to propose fully evidence-based protocols for routine screening of HIV-infected women and women of reproductive age.

Joint effect of obesity and teenage pregnancy on the risk of preeclampsia: a population-based study.

PURPOSE: To determine the joint effect of young maternal age and obesity status on the risk of preeclampsia and eclampsia among a large cohort of singleton pregnancies. METHODS: Data were obtained from birth cohort files recorded in the state of Florida during the years 2004-2007. The study sample consisted of mothers aged 13-24 (n = 290,807), divided into four obesity categories on the basis of prepregnancy body mass index (BMI): nonobese (BMI < 30), Class I obese (30.0 < or = BMI > or = 34.9), Class II obese (35.0 < or = BMI > or = 39.9), and extreme obesity (BMI > or = 40). Nonobese mothers (BMI < 30) between the ages of 20 and 24 years were the reference group. Logistic regression models were generated to adjust for the association between preeclampsia, obesity, and maternal age with sociodemographic variables and pregnancy complications as covariates. RESULTS: The overall prevalence of preeclampsia in the study population was 5.0%. The risk of preeclampsia and eclampsia increased significantly with increasing BMI and decreasing age. Extremely obese teenagers were almost four times as likely to develop preeclampsia and eclampsia compared with nonobese women aged 20-24 years (adjusted odds ratio [95% confidence interval] = 3.79 [3.15-4.55]). Whereas obesity elevated the risk for preeclampsia and eclampsia among all women in the study, teenagers were most at risk because of the combined effects of young age and obesity. CONCLUSION: Effective obesity prevention strategies should continue to be advocated for all teenagers, in addition to innovative approaches to teenage pregnancy prevention.

Partner notification for sexually transmitted infections in developing countries: a systematic review.

BACKGROUND: The feasibility and acceptability of partner notification (PN) for sexually transmitted infections (STIs) in developing countries was assessed through a comprehensive literature review, to help identify future intervention needs. METHODS: The Medline, Embase, and Google Scholar databases were searched to identify studies published between January 1995 and December 2007 on STI PN in developing countries. A systematic review of the research extracted information on: (1) willingness of index patients to notify partners; (2) the proportion of partners notified or referred; (3) client-reported barriers in notifying partners; (4) infrastructure barriers in notifying partners; and (5) PN approaches that were evaluated in developing countries. RESULTS: Out of 609 screened articles, 39 met our criteria. PN outcome varied widely and was implemented more often for spousal partners than for casual or commercial partners. Reported barriers included sociocultural factors such as stigma, fear of abuse for having an STI, and infrastructural factors related to the limited number of STD clinics, and trained providers and reliable diagnostic methods. Client-oriented counselling was found to be effective in improving partner referral outcomes. CONCLUSIONS: STD clinics can improve PN with client-oriented counselling, which should help clients to overcome perceived barriers. The authors speculate that well-designed PN interventions to evaluate the impact on STI prevalence and incidence along with cost-effectiveness components will motivate policy makers in developing countries to allocate more resources towards STI management.

Determinants of third dose of diphtheria-tetanus-pertussis (DTP) completion among children who received DTP1 at rural immunization centres in Pakistan: a cohort study.

OBJECTIVE: In Pakistan, a high proportion of children fail to complete third dose of diphtheria-tetanus-pertussis (DTP3) after having received the first dose (DTP1). A cohort study was conducted to identify the factors predicting three doses of diphtheria-tetanus-pertussis (DTP3) completion among children who have received DTP1 at six centres of Expanded Programme on Immunization (EPI) in rural Pakistan. METHOD: We analyzed a cohort of mother-child pairs enrolled at DTP1 between November 2005 and May 2006 in the standard care group of a larger randomized controlled trial. Data were collected from mothers on a structured questionnaire at enrollment, and each child was followed up at clinic visits for 90 days to record dates of DTP2 and DTP3. Multivariable log-binomial regression analysis was performed to identify the independent predictors of DTP3 completion. RESULTS: Only 39% (149/378) of enrolled children completed DTP3 during the follow-up period. After adjusting for the centre of enrollment in multivariable analysis, DTP3 completion was higher among children who were < or =60 days old at enrolment [adjusted risk ratio (Adj. RR) 1.39, 95% confidence interval (CI): 1.06-1.82], who were living in a household with monthly household income >Rs. 3000 (US$ 50) (Adj. RR 1.76, 95% CI: 1.16-2.65), and who were living < or =10 min away from EPI centre (Adj. RR 1.31, 95% CI: 1.04-1.66). CONCLUSIONS: Interventions targeting childhood immunization dropouts should focus on bringing more children to EPI centres on-time for initial immunization. Relocation of existing EPI centres and creation of new EPI centres at appropriate locations may decrease the travel time to the EPI centres and result in fewer immunization dropouts.

Tuberculosis co-morbidity and perceptions about health care among HIV-infected plasma donors in rural China.

Limited community-based data exist about pulmonary tuberculosis (TB) comorbidity among HIV-infected individuals in China and no data exists about the TB burden in key high risk groups. We recruited 195 known HIV-infected plasma donors in one central China county and identified 9 (4.6%) active TB cases based on clinical assessment, including chest radiography. The low percentage of TB may be explained by improved immunity due to antiretroviral therapy.