Chlamydia trachomatis infections in Nicaragua: preliminary results from a competitive voucher scheme to prevent and treat sexually transmitted infections and HIV/AIDS among sex workers.

A donor-supported competitive voucher scheme in Nicaragua provides prevention and treatment services for sexually transmitted infections (STIs) and HIV/AIDS to high-risk populations such as sex workers and their partners and clients. Beyond detecting and treating STIs, HIV and AIDS, these health services can also raise awareness of risks and promote safer behavior, leading to widespread benefits. This review describes the voucher scheme, summarizes published data on Chlamydia trachomatis infection in Nicaragua and provides preliminary prevalence data on C. trachomatis obtained in 2003 through the voucher scheme.

Hygiene behaviour in rural Nicaragua in relation to diarrhoea.

BACKGROUND: Childhood diarrhoea is a leading cause of morbidity and mortality in Nicaragua. Amongst the risk factors for its transmission are 'poor' hygiene practices. We investigated the effect of a large number of hygiene practices on diarrhoeal disease in children aged <2 years and validated the technique of direct observation of hygiene behaviour. METHODS: A prospective follow-up study was carried out in a rural zone of Nicaragua. From the database of a previously conducted case-control study on water and sanitation 172 families were recruited, half of which had experienced a higher than expected rate of diarrhoea in their children and the other half a lower rate. Hygiene behaviour was observed over two mornings and diarrhoea incidence was recorded with a calendar, filled out by the mother, and collected every week for 5 months. RESULTS: Of 46 'good' practices studied, 39 were associated with a lower risk of diarrhoea, five were unrelated and only for two a higher risk was observed. Washing of hands, domestic cleanliness (kitchen, living room, yard) and the use of a diaper/underclothes by the child had the strongest protective effect. Schooling (>3 years of primary school) and better economic position (possession of a radio) had a positive influence on general hygiene behaviour, education having a slightly stronger effect when a radio was present. Individual hygiene behaviour appeared to be highly variable in contrast with the consistent behaviour of the community as a whole. Feasible and appropriate indicators of hygiene behaviour were found to be domestic cleanliness and the use of a diaper or underclothes by the child. CONCLUSION: A consistent relationship between almost all hygiene practices and diarrhoea was detected, more schooling producing better hygiene behaviour. The high variability of hygiene behaviour at the individual level requires repeated observations (at least two) before and after the hygiene education in the event one wants to measure the impact of the campaign on the individual.

PIP: Poor hygiene practices are among the risk factors for the transmission of childhood diarrhea, a leading cause of morbidity and mortality in Nicaragua. Findings are reported from a prospective follow-up study in rural Nicaragua of the effect of a number of hygiene practices upon diarrheal disease in children under age 2 years old. 172 families, of whom half had experienced a higher than expected rate of diarrhea in their children and the other half a lower rate, participated. Hygiene behavior was observed over 2 mornings and diarrhea incidence was recorded with a calendar over the course of 5 months. Of 46 good practices studied, 39 were associated with a lower risk of diarrhea, 5 were unrelated, and a higher risk was observed for 2. The washing of hands, domestic cleanliness, and the use of a diaper/underclothes by the child had the strongest protective effect against diarrhea. Mothers with more than 3 years of primary school education and in a comparatively better economic position, including having a radio, exhibited comparatively better general hygiene behavior. Education had a slightly stronger effect when a radio was present. However, individual hygiene behavior seems to be highly variable compared to the consistent behavior of the overall community. Appropriate indicators of hygiene behavior were domestic cleanliness and the use of a diaper or underclothes by the child.

A controlled HIV/AIDS-related health education programme in Managua, Nicaragua.

OBJECTIVES: To evaluate the impact of a community-wide intervention to increase HIV/AIDS-related knowledge, change attitudes and increase safer-sex practices in Managua, Nicaragua. DESIGN AND SETTINGS: Household-based health education intervention trial comprising a knowledge, attitudes and practices (KAP) survey at baseline, a health education intervention and a follow-up KAP survey. Four neighbourhoods were included, two received the intervention, and the other two served as controls. Randomly selected residents aged 15-45 years were interviewed at baseline (n = 2160) and follow-up (n = 2271) using an identical questionnaire. The intervention consisted of a health education campaign that emphasized HIV transmission and condom use. OUTCOME AND ANALYSIS: Knowledge levels regarding transmission and prevention of HIV infection, self-reported use of condoms, levels of worries about HIV/AIDS and perceptions of personal risk of HIV infection. Comparisons between baseline and follow-up employed chi 2 tests with continuity correction. The influence of the intervention was examined in multivariate logistic models including an appropriate interaction term. RESULTS: Intervention and control samples were comparable with regard to sex, age, and age at first intercourse. Significantly less intervention residents had formal education (P < 0.001). At baseline, outcome variables were generally similar in control and intervention samples. Condom use increased from 9 to 16% (P = 0.003) among intervention women, but only from 9 to 11% (P = 0.5) in control women (test for interaction, P = 0.08). Among men, increases were from 31 to 41% (P < 0.001) and from 30 to 37% (P = 0.06), respectively (test for interaction, P = 0.3). Levels of worries about HIV/AIDS decreased in all groups, but perception of individual risk increased only among intervention women (test for interaction, P = 0.02). CONCLUSIONS: This household-targeted health education intervention appears to have had some effect; however, sustained efforts are needed further to improve levels of knowledge and to increase condom use in Managua.

[Childhood diarrhea in rural Nicaragua: beliefs and traditional health practices]. / Diarrea infantil en la Nicaragua rural: creencias y prácticas de salud tradicionales.

In Nicaragua, the principal cause of infant mortality is diarrhea, which is responsible for 40% of these deaths annually. This statistic reflects the low usage of health services and oral rehydration therapy (ORT). In an effort to improve the situation, several studies were carried out in Villa Carlos Fonseca municipio. This report describes two of those studies, one ethnographic and the other epidemiologic (conducted in 1989 and 1990, respectively), to find out beliefs and traditional health practices and their influence on the way in which mothers responded to their children's diarrheal illness. The ethnographic study involved interviewing 70 mothers with an average age of 28 years who had children under 2 years of age. The children represented two groups: one at high risk for diarrhea and the other at low risk. The objectives were to learn the traditional names for diarrhea, the perception of risk, and the treatments that were used. The epidemiologic study included 391 mothers over 14 years of age with one or more children under age 5 years, of whom 215 had had diarrhea in the two weeks preceding the survey. The objectives were to describe local beliefs and health practices and to determine the incidence of diarrheas according to the diagnosis made by the mothers. At least 12 types of diarrhea were identified, for which terms such as "empacho" and "sol de vista" were used. In most cases, the mothers had more confidence in folkloric treatments that they themselves or the traditional healers (curanderos) applied than in the services offered at health centers. This attitude limited their use of health services and ORT, although it was observed that in certain cases traditional treatments were used in combination with those of western medicine. There was a direct but nonsignificant correlation between the level of schooling of the mothers and the frequency with which they visited the health center. The authors suggest the effects of massages, herbal baths, and other traditional treatments should be studied to evaluate their effectiveness and adapt them, to the extent possible, to "modern" medicine. Health services providers should become familiar with traditional nomenclature and beliefs in order to be able to communicate better with mothers and steer them away from harmful practices toward improved results in infant diarrheal disease prevention programs.

A randomized trial of the impact of rope-pumps on water quality.

Rope-pumps are now widely promoted as a low cost, easily maintained means to improve water availability in developing countries. However, in some instances their acceptance has been limited by concerns over the microbiological quality of the water. This study looked at the well water quality under a variety of conditions, comparing unimproved bucket and rope wells with wells with a windlass and rope-pump wells with and without a concrete cover. Other factors influencing the water quality were also examined. Results indicate a 62% reduction of the geometric mean of the faecal coliform contamination of the well water as a result of the installation of a rope-pump with or without a concrete cover. Other factors found to influence the level of contamination of water in hand-dug wells were rainfall, number of households using the well, amount of water extracted daily and the distance of the well from the nearest kitchen. The last three factors probably reflect domestic activities with poor hygiene around the well. The installation of a simple rope-pump on family wells improves the water quality and availability at a favourable cost/benefit ratio.

The cultural construction of childhood diarrhoea in rural Nicaragua: relevance for epidemiology and health promotion.

As a component of a series of studies of childhood diarrhoea in rural Nicaragua, lay knowledge regarding the condition and its appropriate management has been investigated through semistructured interviews with 70 mothers. These data have been combined with information from focus group discussions and observations from investigators who have been resident in the study area for many years. For any episode of childhood diarrhoea, the lay nosology influences the treatment path followed. Thus for some types of diarrhoea, treatment at a health centre or health post and the use of rehydration fluids is seen to be appropriate, while for other types the use of traditional healers or home-based treatment, often explicitly without the use of rehydration fluids, is applicable. The implications of lay nosological systems for the interpretation of epidemiological studies and for the implementation of health promotion programmes are discussed.

How many people actually use condoms? An investigation of motel clients in Managua.

Motels in Nicaragua are popular venues for both commercial and non-commercial sexual encounters and thus provide a potential location for the spread of sexually transmitted agents, including the human immunodeficiency virus. Condoms are known to be effective barriers against these infections, but are infrequently used by Nicaraguans. We interviewed all motel owners in one district of Managua and in five randomly selected motels ascertained, by retrieval and inspection, actual rates of condom use by clients. Six out of 26 establishments initially supplied condoms: when provided on entry to the motel condoms were used in 37% of observed encounters. Condom use can be assessed objectively in certain circumstances and this method can provide a reliable outcome measure for condom promotion programmes.

AIDS in Nicaragua: epidemiological, political, and sociocultural perspectives.

The AIDS epidemic in Nicaragua is several years behind that in the United States and neighboring countries of Central and South America. A combination of events, including the isolation caused by the war of the U.S.-backed Contra army against the Sandinista government, the complete economic embargo imposed on Nicaragua by the United States in 1985, self-sufficiency for blood products, and a low rate of recreational injectable-drug use, have contributed to this situation. Since the Sandinistas were defeated in the general election of 1990, people have returned to Nicaragua from areas where HIV is more prevalent, such as Honduras and the United States. It is probable that many HIV-infected persons have now entered the country. Because of the high rates of sexually transmitted diseases and cultural factors such as "machismo," HIV is likely to spread rapidly by heterosexual transmission, unless effective, culturally appropriate education and sexually transmitted disease prevention programs are implemented now.

PIP: AIDS arrived in Nicaragua much later than it did in other Latin American countries, even though both sexually transmitted diseases (STDs) and multiple partners are common. During the 1980s, HIV spread rapidly worldwide, except in a few countries such as Nicaragua. The 10 year US-sponsored low-intensity war and economic embargo isolated Nicaragua, thereby delaying the arrival of HIV. Election of the UNO party in 1990 restored diplomatic and trading relations with the US, resulting in a large influx of repatriates and refugees from countries with a high HIV/AIDS prevalence. The largest number of AIDS cases were identified in 1990-1992 (25 cases which comprised 81% of all cases through 1992). A 30-year-old heterosexual man, diagnosed with AIDS in July 1987, was the first AIDS case diagnosed in Nicaragua. He died within 30 days. As of September 1992, Nicaragua has had the only 31 reported AIDS cases. Since people in Nicaragua often have diarrhea, respiratory infections, and skin conditions, it is possible that AIDS cases have been underdiagnosed and underreported. Yet, serologic surveys have found only 52 HIV-infected persons, confirming that HIV/AIDS has not yet reached epidemic proportions in Nicaragua. Male-to-female ratios show that HIV is spread largely through heterosexual transmission. Only two prostitutes are HIV-positive, but this is likely to change, since prostitution had increased greatly at the same time the economic crisis has intensified. Many Nicaraguans are misinformed about AIDS and other STDs. Few use condoms. A correlation exists between the cumulative number of AIDS cases in Central America and US foreign aid as well as revenues from tourism. IV drug use is increasing. It is not uncommon for unsterilized equipment to be used to inject medically sanctioned drugs. Contaminated blood may soon be a problem, since remunerated blood donations continue to occur in regions with no blood banks. Machismo encourages young men to have intercourse with prostitutes or sexually experienced women and values multiple sexual conquests; thus, machismo will also likely contribute to HIV transmission.

HIV/AIDS-related knowledge, attitudes, and practices among Managuan secondary school students.

In 1990, the AIDS-related knowledge, attitudes, and practices of fifth year (final year) students at four Managuan high schools were assessed. This was done by means of a self-administered questionnaire completed by 451 students (155 males, 296 females) whose mean age was 18 years. Eighty-six percent of the subjects knew AIDS was transmitted sexually, but the percentages aware of other transmission pathways and effective preventive measures were much lower. Use of condoms was cited as a preventive measure by 41% of the students, but by significantly more male respondents than female respondents (55% of the males versus 33% of the females, p = 0.0001). Sixty-four percent of all the survey subjects (90% of the males, 50% of the females) reported experiencing sexual intercourse. Sixty percent of the respondents were "very much" worried about AIDS, but only 23% considered themselves at risk of contracting the disease. Among the sexually active students, 29% of the respondents (38% of the males but only 7% of the females, p = 0.001) indicated a change in sexual behavior because of AIDS. Reported behavior change was strongly associated with concern about AIDS, but the association between reported behavior change and perception of personal risk was weak. Overall, the survey indicated that knowledge about transmission and prevention of AIDS among Managuan high school students was insufficient, especially among females, indicating a need for health education including interventions specifically targeted at female youth.

[Concepts about AIDS among the adult population of Managua]. / Conocimientos acerca del SIDA de la población adulta de Managua.

Nicaragua has the lowest prevalence of AIDS in Central America. In other countries where AIDS is more prevalent, the first epidemic of asymptomatic infections with human immunodeficiency virus (HIV) and the second of clinical cases of AIDS have been followed by a third epidemic of fear and discrimination. In December 1989 a study was conducted to investigate knowledge and attitudes about AIDS in a sample of 287 adults in Managua. Most of the interviewees had heard of the disease from newspapers and television, and more than 90% understood how HIV was principally transmitted. However, between one-third and one-half the interviewees believed that HIV could be transmitted by causal contact such as kissing (53%) or by mosquito bites (49%). In addition, the majority considered that isolation of HIV-infected persons and control of immigration into the country would be effective measures for preventing the spread of the disease. These results are similar to findings from studies carried out in other countries of Latin America where the HIV and AIDS epidemics started much earlier. This would suggest that the so-called "third epidemic" of discrimination and fear is affecting Nicaragua in advance of the other two.

Water supply, sanitation and diarrhoeal disease in Nicaragua: results from a case-control study.

A case-control study of risk factors for child diarrhoeal disease was undertaken in a rural area of Nicaragua. Some 1229 children under the age of five were matched with an equal number of children of the same age presenting with other illnesses unrelated to water and sanitation. The main types of water supply were sampled at monthly intervals and tested for the presence of faecal coliforms in order to characterize their microbiological quality. In spite of marked differences in water quality between the different types of water supply, no relationship was found with diarrhoea morbidity. In contrast, there was a statistically significant association between water availability and diarrhoea morbidity. Children from homes with water supplies over 500 meters from the house had incidence rates of diarrhoea 34% higher than those of children from houses with their own water supply. Owning a latrine was not found to be significantly related to diarrhoea morbidity. A mother's level of schooling was inversely correlated with the frequency of diarrhoea in her children. A significant association was also found between the number of children under the age of five living in the house and the incidence of diarrhoea. These effects remained significant after controlling for confounding variables by conditional logistic regression.

Why do child mortality rates fall? An analysis of the Nicaraguan experience.

A comprehensive review of available sources of mortality data was undertaken to document the changes that have occurred in infant mortality in Nicaragua over the last three decades. It was found that a rapid fall in infant mortality commenced in the early 1970s and has continued steadily since. Trends in several different factors which might have led to this breakthrough were examined including: income, nutrition, breastfeeding practices, maternal education, immunizations, access to health services, provision of water supplies and sanitation, and anti-malarial programs. Of these, improved access to health services appears to have been the most important factor. At a time when the number of hospital beds per capita was dropping, increasing numbers of health care professionals, particularly nurses, were becoming available to staff primary health care facilities built in the 1960s. These were provided at least partly in response to the growing political turmoil enveloping the nation at that time. Certain Nicaraguan cultural attributes may have added to the impact of the reforms. Efforts in the field of public health made since the 1979 insurrection appear to have maintained the decline in child mortality.

Determinants of domestic water use in rural Nicaragua.

In order to investigate the factors affecting domestic water use in rural areas of developing countries, an analysis was performed of water consumption estimates from 1029 different households in Nicaragua collected between May 1986 and December 1988. Eight of the 22 variables hypothesized to be related to per capita domestic water consumption, were included in the final multiple regression model. These were; household size, site of clothes washing, the type of water source, mother's and father's levels of schooling, distance to the water source, wealth, and ownership of cattle. According to this model, a decrease in the distance to the water source from 1000 to 10 m is associated with an increase in per capita water consumption of 20%. Similarly, families where the mother has 6 years of schooling use 17% more water than families where the mother has had no formal education. The same difference in the father's schooling is associated with 12% greater per capita water consumption. A better understanding of the factors affecting domestic water use is needed to improve the design of interventions aimed at reducing the transmission of water-washed disease in developing countries.

Determinants of drinking water quality in rural Nicaragua.

One hundred and fifty-three water samples from rural Nicaragua were examined for the presence of faecal coliforms during both wet and dry periods. A linear model was fitted by analysis of covariance with the logarithm of the faecal coliform count as the dependent variable. As expected, traditional water sources were grossly contaminated at all times whereas piped water sources were much cleaner. Hand-dug protected wells had significantly higher levels of faecal contamination than unprotected riverside wells and springs during the dry season. The possible reasons for this unexpected finding are discussed. A close association between rainfall and faecal contamination was demonstrated but the effect of rainfall depended on the type of water source. An association between water quality and the size of the community served by the source was also detected. The finding that stored water was usually more contaminated than fresh water samples is consistent with the results from other studies. Since it is unusual for water quality to be inversely correlated with accessibility, this study site would be suitable for investigating the relative importance of water-borne versus water-washed transmission mechanisms in childhood diarrhoea.