Bullying behaviours among students in Pavia, Italy: prevalence and association with stress and cannabis use.

BACKGROUND: This study examined the prevalence of students' reported experiences of bullying and victimization in primary and secondary schools and their association with levels of perceived stress and cannabis use. METHODS: We consecutively enrolled 407 students attending three secondary schools in Pavia (Italy). Bullying and victimization were measured using the retrospective bullying questionnaire (RQB). The 10-item perceived stress scale (PSS-10) was used to assess the degree to which situations in life were perceived as stressful. Data on demographic characteristics and cannabis use in the previous 6 months were also collected. RESULTS: There were 328 victims (80.6%) and 221 bullies (52.1%). The results of the stepwise regression analysis with bullying as the dependent variable were significant with either male sex (R2 = 0.030, p = 0.024) or PSS-10 scores (R2 0.056, p = 0.036) in the model. With victimization as the dependent variable, only the PSS-10 scores were retained in the model as an independent predictor variable (R2 = 0.048, p<0.001). CONCLUSIONS: The results from this study indicate that the level of perceived stress has an independent association with both bullying and victimization. Further studies are needed to clarify the psychobiological links between stress, cannabis use and bullying behaviours.

Sexual risk taking, sexually transmitted infections and HIV prevalence among four "high-risk" occupational groups of Indonesian men.

OBJECTIVES: This article reports new surveillance data on the prevalence of sexual risk taking, HIV and other sexually transmitted infections (STI) among four occupational groups of Indonesian men thought to be at elevated risk of infection. METHODS: Behavioural survey data were collected from 3008 men in 11 cities, among whom 2158 men were tested for HIV and syphilis and 1950 for gonorrhoea and chlamydia. Risk factors for STI were assessed using multivariable logistic regression. RESULTS: Thirty-six per cent of men had sex with a female sex worker (FSW) in the previous year and 20% with non-marital female partners. Consistent condom use was low with both sex workers (17%) and other non-marital partners (13%). HIV prevalence was 2% in Papua and less than 1% elsewhere, but was for the first time detectable in a non-core transmitter male population outside of Papua. STI rates were high for a non-core transmitter group, especially syphilis. Truck drivers were the most at risk. Multivariable analyses revealed exposure to FSW and inconsistent condom use, along with geographical location (Papua vs non-Papua) and unobserved factors associated with certain occupational groups, to be key risk factors for STI infection. CONCLUSIONS: The results confirm that men in the four occupational groups are reasonable proxies for "high-risk men" for surveillance purposes in Indonesia. Although HIV prevalence was low, the extent of sexual risk taking and the moderately high levels of STI among these men, along with rising HIV rates among FSW, indicate the potential for HIV/AIDS transmission in Indonesia to accelerate.

Surveillance and modelling of HIV, STI, and risk behaviours in concentrated HIV epidemics.

BACKGROUND: HIV epidemics in most countries are highly concentrated among population subgroups such as female sex workers, injecting drug users, men who have sex with men, mobile populations, and their sexual partners. The perception that they are important only when they cause epidemic expansion to general populations has obscured a critical lack of coverage of preventive interventions in these groups, as well as appropriate methods for monitoring epidemic and behavioural risk trends. The difficulties in accessing such groups have likewise often cast doubt on the representativeness of observed disease and behavioural risk estimates and their validity and reliability, particularly those related to sampling and the measurement of risk behaviours. OBJECTIVES: To review methodological obstacles in conducting surveillance with population subgroups in concentrated HIV epidemics, elaborate on recent advancements that partially overcome these obstacles, and illustrate the importance of modelling integrated HIV, STI, and behavioural surveillance data. METHODS: Review of published HIV, STI, and behavioural surveillance data, research on epidemic dynamics, and case studies from selected countries. CONCLUSIONS: The population subgroups that merit regular and systematic surveillance in concentrated epidemics are best determined through extensive assessment and careful definition. Adherence to recently refined chain referral and time location sampling methods can help to ensure more representative samples. Finally, because of the inherent limitations of cross sectional surveys in understanding associations between complex sexual behaviours and HIV and STI transmission, mathematical models using multiple year data offer opportunities for integrated analysis of behavioural change and HIV/STI trends.

Impact of an integrated adolescent reproductive health program in Brazil.

An impact evaluation of an integrated school- and health-clinic-based adolescent reproductive health initiative was undertaken by the State Secretariats of Health and Education in Bahia, Brazil during 1997-99. The project was initiated in response to continued high pregnancy rates among adolescents and growing numbers of new HIV infections among young adults. It sought to promote responsible sexual and health-seeking behaviors among public secondary-school students, including the use of public health clinics. The study design included a matched control group used to measure project impact. The findings indicate that the project was successful in increasing the flow of sexual and reproductive health information to secondary-school students and that it had an impact on adolescents' intentions to use public health clinics in the future. No effects on sexual or contraceptive-use behaviors or on use of public clinics were observed, however. Client exit-interview data from a subset of project clinics indicate that adolescents who use clinic-based services are overwhelmingly female and considerably older on average and much more likely ever to have been pregnant than are adolescents in the target population for the project.

Correlates of sexual activity and condom use among secondary-school students in urban Peru.

Recent data indicate that adolescent fertility rates in Peru remain high and that Peruvian adolescents and young adults account for a disproportionate share of new HIV infections. The present study was undertaken to identify key risk and protective factors for early sexual activity and unprotected sex among secondary-school students in nine large cities in Peru. Survey data from 6,962 students aged 13-18 are consistent with existing research in indicating that behaviors of Peruvian youth are influenced in important ways by many factors. In the present study, these included region of residence, family economic position, family structure, working for pay, peer behaviors, and self-esteem. Knowledge of pregnancy and of the risks of acquiring sexually transmitted diseases and of the means of avoiding both did not, however, differentiate risk-takers from non-risk-takers. The study findings suggest a need for adolescent health programs to broaden their focus beyond the immediate proximate determinants of behavior, such as sexual and reproductive health knowledge and access to contraceptives, and also to target some of the key contextual factors influencing adolescent behavior.

Cypress in Italy: landscape and pollen monitoring.

In Italy the Cupressaceae pollen has been monitored by the Italian Aeroallergen Network (IAN) in collaboration with the Italian Research Council (CNR) since 1988. The measurements carried out over the last decade show a positive trend of the seasonal emission of the cypress pollen, whose flowering peak occurs in Italy from mid-February to mid-March. During the pollination period the cypress pollen represents 10% to 40% of the total pollen, showing a high variability of its annual production.

The effects of maternal-child health service utilization on subsequent contraceptive use in Morocco.

There are a number of reasons for anticipating that contact by women in developing country settings with modern maternal-child health (MCH) services will lead to increased use of family planning services. Indeed, the expectation of such a relationship underlies the integrated service delivery strategy that has been adopted on a more or less global basis. However, the available empirical evidence in support of this proposition is inconclusive. This study re-examines this issue in Morocco. Household survey data and data on the supply environment for health and family planning services gathered in 1992 are analysed in the study. A full-information maximum likelihood estimator is used to control for the possible endogeneity of health care and contraceptive choices. The findings indicate a substantial and apparently causal relationship between the intensity of MCH service use and subsequent contraceptive use. Policy simulations indicate that sizeable increases in contraceptive prevalence might be realized by increasing the coverage and intensity of use of MCH services.

PIP: This study examined the association between frequency of use of maternal and child health (MCH) services and subsequent contraceptive use (CU) in Morocco. Data were obtained from a 1992 Moroccan Health Survey among 3267 married women with at least 1 live birth and the 1992 Service Availability Module. Analysis was based on full information maximum likelihood estimates and nonparametric, discrete factor strategies. The analysis ignored the possibility that CU can lead to increase MCH use, because few women use contraception before a first birth. Findings indicate that intensity of MCH service use was a statistically significant determinant of subsequent CU. The magnitude of the effect was large. For example, an increase in MCH service use from 2 to 4 would result in an increase of over 71% in contraceptive prevalence, from 32% to 55%. Modern CU would increase from 55% to 65%. Traditional CU would increase from 7% to 19%. Increases were more likely despite controls for individual and household characteristics. Findings do not explain the role of integrated services. Since there are numerous sources of supply, it is likely that counseling and promotion by health facility staff were significant factors. Evidence supports the need to include community-level factors in the analysis, but key community factors remain unmeasured.

Prevention of vaginal stenosis in patients following vaginal brachytherapy.

The assessment of patients following intracavitary irradiation administered as part of the treatment of gynaecological malignancy reveals vaginal stenosis in the majority. Vaginal dilators are available for daily insertion in an attempt to prevent the formation of adhesions. However, the design of the dilator neglects the fact that the vagina is the most distensible in the upper third and hence many patients develop stenosis of the upper vagina. Many clinicians have abandoned the use of dilators and instead advise patients to have sexual intercourse to prevent the problem. In 1994, we designed a new vaginal stent, which was given to all patients who had received intracavitary irradiation with full instructions about its use. This stent was designed to suit better the true anatomy of the vagina and hence, with correct use, should prevent vaginal stenosis. A retrospective study was undertaken to look at the incidence of vaginal stenosis and this was compared with the incidence in patients using the new stent. The study revealed that 57% of the patients who were advised to have sexual intercourse had stenosis, whereas 11% of the patients using the stent had evidence of stenosis, which, however, was related to their incorrect use of the stent. In those who used the stent correctly there was no evidence of vaginal stenosis. Details of the design of the stent and the problems relating to those who used the stent incorrectly are presented. The findings of this study strongly support the continued use of this vaginal stent in patients who have undergone intracavitary irradiation as a means of preventing this common complication.

Vasectomy in the United States, 1991 and 1995.

OBJECTIVES: This study sought to assess whether the controversy surrounding publications linking vasectomy and prostate cancer has had an effect on vasectomy acceptance and practice in the United States. METHODS: National probability surveys of urology, general surgery, and family practices were undertaken in 1992 and 1996. RESULTS: Estimates of the total number of vasectomies performed, population rate, and proportion of practices performing vasectomy were not significantly different in 1991 and 1995. CONCLUSIONS: This study provides no solid evidence that the recent controversy over prostate cancer has influenced vasectomy acceptance or practice in the United States. However, the use of vasectomy appears to have leveled off in the 1990s.

The impact of the family planning supply environment on contraceptive intentions and use in Morocco.

Although the extent to which organized family planning programs influence reproductive preferences remains a subject of debate, most observers would grant that such programs play a key role in helping individuals to realize their contraceptive and reproductive intentions. However, few prior studies have quantified the magnitude of this facilitating or enabling effect of family planning services, given existing demand for contraception. This study takes advantage of panel survey data and linked information on the supply environment for family planning services in Morocco in order to bridge this research gap. In the analysis, contraceptive use during the 1992-95 period is related to contraceptive intentions in 1992; individual-, household-, and community-level determinants of contraceptive behavior; and family planning supply factors. Estimation procedures are used that control for unobserved joint determinants of contraceptive intentions and use. Evidence of a significant enabling or facilitating role of family planning services is found, and the results also suggest that family planning program factors influence contraceptive intentions in important ways.

Clinical aspects of vasectomies performed in the United States in 1995.

OBJECTIVES: Currently, no surveillance system collects data on the numbers and characteristics of vasectomies performed annually in the United States. This study provides nationwide data on the numbers of vasectomies and the use of no-scalpel vasectomy, various occlusion methods, fascial interposition, and protocols for analyzing semen after vasectomy. METHODS: A retrospective mail survey (with telephone follow-up) was conducted of 1800 urology, family practice, and general surgery practices drawn from the American Medical Association's Physician Master File and stratified by specialty and census region. Mail survey and telephone follow-up yielded an 88% response rate. RESULTS: In 1995, approximately 494,000 vasectomies are estimated to have been performed by 15,800 physicians in the United States. Urologists performed 76% of all vasectomies, and nearly all (93%) urology practices performed vasectomies in 1995. Nearly one third (29%) of vasectomies in 1995 were no-scalpel vasectomies, and 37% of physicians performing no-scalpel vasectomies taught themselves the procedure. The most common occlusion method in 1995 (used for 38% of all vasectomies) was concurrent use of ligation and cautery. In 1995, slightly less than half (48%) of all physicians surveyed interposed the fascial sheath over one end of the vas when performing a vasectomy. Protocols for ensuring azoospermia varied: 56% of physicians required one postvasectomy semen specimen; 39% required two, and 5%, three or more. CONCLUSIONS: No-scalpel vasectomy, used by nearly one third of U.S. physicians, has become an accepted part of urologic care. Physicians' variations in occlusion methods, use of fascial interposition, and postvasectomy protocols underscore the need for large scale, controlled, and statistically valid studies to determine the efficacy of occlusion methods and fascial interposition, as well as whether azoospermia is the only determination of a successful vasectomy.

HIV risk behavioral surveillance: a methodology for monitoring behavioral trends.

OBJECTIVE: This article summarizes issues and recommendations for conducting HIV risk behavioral surveillance surveys (BSS) based on experiences from ten BSS projects in eight countries in Asia and Africa. BACKGROUND: BSS consists of systematic and repeated cross-sectional surveys of HIV and sexually transmitted disease-related behaviors, with other knowledge and attitudinal variables added where appropriate. Its major purpose and utility is in detecting trends among selected vulnerable and high-risk population groups whose behavioral change can have the most impact on the epidemic. BSS is also useful for tracking trends in behaviors over time in regions exposed to HIV prevention activities, as a contributing component to the comprehensive monitoring and evaluation of interventions. RECOMMENDATIONS: (i) implement BSS as an essential adjunct to HIV/STD epidemiological surveillance; (ii) use BSS for evaluation purposes in combination with process data and triangulate results with qualitative research; (iii) choose sentinel groups based on epidemiological considerations, evaluation and monitoring needs, representative sampling frames, and political and cultural considerations; (iv) maintain 1-year intervals between survey waves for most groups in order to provide yearly updates on behavioral trends for programmatic adjustments; (v) use internationally standardized indicators and question wording; (vi) maintain strict quality control standards to enhance data validity and reliability; and (vii) develop a clear dissemination strategy during BSS design to increase the likelihood of utilization of BSS results. CONCLUSION: BSS represents a cost-effective way to determine whether programmatic behavioral targets and goals are being met, to identify persisting risk behaviors over time, and to indicate whether new intervention approaches are necessary.

PIP: Public health personnel have long monitored the distributions and trends of communicable and noninfectious diseases. Only recently, however, have efforts been made to monitor risk factors or behaviors which are themselves determinants of disease. Behavioral surveillance systems have been brought on line over the past 25 years to monitor risk factors such as cigarette smoking, drug and alcohol consumption, dietary factors, and physical exercise. The HIV risk behavioral surveillance survey (BSS) methodology is designed to systematically monitor trends in HIV risk behaviors over time in key, high-risk population sub-groups whose behavioral change can have the most impact upon the epidemic. BSS is conducted through repeated cross-sectional surveys conducted at regular intervals on a national or regional scale. BSS is also useful in tracking behavior trends over time in regions exposed to HIV prevention activities, as a contributing component to the comprehensive monitoring and evaluation of interventions. Recommendations for conducting BSS are drawn from the collective experiences of 10 BSS projects conducted in Thailand, the Philippines, Senegal, India, Indonesia, Cambodia, Hong Kong, and China between 1993 and 1997.

The reliability of reporting of contraceptive behavior in DHS calendar data: evidence from Morocco.

This report addresses the consistency of reporting in the contraceptive calendar in the 1992 and 1995 Morocco Demographic and Health Surveys. Because a panel design was used in these surveys, the same women were interviewed in both years, providing a unique opportunity to examine the reliability of responses. Measures of reliability for various aspects of contraceptive-use dynamics are computed, and the impact of reporting errors on contraceptive failure, discontinuation, and switching rates is estimated. Results suggest that reporting of contraceptive behavior in Moroccan DHS calendar data appears to be relatively reliable at the aggregate level. Individual respondents, particularly those whose contraceptive patterns have been complex, have a lower level of reliability. The observed inconsistencies do not appear to affect aggregate-level estimates of contraceptive prevalence; however, measures of contraceptive-use dynamics are less stable.

The impact of primary health care services on under-five mortality in rural Niger.

BACKGROUND: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period. METHODS: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects. RESULTS: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources. CONCLUSIONS: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

PIP: The phased implementation of Niger's Rural Health Improvement Program, in conjunction with a 1985 Ministry of Health survey, facilitated quantification of the contribution of primary health care interventions to the reduction of infant and child mortality. During 1978-84, over 8000 health workers were trained and deployed to unserved villages; in addition, 45% of rural villages were provided with primary care services through dispensaries or village health teams. The 35 rural clusters covered in the survey were grouped into three categories: 1) villages located 5 km or less from a dispensary; 2) those located over 5 km from a dispensary, but with a village health team; and 3) villages located more than 5 km from a dispensary and with no health team. Mothers residing near a dispensary were two to five times more likely than their counterparts in the other two groups to have received prenatal care for the most recent birth, had the delivery attended by trained health personnel, received nutrition and health education, and know how to prepare oral rehydration solution. Children in the dispensary-proximate villages were three times more likely to have been at least partially immunized and to have a health card and twice as likely to have had their most recent diarrhea episode treated by a health worker. The unadjusted proportions of infants and children who died in the five years preceding the survey were 0.191 in villages served by a dispensary, 0.203 in villages served by a health team, and 0.267 in villages with neither resource. Multivariate analyses indicated that significantly lower mortality was associated with the presence of a dispensary, maternal literacy, and the existence in the community of farm machinery or access to seeds to plant the next crop. Overall, these findings confirm the significance of primary health care services, especially treatment of infantile diarrhea and tetanus, to reducing under-five mortality in sub-Saharan Africa.

A not quite as quick but much cleaner alternative to the Expanded Programme on Immunization (EPI) Cluster Survey design.

BACKGROUND: Although the Expanded Programme on Immunization (EPI) cluster survey methodology has been successfully used for assessing levels of immunization programme coverage in developing country settings, certain features of the methodology, as it is usually carried out, make it less-than-optimal choice for large, national surveys and/or surveys with multiple measurement objectives. What is needed is a 'middle ground' between rigorous cluster sampling methods, which are seen as unfeasible for routine use in many developing country settings, and the EPI cluster survey approach. METHODS: This article suggests some fairly straightforward modifications to the basic EPI cluster survey design that put it on a solid probability footing and render it easily adaptable to differing and/or multiple measurement objectives, without incurring prohibitive costs or adding appreciably to the complexity of survey operations. The proposed modifications concern primarily the manner in which households are chosen at the second stage of sample selection. CONCLUSIONS: Because the modified sampling strategy maintains the scientific rigor of conventional cluster sampling methods while retaining many of the desirable features of the EPI survey methodology, the methodology is likely to be a preferred 'middle ground' survey design, relevant for many applications, particularly surveys designed to monitor multiple health indicators over time. The fieldwork burden in the modified design is only marginally higher than in EPI cluster surveys, and considerably lower than in conventional cluster surveys.

Detecting induced abortions from reports of pregnancy terminations in DHS calendar data.

This study considers whether pregnancy terminations reported in Demographic and Health Survey (DHS) calendar data can be classified accurately as having been spontaneous or induced based upon other information collected in the survey interview. A classification scheme is proposed that is an adaptation of the method developed by the World Health Organization for categorizing cases in which women admitted to hospitals experienced complications of pregnancy termination. The scheme is evaluated using data from the 1993 Turkey DHS. Evaluation results indicate that the method identifies true cases of induced abortion accurately, but tends to classify a relatively large number of reported spontaneous terminations as induced abortions. However, when it is corrected for likely respondent misreporting of induced abortions as spontaneous terminations, both the sensitivity and specificity of the method appear to be acceptable.

PIP: The World Health Organization (WHO) classification scheme for pregnancy terminations was modified to evaluate the accuracy of pregnancy terminations as spontaneous or induced abortion in Demographic and Health Survey (DHS) calendar data. The decision algorithm considered length of gestation at time of termination, whether contraception was used during the period before termination and, if so, reason for discontinuation, whether the pregnancy was wanted or unwanted, and age, parity, and marital status at the time of the pregnancy termination. 1993 DHS calendar data on 1539 pregnancy terminations from Turkey were applied to the classification method. The algorithm classified 1413 (92%) of the terminations. It classified 71.8% (1015) as probably induced compared to 63% as reported by survey respondents. The algorithm classified 28.2% (398) as probably spontaneous compared to 37% as reported by survey respondents. The ratio of test positive to true positive (i.e., sensitivity of the method) was 92.5%, showing that the algorithm does a good job at identifying true cases of induced abortions. On the other hand, the ratio of test negatives to true negatives (i.e., specificity of the method) was only 65%, suggesting that the algorithm yields a relatively large number of false positives. When the investigators considered the effects of errors caused by misreporting of classification on the efficacy of the proposed scheme, both sensitivity and specificity increased (assuming 10% error, 92.7% and 67.3%; 25% error, 92.9% and 71.4%; and 50% error, 93.3% and 79.1%, respectively).

Prevalence and differentials of low birth weight in Niamey, Niger.

This study provides population representative data on live births occurring in Niamey, Niger during the period 1980 to 1985. A total of 5097 live births were systematically sampled from maternity registers over the study period. Due to legislation and incentives to register all live births, between 90 and 95 per cent of all live births are represented in this study. The data here suggest that low birth weight (LBW) prevalence may be lower in this urban area than it is in the region as a whole; and that the demographic risk factors are similar to those found in other developing countries. Finally, in many developing countries, maternity coverage of attended births may be quite high, suggesting that record or prospective studies examining trends in LBW and risk factors for perinatal outcomes might be convenient and implemented at very low cost.

Intra-household correlations in maternal-child nutritional status in rural Guinea: implications for programme-screening strategies.

It is commonly assumed in public health practice that households in developing country settings are relatively homogeneous with respect to nutritional status. To the extent that this assumption is valid, nutritional assessments of mothers or individual children would provide an effective screening mechanism for household-level maternal-child nutritional risk. However, there has been no confirmation of the strength of intra-household correlations in nutritional status among women and children. Using data from a cross-sectional survey undertaken in 1990 in rural central Guinea, the present study investigates the nature of within-household relationships in maternal and child nutritional status and considers the implications for programme screening strategies. Mothers and their surviving children under 5 years of age are the focus of the analysis. Correlations between maternal and child nutritional levels are assessed and the performance of maternal-child nutritional indicators as screening tools for household nutritional risk are formally evaluated by analysing the sensitivity, specificity, and positive-negative predictive values of various indicators.

PIP: The authors explore to what extent households may be identified as being at risk of maternal-childhood malnutrition on the basis of a nutritional assessment of one household member. Cross-sectional survey data collected in 1990 from the central Guinean provinces of Labe, Tougue, Lelouma, Dolaba, and Pita, on 780 mothers and their 1118 surviving children under 5 years of age are the focus of the analysis. The survey had been conducted to obtain baseline data on nutrition and health problems in the region. Investigators assessed correlations between maternal and child nutrition, and formally evaluated the performance of maternal-child nutritional indicators as screening tools for household nutrition risk. Although significant intra-households correlations were found with regard to nutritional status among women and children, the data clearly indicate the inefficiency of screening for household-level maternal-child nutritional risk on the basis of anthropometric indicators for mothers and/or individual children under age five years.