Capacity to Consent to Research Among Adolescent-Parent Dyads in Rakai, Uganda.

OBJECTIVES: To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study. STUDY DESIGN: Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests. RESULTS: Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8). CONCLUSIONS: The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches.

HTLV-1aA introduction into Brazil and its association with the trans-Atlantic slave trade.

INTRODUCTION: Human T-lymphotropic virus (HTLV) is an endemic virus in some parts of the world, with Africa being home to most of the viral genetic diversity. In Brazil, HTLV-1 is endemic amongst Japanese and African immigrant populations. Multiple introductions of the virus in Brazil from other epidemic foci were hypothesized. The long terminal repeat (LTR) region of HTLV-1 was used to infer the origin of the virus in Brazil, using phylogenetic analysis. METHODS: LTR sequences were obtained from the HTLV-1 database (http://htlv1db.bahia.fiocruz.br). Sequences were aligned and maximum-likelihood and Bayesian tree topologies were inferred. Brazilian specific clusters were identified and molecular-clock and coalescent models were used to estimate each cluster's time to the most recent common ancestor (tMRCA). RESULTS: Three Brazilian clusters were identified with a posterior probability ranged from 0.61 to 0.99. Molecular clock analysis of these three clusters dated back their respective tMRCAs between the year 1499 and the year 1668. Additional analysis also identified a close association between Brazilian sequences and new sequences from South Africa. CONCLUSION: Our results support the hypothesis of a multiple introductions of HTLV-1 into Brazil, with the majority of introductions occurring in the post-Colombian period. Our results further suggest that HTLV-1 introduction into Brazil was facilitated by the trans-Atlantic slave trade from endemic areas of Africa. The close association between southern African and Brazilian sequences also suggested that greater numbers of the southern African Bantu population might also have been part of the slave trade than previously thought.

Expanding the neutralization scope of the EchiTAb-plus-ICP antivenom to include venoms of elapids from Southern Africa.

EchiTAb-plus-ICP is an antivenom prepared from plasma of horses hyperimmunized with the venoms of the carpet viper (Echis ocellatus), the puff adder (Bitis arietans) and the black-necked spitting cobra (Naja nigricollis). Therefore, the use of this antivenom has been limited to Western Africa. In order to expand the neutralization scope of EchiTAb-plus-ICP, we supplemented the immunogenic mixture with the venoms of B. arietans, the black mamba (Dendroaspis polylepis), the Mozambique spitting cobra (Naja mossambica), the snouted cobra (N. annulifera), and the rinkhals (Hemachatus haemachatus) from Swaziland. The ability of the expanded-scope antivenom, hereby named EchiTAb + ICP, to neutralize the venoms of B. arietans, D. polylepis, N. mossambica and H. haemachatus was similar to those of FAV Afrique and the SVA African antivenoms. In comparison to the SAIMR antivenom, the expanded-scope EchiTAb + ICP had lower ability to neutralize the venom of B. arietans, but similar ability to neutralize the venoms of D. polylepis, N. mossambica and H. haemachatus. Owing to its low protein concentration, the expanded-scope EchiTAb + ICP had lower ability to neutralize the venom of N. annulifera than FAV Afrique and the SAIMR antivenoms. However, when formulated at a protein concentration as high as FAV Afrique and SAIMR antivenoms, the expanded-scope EchiTAb + ICP showed similar capacity to neutralize this poorly immunogenic venom. Our results encourage the transition to the new EchiTAb + ICP antivenom, with an expanded neutralization scope that includes venoms of some of the most medically important elapids from Southern Africa. Clinical trials are required to determine the minimum effective-safe dose of the new EchiTAb + ICP for each type of envenomation.

Transmission of Foot-and-Mouth Disease SAT2 Viruses at the Wildlife-Livestock Interface of Two Major Transfrontier Conservation Areas in Southern Africa.

Over a decade ago, foot-and-mouth disease (FMD) re-emerged in Southern Africa specifically in beef exporting countries that had successfully maintained disease-free areas in the past. FMD virus (FMDV) serotype SAT2 has been responsible for a majority of these outbreaks. Epidemiological studies have revealed the importance of the African buffalo as the major wildlife FMD reservoir in the region. We used phylogeographic analysis to study dynamics of FMD transmission between buffalo and domestic cattle at the interface of the major wildlife protected areas in the region currently encompassing two largest Transfrontier conservation areas: Kavango-Zambezi (KAZA) and Great Limpopo (GL). Results of this study showed restricted local occurrence of each FMDV SAT2 topotypes I, II, and III, with occasional virus migration from KAZA to GL. Origins of outbreaks in livestock are frequently attributed to wild buffalo, but our results suggest that transmission from cattle to buffalo also occurs. We used coalescent Bayesian skyline analysis to study the genetic variation of the virus in cattle and buffalo, and discussed the association of these genetic changes in the virus and relevant epidemiological events that occurred in this area. Our results show that the genetic diversity of FMDV SAT2 has decreased in buffalo and cattle population during the last decade. This study contributes to understand the major dynamics of transmission and genetic variation of FMDV SAT2 in Southern Africa, which will could ultimately help in designing efficient strategies for the control of FMD at a local and regional level.

Savanna fire and the origins of the 'underground forests' of Africa.

The origin of fire-adapted lineages is a long-standing question in ecology. Although phylogeny can provide a significant contribution to the ongoing debate, its use has been precluded by the lack of comprehensive DNA data. Here, we focus on the 'underground trees' (=geoxyles) of southern Africa, one of the most distinctive growth forms characteristic of fire-prone savannas. We placed geoxyles within the most comprehensive dated phylogeny for the regional flora comprising over 1400 woody species. Using this phylogeny, we tested whether African geoxyles evolved concomitantly with those of the South American cerrado and used their phylogenetic position to date the appearance of humid savannas. We found multiple independent origins of the geoxyle life-form mostly from the Pliocene, a period consistent with the origin of cerrado, with the majority of divergences occurring within the last 2 million yr. When contrasted with their tree relatives, geoxyles occur in regions characterized by higher rainfall and greater fire frequency. Our results indicate that the geoxylic growth form may have evolved in response to the interactive effects of frequent fires and high precipitation. As such, geoxyles may be regarded as markers of fire-maintained savannas occurring in climates suitable for forests.

Strong association between the prevalence of bacterial vaginosis and male point-concurrency.

OBJECTIVE: The prevalence of bacterial vaginosis (BV) differs considerably between different populations, and individual-level risk factors such as number of sex partners seem unable to explain these differences. The effect of network-level factors, such as the prevalence of partner concurrency (the proportion of sexual partnerships that overlap in time as opposed to running sequentially) on BV prevalence has not hitherto been investigated. STUDY DESIGN: We performed linear regression to assess the relationship between the prevalence of male concurrency and prevalence of BV in each of 11 countries for which we could obtain comparable data. The data for concurrency prevalence were taken from the WHO/Global Programme on AIDS (GPA) sexual behavioural surveys. BV prevalence rates were obtained from a systematic review of the global patterning of BV. RESULTS: We found a strong relationship between the prevalence of male concurrency and BV prevalence (Pearson's R(2)=0.57; P=0.007). CONCLUSIONS: The findings of a strong ecological-level association between BV and partner concurrency need to be replicated and augmented with different types of studies such as multilevel prospective studies tracking the incidence of BV and associated individual, partner and network level risk factors.

78,000 women die each year from unsafe abortions worldwide. It is estimated that there are 20 million unsafe abortions per year on a global basis.

PIP: At February's Cairo+5 proceedings at the Hague, the Center for Reproductive Law and Policy (CRLP) called a press conference to discuss changes in abortion laws around the world since the International Conference on Population and Development in Cairo in 1994. According to the director of CRLP's International Program, 9 countries have modified their abortion laws since Cairo. Of those, 7 liberalized their laws, while Poland and El Salvador further restricted legislation. The CRLP supports the liberalization of abortion laws for all women in all countries. Abortion law has been liberalized in South Africa since Cairo, with the enactment in 1997 of the Termination of Pregnancy Act. In contrast, however, anti-choice groups in Poland successfully challenged the legality of abortion in 1996 by declaring it against the Polish Constitution. Abortion is prohibited in Chile in all circumstances, even to save the life of the woman. However, despite the illegality of abortion in that country, half of all pregnancies in Chile end in abortion. Unsafe abortion contributes to the 50% maternal mortality rate in Nepal. Abortion in the country is punishable by a 20-year prison sentence, regardless of the age of the woman.^ieng

The strategic approach to contraceptive introduction.

The introduction of new contraceptive technologies has great potential for expanding contraceptive choice, but in practice, benefits have not always materialized as new methods have been added to public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP) has taken major steps to develop a new approach and to support governments interested in its implementation. After reviewing previous experience with contraceptive introduction, the article outlines the strategic approach and discusses lessons from eight countries. This new approach shifts attention from promotion of a particular technology to an emphasis on the method mix, the capacity to provide services with quality of care, reproductive choice, and users' perspectives and needs. It also suggests that technology choice should be undertaken through a participatory process that begins with an assessment of the need for contraceptive introduction and is followed by research and policy and program development. Initial results from Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, and Zambia confirm the value of the new approach.

PIP: In response to difficulties associated with the introduction of new contraceptive technologies to public sector service systems, the UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction has formulated a new model. The strategic approach to contraceptive introduction shifts the emphasis from the promotion of a particular technology to quality of care issues, a reproductive health focus, and users' perspectives and needs. It further entails a participatory approach with collaboration among governments, women's health groups, community groups, nongovernmental providers, researchers, international donors, and technical assistance agencies. The underlying philosophy is that method introduction should proceed only when a system's ability to provide high-quality services exists or can be generated. Since 1993, WHO has provided support for the implementation of this perspective in public sector programs in Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Viet Nam, and Zambia. Preliminary assessments in these countries revealed major structural, managerial, and philosophical barriers to high-quality family planning services. In cases where assessments have indicated the feasibility of new method introduction, this has been implemented through a carefully phased, research-based process intended to encourage the development of appropriate managerial capacity and to promote a humanistic philosophy of care.

Women and energy: household energy for developing communities, South African experience. Sustainability energy development.

PIP: This paper aims to promote a change in attitudes and perceptions which may contribute towards a gender-sensitive approach in the development, management, and utilization of energy, whereby women's needs, interests, and roles are addressed. It argues that a gender-sensitive approach concerns women and the conditions they face, economically, socially, and sexually, which requires a continuous and consistent policy planning and evaluation process. In South Africa, where the women's situation is systematically worsened by apartheid, effective energy planning needs to recognize complex dynamics and address the particular needs of women at the grassroots level. Current development approaches in South Africa to resolve their domestic energy crisis include: South African Energy Policy Research and Training Programme; Integrated Energy Planning method; South Africa Reconstruction and Development Program; and Women Energy Group.^ieng

Let's talk reproductive health -- young people's voices.

PIP: This article presents extracts from comments made by young people in various parts of the world about the meaning of the term "safe motherhood." A Ghanian woman noted that young girls, who often bear a heavier workload than boys but receive less food, need to be given the same diet as boys. A young Senegalese mother relayed that she found out she was pregnant when she went to a hospital with stomach pains shortly before her 14th birthday. Until then she had no idea that sexual intercourse led to pregnancy. A Mexican youth cited the problems that accompany adolescent pregnancy and motherhood, and a young woman in India called for delivery of proper medical care to all young mothers and presentation of health education about safe motherhood in schools. An Egyptian youth extolled the benefits of a project that involved young people from rural youth organizations in safe motherhood IEC (information, education, and communication) activities. Previously, adolescents had not received any special attention. Finally, a youth working in a family planning educational booth in Botswana stated that many youth who engage in sexual intercourse at an early age have no idea of the consequences of their actions.^ieng

Sex education and young people.

PIP: Young people comprise up to 60% of Belize's total population of more than 200,000. Many of them have dropped out of school and simply loiter on the streets with little or nothing to do. The only nongovernmental organization in Belize providing family planning and sexual and reproductive health care services, the Belize Family Life Association (BFLA) is well aware of the many problems facing youth, such as AIDS, teen pregnancy, sexually transmitted disease, poverty, and gangs. In an effort to improve conditions for youth and to address their problems, the BFLA established a successful teen center in the Mesopotamia Area and the Belizean Youths with an Aim for Prosperity (BYAP), a project designed to foster and support entrepreneurship among a group comprised mainly of out-of-school at-risk youths. Population Concern is helping to fund reproductive health projects for youth in South Africa with the goal of reducing the prevalence of unwanted pregnancy, sexually transmitted diseases, and unsafe abortion through reproductive health services and education. Young people are helping design the project by explaining their perceived needs to the project team. In Trinidad and Tobago, controversy followed the Family Planning Association of Trinidad and Tobago's (FPATT) recent launch of its annual Family Life Education Training program for teachers, while 2 recent hurricanes, unemployment, and illicit drug sales and use are some of the problems facing the Dominica Planned Parenthood Federation and Dominica's youth.^ieng

Promoting the status of women should not be construed as actions against men.

PIP: As part of the International Meeting of Parliamentarians on Population and Social Development, held in Denmark March 4-5, 1995, a panel discussion on women's status was convened. Ms. Billie Miller, Deputy Prime Minister of Barbados, reported that the efforts of grass-roots women's organizations to influence male parliamentarians resulted in legal recognition of consensual unions and positive family and social welfare legislation. Ms. Girija Vyas, Prime Minister of India, noted that centuries of male domination and adherence to traditional practices have led many Asian women to accept their low status; however, the Government of India is endeavoring to change this through increasing women's participation in social, economic, and political development. Manto Tshabalala-Nsimang, Prime Minister of South Africa, noted that although the struggle of the African National Congress for freedom has given women access to some positions of influence, national mechanisms are being developed to ensure that these gains are not lost and that the Convention of the Elimination of All Forms of Discrimination Against Women is implemented.^ieng

People living with HIV / AIDS talk about their families.

PIP: Five positive and negative experiences of families dealing with AIDS are recounted. Imrat in Malaysia is an HIV-infected son who was not rejected by his family. Prudence of Botswana is an infected widow with five children who had a less positive experience with her in-laws, while Eric of Sweden considers his friends to constitute his family. His relationships with friends have only strengthened since his HIV-positive status became known. Mary of Zimbabwe, however, was infected with HIV by her husband. She was formerly angry at him for having brought home the virus, but they have since stop quarreling and are focusing upon building a stronger relationship. Finally, the brief story of Juan in Colombia is told. Thirty-two years old, married, and with a 17-month old daughter, Juan did not tell his wife that he was actively bisexual. Once infected with HIV, Juan's wife threw him out, more because he had sex with men than because of his HIV serostatus.^ieng

Growth charts only marginally improved maternal learning from nutrition education and growth monitoring in Lesotho.

A study done in Lesotho in 1985-1986 assessed whether growth charts increased the impact of nutrition education and growth monitoring on maternal learning about weaning practices and diarrhea. Seven hundred and seventy six mothers were given three monthly sessions of group nutrition education along with growth monitoring of children and individual counseling. Growth charts, which were taught to one of two groups, fostered learning but only on issues related to diarrhea and only among new clinic attendants, mothers with less than secondary schooling and mothers of malnourished children. These benefits, however, were small (differences less than 10%) compared with the overall impact of the nutrition education and growth monitoring intervention (increases between baseline and post-intervention were greater than 50% for some questions). Our findings suggest that well-designed clinic-based nutrition education and growth monitoring can have a significant impact on maternal nutrition knowledge. Teaching growth charts to mothers may not be necessary for obtaining such results in programs conducted under ideal conditions. More research is needed to determine under what circumstances, for what purposes and for whom growth charts may be beneficial.

PIP: Between December 1985 and November 1986, before and after 3 monthly sessions of group nutrition counseling and individual counseling about weaning and diarrhea management at 9 primary health clinics in Lesotho, researchers compared data on 575 mothers who received a growth chart to monitor their 2-year old children's growth with data on 201 mothers of 2-year old children who did not receive a growth chart. They wanted to learn whether growth charts promoted maternal learning and whether the growth charts better served some mothers than other mothers. Growth monitoring intervention improved knowledge of diarrhea management but not weaning practices. This improvement in learning about diarrhea management was limited to new clinic attendants, mothers with less than high school education, and mothers with malnourished children, however. Yet the differences in benefits between these 2 groups were 10% and insignificant. Nutrition education interventions had significantly improved knowledge of weaning practices and diarrhea management for both groups of mothers (range of improvement 3-119.2%; p.05). The greatest improvements occurred in correct responses to continuous feeding of solid foods during diarrhea (119.2% for mothers who did not receive charts and 85.2% for those who did) and to introduction of protein rich vegetables to children's diet (42.6% and 58.9%, respectively). Thus use of growth charts contributed only slightly to increased effectiveness of nutrition education. It appeared that the quality and specificity of educational projects and proper use of weight information during individual counseling contributed the most to improved maternal learning. Nevertheless further research is warranted to learn the circumstances, purposes, and target audience under which use of growth charts would bring the most benefits.

The mediating effect of maternal nutrition knowledge on the association between maternal schooling and child nutritional status in Lesotho.

The present study tested whether maternal nutrition knowledge was a mediating factor in the association between maternal schooling and child nutritional status, and whether the mechanism involved differed according to socioeconomic status. The data were collected in Lesotho on 921 mother-child pairs and included scores from a nutrition knowledge test, socioeconomic and demographic information, and the child's anthropometric data. A wealth factor derived from a factor analysis was used to stratify the sample into two socioeconomic groups. Two-stage least-squares estimation was used to test the mediating role of nutrition knowledge between maternal schooling and child weight-for-age. Results showed that both the importance of maternal schooling and the mechanism by which it affects the child's weight-for-age are contingent upon the family's socioeconomic status. While maternal schooling was positively associated with weight-for-age for both wealthier and poorer households, the size of the effect was much larger for the latter group. The effect of maternal schooling on weight-for-age was mediated by the mother's nutrition knowledge only among wealthier households. These results imply that, in Lesotho, nutrition education for mothers could contribute to improving children's growth, but only in households that have access to a minimum level of resources. For poorer households, nutrition education would not be sufficient.

Impact of a clinic-based growth monitoring programme on maternal nutrition knowledge in Lesotho.

An evaluation of the impact of a nationwide clinic-based growth monitoring (GM) programme was done in Lesotho to determine if clinic attendance was associated with improved maternal knowledge of weaning practices and diarrhoea. A total of 907 mothers from eight clinics were included in the study. Our results showed that mothers who had attended the clinics knew more about the appropriate timing for introducing animal protein-rich foods in the child's diet and about the use of oral rehydration salts for diarrhoea, than those who had not. The difference in knowledge between previous clinic attendants and new attendants was particularly marked among mothers with less than secondary schooling and mothers with young babies (less than 6 months). From observation in the clinics, we believe that group nutrition education, although it was not integrated with growth monitoring, was probably responsible for the positive association between clinic attendance and maternal knowledge. Prior clinic attendance was not specifically associated with improved knowledge about feeding during diarrhoea or the need to stop breastfeeding gradually. These need to be better incorporated into present clinic nutrition education. Whether improvements in growth monitoring would further significantly improve nutrition education remains to be seen.

PIP: Between December 1985-November 1986, survey data from 907 mothers of 2-year-old children in 8 Catholic Relief Services (CRS) clinics in Mahale's Hoek and Mafeteng districts in Lesotho were analyzed to determine if attendance at a typical nationwide clinic-based growth monitoring program improved maternal knowledge of weaning practices and diarrhea management. 85% of the mothers were Basotho women. At the clinics, the mothers did not undergo individual counseling or receive training in growth charts. Group nutrition education efforts did occur, however, but separately from the program. Mothers who attended a clinic had a significantly higher increased knowledge of the appropriate timing for introducing animal protein rich foods and about the use of oral rehydration salts than those who did not attend (p.05). This association was especially significant for mothers with only primary education and those with infants 6 months old. The mothers reported breast feeding a mean of 2 years. 85% knew to introduce cereals and liquids between 4-6 months old. Yet few mothers knew how to appropriately stop breast feeding. For example, 50% believed it should stop in 1 day. The researchers believed that the separate group nutrition activities contributed to the positive effect of clinic attendance on maternal knowledge of nutrition and diarrhea management. Other research needs to be done to determine if teaching of growth charts and individual counseling would significantly improve maternal knowledge. Clinic staff delivering improved educational messages could have a significant positive effect on the growth and health of Basotho children who are undergoing weaning.

Human growth, nutrition, and health status in Sub-Saharan Africa.

PIP: Sub-Saharan Africa (SSA) has the greatest population growth rates, the highest levels of infant and child mortality, and the poorest economies in the world. The physical quality of life index for developed countries is 80, yet for 33 SSA countries it ranges from 20.5-66. Routine monitoring of growth and nutritional status of children demonstrates their health status. The proportion of low birth weight infants is high in SSA with most countries having levels 10-20% . Further even though average birth weight consistently rose during the 1980s in SSA, the range of smallest to largest mean birth weights is lower than the medians for developed counties. Moreover 40% of 5 year olds are mild or moderately malnourished as evidenced by growth retardation and some biochemical changes, yet they exhibit or clinical signs and symptoms. Besides diarrhea often exacerbates malnutrition. Through childhood and adolescence, growth patterns (particularly among the rural Turkana pastoralists) steadily deviate from the 50th centile of US norms. Thus almost 50% of early adolescents in rural areas are below the 5th centile. Studies have found that pastoralist children tend to begin being slightly above the 5th centile of US norms and gradually fall below it. Further peak growth velocities among SSA children are low, but postpeak velocities are higher than equal velocities for children in developed countries. Thus adult heights are only between the 5th-50th centiles. Throughout childhood and adolescence, US Blacks have higher absolute levels of subcutaneous fat than children in SSA. Yet the main centralized patterning of fat in SSA children basically equals that of US Blacks, but invariably less marginal than in Whites. In conclusion, adverse socioeconomic conditions in SSA result in low levels of health at all growth phases thereby confounding their genetic potential.^ieng

National community health worker programs: how can they be strengthened?

This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.

PIP: A collaborative research study of policy and practice in large, national community health worker (CHW) programs in developing countries was conducted. The report was based on a review of the literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop on the future of CHW programs. The objective of the study was to reexamine the implementation of national CHW programs, looking at policy, planning and management implications to suggest improvements. The chief findings were poor initial planning, unrealistic expectations of the workers, difficulties in maintaining quality and problems of sustainability. National CHW programs have suffered from conceptual and implementation problems. With political will, however, governments can adopt more flexible approaches by planning CHW programs within the context of overall health sector activities, rather than as a separate activity. Weaknesses in training, task allocation and supervision need to addressed immediately. CHWs represent an important health resource whose potential in providing and extending a reasonable level of health care to undeserved populations must be fully tapped.

Maternal-infant vitamin D relationships during breast-feeding.

To evaluate the effect of maternal dietary vitamin D intake on infant vitamin D status in a country with a temperate climate, but where the commercial milk supply is not vitamin D fortified, this randomized, double-blind study was conducted on term mother-infant pairs during the winter months. Well-nourished, white nursing mothers were given a placebo, 500 IU vitamin D/day or 1,000 IU vitamin D/day; their infants were not given supplemental vitamin D. After six weeks, mothers receiving supplemental vitamin D had higher levels of 25-hydroxyvitamin D than had mothers receiving placebo. A direct relationship was observed between maternal and infant levels of 25-hydroxyvitamin D at six weeks, implying that maternal vitamin D intake directly affects the vitamin D concentration in breast milk. A control group of infants who had received 400 IU vitamin D/day had even higher concentrations of 25-hydroxyvitamin D, suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation. Despite the favorable climate in South Africa, during winter breast-fed infants have low serum vitamin D values if maternal dietary vitamin D intake is low.