"There is iron and iron " Burkinabè women's perceptions of iron supplementation: a qualitative study.

Most pregnant women in Burkina Faso are iron deficient and many are anemic. This study assessed women's understanding of anemia and the role of iron in preventing and treating this condition. A qualitative study was conducted within a randomized controlled trial of weekly iron supplementation in a rural malaria endemic area. Focus groups with women of similar age, parity, and marital status took place in 12 of 24 study villages. Two additional focus groups were conducted with female field workers. Tape-recorded transcripts were translated into French and analyzed using Framework analysis. Anemia, for which no Mooré term or traditional treatment for anemia was evident, was described in terms of blood volume. Moderate blood loss (diminished blood) could be easily replaced by eating well and was not considered serious. Massive blood loss (finished blood) was a rare, life-threatening illness. Iron tablets could increase blood volume and help women withstand massive blood loss at delivery, but for the latter, transfusion was indicated. Women had no knowledge of iron's role and did not readily concede that iron supplements contained elemental iron. Neither adolescents nor field workers were convinced of the benefits of supplementing non-pregnant adolescents, who were incorrectly considered to be at low risk of anemia. Young women's knowledge of anemia did not provide an adequate explanatory framework to motivate anemia prevention. Improving information on the role of iron is especially important for adolescent girls who may be incorrectly considered at low risk of anemia as they have not yet experienced pregnancy.

Increasing rates of cervical cancer in young women in England: an analysis of national data 1982-2006.

BACKGROUND: In England, cervical cancer is the second most common cancer in women aged under 35 years. Overall incidence of cervical cancer has decreased since the introduction of the national screening programme in 1988 but recent trends of incidence in young women have not been studied in detail. METHODS: Information on 71,511 incident cases of cervical cancer in England, 1982-2006, in 20-79-year-olds was extracted from a national cancer registration database. Changes in incidence were analysed by age group, time period and birth cohort. Poisson regression was used to estimate annual percentage change (APC). RESULTS: Overall incidence, during 1982-2006, fell significantly from 213 to 112 per million person years. However, in 20-29-year-olds, after an initial fall, incidence increased significantly during 1992-2006, (APC 2.16). In 30-39-year-olds incidence stabilised during the latter part of the study period. The pattern was most marked in the North East, Yorkshire and the Humber and East Midlands regions. Birth cohorts that were initially called for screening between 60-64 and 35-39 years of age show an incidence peak soon after the age of presumed first screen, whereas younger birth cohorts show a peak at about 35 years of age. Incidence in the 1977-1981 birth cohort has increased relative to that among women born between 1962 and 1976. CONCLUSION: These results have implications for cervical screening, human papilloma virus vaccination and other public health interventions targeting young people.

Human papillomavirus vaccination and social inequality: results from a prospective cohort study.

We investigated the effect of social inequalities on the uptake of human papillomavirus (HPV) vaccination, combining data from a feasibility study conducted in 2007-2008 in 2817 secondary schoolgirls in two UK primary-care trusts, with census and child health records. Uptake was significantly lower in more deprived areas (P<0·001) and in ethnic minority girls (P=0·013). The relatively small proportion of parents who actively refused vaccination by returning a negative consent form were more likely to come from more advantaged areas (P<0·001). Non-responding parents were from more deprived (P<0·001) and ethnic minority (P=0·001) backgrounds. Girls who did not receive HPV vaccination were less likely to have received all their childhood immunizations particularly measles, mumps and rubella (MMR). Different approaches may be needed to maximize HPV vaccine uptake in engaged and non-responding parents, including ethnic-specific approaches for non-responders.

A qualitative study of pharmacists' views on offering chlamydia screening to women requesting Emergency Hormonal Contraception.

This was a qualitative study to understand why pharmacists, asked to offer free chlamydia postal screening to Emergency Hormonal Contraception clients, had not offered screening to all eligible women. Twenty-six pharmacists completed exit interviews and 12 agreed to semi-structured in-depth interviews. Although pharmacists were keen to expand their services, they were reluctant to offer chlamydia screening to women who were married or in a long term relationship. To avoid offence they selected women based on age, education and ethnicity. The rationale for chlamydia screening in pharmacy-based EHC schemes is compromised if pharmacists do not offer screening comprehensively.

A survey of adolescent experiences of human papillomavirus vaccination in the Manchester study.

BACKGROUND: There is little information on girls' experiences of human papillomavirus (HPV) vaccination in the prevention of cervical cancer. We investigated the views of adolescent girls who had been offered the vaccine as part of a feasibility study conducted in Manchester. METHODS: All 12 to 13-year-old girls in two primary care trusts were offered three doses of Cervarix (manufactured by GlaxoSmithKline). A letter was sent to 1084 parents who had consented to research follow-up. It requested parents to pass a questionnaire regarding HPV vaccination to their daughters to complete and post back in a prepaid envelope. RESULTS: A total of 553 girls completed the questionnaire. Altogether, 77% (422) had shared with their parents in the vaccine decision. In all, 42% (n=13) of girls, whose parents refused vaccination, stated that they wanted the vaccine, whereas 10% (50) of those who were vaccinated did not want the vaccine. Although 54% (277) said the vaccine was very important to them, 39% (153) of vaccinated girls thought they might not recommend it to others. The vaccine was perceived to be painful and there were exaggerated rumours of serious adverse events and needle scares. A total of 79% (420) of girls agreed with a statement that vaccination reminded them of the risks of sexual contact, but 14% (73) agreed they might take more sexual risks because they had been vaccinated. CONCLUSION: Girls of this age form their own views on HPV vaccination but parental support for vaccination remains important, especially for completing the three doses. By discussing the vaccine, parents can encourage their daughters to determine the importance and implications of HPV vaccination.

Mucosal lactoferrin response to genital tract infections is associated with iron and nutritional biomarkers in young Burkinabé women.

BACKGROUND/OBJECTIVES: The iron-binding affinity of vaginal lactoferrin (Lf) reduces iron available to genital pathogens. We describe host reproductive, nutritional, infection and iron biomarker profiles affecting vaginal Lf concentration in young nulliparous and primigravid women in Burkina Faso. SUBJECTS/METHODS: Vaginal eluates from women who had participated in a randomized, controlled periconceptional iron supplementation trial were used to measure Lf using a competitive double-sandwich ELISA. For this analysis samples from both trial arms were combined and pregnant and non-pregnant cohorts compared. Following randomization Lf was measured after 18 months (end assessment) for women remaining non-pregnant, and at two antenatal visits for those becoming pregnant. Associations between log Lf levels and demographic, anthropometric, infection and iron biomarker variables were assessed using linear mixed models. RESULTS: Lf samples were available for 712 non-pregnant women at end assessment and for 303 women seen at an antenatal visit. Lf concentrations of pregnant women were comparable to those of non-pregnant, sexually active women. Lf concentration increased with mid-upper-arm circumference, (P = 0.047), body mass index (P = 0.018), Trichomonas vaginalis (P < 0.001) infection, bacterial vaginosis (P < 0.001), serum C-reactive protein (P = 0.048) and microbiota community state types III/IV. Adjusted Lf concentration was positively associated with serum hepcidin (P = 0.047), serum ferritin (P = 0.018) and total body iron stores (P = 0.042). There was evidence that some women maintained persistently high or low Lf concentrations from before, and through, pregnancy. CONCLUSION: Lf concentrations increased with genital infection, higher BMI, MUAC, body iron stores and hepcidin, suggesting nutritional and iron status influence homeostatic mechanisms controlling vaginal Lf responses.

Parental attitudes and information needs in an adolescent HPV vaccination programme.

We sent a questionnaire to 38% (1084) of 2817 parents whose daughters had been offered human papillomavirus vaccination and who had agreed to participate. Of these, 60% (651) returned a questionnaire. Responses suggested that fact sheets and parent information evenings confirmed, rather than changed, consent decisions. The views of active refusers on safety and efficacy may be difficult to change, lowering vaccine coverage.

The right to remain silent: a qualitative study of the medical and social ramifications of pregnancy disclosure for Gambian women.

OBJECTIVES: Control of infectious diseases in developing countries often requires using drugs that are contraindicated during pregnancy. Avoiding inadvertent exposure to drugs involves women (a) recognising pregnancy early, (b) disclosing the pregnancy to health workers and (c) using medicines in an informed manner. We explored these factors to inform and improve the process by which health workers provide care and treatment to pregnant women. DESIGN: Qualitative study. SETTING: The Gambia. POPULATION: Rural women and men. METHODS: We conducted 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants (TBAs). MAIN OUTCOME MEASURE: Pregnancy disclosure. RESULTS: Most women recognised early signs and symptoms of pregnancy and believed other people could easily do so. To avoid gossip, women hid their pregnancies and delayed antenatal care, even though husbands and TBAs insisted on attendance. Women acutely ill in early pregnancy hoped health workers would recognise pregnancy without explicit disclosure. Women said that they knew, and sought to avoid, some contraindicated drugs, but their knowledge was rudimentary. Health workers stressed the benefits, not the risks of prescribed drugs. CONCLUSIONS: Despite public health and clinical benefits of preventing and treating pregnancy infections, women were ill informed and pressurised into taking drugs. These ethical issues should be more widely addressed.

A cluster randomized trial of strategies to increase uptake amongst young women invited for their first cervical screen: The STRATEGIC trial.

Objectives To measure the feasibility and effectiveness of interventions to increase cervical screening uptake amongst young women. Methods A two-phase cluster randomized trial conducted in general practices in the NHS Cervical Screening Programme. In Phase 1, women in practices randomized to intervention due for their first invitation to cervical screening received a pre-invitation leaflet and, separately, access to online booking. In Phase 2, non-attenders at six months were randomized to one of: vaginal self-sample kits sent unrequested or offered; timed appointments; nurse navigator; or the choice between nurse navigator or self-sample kits. Primary outcome was uplift in intervention vs. control practices, at 3 and 12 months post invitation. Results Phase 1 randomized 20,879 women. Neither pre-invitation leaflet nor online booking increased screening uptake by three months (18.8% pre-invitation leaflet vs. 19.2% control and 17.8% online booking vs. 17.2% control). Uptake was higher amongst human papillomavirus vaccinees at three months (OR 2.07, 95% CI 1.69-2.53, p < 0.001). Phase 2 randomized 10,126 non-attenders, with 32-34 clusters for each intervention and 100 clusters as controls. Sending self-sample kits increased uptake at 12 months (OR 1.51, 95% CI 1.20-1.91, p = 0.001), as did timed appointments (OR 1.41, 95% CI 1.14-1.74, p = 0.001). The offer of a nurse navigator, a self-sample kits on request, and choice between timed appointments and nurse navigator were ineffective. Conclusions Amongst non-attenders, self-sample kits sent and timed appointments achieved an uplift in screening over the short term; longer term impact is less certain. Prior human papillomavirus vaccination was associated with increased screening uptake.

The cost of successful adolescent growth and development in girls in relation to iron and vitamin A status.

The role of iron and vitamin A in adolescent growth and development is not well described. During adolescence iron requirements are increased, reaching a maximum at peak growth, but after menarche, menstrual iron loss must also be replaced. An observed rise in retinol-binding protein concentrations at puberty level 4 indicates a role for vitamin A in sexual maturation. Iron and vitamin A deficiencies may slow the tempo of growth. Conversely, for girls on marginal diets, an extended catch-up growth period may lead to depletion of these nutrients. The costs of achieving growth may also include cephalopelvic disproportion in girls becoming pregnant and increased risk of menorrhagia.

PIP: Few studies have investigated how nutrients such as iron and vitamin A promote adolescent growth or whether the effort of catching up on growth may result in a reduction of iron and vitamin A stores. The intake of these nutrients probably does not rise along with maturational requirements in many developing countries. In situations where adolescent females have a heavy workload, low social status, low priority in food distribution, and high infectious disease rates, growth may be achieved, but at the cost of reductions in stores of certain nutrients. Women's health will be compromised during pregnancy. It is proposed in this paper that growth requirements increase demands for iron and vitamin A and that deficiencies of these nutrients may be a consequence of growth and sexual development in adolescent females on marginal diets. One consequence of reduced iron and vitamin A stores in nonpregnant adolescents may be increased risk of menorrhagia, which contributes further to the problems of anemia in poorly nourished girls in their prereproductive years and beyond. The costs of achieving growth may also include cephalopelvic disproportion in girls becoming pregnant. Sections discuss iron and vitamin A requirements during adolescence, the cost of successful growth, and interactions of vitamin A and iron.

Difficulties of interpreting PPD reactions of women living in Madang, Papua New Guinea.

Malaria surveys in Madang, Papua New Guinea, previously distinguished 2 populations of women with significantly different spleen rates and immune responses to malaria. Differences between the high (HS) and low (LS) spleen rate groups suggested a defect in cellular immunity in the HS group. This paper reports a survey of purified protein derivative (PPD) responses in a sample of HS and LS women. Eighty-eight of 162 women were PPD positive (reaction size > 5 mm). There was a marked difference in the range and size of PPD reaction between the HS and LS groups. Mean size in the LS group was 20.7 mm and in the HS group it was 12.1 mm (P = 0.02). Failure to show differences in other indicators of specific malaria immunity indicated that the difference in PPD response was not the result of malaria-specific cell-mediated immune suppression. Many women were PPD non-responders in spite of evidence of multiple bacillus Calmette-Guérin (BCG) vaccination scars. There was no difference between HS and LS groups in the level of non-response to PPD. The results confirm an early tuberculosis survey indicating that New Guineans rapidly lose PPD reactivity to BCG vaccination. Ability to maintain a PPD response, and the quality of response, may vary according to sex and genetic background.

High and low spleen rates distinguish two populations of women living under the same malaria endemic conditions in Madang, Papua, New Guinea.

In a malariometric survey of 594 non-pregnant women living in 17 villages in Madang Province, Papua New Guinea, village groups were identified with average spleen rates of less than 35%, 40-49% and greater than or equal to 50%, with no difference in parasite rates between groups. Most villages where a non-Austronesian language was spoken had high spleen rates, but the association was not consistent. Some women were not indigenous to the study area and to control for the effects of migration on spleen rates, women were grouped according to their area of origin. This analysis, which cuts across village groups, identified 2 subpopulations, one with a high, and the other with a low spleen rate (relative risk 2.23; P less than 0.0001). Persistent splenomegaly was observed more frequently in the high spleen rate population (P less than 0.025) which also showed a significantly increased spleen size (P less than 0.01). The existence of 2 subpopulations living under the same conditions of malaria endemicity, but with different splenic responses to malaria, suggests an altered host immune response to malaria in the high spleen rate group. The absence of intermarriage between these two subpopulations indicates genetic differences distinguish them.

A longitudinal study of splenomegaly in pregnancy in a malaria endemic area in Papua New Guinea.

582 pregnant women living in a defined population were examined for splenomegaly when attending monthly rural antenatal clinics in Madang Province, Papua New Guinea, in an area with all-year malaria transmission. 712 non-pregnant women of child-bearing age from the same population were examined as controls. In non-pregnant women who later became pregnant spleen rates increased in early pregnancy. Peak spleen rates in early pregnancy occurred before 16 weeks gestation for all gravida classes. There was a decrease in spleen rate and a fall in average enlarged spleen size with increasing gestational age for women attending on a first clinic visit and before receiving chloroquine prophylaxis. It is suggested that pregnancy induces a change in splenic function early in gestation, which in primigravidae results in increased frequency of Plasmodium falciparum parasitaemia. In multigravidae these early gestational spleen changes did not predispose to parasitaemia, which indicated that these women had developed enhanced malaria immunity. There was a significant rise in spleen rates with rising parity in non-pregnant women with a peak rate at parity 3. This rise is considered to relate to responses induced by pregnancy in the first and second pregnancies. Weekly chloroquine prophylaxis increased the frequency of splenomegaly in pregnant women attending for 3 consecutive months, indicating that chloroquine had biological activity on the splenic immune response in vivo.

Tetanus antibody levels among adolescent girls in developing countries.

Neonatal and maternal tetanus infections remain an important cause of death in many countries. Few studies have reported tetanus toxoid antibody levels of adolescent girls. As part of the Expanded Programme on Immunization most girls receive up to 3 injections in early childhood, and many subsequently do not receive booster vaccinations until pregnant. We determined (by ELISA) tetanus antibody seropositivity in adolescent girls from Malawi (in 1996), Nigeria (in 1993) and Pakistan (in 1996), and response to tetanus vaccination in adolescent girls from Pakistan. Geometric mean titres (GMT, IU/mL) were 0.94 in 117 Malawian, 0.32 in 154 Nigerian and 1.08 in 162 Pakistani girls. In Nigeria, 54.7% of adolescents were seronegative, of whom 26.8% had a history of unsafe abortion. In Malawi and Pakistan all girls were seropositive and in Pakistan, following a booster vaccination, titres increased 3-fold, with a lower response in older girls. The results indicated that adequate childhood immunization is likely to provide protective levels through adolescence. Booster vaccination in late childhood/early adolescence should protect the majority of women throughout their reproductive lives. This practice would reduce the risks of girls exposed to infection through unsafe abortions, and may be the best option for countries seeking to improve their vaccination schedule, especially where tetanus vaccine coverage in pregnant women is unacceptably low.

Two populations of women with high and low spleen rates living in the same area of Madang, Papua New Guinea, demonstrate different immune responses to malaria.

Specific malaria and total IgM antibody responses were measured in 2 linguistically distinct coastal Papua New Guinean populations living in the same endemic malarious area, but exhibiting different adult female spleen rates (51% and 30%), in order to establish whether the higher spleen rates in the former group were due to hyper-reactive malarious splenomegaly (HMS). Malaria parasite rates were comparable, and geometric mean titres of IgG malaria antibody were the same, in both groups, indicating comparable exposure to malaria. A higher mean total IgM was observed in the high spleen (HS) rate group (6.07 g/litre, compared with 4.62 g/litre), a higher proportion was seropositive for IgM antibody to Plasmodium falciparum (63% compared with 54%), and HMS was found rather more frequently (4.7% compared with 2.6%). In both groups total IgM concentrations increased significantly with rising parity, and the mean level of 5.27 g/litre in young nulliparous women from the HS group suggested that IgM levels in this group at least were elevated from childhood. In both groups a rise in total IgM was associated with higher P. falciparum IgM geometric mean titres of antibody activity, a fall in parasite rates (HS group: 30% to 15%, P = 0.02; LS group: 24% to 0%, P = 0.034), and higher spleen rates (HS group: 38% to 65%, P = 0.001; LS group: 20% to 67%, P = 0.00012). It is concluded that the difference in spleen rates between the 2 groups was the result of differing degrees of acquired immunity to malaria, probably due to genetic differences in immune responses.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between splenomegaly and antibody to the circumsporozoite protein of Plasmodium falciparum in two groups of women with high and low enlarged spleen rates in Madang, Papua New Guinea.

The objective of this study was to determine the prevalence of antibodies recognizing the circumsporozoite (CS) protein of Plasmodium by an enzyme-linked immunosorbent assay, in 2 subpopulations of women with significantly different enlarged spleen rates but similar exposure to malaria, on the north coast of Papua New Guinea. Antibody levels of immunoglobulin G (IgG) antibody to CS protein in the high and low spleen rate groups were similar (56.2% and 55.1%) but there was a significant difference in IgM (29.6% and 16.7%). In neither group did antibodies increase with parity (age). In both groups a high level of either IgG or IgM antibody to CS protein was associated with a high spleen rate and women with hyper-reactive malarious splenomegaly were more likely to be positive for both. Lower parasite rates were associated only with increased IgM antibody titres. High levels of antibody to blood-stage parasites were also present in the high spleen rate group, suggesting that antibodies to the CS protein were not protective. It is considered that cell-mediated immunity may be deficient in women with persistent splenomegaly.

Providing accessible health care for adolescents with sexually transmitted disease.

Provision of sexually transmitted disease (STD) care for sexually active adolescents has been neglected in developing countries, although this is changing. Available evidence indicates that STDs are a serious problem among adolescents (10-19 years), especially in rural areas where services are limited for any age group. Curative care is hampered by the inadequacy of the syndromic approach for identifying adolescents with asymptomatic infections, especially Chlamydia trachomatis. There is an urgent need to asses STD interventions for adolescents in controlled studies, with numbers and follow-up sufficient to monitor changes in STD markers. Many programmes report increased uptake of condoms by youth but have been unable to demonstrate its effect on STD/HIV rates. It is unlikely that any one approach to adolescent STD services will be feasible and hence the importance of understanding the benefits and limitations of each approach.

Clinical management and prevention of sexually transmitted diseases: a review focusing on women.

This review highlights some of the difficulties inherent in controlling sexually transmitted diseases (STDs) in developing countries--especially amongst women. Considerable efforts have been made to improve the syndromic approach to STD management but the poor performance of the algorithm for managing vaginal discharge limits the effectiveness of this strategy. The facilitating role of the human immunodeficiency virus (HIV) has been the main impetus to STD control rather than reduction of morbidity in women, especially pregnant women and their children. There are no easy solutions--but action on several fronts, with more attention to core groups, men and adolescents is indicated.

A community based study of vitamin A and vitamin E status of adolescent girls living in the Shire Valley, Southern Malawi.

OBJECTIVE: To assess vitamin A and E status and anaemia in non-pregnant Malawian adolescent girls. DESIGN: A cross-sectional study in rural village communities in the Shire Valley, Southern Malawi. SUBJECTS: Adolescent girls, n = 118, aged between 10 and 19 y, 112 of whom were unmarried. METHODS: Socio-demographic information was collected by questionnaire, heights and weights were measured. Vitamin A was assessed by the Modified Relative Dose Response (MRDR) test, in addition to serum retinol values. Blood samples were collected 4-5 h after administration of 3,4-didehydroretinyl acetate. Retinol and alpha-tocopherol levels were measured by HPLC. Serum retinol results for non-pregnant girls were compared with values for 43 adolescent pregnant girls which were available from a previous study. RESULTS: 26.6% of non-pregnant girls had serum retinol values < 0.70 micromol/L; 40.2% had an MRDR ratio > 0.060. In 59.3%, serum tocopherol levels were < 11.5 micromol/L and the tocopherol/cholesterol ratio was < 2.2 in 23.9%. 11.3% had a haemoglobin > or = 12 g/dl. Vitamin A levels were significantly related to age, and younger girls were more likely to be deficient. Significant correlations were found between serum retinol, MRDR values and serum tocopherol. Girls with a low body mass index for age had tocopherol cholesterol ratios < 2.2. Low serum retinol values occurred significantly more often in stunted girls (P=0.01). Serum retinol values of adolescent pregnant girls were significantly lower than those of non-pregnant adolescents (P=0.002). CONCLUSIONS: Vitamin A and E deficiency and anaemia were common in adolescent non-pregnant girls, and thought to partly result from increased growth requirements. Girls who become pregnant at an early age are at risk of depletion of their nutritional reserves. Measures to reduce nutritional deficiencies before the first pregnancy are needed.