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Women who receive one cycle of oral contraceptive pills at initiation are no more likely than those who receive multiple cycles to still be using the method after four months, according to a study conducted in matched public-sector clinics in Jamaica between 2002 and 2004.1 Of the 956 pill initiators—half of whom were randomly selected to receive four packs of contraceptives at their initial clinic visit, and half who received a one-month supply at first and three additional cycles at their subsequent visit—655 returned for follow-up four months after method initiation. Seventy-two percent of women in the four-pack group and 65% of those in the one-plus-three–pack group reported still using the pill after four months; side effects and health issues were the main reasons cited by women for discontinuing method use. Women's likelihood of method continuation did not differ significantly by delivery regimen. The two groups did differ, however, in the proportion of women who returned late to obtain their fifth cycle of pills (58% in the one-plus-three–pack group vs. 28% in the four-pack group). Given the costs in money and time to clients and providers associated with additional clinic visits, as well as the increased likelihood of gaps in coverage due to late visits, the authors comment that "If there is no difference in the use of oral contraceptive pills beyond four months, then provision of multiple cycles to new pill clients should be the rule rather than the exception."

1. Chin-Quee D et al., One versus multiple packs for women starting oral contraceptive pills: a comparison of two distribution regimens, Contraception, 2009, 79(5):369– 374.


Interventions that focus on improving maternal health services at primary care facilities may be particularly effective in increasing poor women's access to and use of skilled care during childbirth, according to a study conducted in two rural districts in southeastern Burkina Faso.1 In Ouargaye—where an intervention that focused on improving the quality, availability and accessibility of routine and emergency obstetric care was implemented in 2003 at the district hospital and health centers—the proportion of women who had been pregnant in the past two years who had delivered in a health facility doubled from 29% at baseline to 57% in 2006; the proportion of births attended by a doctor, nurse or midwife more than doubled during that period, from 24% to 56%. In the matched nonintervention district of Diapaga, the proportion of women who delivered in a health facility did not increase over the study period and the proportion who used a skilled attendant rose only slightly (from 32% to 36%). At baseline, women in the wealthiest quintile were much more likely than those in the poorest to deliver in a health facility in both Ouargaye (44% vs. 14%) and Diapaga (60% vs. 25%). By the end of the study period, the wealth gap had closed considerably in Ouargaye (60% vs. 55%)—with almost all of the change attributed to poor women's increased use of lower level health facilities, not hospitals, for both normal and complicated deliveries. In Diapaga, however, the wealth difference actually widened over the period (70% vs. 26%). In multivariate analyses, the intervention attenuated the association between wealth and use of a health care facility, even when controlling for age and education. The authors conclude that "focusing on primary care facilities may be an effective way to target the poor with maternal health services."

1. Brazier E et al., Improving poor women's access to maternity care: findings from a primary care intervention in Burkina Faso, Social Science & Medicine, 2009, 69(5):682–690.


The annual number of worldwide deaths of children younger than five has fallen below nine million for the first time in modern history.1 According to data reported by UNICEF, 8.8 million children died before the age of five in 2008—a 28% decrease from the almost 13 million deaths in that age-group in 1990. Progress in reducing under-five mortality continues to be made in every region of the world, with the most substantial declines between 1990 and 2008 occurring in Latin America and the Caribbean, and the Central/ Eastern Europe and Commonwealth of Independent States regions (55–56%). In addition, the average annual rate of decline in under-five mortality was higher in 2000–2008 than in 1990– 2000 (2.3% vs. 1.4%). However, under-five mortality has become increasingly concentrated, with half of all deaths now occurring in only five countries: China, Democratic Republic of Congo, India, Nigeria and Pakistan. Moreover, in most regions of the world—particularly Sub-Saharan Africa and South Asia—the decline in the child mortality rate is insufficient to reach the fourth Millennium Development Goal, which calls for a two-thirds reduction in the 1990 level of under-five mortality by 2015. The authors comment that "Accelerated progress can be achieved, even in the poorest environments, through: integrated, evidence-driven, and community-based programmes that focus on addressing the major causes of death, including pneumonia, diarrhœa, newborn disorders, malaria, HIV, and undernutrition."

1. You D et al., Levels and trends in under-5 mortality, 1990–2008, Lancet, 2009, doi:10.1016/S0140-6736(09) 61601-9.


Programs in low-resource areas to introduce and increase acceptance of the vaccine against human papillomavirus (HPV) should incorporate evidence-based education and communication strategies to address the concerns of local communities, according to an analysis of focus-group, in-depth interview and survey data of parents and children in four developing countries: India, Peru, Uganda and Vietnam.1 In all four countries, parents—primarily mothers—made the decisions in regard to health issues such as vaccinations. Although parents and children had some knowledge of cancer in general, understanding of the term "cervical cancer" and its link to HPV was low, especially in India and Uganda. Overall, participants in all four countries supported vaccinations, and understood that such public health campaigns protect children from experiencing illness; however, parents expressed various specific concerns about, for example, the quality of vaccines and the level of training of the health care providers giving the vaccinations. In addition, parents worried about potential side effects associated with the HPV vaccine, especially its impact on daughters' future fertility. In light of their findings, the authors suggest "a communication strategy that incorporates simple evidence-based information on HPV and cervical cancer and truthful reassurances regarding the specific concerns raised."

1. Bingham A, Drake JK and LaMontagne DS, Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings, Archives of Pediatrics and Adolescent Medicine, 2009, 163(5):455–461.


Interventions to increase use of skilled birth attendants that respect and incorporate local and traditional preferences can be effective in poor and isolated rural settings.1 According to an evaluation of a program implemented in 2000–2001 in Ayacucho, Peru—which included such culturally appropriate aspects as having health professionals use the local Quechua language, allowing women to wear their own clothes instead of hospital gowns and providing a rope and bench for the vertical delivery position preferred by women in the region—delivery in a health care facility increased from 6% at baseline in 1999 to 83% by 2007. Use of a skilled birth attendant, either at a health care facility or at home, increased from 43% in 1999 to 95% in 2007. Most of the increase in skilled delivery occurred within the first two years of program initiation, with high satisfaction reported by both women and health professionals. The authors comment that their study "clearly demonstrates the feasibility of creating and implementing a model of skilled delivery attendance that integrates modern medical and traditional Andean elements." They add that "Instead of ascribing the high levels of home birth to 'cultural preferences' or 'ignorance,' the health system should first strive to offer high quality and financially, geographically and culturally accessible services respecting the needs and human rights of the people they serve."

1. Gabrysch S et al., Cultural adaptation of birth services in rural Ayacucho, Peru, Bulletin of the World Health Organization, 2009, 87(9):724–729.


In Indonesia, four occupational groups of men—truck drivers, taxi drivers, dock workers and seafarers—comprise a high-risk population that could potentially spread HIV from core transmitters (e.g., intravenous drug users and female sex workers) to the general population, according to a study conducted in 11 Indonesian cities between August and November 2007.1 Of the 2,798 sexually experienced men in the four occupational groups surveyed, 70% were married, 49% had ever had sex with a female sex worker, 36% had been with a sex worker in the past year and 20% had had sex in the past year with a casual sex partner other than a sex worker. Condom use at last sex ranged from 30% with a female sex worker to 8% with a spouse; few men consistently used condoms with sex workers (17%) and casual partners (12%). Among those who provided blood or urine samples for STI testing, the prevalence of any STI (excluding HIV) was 21% in Papua and 8% elsewhere in Indonesia. The prevalence of HIV was 1.8% in Papua and 0.3% elsewhere; according to the authors, this is the first time that detectable rates of HIV have been found in a non–core transmitter male population in Indonesia outside of Papua. The authors comment that "the levels of sexual risk being taken by the men studied, relatively high levels of STI among both sex workers in Indonesia and their clients, and increasing HIV prevalence among [female sex workers] indicate the potential for the HIV/AIDS epidemic in Indonesia to continue to expand unless stronger and more effective action is taken."

1. Mustikawati DE et al., Sexual risk taking, sexually transmitted infections and HIV prevalence among four "high-risk" occupational groups of Indonesian men, Sexually Transmitted Infections, 2009, 85(5):391–396.


Nearly one in five men in Vietnam who are living with HIV experience symptoms of depression—a far greater prevalence than in the general male population.1 Of the 584 HIV-positive men surveyed in Hanoi and Ho Chi Minh City in 2007 and 2008, 66% had received their diagnosis more than one year before; 40% reported experiencing one HIV symptom, 15% two and 11% three or more. Fifty-seven percent of men were currently receiving antiretroviral treatment, and 22% were being treated for opportunistic infections; only 6% were receiving mental health treatment. Among men living with HIV, the prevalence of depression during the previous month was 19%; in comparison, the rate of depression in the general male population was 1%. Depression in HIV-positive men was associated with increasing numbers of HIV symptoms and stressful life events. The authors comment that "Integrating mental health with HIV efforts on a national scale will help reduce dual morbidity [of HIV and psychiatric illness]…and raise awareness of the importance of mental health in the broader context of Vietnam."

1. Esposito CA et al., The prevalence of depression among men living with HIV infection in Vietnam, American Journal of Public Health, 2009, 99(S2):S439–S444.