Home > Global > Urban Health Bulletin – July 2010

Urban Health Bulletin – July 2010

The July 2010 issue of the Urban Health Bulletin contains citations and abstracts of recently published studies. Entries are arranged alphabetically by journal title.

1. AIDS. 2010 Jul;24 Suppl 2:S39-44.

Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.

Nada KH, Suliman el DA. Population Council, West Asia and North Africa Regional Office, Maadi, Cario, Egypt.

OBJECTIVES: To measure the prevalence of HIV/AIDS risk behaviors and related factors in a large, probability-based sample of boys and girls aged 12-17 years living on the streets of Egypt’s largest urban centers of Greater Cairo and Alexandria.

METHODS: Time-location sampling (TLS) was used to recruit a cross-sectional sample of street children. Procedures entailed using key informants and field observation to create a sampling frame of locations at predetermined time intervals of the day, where street children congregate in the two cities, selecting a random sample of time-locations from the complete list, and intercepting children in the selected time- locations to assess eligibility and conduct interviews. Interviews gathered basic demographic information, life
events on the street (including violence, abuse, forced sex), sexual and drug use behaviors, and HIV/AIDS knowledge.

RESULTS: A total of 857 street children were enrolled in the two cities, with an age, sex, and time-location composition matching the sampling frame. The majority of these children had faced harassment or abuse (93%) typically by police and other street children, had used drugs (62%), and, among the older adolescents, were sexually active (67%). Among the sexually active 15-17-year-olds, most reported multiple partners (54%) and never using condoms (52%). Most girls (53% in Greater Cairo and 90% in Alexandria) had experienced sexual abuse. The majority of street children experienced more than one of these risks. Overlaps with populations at highest risk for HIV were substantial, namely men who have sex with men, commercial sex workers, and injection drug users.

CONCLUSION: Our study using a randomized TLS approach produced a rigorous, diverse, probability-based sample of street children and documented very high levels of multiple concurrent risks. Our findings strongly advocate for multiple services including those addressing HIV and STI prevention and care, substance use, shelters, and sensitization of authorities to the plight of street children in Egypt.

2. Am J Clin Nutr. 2010 Jul;92(1):170-6

Iron-fortified milk and noodle consumption is associated with lower risk of anemia among children aged 6-59 mo in Indonesia.

Semba RD, Moench-Pfanner R, Sun K, de Pee S, Akhter N, Rah JH, Campbell AA, Badham J, Bloem MW, Kraemer K.

Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. rdsemba@jhmi.edu

BACKGROUND: Anemia is common among children in developing countries and is associated with decreased cognitive and physical development. Iron-fortified foods may decrease child anemia.

OBJECTIVE: The objective was to describe the association between iron-fortified milk and iron-fortified noodle consumption and anemia in children aged 6-59 mo.

DESIGN: Consumption of fortified milk and fortified noodles and child anemia were assessed in 81,885 families from rural and 26,653 families from urban slum areas in Indonesia.

RESULTS: The proportions of children who received fortified milk and noodles were 30.1% and 22.6%, respectively, in rural families and 40.1% and 48.9%, respectively, in urban families. The prevalence of anemia among children from rural families was 55.9% and from urban families was 60.8%. Children from rural and urban families were less likely to be anemic if they received fortified milk [odds ratio (OR): 0.76; 95% CI: 0.72, 0.80 (P < 0.0001) and OR: 0.79; 95% CI: 0.74, 0.86 (P < 0.0001), respectively] but not fortified noodles [OR: 0.98; 95% CI: 0.93, 1.09 (P = 0.56) and OR: 0.95; 95% CI: 0.88, 1.02 (P = 0.16), respectively] in multiple logistic regression models with adjustment for potential confounders. In rural families, the odds of anemia were lower when the child who consumed fortified milk also consumed fortified noodles or when the child who consumed fortified noodles also consumed fortified milk.

CONCLUSIONS: In Indonesia, consumption of fortified milk and noodles was associated with decreased odds of child anemia. Iron-fortified milk and noodles may be a strategy that could be applied more widely as an intervention to decrease child anemia.

3 – Asia Pac J Public Health. 2010 Jul;22(3 Suppl):254S-261S.

Urban environment and health: food security.

Galal O, Corroon M, Tirado C. Center for Global and Immigrant Health, UCLA School of Public Health, Los Angeles, CA 90095-1772, USA. ogalal@ucla.edu

The authors examine the impact of urbanization on food security and human health in the Middle East. Within urban-population disparities in food security represent one of the most dramatic indicators of economic and health disparities. These disparities are reflected in a double burden of health outcomes: increasing levels of chronic disease as well as growing numbers of undernourished among the urban poor. These require further comprehensive solutions.

Some of the factors leading to food insecurity are an overdependence on purchased food commodities, lack of sufficient livelihoods, rapid reductions in peripheral agricultural land, and adverse impacts of climate change. The Food and Agriculture Organization of the United Nations (FAO) Food Security Framework is used to examine and compare 2 cities in the Middle East: Amman, Jordan, and Manama, Bahrain.

4. Glob Public Health. 2010 Jul 13:1-13.

Discourses of illegality and exclusion: When water access matters.

Mudege NN, Zulu EM. African Population and Health Research Center, Shelter Afrique Center, Nairobi, Kenya.

This paper examines the politics and the underlying discourses of water provisioning and how residents of Korogocho and Viwandani slum settlements in Nairobi city cope with challenges relating to water access. We use qualitative data from 36 focus group discussions conducted in the two slums to unravel discourses regarding water provisioning in the rapidly growing slum settlements in African cities.

Results show that the problems concerning water provisioning within Nairobi slums are less about water scarcity and more about unequal distribution and the marginalisation of slum areas in development plans. Poor water management, lack of equity-based policies and programmes, and other slum-specific features such as land-tenure systems and insecurity exacerbate water-supply problems within slum areas.

It is hard to see how water supply in these communities can improve without the direct and active involvement of the government in infrastructural development and oversight of the water-supply actors. Innovative public-private partnerships in water provision and the harnessing of existing community efforts to improve the water supply would go a long way towards improving the water supply to the rapidly growing urban poor population in Africa.

5. Int J Infect Dis. 2010 Jul 16.

The effect of Helicobacter pylori infection on growth velocity in young children from poor urban communities in Ecuador.

Egorov AI, Sempértegui F, Estrella B, Egas J, Naumova EN, Griffiths JK. US Environmental Protection Agency, National Center for Environmental Assessment, 26 W. Martin Luther King Drive, MS A110, Cincinnati, OH 45268, USA; Tufts School of Medicine, Department of Public Health and Family Medicine, Boston, Massachusetts, USA.

OBJECTIVE: To characterize the potential effects of Helicobacter infections on growth velocity in low socioeconomic status young children in a developing country.

METHODS: Children were recruited in poor suburbs of Quito, Ecuador. Normally nourished, mildly and substantially malnourished children (defined using weight-for-age Z-scores at recruitment) formed equal strata. Six height and weight measurements were collected during one year. Enrollment and exit serum samples were analyzed for anti-Helicobacter IgG and exit non-diarrheal feces tested for Helicobacter antigen.

RESULTS: Among 124 participants (enrollment age 19+/-9 months), 76 (61%) excreted fecal antigen at exit (were infected). Of these, 44 were seropositive at least once (chronic infections) and 32 tested seronegative both times (new or acute phase infections). The adjusted linear growth velocity during follow-up in children with new infections was reduced by 9.7 (3.8, 15.6) mm/year compared to uninfected controls and 6.4 (0.0, 12.9) mm/year compared to children with chronic infections. The effects of Helicobacter infections on ponderal growth were not significant.

CONCLUSION: These results suggest that linear growth velocity is reduced in young children during the initial phase of Helicobacter infection.

6. Indian J Pediatr. 2010 Jul;77(7):759-62.

Human touch to detect hypothermia in neonates in Indian slum dwellings.

Agarwal S, Sethi V, Srivastava K, Jha P, Baqui AH. Urban Health Resource Center, New Delhi, India. siddharth@uhrc.in

OBJECTIVE: To assess the validity of human touch (HT) method to measure hypothermia compared against axillary digital thermometry (ADT) and study association of hypothermia with poor suckle and underweight status in newborns and environmental temperature in 11 slums of Indore city, India.

METHODS: Field supervisors of slum-based health volunteers measured body temperature of 152 newborns by HT and ADT, observed suckling and weighed newborns. Underweight status was determined using WHO growth standards.

RESULTS: Hypothermia prevalence (axillary temperature <36.5 degrees C) was 30.9%. Prevalence varied by season but insignificantly. Hypothermia was insignificantly associated with poor suckle (31% vs 19.7%, p=0.21) and undernutrition (33.3% vs 25.3%, p=0.4). HT had moderate diagnostic accuracy when compared with ADT (kappa: 0.38, sensitivity: 74.5%, specificity: 68.5%).

CONCLUSIONS: HT emerged simpler and programmatically feasible. There is a need to examine whether trained and supervised community-based health workers and mothers can use HT accurately to identify and manage hypothermia and other simple signs of newborn illness using minimal algorithm at home and more confidently refer such newborns to proximal facilities linked to the program to ensure prompt management of illness.

7. J Biosoc Sci. 2010 Jul;42(4):511-30

Intra- and inter-household differences in antenatal care, delivery practices and postnatal care between last neonatal deaths and last surviving children in a peri-urban area of India.

Ghosh R, Sharma AK. Department of Humanities and Social Sciences, Indian Institute of Technology, Kanpur, India.

Nearly a quarter of the world’s neonatal deaths take place in India. The state of Uttar Pradesh alone accounts for one-quarter of all neonatal deaths in the country. In this study 892 married women aged less than 50 years living in a peri-urban area of Kanpur city in Uttar Pradesh were interviewed. In all, 109 women reported neonatal deaths. Characteristics of the last neonatal deaths of these 109 women were compared with those of the last surviving children.

Also, characteristics of women who had a neonatal death were compared with those of 783 women who had no neonatal death. It was found that as compared with neonatal deaths, the last surviving children of the 109 women had: (a) significantly better antenatal tests during pregnancy, intake of iron/folic acid tablets and higher percentage of tetanus toxoid immunization; (b) safer delivery practices such as a higher percentage of institutional delivery, sterilization of instruments and application of antiseptic after removal of umbilical cord; (c) postnatal care, such as application of antiseptic to the navel and postnatal checkups; and (d) higher maternal age and greater birth spacing.

Likewise, better antenatal care and safer delivery practices and postnatal care were observed among the 783 women with no neonatal deaths, when compared with women who had experienced neonatal death. The complexities of inter- and intra-household differences in health care are discussed. The paper concludes that to improve child survival general education and awareness regarding safe delivery should be increased. Continuing cultural stigmas and misconceptions about birth practices before, during and after childbirth should be an important part of the awareness campaigns.

8. Lancet Neurol. 2010 Aug;9(8):786-792.

Stroke incidence in rural and urban Tanzania: a prospective, community-based study.

Walker R, Whiting D, Unwin N, Mugusi F, Swai M, Aris E, Jusabani A, Kabadi G, Gray WK, Lewanga M, Alberti G.

Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK; Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.

BACKGROUND: There are no methodologically rigorous studies of the incidence of stroke in sub-Saharan Africa. We aimed to provide reliable data on the incidence of stroke in rural and urban Tanzania.

METHODS: The Tanzania Stroke Incidence Project (TSIP) recorded stroke incidence in two well defined demographic surveillance sites (DSS) over a 3-year period from June, 2003. The Hai DSS (population 159 814) is rural and the Dar-es-Salaam DSS (population 56 517) is urban. Patients with stroke were identified by use of a system of community-based investigators and liaison with local hospital and medical centre staff. Patients who died from stroke before recruitment into the TSIP were identified via verbal autopsy, which was done on all those who died within the study areas.

FINDINGS: There were 636 strokes during the 3-year period (453 in Hai and 183 in Dar-es-Salaam). Overall crude yearly stroke incidence rates were 94.5 per 100 000 (95% CI 76.0-115.0) in Hai and 107.9 per 100 000 (88.1-129.8) in Dar-es-Salaam. When age-standardised to the WHO world population, yearly stroke incidence rates were 108.6 per 100 000 (95% CI 89.0-130.9) in Hai and 315.9 per 100 000 (281.6-352.3) in Dar-es-Salaam.

INTERPRETATION: Age-standardised stroke incidence rates in Hai were similar to those seen in developed countries. However, age-standardised incidence rates in Dar-es-Salaam were higher than seen in most studies in developed countries; this could be because of a difference in the prevalence of risk factors and emphasises the importance of health screening at a community level. Health policy makers must continue to monitor the incidence of stroke in sub-Saharan Africa and should base future funding decisions on such data. FUNDING: The Wellcome Trust.

9. Science. 2010 Jul 19.

Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women.

Karim QA, Karim SS, Frohlich JA, Grobler AC, Baxter C, Mansoor LE, Kharsany AB, Sibeko S, Mlisana KP, Omar Z, Gengiah TN, Maarschalk S, Arulappan N, Mlotshwa M, Morris L, Taylor D; on behalf of the CAPRISA 004 Trial Group. Centre for the AIDS Program of Research in South Africa (CAPRISA), Durban, South Africa.

The CAPRISA 004 trial assessed effectiveness and safety of a 1% vaginal gel formulation of tenofovir, a nucleotide reverse transcriptase inhibitor, for the prevention of HIV acquisition in women. A double-blind, randomized controlled trial was conducted comparing tenofovir gel (n = 445) with placebo gel (n = 444) in sexually active, HIV-uninfected 18- to 40-year-old women in urban and rural KwaZulu-Natal, South Africa. HIV serostatus, safety, sexual behavior, and gel and condom use were assessed at monthly follow-up visits for 30 months. HIV incidence in the tenofovir gel arm was 5.6 per 100 women-years, i.e., person time of study observation (38/680.6 women-years), compared to 9.1 per 100 women-years (60/660.7 women-years) in the placebo gel arm (incidence rate ratio = 0.61; P = 0.017). In high adherers (gel adherence >80%), HIV incidence was 54% lower (P = 0.025) in the tenofovir gel arm. In intermediate adherers (gel adherence 50 to 80%) and low adherers (gel adherence <50%), the HIV incidence reduction was 38% and 28%, respectively. Tenofovir gel reduced HIV acquisition by an estimated 39% overall and by 54% in women with high gel adherence. No increase in the overall adverse event rates was observed. There were no changes in viral load and no tenofovir resistance in HIV seroconverters. Tenofovir gel could potentially fill an important HIV prevention gap, especially for women unable to successfully negotiate mutual monogamy or condom use.

10. Soc Sci Med. 2010 Jul;71(1):62-70.

Choosing early pregnancy termination methods in Urban Mozambique.

Mitchell EM, Kwizera A, Usta M, Gebreselassie H. Academic Medical Center, University of Amsterdam, CINIMA, Amsterdam, Netherlands. mitchelle@kncvtbc.nl

Little is known about who chooses medication abortion with misoprostol and why. Women seeking early abortion in 5 public hospitals in Maputo, Mozambique were recruited in 2005 and 2006 to explore decision making strategies, method preferences and experiences with misoprostol and vacuum aspiration for early abortion. Client screenings (n=1799), structured clinical surveys (n=837), in-depth exit interviews (n=70), and nurse focus groups (n=2) were conducted. Triangulation of qualitative and quantitative data revealed seemingly contradictory findings.

Choice of method reflected women’s heightened concerns about privacy, pain, quality of home support, HIV infection risk, sexuality, and safety of research participation. Urban Mozambican women are highly motivated to find early pregnancy termination techniques that they deem socially and clinically low-risk. Although 42% found vaginal misoprostol self-administration challenging and 25% delayed care for over a week to amass funds for user fees, almost all (96%) reported adequate preparation and comfort with home management.

Women reported satisfaction with all methods and quality of care, even if the initial method failed or pain management or postabortion contraception were not offered. A more nuanced understanding of what women value most can yield service delivery models that are responsive and effective in reducing maternal death and disability from unsafe abortion.

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