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1.  HIV/AIDS awareness and risk behavior among students in Semey, Kazakhstan: a cross-sectional survey 
Background
Until recently, young people in Kazakhstan have been only moderately affected by the global HIV epidemic. Today, however, the HIV epidemic in Central Asia is one of the most rapidly increasing epidemics in the world. It is mainly concentrated to vulnerable groups such as intravenous drug users, sex workers, the purchasers of sexual services and the financially marginalized. Young, sexually active people may however be the gateway for the epidemic to the general population, and knowledge about their attitudes and behavior is therefore important in planning preventive measures.
Methods
To gather information about young students and their attitudes and knowledge about HIV/AIDS, we collected 600 structured questionnaires and made 23 semi-structured interviews among three groups of students. Response rate was 99%.
Results
Almost 99% of the respondents had heard of HIV/AIDS, and 89% could identify ways to protect oneself against sexually transmitted HIV/AIDS. The main routes of transmission, sexual contact without condom and intravenous drug use, were both identified by 97% of the students. Twenty-five percent of the female students and 75% of the male students had had one or more sexual partners. More than 30% of the young men had purchased sex, and homosexuality was widely stigmatized.
Conclusion
Risks for the spread of HIV/AIDS among young people in Kazakhstan include prostitution as well as stigmatization of the HIV positive and of homosexuals. Protective factors are good knowledge about risks and protection, and opportunities to talk and gather information about sexuality and HIV/AIDS.
doi:10.1186/1472-698X-8-14
PMCID: PMC2630293  PMID: 19087297
2.  "One country, two systems": Sociopolitical implications for female migrant sex workers in Hong Kong 
Background
Under the "two countries, one system" policy implemented by China to manage the return of Hong Kong's sovereignty, Hong Kong has maintained a comparatively prosperous economy within the Asian region. This has resulted in an environment which fosters migration from the mainland to Hong Kong, due largely to proximity, higher earning potential, common language, and a relaxing of border control measures. However not all mainland China citizens are equally able to access these new migration schemes and indeed a number of women such as sex workers are either migrating and/or working illegally and without occupational, legal and health protection within Hong Kong.
Discussion
Female migrant sex workers are exposed to a number of significant threats to their health, however their illegal status contributes to even greater vulnerability. The prevailing discourses which view these women as either "trafficked women" or as "illegal immigrants" do not adequately account for the complex situations which result in such women's employment in Hong Kong's sex industry. Rather, their position can best be understood within the broader frameworks provided by migration literature and the concept of "structural violence". This allows for a greater understanding of the socio-political issues which are systematically denying migrant sex workers adequate access to health care and other opportunities for social advancement. When these issues are taken into account, it becomes clear that the current relevant legislation regarding both immigration and sex work is perpetuating the marginalised and vulnerable status of migrant sex workers. Unless changes are made, structural barriers will remain in place which impede the ability of migrant sex workers to manage their own health needs and status.
Conclusion
Female migrant sex workers in Hong Kong are extremely vulnerable to a number of occupational health and safety hazards which have significantly detrimental effects on their health. These risks can best be understood within a broad framework of socio-political factors contributing to their vulnerability. Ensuring that migrant sex workers have adequate support for their health and legal rights requires require structural interventions such as decriminalisation and providing open and inclusive access to health service to counteract such factors.
doi:10.1186/1472-698X-8-13
PMCID: PMC2629761  PMID: 19077260
3.  "I never had the money for blood testing" – Caretakers' experiences of care-seeking for fatal childhood fevers in rural Uganda – a mixed methods study 
Background
The main killer diseases of children all manifest as acute febrile illness, yet are curable with timely and adequate management. To avoid a fatal outcome, three essential steps must be completed: caretakers must recognize illness, decide to seek care and reach an appropriate source of care, and then receive appropriate treatment. In a fatal outcome some or all of these steps have failed and it remains to be elucidated to what extent these fatal outcomes are caused by local disease perceptions, inappropriate care-seeking or inadequate resources in the family or health system. This study explores caretakers' experiences of care-seeking for childhood febrile illness with fatal outcome in rural Uganda to elucidate the most influential barriers to adequate care.
Methods
A mixed methods approach using structured Verbal/Social autopsy interviews and in-depth interviews was employed with 26 caretakers living in Iganga/Mayuge Demographic Surveillance Site who had lost a child 1–59 months old due to acute febrile illness between March and June 2006. In-depth interviews were analysed using content analysis with deductive category application.
Results
Final categories of barriers to care were: 1) "Illness interpretation barriers" involving children who received delayed or inappropriate care due to caretakers' labelling of the illness, 2) "Barriers to seeking care" with gender roles and household financial constraints hindering adequate care and 3) "Barriers to receiving adequate treatment" revealing discontents with providers and possible deficiencies in quality of care. Resource constraints were identified as the underlying theme for adequate management, both at individual and at health system levels.
Conclusion
The management of severely ill children in this rural setting has several shortcomings. However, the majority of children were seen by an allopathic health care provider during the final illness. Improvements of basic health care for children suffering from acute febrile illness are likely to contribute to a substantial reduction of fatal outcomes. Health care providers at all levels and private as well as public should receive training, support, equipment and supplies to enable basic health care for children suffering from common illnesses.
doi:10.1186/1472-698X-8-12
PMCID: PMC2614407  PMID: 19055738
4.  Using data envelopment analysis to measure the extent of technical efficiency of public health centres in Ghana 
Background
Data Envelopment Analysis (DEA) has been used to analyze the efficiency of the health sector in the developed world for sometime now. However, in developing economies and particularly in Africa only a few studies have applied DEA in measuring the efficiency of their health care systems.
Methods
This study uses the DEA method, to calculate the technical efficiency of 89 randomly sampled health centers in Ghana. The aim was to determine the degree of efficiency of health centers and recommend performance targets for the inefficient facilities.
Results
The findings showed that 65% of health centers were technically inefficient and so were using resources that they did not actually need.
Conclusion
The results broadly point to grave inefficiency in the health care delivery system of public health centers and that significant amounts of resources could be saved if measures were put in place to curb the waste.
doi:10.1186/1472-698X-8-11
PMCID: PMC2605432  PMID: 19021906
5.  Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey 
Background
The burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices.
Methods
We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds.
Results
Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves.
Conclusion
Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.
doi:10.1186/1472-698X-8-10
PMCID: PMC2491593  PMID: 18644103
6.  A multilevel analysis of effect of neighbourhood and individual wealth status on sexual behaviour among women: evidence from Nigeria 2003 Demographic and Health Survey 
Background
Nigeria is home to more people living with HIV than any other country in the world, except South Africa and India – where an estimated 2.9 million [1.7 million – 4.2 million] people were living with the virus in 2005. Women bear the greatest burden of frequent high-risk pregnancies, raising large families, and increasingly, the AIDS epidemic. Thus, there is a need for better understanding of the determinants of high risk sexual behaviour among women. In this study, we examined factors associated with extra-marital sex among women in Nigeria and investigated how much variation in reported extra-marital sex can be attributed to individual-, and community-level factors.
Methods
We analyzed data from 6362 sexually active women aged 15 – 49 years who participated in the Nigeria 2003 Demographic and Health Survey using multilevel logistic regression models. Results are presented as odds ratio with 95% confidence interval.
Results
Independent of other factors, compared to women aged 15–24 years, those 25 – 34 years (odds ratio [OR] 0.59; 95% CI: 0.44 – 0.79) and 35 years or older (OR 0.36; 95% CI: 0.24 – 0.54) were less likely to have reported multiple concurrent sex partners in the last 12 years. As expected, women currently or formerly married were less likely to have reported multiple concurrent sex partners than women never married. Women who drank alcohol in the last three months were more likely to have reported multiple concurrent sex partners. Compared to women from richest household, women from poorest and middle household were 83% and 51% more likely to multiple concurrent sex partners in the last 12 month respectively. After individual compositional and contextual factors, community wealth status was statistically significant with sexual behaviour.
Conclusion
The study has demonstrated that individual and community wealth status are independent predictors of women's sexual behaviour, and that there is significant neighbourhood variation in odds of multiple concurrent sex partners, even after controlling for effects of both individual- and community-level characteristics. Scholars trying to understand variation individual high risk sexual behaviour should pay attention to the characteristics of both individuals and places of residence.
doi:10.1186/1472-698X-8-9
PMCID: PMC2453105  PMID: 18588679
7.  Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation 
Background
Many refugees live for years in exile. The combination of stress in the host country, together with long-term effects resulting from traumatic stress usually experienced in the home country may affect mental health. Little is known, to what extent these and other factors promote or stall the willingness to return to the country of origin. Here, we investigate, as an example, refugees who will return to their country of origin after having lived in exile in Germany for some 11 years.
Objective
What is the mental health status of returnees before the actual return who have been living in exile for an extended period? We also asked, what are the current living conditions in Germany and what are the motives for and reasons against a voluntary return to the country of origin?
Methods
Forty-seven participants of programs for assisted voluntarreturn were interviewed about their present living situation, their view regarding their home country and voluntary return. These findings were compared to a group of 53 refugees who had decided to remain in Germany (stayers). Participants were recruited by means of advertisements posted in refugee centres, language schools, at doctors' offices and in organisations involved in the management of voluntary return in Germany. The prevalence of psychiatric disorders among respondents was tested using the structured interview M.I.N.I. The Posttraumatic Stress Diagnostic Scale (PDS) was used to assess PTSD in more detail and EUROHIS was applied to measure the subjective quality of life of participants.
Results
We found a prevalence rate of 44% psychiatric disorders in the group of returnees and a rate of 78% in the group of stayers. We also recorded substantial correlations between the living situation in Germany, disposition to return and mental health. In almost two thirds of the participants the decision to return was not voluntary but strongly influenced by immigration authorities. The most important reason for participants to opt for a stay in Germany were their children, who have been born and raised in Germany.
Conclusion
Psychological strains among the study participants were very high. Traumatic stress, experienced during war and refuge, has left the victims vulnerable and not well equipped to cope with post-migration stressors in exile. It is noteworthy that the majority returned under pressure of the immigration authorities. The fear of an uncertain future after the return was substantial. These factors should be taken into account in programs designed to assist returnees, including those that offer support after return to the country of origin.
doi:10.1186/1472-698X-8-8
PMCID: PMC2442043  PMID: 18549469
8.  Self-rated health among Mayan women participating in a randomised intervention trial reducing indoor air pollution in Guatemala 
Background
Indoor air pollution (IAP) from solid fuels is a serious health problem in low-income countries that can be alleviated using improved stoves. Although women are the principal users, few studies have investigated the self-assessed impact of the stoves on their health and lives.
Methods
This study was conducted in rural highland Guatemala, involving 89 intervention and 80 control Mayan Indian young women (mean 27.8 years, SD 7.2). Outcomes were assessed after approximately 18 months use of the new stove. Our objectives were to compare self-rated health and change in health among women participating in a randomised control trial comparing a chimney stove with an open fire, to describe impacts on women's daily lives and their perceptions of how reduced kitchen smoke affects their own and their children's health.
Results
On intention-to-treat analysis, 52.8% of intervention women reported improvement in health, compared to 23.8% of control women (p < 0.001). Among 84 intervention women who reported reduced kitchen smoke as an important change, 88% linked this to improvement in their own health, particularly for non-respiratory symptoms (for example eye discomfort, headache); 57% linked reduced smoke to improvement in their children's health, particularly sore eyes.
Conclusion
Women's perception of their health was improved, but although smoke reduction was valued, this was linked mainly with alleviation of non-respiratory symptoms like eye discomfort and headache. More focus on such symptoms may help in promoting demand for improved stoves and cleaner fuels, but education about more severe consequences of IAP exposure is also required.
doi:10.1186/1472-698X-8-7
PMCID: PMC2427013  PMID: 18533994
9.  Health and lifestyle of Nepalese migrants in the UK 
Background
The health status and lifestyle of migrants is often poorer than that of the general population of their host countries. The Nepalese represent a relatively small, but growing, immigrant community in the UK, about whom very little is known in term of public health. Therefore, our study examined the health and lifestyle of Nepalese migrants in the UK.
Methods
A cross-sectional survey of Nepalese migrants in UK was conducted in early 2007 using a postal, self-administered questionnaire in England and Scotland (n = 312), and telephone interviews in Wales (n = 15). The total response rate was 68% (327 out of 480). Data were analyzed to establish whether there are associations between socio-economic and lifestyle factors. A multivariate binary logistic regression was applied to find out independent effect of personal factors on health status.
Results
The majority of respondents was male (75%), aged between 30 and 45 (66%), married or had a civil partner (83%), had university education (47%) and an annual family income (69%) ranging from £5,035 to £33,300. More than one third (39%) of the respondents have lived in the UK for 1 to 5 years and approximately half (46%) were longer-term residents. Most (95%) were registered with a family doctor, but only 38% with a dentist. A low proportion (14%) of respondents smoked but more than half (61%) consumed alcohol. More than half (57%) did not do regular exercises and nearly one fourth (23%) of respondents rated their health as poor. Self reported 'good' health status of the respondents was independently associated with immigration status and doing regular exercise
Conclusion
The self reported health status and lifestyle, health seeking behaviour of Nepalese people who are residing in UK appears to be good. However, the overall regular exercise and dentist registration was rather poor. Health promotion, especially aimed at Nepalese migrants could help encourage them to exercise regularly and assist them to register with a dentist.
doi:10.1186/1472-698X-8-6
PMCID: PMC2432045  PMID: 18500980
10.  Metabolic control in a nationally representative diabetic elderly sample in Costa Rica: patients at community health centers vs. patients at other health care settings 
Background
Costa Rica, like other developing countries, is experiencing an increasing burden of chronic conditions such as diabetes mellitus (DM), especially among its elderly population. This article has two goals: (1) to assess the level of metabolic control among the diabetic population age ≥ 60 years old in Costa Rica, and (2) to test whether diabetic elderly patients of community health centers differ from patients in other health care settings in terms of the level of metabolic control.
Methods
Data come from the project CRELES, a nationally representative study of people aged 60 and over in Costa Rica. This article analyzes a subsample of 542 participants in CRELES with self-reported diagnosis of diabetes mellitus. Odds ratios of poor levels of metabolic control at different health care settings are computed using logistic regressions.
Results
Lack of metabolic control among elderly diabetic population in Costa Rica is described as follows: 37% have glycated hemoglobin ≥ 7%; 78% have systolic blood pressure ≥ 130 mmHg; 66% have diastolic blood pressure ≥ 80 mmHg; 48% have triglycerides ≥ 150 mg/dl; 78% have LDL ≥ 100 mg/dl; 70% have HDL ≤ 40 mg/dl. Elevated levels of triglycerides and LDL were higher in patients of community health centers than in patients of other clinical settings. There were no statistical differences in the other metabolic control indicators across health care settings.
Conclusion
Levels of metabolic control among elderly population with DM in Costa Rica are not that different from those observed in industrialized countries. Elevated levels of triglycerides and LDL at community health centers may indicate problems of dyslipidemia treatment among diabetic patients; these problems are not observed in other health care settings. The Costa Rican health care system should address this problem, given that community health centers constitute a means of democratizing access to primary health care to underserved and poor areas.
doi:10.1186/1472-698X-8-5
PMCID: PMC2396151  PMID: 18447930
11.  Unreported births and deaths, a severe obstacle for improved neonatal survival in low-income countries; a population based study 
Background
In order to improve child survival there is a need to target neonatal mortality. In this pursuit, valid local and national statistics on child health are essential. We analyze to what extent births and neonatal deaths are unreported in a low-income country and discuss the consequences at local and international levels for efforts to save newborn lives.
Methods
Information on all births and neonatal deaths in Quang Ninh province in Northern Vietnam in 2005 was ascertained by systematic inventory through group interviews with key informants, questionnaires and examination of health facility records. Health care staff at 187 Community Health Centers (CHC) and 18 hospitals, in addition to 1372 Village Health Workers (VHW), were included in the study. Results were compared with the official reports of the Provincial Health Bureau.
Results
The neonatal mortality rate (NMR) was 16/1000 (284 neonatal deaths/17 519 births), as compared to the official rate of 4.2/1000. The NMR varied between 44/1000 and 10/1000 in the different districts of the province. The under-reporting was mainly attributable to a dysfunctional reporting system and the fact that families, not the health system, were made responsible to register births and deaths. This under-reporting has severe consequences at local, national and international levels. At a local level, it results in a lack of awareness of the magnitude and differentials in NMR, leading to an indifference towards the problem. At a national and international level the perceived low mortality rate is manifested in a lack of investments in perinatal health programs.
Conclusion
This example of a faulty health information system is reportedly not unique in low and middle income countries where needs for neonatal health reforms are greatest. Improving reporting systems on births and neonatal deaths is a matter of human rights and a prerequisite for reducing neonatal mortality in order to reach the fourth millennium goal.
doi:10.1186/1472-698X-8-4
PMCID: PMC2292136  PMID: 18373839
12.  Systematic synthesis of community-based rehabilitation (CBR) project evaluation reports for evidence-based policy: a proof-of-concept study 
Background
This paper presents the methodology and findings from a proof-of-concept study undertaken to explore the viability of conducting a systematic, largely qualitative synthesis of evaluation reports emanating from Community Based Rehabilitation (CBR) projects in developing countries.
Methods
Computer assisted thematic qualitative analysis was conducted on recommendation sections from 37 evaluation reports, arising from 36 disability and development projects in 22 countries. Quantitative overviews and qualitative summaries of the data were developed.
Results
The methodology was found to be feasible and productive. Fifty-one themes were identified and the most important ones of these are presented to illustrate the significance of the method. The relative priorities of these themes indicated that "management" issues were the primary areas in which recommendations were made. Further analysis of themes reflected the emphasis evaluators placed on the need for enhanced management, organisational, personnel and administrative infrastructure in CBR projects. Evaluators consistently recommended that CBR projects should be more connected and collaborative at governmental, organisational, political and community levels. The synthesis also noted that evaluators questioned the emphasis in CBR on project expansion and income generation.
Conclusion
The application of the synthesis methodology utilised in this proof-of-concept study was found to be potentially very beneficial for future research in CBR, and indeed in any area within health services or international development in which evaluation reports rather than formal "research evidence" is the primary source material. The proof-of-concept study identified a number of limitations which are outlined. Based on the conclusions of 37 evaluation reports, future policy frameworks and implementation strategies in CBR should include a stronger emphasis on technical, organisational, administrative and personnel aspects of management and strategic leadership.
doi:10.1186/1472-698X-8-3
PMCID: PMC2294110  PMID: 18325121
13.  Exploring synergies between human rights and public health ethics: A whole greater than the sum of its parts 
Background
The fields of human rights and public health ethics are each concerned with promoting health and elucidating norms for action. To date, however, little has been written about the contribution that these two justificatory frameworks can make together. This article explores how a combined approach may make a more comprehensive contribution to resolving normative health issues and to advancing a normative framework for global health action than either approach made alone. We explore this synergy by first providing overviews of public health ethics and of international human rights law relevant to health and, second, by articulating complementarities between human rights and public health ethics.
Discussion
We argue that public health ethics can contribute to human rights by: (a) reinforcing the normative claims of international human rights law, (b) strengthening advocacy for human rights, and (c) bridging the divide between public health practitioners and human rights advocates in certain contemporary health domains. We then discuss how human rights can contribute to public health ethics by contributing to discourses on the determinants of health through: (a) definitions of the right to health and the notion of the indivisibility of rights, (b) emphasis on the duties of states to progressively realize the health of citizens, and (c) recognition of the protection of human rights as itself a determinant of health. We also discuss the role that human rights can play for the emergent field of public health ethics by refocusing attention on the health and illness on marginalized individuals and populations.
Summary
Actors within the fields of public health, ethics and human rights can gain analytic tools by embracing the untapped potential for collaboration inherent in such a combined approach.
doi:10.1186/1472-698X-8-2
PMCID: PMC2268657  PMID: 18237409
14.  Correlates of current cigarette smoking among school-going adolescents in Punjab, India: results from the Global Youth Tobacco Survey 2003 
Background
Smoking is a leading cause of morbidity and mortality globally. There is therefore need to identify relevant factors associated with smoking among adolescents in order to better tailor public health interventions aimed at preventing smoking.
Methods
We used data from the Global Youth Tobacco Survey (GYTS) conducted in 2003 in Punjab, India, on 2014 adolescents of whom 58.9% were males. We conducted a weighted logistic regression analysis, adjusting for age and sex, to determine associations between predictor variables and current tobacco smoking status.
Results
A total of 2014 adolescents participated in the survey in 2003, and of these 58.9% were males. Male respondents tended to be older than females (21.2% of males, and 13.1% of females were of age 16 years or above). The percent of males and females in the other age groups were: 23.0% and 28.6% for <14 years, 27.3% and 31.0% for 14 years, and 28.4% and 27.0% for 15 years, respectively. The following factors were positively associated with smoking: adolescents who received pocket money; adolescents who had parents who smoked, chewed or applied tobacco; adolescents who said that boys or girls who smoke or chew tobacco have more friends; adolescents who said that smoking or chewing tobacco makes boys look less attractive; adolescents who said that there is no difference in weight between smokers and non-smokers; adolescents who said that smoking makes one gain weight; and adolescents who had most or all of their closest friends who smoked. The factors that were negatively associated with smoking were: adolescents who said that boys or girls who smoke or chew tobacco have less number of friends; adolescents who said that girls who smoke or chew tobacco are less attractive; and adolescents who had some of their closest friends who smoked.
Conclusion
The observed associations between current smoking on one hand and peer smoking, and perception that boys who smoke are less attractive on the other, deserve further studies. The factors reported in the current study should be considered in the design of public health interventions aimed to reduce adolescent cigarette smoking.
doi:10.1186/1472-698X-8-1
PMCID: PMC2244596  PMID: 18194550

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