with a population of over 131 million and a fertility rate of 29·9 per 1000, population growth constitutes a primary threat to continued economic growth and development in bangladesh. one strategy that has been used to cease further increases in fertility in bangladesh involves using family planning outreach workers who travel throughout rural and urban areas educating women regarding contraceptive alternatives. this study uses a longitudinal database to assess the impact of family planning outreach workers’ contact upon contraceptive switching and upon the risk of an unintended pregnancy. using longitudinal data on contraceptive use from the operations research project (orp) of the international centre for diarrhoeal disease research (icddr,b) in bangladesh, multiple decrement life table analysis and multilevel, discrete-time competing risk hazards models were used to estimate the cumulative probabilities of switching to an alternative form of contraceptive use after a woman engaged in a discussion with an outreach worker. after controlling for the effects of socio-demographic and economic characteristics, the analysis revealed that family planning outreach workers’ contact with women significantly decreases the risk of transitioning to the non-use of contraceptives. this contact also reduces the risk of an unintended pregnancy. family planning workers’ contact with women is associated with the increased risk of a woman switching from one modern method to another modern method. the study results indicate that side-effects and other method-related reasons are the two primary reasons for contraceptive discontinuation in rural bangladesh.

As part of a survey of the biological history of Alpine populations, the lineages of all the families of the Vallouise valley (a French ‘department’ of the Hautes Alpes) have been reconstructed over several centuries. The genealogies have been included in a computerized population record, known as ‘Vallouise in the Briançon area (14th–20th centuries)’, using the French–Canadian programme Analypop. Most of the professions of the family heads were included in the files. In this study, various profession groups were identified and their descents determined over successive generations. In this mountain area, where over 92% of marriages took place among relatives during the 19th century, the profession groups modulated their descents according to chosen strategies, sometimes with considerable differences among groups but with a remarkable consistency of behaviour. Moreover, there was weak interpenetration in the descents of each profession at both the 2nd and 3rd generations.

This paper uses retrospective event-history data covering a four-year period to examine the timing of exposure to HIV/AIDS education and social marketing condom promotion campaigns, relative to the timing of changes in sexual risk behaviour in Tanzania. Analysis of the event-history data shows that the process of exposure to AIDS education messages and exposure to brand advertising for Salama brand condoms was very different. While exposure to AIDS education was early and gradual, exposure to Salama brand condoms started later, but was much more rapid. After one year of advertising, over half of the target population had been reached by the Salama advertising campaign, mostly through newspapers, radio and television. During the study period, condom use increased from 15% at the beginning of 1993 to 42% at the end of 1996. Increases in condom use were driven both by men who became sexually active, and by men who were not yet protected, or not fully protected. The results further show that it is uncommon for men who adopted condom use to return to more risky behaviour, which suggests that behaviour change in the study population is permanent.

This is a critical, systematic review of the relationship between socioeconomic status (SES) and HIV infection in women in Southern, Central and Eastern Africa. In light of the interest in micro-credit programmes and other HIV prevention interventions structured to empower women through increasing women’s access to funds and education, this review examines the epidemiological and public health literature, which ascertains the association between low SES using different measurements of SES and risk of HIV infection in women. Also, given the focus on structural violence and poverty as factors driving the HIV epidemic at a structural/ecological level, as advocated by Paul Farmer and others, this study examines the extent to which differences in SES between individuals in areas with generalized poverty affect risk for SES. Out of 71 studies retrieved, 36 studies met the inclusion criteria including 30 cross-sectional, one case-control and five prospective cohort or nested case-control studies. Thirty-five studies used at least one measurement of female’s SES and fourteen also included a measurement of partner’s SES. Studies used variables measuring educational level, household income and occupation or employment status at the individual and neighbourhood level to ascertain SES. Of the 36 studies, fifteen found no association between SES and HIV infection, twelve found an association between high SES and HIV infection, eight found an association between low SES and HIV infection and one was mixed. In interpreting these results, this review examines the role of potential confounders and effect modifiers such as history of STDs, number of partners, living in urban or rural areas and time and location of study in sub-Saharan Africa. It is argued that STDs and number of partners are on the causal pathway under investigation between HIV and SES and should not be adjusted as confounders in any analysis. In conclusion, it is argued that in low-income sub-Saharan Africans countries, where poverty is widespread, increasing access to resources for women may initially increase risk of HIV or have no effect on risk-taking behaviours. In some parts of Southern Africa where per capita income is higher and within-country inequalities in wealth are greater, studies suggest that increasing SES may decrease risk. This review concludes that increased SES may have differential effects on married and unmarried women and further studies should use multiple measures of SES. Lastly, it is suggested that the partner’s SES (measured by education or income/employment) may be a stronger predictor of female HIV serostatus than measures of female SES.

Respiratory illness continues to be a leading cause of paediatric morbidity and mortality in Indonesia. The Indonesian government is moving towards a more managed care-based approach as it reforms its health care system following the 1997 financial crisis. In order to better design contractual relationships between the payor and different providers, there needs to be a better understanding of the patterns and predictors of health services utilization for respiratory illness. This study uses the Indonesia Demographic and Health Survey to study the determinants of private, public and non-formal provider utilization for respiratory illness. Multinomial logistic regression models for predicting use were constructed using the Andersen Behavioural Model as the conceptual framework. The findings indicate that age, household size, maternal education, religion, the asset index, location and illness severity play a role in determining use of private, public or non-formal providers. The results indicate that from a policy perspective, the Indonesian government needs be inclusive rather than exclusive in the choice of providers that are contracted by the managed care plans, in order to safeguard the health of the under-five population.

Maternal morbidity and mortality are high in the Indian context, but the majority of maternal deaths could be avoided by prompt and effective access to intrapartum care (WHO, 1999). Understanding the care seeking responses to intrapartum morbidities is crucial if maternal health is to be effectively improved, and maternal mortality reduced. This paper presents the results of a prospective study of 388 women followed through delivery and traditional postpartum in rural Karnataka in southern India. In this setting, few women use the existing health facilities and most deliveries occur at home. The analysis uses quantitative data, collected via questionnaires administered to women both during pregnancy and immediately after delivery. By virtue of its prospective design, the study gives a unique insight into intentions for intrapartum care during pregnancy as well as events following morbidities during labour. Routine care in the intrapartum period, both within institutions and at home, and impediments to appropriate care are also examined. The study was designed to collect information about health seeking decisions made by women and their families as pregnancies unfolded, rather than trying to capture women’s experience from a retrospective instrument. The data set is therefore a rich source of quantitative information, which incorporates details of event sequences and health service utilization not previously collected in a Safe Motherhood study. Additional qualitative information was also available from concurrent in-depth interviews with pregnant women, their families, health care providers and other key informants in the area. The level of unplanned institutional care seeking during the intrapartum period within the study area was very high, increasing from 11% planning deliveries at a facility to an eventual 35% actually delivering in hospitals. In addition there was a significant move away from planned deliveries with the auxiliary nurse midwive (ANM), to births with a lay attendant or dai. The proportion of women who planned for an ANM to assist was 49%, as compared with the actual occurrence, which was less than half of this proportion. Perceived quality of care was found to be an important factor in health seeking behaviour, as was wealth, caste, education and experience of previous problems in pregnancy. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements. As a response to serious morbidities experienced within the study period, many women were able to seek care although sometimes after a long delay. Those women who experienced inadequate progression of labour pains were most likely to proceed unexpectedly to a hospital delivery.

This paper examines age patterns of first marriage and motherhood and covariates of early marriage, delayed consummation of marriage and early motherhood in Nepal using data from the 2000 Nepal Adolescent and Young Adult Survey (NAYA). Both unmarried and married male and female youths (age 14–22) were included in the survey. The analysis is based on 2800 urban youths and 5075 rural youths with complete information on the variables examined. Proportional hazard models are used to estimate covariates of early marriage and early motherhood, and logistic regression models are used to estimate covariates of delayed consummation of marriage. The results show that early marriage and early motherhood are quite common among Nepalese women, especially in rural areas. Early marriage is much less common among men. Delayed consummation of marriage is common among very young brides, especially in rural areas. The main covariates associated with early marriage and early motherhood are respondent’s education, region of residence and ethnicity. The main covariates of delayed consummation of marriage are age at first marriage, region of residence and ethnicity. The study highlights the need to focus on less educated female youths in the Terai region in order to reduce the reproductive and child health risks associated with early marriage and early childbearing.

some propositions on male and female sexual orientation will be considered. some of these are established; others are more speculative. the aim is to offer some notes towards a coherent, comprehensive theory of sexual orientation. 1. the distinction between butch and femme lesbians seems real rather than a social construct. 2. high levels of prenatal steroid hormones seem to be causally associated with the sexual orientation of butch lesbians. however it is not established whether the causal process operates prenatally or postnatally (or both). this is so because prenatal hormone levels are thought to correlate positively with postnatal hormone levels. and high postnatal hormone levels may facilitate homosexual behaviour as a consequence of sensation-seeking. 3. male bisexuals also are interpreted to have been exposed to high prenatal testosterone levels. but (for reasons similar to those outlined above in regard to butch lesbians) it is unclear whether these have a direct prenatal effect on the brain or whether they are precursors of high postnatal testosterone levels, which are associated with male bisexual orientation by promoting sensation-seeking behaviour. 4. postnatal learning processes seem to be causally involved in the sexual orientation of some femme lesbians and some exclusive male homosexuals. 5. some homosexual men have genes that predispose to their sexual orientation. 6. the same may apply to some lesbians, but such genes have not, as far as i know, been identified. 7. people (of both sexes) who engage in same-sex sexual behaviour may be classified simultaneously in two ways, viz (1) ‘active’ vs ‘passive’ and (2) those who do and those who do not engage (or consider engaging) in sex with members of the opposite sex. ex hypothesi, some of the ‘active’ ones initiate some of the ‘passive’ ones. the active ones are driven more by hormones and the passive ones by psychosocial factors. the active males contain a substantial proportion of self-identified bisexuals; and the active females a substantial proportion of self-identified butches. 8. these two active categories (butch lesbians and male bisexuals) share a number of endocrinological, psychological, morphological and behavioural features vis-à-vis their exclusively homosexual and heterosexual peers. methods of testing some of these ideas are presented.

Millions of children who were born during the first decade after the Islamic revolution in Iran are now reaching the age of marriage and childbearing. Short spacing between marriage and the birth of the first child has the potential to cause an excessive and costly increase in the growth of population in Iran. Research into the motivations for the birth of first child among newly married couples can create a knowledge base that will enable health centres to help these couples make better decisions about the timing of their first pregnancy. Using a consecutive sampling technique and administering Miller’s Childbearing Questionnaire, data were gathered regarding the childbearing motivations and desires of 300 couples who had been referred to the Shiraz Health Center for premarital counselling. The Childbearing Questionnaire, with some minor modifications, was found to be a valid and reliable instrument for measuring the childbearing motivations of newly married couples of Shiraz County, Fars Province, Iran. The utility of these findings for counselling in health centres is discussed. Based on the results, a longitudinal study is being designed that will allow the development of models for predicting the time of first pregnancy after marriage.

This study aimed to determine the factors influencing the use of spacing contraceptive methods in India, particularly from men’s perspective. Data were obtained through a semi-structured interview schedule from 2687 married men aged between 18 and 40 years from central Mumbai City, India, during 1999. Chi-squared tests and binary logistic regression analysis was carried out to determine the relationship between various variables and the likelihood of a couple using spacing contraceptive methods. Of the 2687 couples, 1395 (51·9%) were using one or other method of spacing contraceptives and 1292 (48·1%) were not using any method at the time of survey. Male participation in contraceptive use was 23% (condom and withdrawal). The results indicate that the use of spacing contraceptive methods was significantly higher among those couples where the men desired one or two children (OR=4·3), had knowledge of five or more contraceptive methods (OR=1·9) and discussed with their wives obtaining family planning information (OR=3·2), spacing (OR=2·7) and permanent (OR=2) contraceptive methods. Age, income, desired number of children, knowledge of a greater number of contraceptive methods, inter-spouse communication regarding obtaining family planning information, spacing and permanent methods were found to be strong predictors of the use of spacing contraceptive methods. The study underlines the importance of intervention programmes aimed at promoting a small family norm, increasing the number of contraceptive choices available and encouraging inter-spouse communication. Hence, policymakers and programme managers should encourage interventions in this direction, targeting couples to enhance the use of spacing contraceptive methods.

The Sundanese inhabiting West Java, the second largest ethnic group in Indonesia, are characterized by a high prevalence of child malnutrition, together with high fertility. Based on an anthropometric measurement and interview survey of 310 children aged 5–12 years in a rural Sundanese village, this study examined the relative significance of the effects of eight biological, eight socioeconomic status (SES) and four health behavioural factors on their Z scores for height-for-age (HAZ) and weight-for-age (WAZ) in particular. Three biological factors, i.e. birth interval, birth weight and mother’s body weight, and one SES factor, i.e. mother’s occupation, were selected as the predictors of the two Z scores by regression analysis, indicating more significant effects of the biological factors than the other factors. This pattern is judged to occur in less-developed and high-fertility populations. Since these two Z scores were worse in the subject children than in the under-5-year-old children from the same village, more attention should be paid to the long-lasting effects of birth-related biological factors up to pre-adolescent ages, as an insufficient nutritional status tends to damage growth and health in adolescence and adulthood.

The aim of this study was to determine men’s perceptions about family planning and how they participate or wish to participate in family planning activities in Mpigi District, central Uganda. Four focus group discussions were conducted with married men and with family planning providers from both the government and private sector. In addition, seven key informants were interviewed using a semi-structured interview guide. The results indicate that men have limited knowledge about family planning, that family planning services do not adequately meet the needs of men, and that spousal communication about family planning issues is generally poor. However, almost all men approved of modern family planning and expressed great interest in participating. The positive change of the beliefs and attitudes of men towards family planning in the past years has not been recognized by family planning programme managers, since available services are not in line with current public attitudes. A more couple-oriented approach to family planning is needed. Measures could include, for example, recruiting males as family planning providers, offering more family planning counselling for couples, and promoting female-oriented methods with men and vice versa.

Following the 1994 UN International Conference on Population and Development, there was a shift in emphasis on women’s reproductive health and there emerged a need for more knowledge about levels and differentials of infertility. Using the data from the 1988 National TwoPer-Thousand Sample Survey on Fertility and Contraception, this paper estimated the prevalence of primary infertility in China. To determine the predictors of primary infertility, multiple logistic regression analyses were done on three minority province/autonomous regions where primary infertility was the highest. A non-contracepting, sexually active woman was considered to have primary infertility if she had not reported a recognized pregnancy after at least seven years of marriage. The analysis shows that the national level of primary infertility was relatively low (1·3%). Primary infertility was higher in Qinghai (2·3%), Tibet (3·7%) and Xinjiang (3·7%) compared with other provinces. Tibetans in Qinghai and Uygurs in Xinjiang had a higher level of primary infertility than the Han Chinese. Ethnic differences remained after adjusting for other background characteristics. Divorced and remarried women had significantly higher odds of primary infertility compared with first-married women in Qinghai and Xinjiang. The elevated level of primary infertility in Qinghai, Tibet and Xinjiang and its disproportionate prevalence among Tibetans and Uygurs highlight the need for further work to understand the causes and social consequences of infertility for the minority population in China.

Official figures show that life expectancy in Costa Rica is longer than in the United States (US), in spite of the fact that per capita health expenditure is only one-tenth that of the US. To check whether this is for real and to explore some of its determinants, 900 Costa Ricans aged 60+ were followed from 1984 to 2001. Follow-up household visits were made, deaths were tracked in the national death registry, and survival status in the voting registry was double-checked. In addition, the survivors were contacted in 2002. Two-thirds of the panel had died by December 2001. Kaplan–Meier curves, life tables and Cox regression were used to analyse the panel’s survival. Mortality in the panel was slightly higher than the Costa Rican average and similar to that in the US, confirming the exceptional longevity of Costa Ricans. Survival was substantially lower among unmarried men and individuals with limited autonomy at the beginning of the study. The effect of socioeconomic status is weak. Insurance effects seem to be confounded by selection biases.

Surnames were obtained for the second half of the 20th century from civil and religious marriage registers on fifteen Provençal-Italian and five Italian villages of Cuneo Province, Italy. To insert in the analysis an outward comparison, surnames from two Italian villages of Turin Province, one parish of Turin, one village of Alessandria Province and one village of Asti Province were also collected. Ethnicity does not seem to be the main factor affecting the present genetic structure of the Provençal-Italians. They are an open community, and evidence the end of the genetic isolation of the alpine populations.

the paper discusses factors associated with sexual risk behaviour, i.e. failure to use condoms consistently during sexual intercourse, among unmarried sexually experienced youths in south africa. data from the ‘transitions to adulthood in the context of aids in south africa’ surveys of 1999 and 2001 were analysed to identify factors associated with high sexual risk behaviour among the youth. the multinomial regression models for male and female youths were fitted separately for the 1999 and 2001 data sets. the results show increasingly consistent use of condoms during sexual intercourse and that high sexual risk behaviour among youths is predominantly determined by social factors such as ‘ever-pregnant’ or ‘ever made pregnant’, ‘ever given something for sex’, age of sexual partner, currently in school, pressured by friends to have sex, peer influence on safe sex and education level for males. there is evidence that availability of contraception information is important in strategic interventions that seek to change the sexual behaviour of the youth in south africa.

The aim of this analysis was to examine the effects on stature in two nationally representative samples of Polish 19-year-old conscripts of maternal and paternal education level, and of degree of urbanization, before and after the economic transition of 1990. Data were from two national surveys of 19-year-old Polish conscripts: 27,236 in 1986 and 28,151 in 2001. In addition to taking height measurements, each subject was asked about the socioeconomic background of their families, including paternal and maternal education, and the name of the locality of residence. The net effect of each of these social factors on stature was determined using four-factor analysis of variance. The secular trend towards increased stature of Polish conscripts has slowed down from a rate 2·1 cm per decade across the period 1965–1986 to 1·5 cm per decade between 1986 and 2001. In both cohorts, mean statures increase with increasing size of locality of residence, paternal education and maternal education. The effect of each of these three social factors on conscript height is highly significant in both cohorts. However, the effect of maternal education has increased substantially while that of size of locality of residence and paternal education diminished between 1986 and 2001. These results imply that the influence of parental education on child growth cannot be due solely to a relationship between education and income, but is also perhaps a reflection of household financial management which benefits child health and growth by better educated parents, regardless of level of income. In addition they suggest that, irrespective of whether there are one or two breadwinners in the family, it is the mother, more so than the father, who is principally responsible for the extent to which such management best favours child health and growth. The asymmetry between the importance of maternal as against paternal education for child growth, clearly seen in the 1986 cohort, became more accentuated in 2001, after the abrupt transition from a command to a free-market economy in the early 1990s.

This study further examined the negative association between boys’ growth and the presence of sisters within a relatively affluent community in Taipei, Taiwan. Among 596 boys born in 1976–77, differences in height and log-transformed weight were judged using analysis of covariance (ANCOVA) with measurement age as a covariate, and parental education level (four levels), number of sisters (0, 1, 2 or 3+) and number of brothers (0, 1, 2+) as predictors. The relative importance of birth order and sibling sex was examined among the near majority of boys with one sibling (47%, 278/596). The sibling composition variable was defined using mutually exclusive categories representing individuals with one sibling: either one older or younger brother or sister. All boys contributed information before leaving middle school at a mean age of 14·9±0·4 years SD. The results were compared with similar analyses of data for 154 of these same boys for whom measurements were available from primary school entry at a mean age of 6·4±0·3 years SD onward. Results were also compared with data for a cohort of 153 boys who entered primary school later in 1986. Results confirm that boys from the Da-an area born in the mid-1970s who did not have sisters were significantly taller (2·2–2·5 cm, p≤0·008) and heavier (3·0–3·9 kg, p≤0·016) than those with one or two sisters. However, the 26 boys with three or more sisters, most of whom were last-born, were somewhat taller than those with one or two sisters. The same curvilinear relationships in height and weight appeared both among boys as they prepared to leave middle school and among the subset also measured just after entering primary school. When numbers of sisters were statistically controlled, the presence of two or more brothers was also significantly negatively associated with mean stature, but not weight, among middle school boys. Analyses among boys with one sibling revealed that birth order was associated with mean stature, but only if the sibling was female; an older sister was associated with a greater deficit in mean stature than a younger sister. Evidence of rising educational expectations, continued declines in family size with fewer gender-related differences in numbers of siblings, and a clear secular increase in body size in this community among children entering primary school from 1982 to 1986 suggest a possible explanatory model.

this paper explores client satisfaction with abortion care, looking at overall satisfaction and satisfaction with hygiene, comfort and courtesy. the analysis aimed to determine whether client satisfaction was related to the characteristics of the client, in order to guide quality improvement efforts. the analysis is a secondary analysis of data collected in a survey of 489 abortion clients who attended a limited number of hospitals in three cities in russia. the data were analysed using logistic regression. client characteristics, in general, did not affect overall satisfaction though there were significant differences in overall satisfaction for unmarried versus married women (or=0·29, ci=0·13, 0·63). similarly, most characteristics of the abortion visit were not related to client satisfaction, although women who were awake for the procedure were less likely to be satisfied (or=0·37, ci=0·16, 0·89). information provided to abortion clients about self-care was the most important predictor of overall satisfaction for abortion clients (or=3·55, ci=1·64, 7·69). this suggests that improving the information provided to clients, through training providers and other staff, is important in these settings.

The paper aims to provide evidence on consistent condom use dynamics among sex workers in Central America between 1997 and 2000, and to examine the most important predictors of use behaviour important for policy and programme interventions in the region. Data on 3500 sex workers, 1500 from 1997 and 2000 from the year 2000, were analysed. The samples represented sex workers in low socioeconomic neighbourhoods who met their clients at known sex establishments or by the roadside. Sex workers were more likely to have used condoms consistently in 2000 than in 1997 (Odds Ratio (OR)=1·4, p≤0·05). Sex workers who discussed condoms with their partners or lovers used them consistently with all clients more than those who did not (OR=1·3, p≤0·10). Knowledge of condom advantages had a positive influence on consistent use. Sex workers who reported using condoms to prevent pregnancy or STDs used them consistently with all clients more than those who did not (OR=1·2, and 1·3 respectively, p≤0·10). The source of condoms is an important predictor of consistent condom use. Sex workers who bought condoms from health establishments or from brothels used them consistently more than those who did not (both OR=1·3, p≤0·10, and p≤0·05, respectively). Self-efficacy had a positive effect on consistent condom use. Sex workers who reported that they would use condoms even if clients offered to pay more for unprotected sex used them consistently with all clients more than those who did not (OR=1·8, p≤0·001). The findings suggest that having condom skill is positively related to condom use. Sex workers who had all four skills used condoms more consistently than those who had none (OR=1·6, p≤0·01). In order to increase consistent condom use and avert more incidences of HIV/AIDS and other STIs, programme interventions need to use the most efficient way to provide quality information, and provide repeated training on condom negotiation and use skills to sex workers.