Few studies have attempted to examine why the observed racial disparity in unintended pregnancy exists between African-American and White women. This dissertation combines alternative theories of adolescent childbearing in socially disadvantaged African-American communities, results of preliminary qualitative work, and a quantitative survey approach to build an explanation for the elevated risk of unintended pregnancy among African-American women, and thus the observed racial disparity. It hypothesizes that elevated levels of unintended pregnancy, estimated by a nationally recognized survey called the National Survey of Family Growth (NSFG), might be explained by the high adolescent pregnancy rate and the over-report of the unintended status of those adolescent pregnancies. To examine over-report of unintended pregnancy, this study uses a New Orleans case study to: (1) quantitatively explore experimental measures of two dimensions of pregnancy intentions: valorization of motherhood and the perceived importance of pregnancy timing; (2) determine which dimension is more congruent with women's contraceptive and childbearing behavior; and (3) assess the relationship between the two dimensions and the NSFG intention categories / acase@tulane.edu

Human African trypanosomiasis, or sleeping sickness, is a parasitic disease affecting rural populations in up to 36 countries in Africa. Sixty million people are at risk for the disease but surveillance is poor. An estimated 300,000 new cases occur each year with 100,000 deaths. Sleeping sickness is invariably fatal if left untreated. The medications used to treat sleeping sickness were developed more than 50 years ago and have severe adverse side effects. Few alternatives are available. From five to thirty percent of late-stage patients suffer treatment failures (relapse) and recent evidence suggests that the rate of treatment failure in many sleeping sickness endemic areas is rising. Given the lack of alternative medication, the decrease in effectiveness of first-line medications for sleeping sickness is alarming If sleeping sickness patients can be identified as likely to relapse, treatment regimens could be altered to improve outcomes. During a sleeping sickness epidemic in Tambura County, South Sudan, 2,324 cases were treated, with 180 relapses (7.8%), between 1997 and 1999. Clinical and demographic variables were examined for their predictive value for relapse in Pearson's Chi-square, Kaplan-Meier and Cox regression analyses. Relapse rates were documented for a number of sub-populations and the temporal aspects of treatment failure were explored. Finally, the geographic distribution of sleeping sickness cases was investigated for trends, an indication of drug resistant strains While controlling for the effects of other variables, trypanosomes in cerebrospinal fluid (CSF) doubled the risk of relapse (RR: 1.98, 95% CI: [1.30--3.01]) and an elevated CSF white blood cell count resulted in a two percent increased risk for every increase of 10 cells/mm3 CSF (RR: 1.002, 95% CI: [1.001--1.003]). Evidence of trypanosomes in the lymph system and gender were also predictive of relapse, but to a lesser degree. The rate of relapse in the population was 20.1/1000 person-months, or 15.3% of the population. Eighty-five percent of relapses occurred in the first year post treatment and time-to-event analyses indicated that time does not influence the probability of relapse. There was little evidence of geographic clustering of relapse cases and therefore, no indication of drug-resistant strains of trypanosomiasis / acase@tulane.edu

This study examines the feasibility of utilizing focus group research as an alternative to a knowledge, attitude and practice (KAP) survey. Data from focus group research on male attitudes towards voluntary sterilization and other family planning issues is compared to a sample survey conducted among the same population. Both studies shared the same objectives. The principal objective of the comparison is to evaluate whether the focus groups provide comparable results for program planning purposes The study was conducted from May to August of 1987 in low-income semi-urban areas of Tegucigalpa and San Pedro Sula, Honduras. Twelve focus group sessions were conducted among men between the ages of 30 and 50. Subsequently, a household survey of 959 men in this age range was conducted in the same communities The research content was broken down into 43 variables and each variable was classified on the basis of the agreement between the results from the focus groups and the survey. It was found that for the majority of the variables examined, (62.8 percent) the results were classified as similar or highly similar. The focus groups provided more information for a somewhat higher number of variables (24.4 percent) than the survey, (24.4 percent to 19.5 percent, respectively). The focus group information was found to be more complete with respect to attitudinal variables, while the survey was found to be stronger for the provision of information concerning population characteristics of the population, knowledge and practices. The focus groups also provided more information for a majority of the variables which related directly to program planning (those which reflected potential demand and population preferences concerning services) The final conclusion of the study was that for the purposes of program management and planning, the results of focus group research can be comparable to those derived from a KAP survey. Furthermore, the focus group research can be conducted at a much lower cost (18 percent of the cost of the survey) / acase@tulane.edu

Background. A policy of voluntary HIV counseling and testing (VCT) was mandated for antenatal care (ANC) facilities in Thailand in 2000. This study evaluated the VCT program in government ANC facilities in Bangkok. The goal of the study was to determine what factors motivate pregnant women to test and return for their test results, and to evaluate the relationship between testing and HIV risk perception and knowledge of prevention of mother-to-child HIV transmission (PMTC) Methods. This ANC clinic-based study combined 5 focus group discussions with pregnant women, 10 key informant interviews with ANC clinic staff and a cross-sectional survey of pregnant women (n = 675). Fourteen ANC facilities were randomly selected and women were surveyed using a self-administered questionnaire in December 2003 Results. Percentage of participants receiving the HIV test was 98%. Of those tested, 98% planned to return to hear their test results. However, key informants revealed that, while the Thai policy is that the HIV test is voluntary, in practice the test is not voluntary and all women must test Knowledge of PMTC was low. Only 42% of women reporting knowing about medicine for PMTC and 44% reporting that they knew any method of prevention. Higher income was associated with knowing a method of PMTC (p = 0.037). Only 4% often worried about risk of HIV from their partner and 19% sometimes worried. Low perception of risk from partner was associated with education level higher than compulsory (p = 0.014) and being in their first pregnancy (p = 0.014). High perception of risk from partner was associated with being unmarried (p = 0.001), recent migration to Bangkok (p = 0.010), lower income (p = 0.040), not knowing if partner had ever tested for HIV (p = 0.033) and ever discussing the HIV test with partner (p = 0.033) Conclusions. Acceptance of the HIV test and intent to return is nearly universal and both pregnant women and ANC staff strongly support the testing program. However, women are not allowed access to ANC services without having the HIV test. Both knowledge of PMTC and HIV risk perception from partner were low / acase@tulane.edu

Individuals who are unable to achieve an undetectable plasma HIV-1 RNA level (viral load) after the initiation of highly active antiretroviral therapy (HAART) may be at an increased risk of accelerated virological rebound. The purpose of this study was to determine how the six month viral nadir in response to HAART is related to the future probability of virological rebound A non-concurrent cohort study of all HIV-infected, protease inhibitor and non-nucleoside reverse transcriptase inhibitor naive individuals initiating HAART at the HIV Outpatient Program clinic in New Orleans, LA between January 1997 and December 2000 was conducted. Patients were followed for six months in order to allow sufficient time to achieve their virological nadir. At six months, patients were classified as complete responders (undetectable viral load), incomplete responders (>400 copies/mL and &ge;0.5 log10 decrease in the viral load) or non-responders (<0.5log10 decrease in the viral load). All patients were then followed to virological rebound (&ge;0.5 log10 increase in the viral load) or study end. Multivariate logistic and Cox proportional hazards regression were used to examine predictors of achieving an undetectable plasma HIV-1 RNA level six months after the initiation of HAART and experiencing treatment failure after the viral nadir had been achieved Of the 1755 participants included in the analyses, 76% were male, 64% non-white, 39% had a baseline CD4 cell count &le;200 cell/mm3, 58% had a baseline viral load &le;10,000 copies/mL, and 29% had prior medication experience. In multivariate analyses, individuals with the greatest degree of immune suppression were at the greatest risk of virological rebound. The prognostic significance of an intermediate response to HAART was most apparent for individuals who began HAART with a baseline plasma HIV-1 RNA level greater than 30,000 copies/mL. These individuals were 2.22 (95% C.I. 1.25, 3.93) times more likely to virological rebound than individuals who began HAART with a baseline viral load <10,000 copies/mL. Patients with incomplete responses to HAART at six months remained at a significantly greater risk of virological rebound. Intensification strategies may be warranted in this population / acase@tulane.edu

This dissertation examines the postulated socio-demographic, economic and malaria-related factors that affect whether an innovative malaria prevention strategy could be successfully adopted as an effective and sustainable disease prevention program in Samburu District, northern Kenya. An efficacy trial, conducted in the same area, had demonstrated that insecticide-treated shukas (ITSs), locally worn wraps and bed-sheets, had the potential to reduce malaria transmission. While these are exciting results, they do not address how this strategy would operate outside of controlled, study-trial conditions A mixed-method research design using both qualitative and quantitative data collection methods explored four research questions related to this topic: (1) Was the population willing to impregnate their personal clothing with a chemical insecticide? (2) Would community household heads agree to participate in community-wide impregnation efforts? (3) Were household heads willing to pay for insecticide treatment of shukas? and, (4) What was the maximum amount that household heads would agree to pay for ITSs? Data collection took place during two phases. Rapid ethnographic techniques, including in-depth interviews and focus group discussions, were used to collect information related to the ethnomedical and socio-cultural context of febrile illnesses including malaria in the study area. Results from these activities informed the design of a structured questionnaire used to conduct a community-based household survey, including a contingent valuation component in Phase 2 of the research Ethnomedical results indicate that two local illness terms, nkirewa---'fever' and nkirewa enkajingani ---'fever of mosquitoes', approximate the biomedical definition of malaria infection. Moreover, triangulated qualitative and quantitative information demonstrate an inverse association between the perceived severity of the illness constructs and treatment seeking at the local dispensary. With regard to the specific study questions, approximately 9 out of 10 household heads were willing to impregnate their shukas (97.3%), participate in impregnation efforts (87.7%), and pay for ITSs (91.1%). However, the maximum amount that individuals were willing to pay per shuka treated (mean 24 Ksh; median 15 Ksh) will necessitate subsidization by the implementing organization if ITSs are to be offered as a malaria prevention option / acase@tulane.edu

Background. Influenza is recognized as an important cause of illness, death, and economic losses in developed countries in temperate climates but little is known about influenza in developing tropical countries such as Thailand. Information is needed to guide national vaccine policy decisions Methods. The status of influenza surveillance, research, and vaccination in Thailand was reviewed. To describe the incidence and seasonality of influenza, between September 2003 and August 2004 all patients hospitalized with pneumonia and a sample of outpatients with influenza-like illness in a rural province was prospectively identified. Influenza infection was confirmed by cell culture, RT-PCR, serology, and a rapid influenza diagnostic test. Rapid test performance was compared to cell culture and RT-PCR. Medical record reviews, patient interviews, and national economic data were used to estimate losses due to influenza. Provincial data were extrapolated to construct national estimates of disease burden and cost Results. Vaccine distribution figures indicate that less than 1% of the population is immunized against influenza. The sensitivity and specificity of the rapid influenza test compared to viral culture was 77% and 96%, respectively. Influenza was identified in 80 (11%) of 761 pneumonia patients. The incidence of influenza pneumonia requiring hospitalization was between 18-111/100,000 population with a projected 12,575 and 75,801 hospitalizations nationwide. Children < 5 years of age and adults &ge; 60 experienced the heaviest burden. Influenza was confirmed in 252 of 1092 (23%) of ILI cases with peak activity in June-October resulting in a projected 924,478 outpatient visits nationwide. Influenza caused a projected U.S. $23.4 and $62.9 million in economic losses. The incidence of influenza was 1,420/100,000, a rate 43 fold greater than reported by the national passive surveillance system during the same period Conclusion. During 2003-04, influenza was a leading cause of severe pneumonia requiring hospitalization and an important cause of outpatient visits in Thailand. The seasonality of influenza suggests that March and April may be the most appropriate months to vaccinate. Economic losses attributable to influenza were substantial. Thailand's growing economy and effective immunization program may allow the country to consider targeted influenza vaccination to reduce the burden of disease / acase@tulane.edu

Background. Birth weight (BW) has been found to be associated with cardiovascular (CV) mortality and morbidity, as well as with an adverse profile of many CV risk factors. One possible mechanism mediating the relationship between BW and adulthood risk of CV diseases is an increased arterial rigidity in persons with low BW Methods. Between 1973 and 2001, seven cross-sectional surveys of children 5--17 years and 7 cross-sectional surveys of young adults 18 to 44 were conducted in the Bogalusa Heart Study (BHS). Names of 2780 volunteers were included in the study. A subgroup (n = 835) for whom PWV measurements were available, were assessed for the relationship between BW and arterial rigidity. All clinical and laboratory measurements were obtained according to the established protocol of the BHS. Brachial-ankle pulse wave velocity was measured using oscillometric instrument. Lifestyle, socio-economic and family history data were obtained using standard questionnaires. Birth data were obtained from subjects' birth certificates Results. Birth weight was inversely associated with serum triglycerides (p < 0.01), total cholesterol (p = 0.053), HOMA-IR (p < 0.01), systolic BP (p < 0.01), diastolic BP (p = 0.01) and PP (p < 0.01), but was not associated with LDL-C or HDL-C (p = 0.14 and p = 0.40 respectively). Birth weight was inversely associated with baPWV and PP, adjusting for age, gender, ethnicity and BMI (beta = -24.1; 95% CI = -46.5, -1.7 and beta = -0.9; 95% CI = -1.7, 0.0 for PWV and PP outcomes, respectively) The interaction of BW with ethnicity was not significant for any outcome. In persons born at term, the interaction was significant only for total cholesterol levels and the association was stronger in AA than in Whites beta = -11.5, p < 0.01 and beta = -1.2, p = 0.48 in AA and Whites, respectively) Conclusions. Birth weight was inversely associated with later blood pressure, plasma triglycerides and insulin resistance. The relationship between birth weight and CV risk factors development did not differ between African-Americans and Whites. Persons with lower birth weight tended to have stiffer arteries and the relationship between low birth weight and increased PP is stronger in whites than in African-Americans / acase@tulane.edu

The present study was conducted to determine if the well-documented adverse effects of a sedentary lifestyle on cardiovascular disease risk in adults could be detected in children. A sample of 71 fifth and sixth grade children in an elementary school in Metairie, Louisiana were screened for cardiovascular disease risk factors. A 3-day activity diary was used to assess (1) average daily energy expenditure, and the usual amount of time spent at (2) leisure sport activities and (3) active sport activities. Physical fitness levels were assigned according to performance on a 1-mile run/walk In girls, all three measures of physical activity were inversely associated with systolic blood pressure, diastolic blood pressure and percent body fat. In addition, quantity of time spent at leisure and total sport activities was negatively correlated with total and LDL cholesterol. Increased level of fitness was associated with lower diastolic blood pressure (p $<$ 0.05), total cholesterol, LDL, the LDL/HDL ratio, and estimated percent body fat (p $<$ 0.001). Among boys, only time spent at leisure sport activity demonstrated inverse associations with systolic blood pressure, total cholesterol, LDL, and the LDL/HDL ratio. Increased fitness levels were equated with lower systolic (p = 0.07) and diastolic blood pressure, the LDL/HDL ratio (p = 0.08), and percent body fat (p $<$ 0.0001). Positive correlations among fitness and HDL were observed for both sexes, but they were statistically significant only for the boys (p $<$ 0.01) The fitness-risk factor associations were always of greater magnitude than the physical activity-risk factor associations. These preliminary data suggest that the adverse effects of a sedentary lifestyle may already be evident in childhood / acase@tulane.edu

This dissertation represents the first formal investigation of malaria during pregnancy in the hypoendemic regions of the Peruvian Amazon lowlands. The three manuscripts presented demonstrate a progression in the assessment of malaria among pregnant women in this region, and provides new insight into the characteristics of malarial infection during pregnancy. The first manuscript used passive and active surveillance to investigate the prevalence of symptomatic clinical malaria and incidence of malarial infection of pregnant women in communities surrounding Iquitos, Peru. The results demonstrated that pregnant women in this region have an increased risk of P. falciparum infection, and not P. vivax infection, compared to non-pregnant women of the same age group [OR=2.3, 95% CI (1.3, 3.9) p = 0.004]. The second manuscript reports the frequency of malarial infection as detected by microscopy, PCR, and serologic responses in a hospital-based cross-sectional study of pregnant women at delivery. A low frequency of enrolled subjects were parasitemic at time of delivery, however 87% demonstrated an IgG or IgM response to the merozoite surface protein of either P. vivax or P. falciparum. Specific IgM responses to P. vivax were significantly associated with decreased infant birthweight and gestational age (p = 0.01 and p = 0.06). The third manuscript describes the frequency of placental infection in the study population, and compared the placental pathology between infected and non-infected in a case-control analysis. None of the placentas were parasitemic at the time of delivery, but 23% had malaria pigment, indicating past placental infection. Cases with placental hemozoin had increased monocytes in the intervillous space compared to controls with no hemozoin (44.7 vs. 25.5, p=0.012). Pigmented monocytes were found in fetal vessels of 33% of cases indicating that parasites may breach the placental barrier, and that congenital infection may occur frequently. In conclusion, this dissertation provides evidence for a high frequency of subclinical malarial infection during pregnancy, indicating that pregnant women in this region may have developed a protective immunity to clinical malaria. Further studies are necessary to gain a greater understanding of the factors associated with subclinical malarial infection during pregnancy and the apparent protection from clinical disease / acase@tulane.edu