While many national family planning programs in developing countries are emphasizing improvements in service quality to increase contraceptive use, there is little empirical evidence to support this relationship due to limited data on how programs function. This paper presents data from a pilot study conducted in Morocco that links quality of care measures from public family planning facilities to contraceptive use data from the 1992 Morocco Demographic and Health Survey to investigate whether the quality of family planning services affects the contraceptive use of women who reside in the same area, controlling for individual, household, and community characteristics. In addition, the methodological issues involved in measuring quality and linking quality measures to contraceptive use are discussed. Several indicators of quality were found to be significantly related to contraceptive use net of individual, household, and community variables. However, further research is needed to improve the linkage of facility-based quality of care measure and population level data on contraceptive use / acase@tulane.edu

Population based estimates of recent incidence and prevalence of HIV are needed to effectively plan and evaluate programs for prevention, treatment, and services. Historically, backcalculation techniques were used to reconstruct the HIV epidemic by applying estimated incubation period distributions to AIDS incidence data, yielding imprecise estimates. Since then, these methodologies have been complicated by additional theoretical considerations. In addition, population-based detection rates among infected persons in Louisiana have not been examined. The purpose of this dissertation was to develop a valid and reliable model to estimate HIV incidence and detection rates among infected persons in Louisiana A time-inhomogeneous discrete Markov model of disease progression, detection, and treatment was developed and applied to quarterly HIV/AIDS surveillance data reported to the Louisiana health department, including HIV (non-AIDS) data, from 1981 to 1996. The model estimated incidence and stage-specific detection rates based on joint distributions of HIV detection and AIDS diagnosis dates for selected demographic and risk subgroups. The development of the model addressed the 1993 change in the AIDS case definition, pre-AIDS mortality, reporting delays, flexible treatment uptake and response, changes in detection over calendar time and stage of disease progression, and inclusion of casts with missing risk Evenly distributed across the three major risk groups, the total estimated number of new infections was 1,300 cases (plausible range: 1,200--1,500) in 1996. Of the estimated 20,500 (19,850--21,250) cases infected by 1996, 14,800 were alive and two-thirds had been detected and reported. Incident cases among women and African-American men were double those of white men. Incidence trends indicated a steady increase in high-risk heterosexual transmission and a substantial decrease among men who have sex with men. Detection rates increased steadily from 1985 until 1993, after which they remained stable across all subgroups. Due to the changes in detection, trends in HIV surveillance data were not good indicators of incidence. In addition to elucidating issues regarding the interpretation of HIV surveillance data, the methodology provided a viable and flexible approach to addressing the current data needs while accounting for some of the major challenges in monitoring the HIV/AIDS epidemic in Louisiana / acase@tulane.edu

Background. Although monetary poverty is undoubtedly a primary cause of increased vulnerability to HIV/AIDS, there is a growing body of literature that stresses the need to explore and document other, largely invisible, assets at the community-level that may be used to mitigate the negative association between 'poverty' and increased HIV/AIDS risk for adolescents. Objective. Determine if the significant association between household poverty and increased participation in HIV sexual risk-taking behaviors is attenuated by neighborhood characteristics of social organization (human capital, social capital, neighborhood physical conditions and safety). Methods. 3,052 South African youth between the ages of 15--22 were interviewed and included in the study. In addition, information was collected from 2,007 households, as well as information regarding 113 of the surrounding enumeration areas (EAs) through direct community observation. Contextual models were run for three sexual risk-taking behaviors of interest: Timing of sexual initiation, condom use at sexual initiation, and the consistent use of condoms with up to three partners. Results . Overall, human capital appeared to have the strongest mitigating effect on the poverty-sexual risk-taking behavior relationship for boys. Community-level social organization, however, did not attenuate girls' risk of increased sexual risk-taking behaviors. In fact, the negative effect of poverty on girls' increased risk for HIV/AIDS was often exacerbated when factors at the structural level were taken into account. Conclusions. The results of this study indicate that while HIV/AIDS risk may decrease for disadvantaged boys living in more socially organized neighborhoods, poverty remains a primary HIV/AIDS risk factor for girls, regardless of the available assets at the community level / acase@tulane.edu

Objective. To examine risk factors for end-stage renal disease (ESRD) incidence in 158,982 men and women aged 40 years or older over 10 years of follow-up in China Methods. Baseline blood pressure (BP), body weight, height, cigarette smoking, alcohol consumption, and history of cardiovascular disease (CVD) were collected as part of the 1991 China National Hypertension Survey. Follow-up, conducted in 1999--2000, included an in-person interview and review of hospital records and death certificates to identify ESRD cases. Time-to-event methods were used to examine the relationship between baseline risk factors and the incidence of ESRD Results. During 1.2 million person-years of observation. 382 participants (30.8 cases per 100,000 person-years) initiated renal replacement therapy (n = 122) or died from renal failure (n = 260). A strong, graded, and significant relationship between BP and incidence of all-cause and glomerulonephritis-related ESRD was present, independent of age, gender, geographic region, education, cigarette smoking, alcohol consumption, body mass index (BMI), physical activity, and history of diabetes and CVD. The relative risk (RR) and 95% confidence interval (CI) of ESRD for prehypertension, stage-1 and stage-2 hypertension compared to normal was 1.42 (1.05--1.94), 1.53 (1.08--2.17), and 2.41 (1.72--3.38), respectively. Systolic BP was a stronger predictor of ESRD than diastolic BP or pulse pressure. The associations between BMI and ESRD were positive and graded even after multivariate adjustment. A standard deviation increase in BMI among women (3.94 kg/m2) was associated with a 17% increased risk in developing ESRD (RR, 1.17; 95% CI, 1.01--1.35). Compared to male non-drinkers, alcohol consumption among men was associated with a reduced risk of all-cause ESRD and glomerulonephritis-related ESRD. Men consuming ≥50.6 grams of alcohol/day had a 63% reduced risk in developing all-cause ESRD (RR, 0.37; 95% CI, 0.19--0.74), compared to male non-drinkers Conclusion. The present study adds new information on the relationship of BP with development of glomerulonephritis-related ESRD and to the limited epidemiologic data on the relationships of BMI and alcohol consumption with development of ESRD. These findings document the importance of high BP and overweight as modifiable risk factors for development of ESRD. These results also indicate that alcohol consumption may be renoprotective / acase@tulane.edu

Objectives. To compare stage at diagnosis and stage-specific treatment of prostate cancer by race and by urban/rural residence in Louisiana Methods. In 1997, a total of 2,953 prostate cancer cases were diagnosed in Louisiana. Of these, the study cohort included all eligible African Americans (N = 841) and a random sample of eligible whites (N = 811). Data came from the Louisiana Tumor Registry and the 'Pattern of Patient Care for Prostate Cancer in Louisiana' special study. The tumor registry documents patients' demographics, report source, tumor stage at diagnosis and first course of treatment. The special study verified treatment information, collected additional therapeutic information from urologist offices, and recorded Gleason score, prediagnostic PSA value, comorbidity, and type of insurance. Stage at diagnosis and stage-specific treatment patterns were outcomes in this analysis Results. African-American men were about twice as likely as whites to be diagnosed with advanced stages of prostate cancer (OR = 1.96, 95% CI 1.49--2.58). Adjustment for age at diagnosis, comorbidity, insurance, place of residence, and family history of cancer did not change the odds ratio. Rural residents, particularly African-Americans, were more likely than urban men to present with Stage IV (20.3% versus 8.2%) or unknown stage (6.2% versus 3.7%) disease A marked racial difference was observed in receiving aggressive therapy for early stages of prostate cancer. Approximately three quarters of white patients and half of the African Americans with Stage I disease received either radical prostatectomy or radiation therapy. Comparable findings were also noted for Stage II diagnoses (76.3% and 63.7% respectively). While PSA, age, comorbidity, place of residence, and insurance were significantly associated with aggressive treatments, African-American men remained significantly less likely to be treated aggressively than whites for same stage of prostate cancer (Stage I, OR = 2.38 95% CI 1.57--3.60; Stage II, OR = 2.27, 95% CI 1.45--3.55) after adjustment for these factors The racial difference in treatments was not significantly different for Stages III and IV. Rural men, especially African Americans, were less likely to undergo radical prostatectomy or radiation therapy for Stage I and II disease Conclusion. African-American men and rural residents in Louisiana are at increased risk for diagnosis with advanced stages of prostate cancer and are less likely to receive stage-specific aggressive cancer treatment for early stage disease than their white or urban counterparts / acase@tulane.edu

Children with the sickle-cell trait are known to be partially protected against Plasmodium falciparum malaria, presumably by mechanisms which are manifested at the level of the erythrocytes. The hypothesis tested in this study is that the protection afforded by the sickle-cell trait does not operate entirely at the erythrocyte level, but that the modulation of the immune response is also involved. The goal of the present study was to determine the differences in the antimalarial immune profiles of sickle-cell trait carriers and children with normal hemoglobin, aged 2 to 5 years, using parasitologic, humoral and cellular immunity parameters The study was carried out in Obala (Cameroon), a malaria endemic area, from September 1989 to January 1990. Children (58 sickle-cell trait carriers (HbAS) and 194 with normal hemoglobin (HbAA)) were randomly selected from the local Catholic School. Blood samples were collected from each child for the electrophoresis of hemoglobin, the determination of parasite density, the study of serum reactivity to malaria antigens by indirect immunofluorescent antibody assay (IFA) and the determination of serum levels of soluble interleukin-2 receptors (sIL-2R). A questionnaire was administered to the study sample to evaluate the influence of chloroquine use on the evolution of malaria parasitemia Plasmodium falciparum infection occurred more frequently in 124/194 (64%) of children with normal hemoglobin, compared with 21/58 (36%) of sickle-cell trait carriers (p $$ 0.05). Serum levels of sIL-2R were similar in sickle-cell trait carriers and in children with normal hemoglobin, parasitemic and non parasitemic children. Parasitized sickle-cell trait carriers had higher serum levels of sIL-2R than parasitized children with normal hemoglobin Cell mediated immune response as measured by the serum levels of soluble interleukin-2 (sIL-2R), explains at least some of the differences observed between malaria-infected sickle-cell carriers and children with normal hemoglobin, supporting the hypothesis that not all of the protection afforded to HbAS individuals is entirely mediated at the level of the erythrocyte / acase@tulane.edu

Objective. To examine the relationship between race, blood pressure (BP), and illicit drug use with the decline in renal function in hypertensive males Methods. This study uses a non-concurrent cohort study design with repeated measurements on risk factors and outcome over follow-up. Data was collected by abstraction and patient interviews of 890 male hypertension patients attending the Hypertension Clinic at the Veterans Administration Medical Center of New Orleans. Change in renal function was assessed by the annual change in the reciprocal of serum creatinine and by early decline in renal function (defined as a change in serum creatinine over follow-up of &ge; 0.6 mg/dl). Mixed effects models were used to assess the relationship between risk factors and annual change in the reciprocal of serum creatinine. Cox models were used to examine the relationship between risk factors and incidence of early decline in renal function Results. The annual change in systolic BP, diastolic BP and serum creatinine were -0.983 mm Hg/year, -1.75 mm Hg/year, and 0.021 mg/dl/year, respectively, over a maximum of 23 years of follow-up in our study population of 816 hypertensive, predominantly African-American men. The incidence of early decline in renal function over 15 years of follow-up was 17.8% for African-Americans and 15.6% for white, although this difference was not statistically significant. The crude and multivariate adjusted relative risks of early decline in renal function for African-Americans compared to whites was also not statistically significant among the study participants, who have similar SES, access to health and health care provider. Treated systolic and diastolic BPs, as well as BP control of &ge;160/95 (systolic/diastolic) compared to <140/90, were significantly and positively associated with early decline in renal function. A one standard deviation difference in systolic BP (18 mmHg) and diastolic BP (10mmHg) was associated with a 1.9 and 1.4-fold greater risk of early renal function decline (both p < 0.01), respectively. BP control of >160/95 (systolic/diastolic) compared to <140/90 was associated with a 4.3-fold greater risk of early decline in renal function (p < 0.001); and BP control of 140--159/90--94 compared to <140/90 was associated with a 2.4-fold greater risk of early decline in renal function (p < 0.05) after adjustment for important covariables. Our study also demonstrated that the use of illicit drugs was associated with a 2.3-fold greater risk of developing early renal function decline (p < 0.05). Specifically, cocaine/crack users and hallucinogen users had a 3.0 and 3.9-fold greater risk of early decline in renal function (both p < 0.05), respectively, after adjusting for important covariables Conclusions. Our study suggests that modifiable risk factors such as SES, access to health care and health care provider may be responsible for the excess risk of renal disease experienced by African-Americans. In addition, our results indicate that more aggressive control of blood pressure among hypertensive men may slow the progression of renal disease and may delay the onset of end-stage renal disease. Finally, we showed that the use of illicit drugs, specifically cocaine/crack and hallucinogens, may be associated with early deterioration of renal function / acase@tulane.edu

The control of morbidity in endemic and high risk populations can be accomplished with currently available antischistosomal drugs. This study measured the impact of community-based distribution of metrifonate to people with presumptive infection with S. haematobium Urinary schistosomiasis is endemic in the Diamare division of the Far-North province of Cameroon and is an important cause of morbidity in the population, especially among school-age children. W.H.O. proposes the use of the primary health care approach in controlling morbidity This community-based, controlled field experiment involved three villages and two interventions. Two case villages received either health education alone (HE) or health education in addition to the availability of single-dose metrifonate therapy dispensed by community health workers, on presumptive diagnosis of schistosomiasis (HE/CHW). A control village received no intervention. The objectives were to determine (a) if health education increased knowledge about the disease, (b) if treatment-seeking behaviour changed with either intervention, and (c) if there was a reduction in the total S. haematobium egg output in each village, depending on the intervention received The baseline prevalence of infection in the study populations of the three villages was less than 10 percent, but the prevalence in the 10-19 year olds was much higher (49%, 19% and 4% in the three villages respectively) The study showed that health education did indeed increase knowledge about schistosomiasis. It was also demonstrated that the positive predictive value of microscopic haematuria was adequate to be used for presumptive diagnosis of urinary schistosomiasis. The results, however, indicated that increased knowledge about the disease was not sufficient to affect treatment-seeking behaviour. Rather, the convenient availability of inexpensive and safe medication in the immediate community provided the key incentive for infected people to seek treatment. There was a 99.8 percent reduction in the total number of eggs shed by infected persons who received a single 10mg/kg dose of metrifonate between baseline and final surveys The use of community health workers in diagnosing and treating urinary schistosomiasis would greatly assist in morbidity control and in improving the health delivery system of medically underserved areas of Cameroon / acase@tulane.edu

Background. Mortality from cardiovascular diseases (CVD) has declined substantially in the US during the past several decades. However, it is not certain to what extent the decline in CVD mortality is due to a reduction in incidence and/or improvements in case-fatality rates Objectives. To compare age-adjusted CVD mortality, incidence, and case-fatality rates between 1971--1982 and 1982--1992, to evaluate the contribution of CVD incidence and case-fatality rate to the secular trends in CVD mortality, and to compare CVD rates among normotensive and hypertensive, high socioeconomic and low socioeconomic status, and physically active and inactive participants of the National Health and Nutrition Examination Survey I Epidemiologic Followup Study (NHEFS). Methods. The NHEFS cohort included 14,407 persons 25--74 years of age who completed a medical examination at NHANES I in 1971--75. Two national cohorts of adults aged 35 to 74 years were created from these data. 10,869 subjects in the 1971--82 cohort and 9,774 subjects in the 1982--92 cohort were available for the analysis. The cohorts were followed-up prospectively for CVD incidence and mortality for an average of 9.5 and 8.4 years, respectively. Follow-up interviews, hospital record reviews, and death certificate searches were conducted in 1982--84, 1986, 1987, and 1992--93 as part of the NHEFS Results. Age-adjusted CVD mortality declined by 31 percent from 1971--1982 to 1982--1992. The mortality decline was observed among all race-gender groups, and normotensive and hypertensive, low and high socioeconomic status, and physically active and inactive subjects, albeit less significantly in hypertensive, low socioeconomic, and physically inactive subjects. The decrease in overall CVD mortality was accompanied by a decline in the CVD incidence and improvements in 28-day and long-term case fatality rates in all groups, but improved case fatality rate was the major contributor to the CVD mortality decline among hypertensives, low socioeconomic status, and inactive participants Conclusions. These findings suggest that the decrease in mortality from CVD between the periods was due to a combined effect of reduced incidence and, most importantly, improvements in case fatality rates of CVD. However, the decline was mainly due to the improvement in survival in hypertensive, low socioeconomic status and physically inactive subjects / acase@tulane.edu

Salt has been identified as a risk factor for gastric cancer and essential hypertension. The purpose of this study was to test the relationship between salt intake and gastric precancerous lesions and blood pressure levels. This study also provided an opportunity to link salt intake with specific phases in the pathogenesis of precancerous lesions in the stomach A cross-sectional study was conducted in the Andean population in Colombia, which has one of the highest incidence rates of gastric cancer in the world. Subjects with gastric precancerous lesions were compared with normal subjects regarding their salt intake. A total of 289 subjects were examined by gastroscope and four gastric biopsies and a sample of gastric juice were obtained from each of them Urine samples were collected for sodium, potassium and creatinine measurements. All subjects were interviewed and their blood pressures were recorded. Sodium-creatinine ratio was the end point used for correlation with detailed histologic data from the biopsies. Using the same criterion, the role of high nitrite content in gastric juice as a risk factor for gastric cancer was evaluated. Sodium-potassium ratio was used to test the association between salt intake and blood pressure Two diagnostic schemes were used in this study, the global diagnosis and the numerical pathological scores describing the severity and extent of the lesions. The results of the analyses on salt indicated that high salt intake was a risk factor of gastric precancerous lesions. Chronic atrophic gastritis was found to be the stage at which high salt appeared to act as a co-carcinogen. A significant correlation was obtained between sodium-potassium ratio (Na/K) and systolic blood pressure The results also showed that pH and nitrite level in the gastric juice were higher for subjects with gastric precursor lesions relative to lesion-free subjects. A significant relationship was also demonstrated between a rise in pH and an increase in nitrite levels. Furthermore, the results showed that high nitrite concentration in gastric juice was a risk factor in the development of histologically diagnosed precancerous lesions of the stomach, namely, intestinal metaplasia and dysplasia. (Abstract shortened with permission of author.) / acase@tulane.edu