Thesis (Ph. D.)--University of Wisconsin--Madison, 1963. / Typescript. Vita. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 331-349).

This thesis presents perspectives of men regarding abortion, contraceptive use and sexuality. Contrary to what we had expected, men expressed anxiety over abortion and contraceptive use, not because the issues concerned women’s health, but rather because men associated them with extramarital sexual activity they thought women were concealing. To understand the meanings of sexuality and factors shaping these meanings appeared to be a necessary step in promoting women’s health. We thus included in the study participants with different characteristics including men, women and adolescents, and used a variety of qualitative methods to explore in-depth these issues. Men’s anxiety over wives’ sexuality seemed to be exacerbated by their separation from the family through labour migration, and their inability to play the expected role of the family breadwinner. The men described using different strategies to ensure their wives did not use contraceptives. Men’s perspectives and the related dynamics seem therefore to be a manifestation of contradictory experiences of gender power within contexts of spousal separation. The thesis also illuminates the paradoxical situation of adolescents and adolescent sexual and reproductive health. As guardians, the men described how they are intolerant to premarital sex and pregnancy, which might threaten the expected bride wealth from the marriage of a daughter or sister. They therefore respond with violence. Ironically, information or service which would enable unmarried girls to prevent pregnancy is also denied. This is so in spite of the great concern by families over premarital pregnancy, and common knowledge that young girls are sexually abused by adult men. The men and boys described the pressure they exert on the girls for sex, but also how they then blame the girls for deliberately becoming pregnant in order to trap them into marriage. The boys are nevertheless anxious about pregnancy also for fear of family violence and the threat of being forced to terminate schooling. The girls expressed feeling trapped between the violence from guardians and partners, a situation which may lead to unsafe abortion. The silence, denial and violence imply the young people generally cannot discuss sexual abuse or abortion with parents, or seek health care when needed. Rather, sexually transmitted infections may be ndured or even self-treated, and abortion sought in silence. Preventive actions such as condom use are similarly difficult for the youth. The knowledge the youth may have about AIDS may also simply become a burden when room for applying it is limited. This thesis challenges public health promotion approaches that assume firstly a universal manifestation of gender power, and secondly ability of individuals to effect behaviour change once provided with information regardless of contextual factors. Whether in AIDS education or involvement of men in sexual and reproductive health, understanding social contexts and dynamics, and identities and experiences within these contexts is crucial.

FOOD HABITS, DIETARY INTAKE AND NUTRITIONAL STATUS DURING ECONOMIC CRISIS AMONG PREGNANT WOMEN IN CENTRAL JAVA, INDONESIA Th. Ninuk Sri Hartini, Epidemiology and Public Health Sciences, Dept. of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Community Health and Nutrition Research Laboratories, Gadjah Mada University, Jogjakarta, Indonesia; Nutrition Academy, Ministry of Health, Jogjakarta, Indonesia ABSTRACT Objectives: The overall objective of this thesis was to study the effect of the economic crisis on food habits, dietary intake and nutritional status among pregnant women in Purworejo District, Central Java, Indonesia. Subjects and methods: Since 1994, the Community Health and Nutrition Research Laboratories (CHN-RL), Gadjah Mada University, Jogjakarta, Indonesia have operated a surveillance system in Purworejo District, Central Java, Indonesia. Between 1996 and 1998, a monthly monitoring of new pregnancies took place within the surveillance system. This project included a detailed evaluation of dietary intake during pregnancy. Each trimester six repeated 24-hour recalls were conducted on 450 pregnant women. Weight and mid-upper arm circumference (MUAC) were measured monthly, height and serum ferritin concentration was measured once. Here, the dietary intake and nutritional status of the women during the second trimester are evaluated in relation to the emergence of the economic crisis, that started in 1997. Women were classified into four socio-economic groups. A computer program (Inafood) was developed to calculate nutrient intake. To support the quantitative results, a qualitative study was carried out between January and June 1999. Focus group discussions were held with four groups of women, in-depth interviews with 16 women, three traditional birth attendants and four midwives, and observations were carried out with four women. Here, food habits and coping strategies in relation to the economic crisis were explored. Results: Before the crisis, more than 80% of the pregnant women had inadequate energy and 40% had inadequate protein and vitamin A intake. All women had inadequate calcium and iron intake. The food intake consisted of rice, nuts and pulses and vegetables, meaning that it was mainly plant-based food. Rice behaved as a strongly inferior good in economic term, meaning that its consumption increased in spite of its price increase. Rice remained an important supplier of energy, protein and carbohydrates also during the crisis. Especially, rural, poor women with access to rice fields increased their rice intake and decreased their intake of non-rice staple foods. Reasons for the continued rice intake included the women had been accustomed to eating rice since they were born and that cooking methods for non-rice staple foods were difficult. The intake of animal food was low initially and decreased further during the economic crisis. Rich women decreased their intake of fat. The intake of nuts and pulses and vegetables increased for most groups. Nuts and pulses were an important supplier of calcium and iron, and vegetables were an important supplier of vitamin A. The rural, poor women with access to rice fields kept their food taboos also during the crisis. Rich women were able to maintain a good nutrient intake during the crisis, although fat intake decreased. Also, urban poor and rural, poor, landless women had an increased intake “during crisis” because relatives and neighbour provided some foods and perhaps also because of the government support programme. Conclusion: Before the crisis, energy and nutrient intake of pregnant women were inadequate. The food pattern of the women was predominately plant-based. Rich women were able to maintain a good nutrient intake during the crisis, although fat intake decreased. Rural poor women with access to rice fields had a higher rice intake than other groups throughout the crisis. Urban poor and rural poor, landless women experienced a decreased intake of most nutrients in the transition period but an increased intake during the crisis, reflecting government intervention and support from relatives and neighbours. The latter, however, is not sustainable. Thus, vulnerable groups are at risk of developing nutritional deficiencies without food support programmes. Key words: Food intake, nutrient intake, nutritional status, food pattern, pregnancy, food habits, coping strategies, economic crisis, Indonesia.

Background: Iron and zinc are difficult to provide in sufficient amounts in complementary foods to infants world-wide, resulting in high prevalence of both iron and zinc deficiency. These deficiency states cause anemia, delayed neurodevelopment, impaired growth, and increased susceptibility to infections such as diarrhea and respiratory infections. Design: Two different intervention strategies; reduction of a possible inhibitor of iron and zinc absorption, i.e. phytate, or supplementation with iron and zinc, were applied to two different populations in order to improve iron and zinc nutrition: In a high-income population (Umeå, Sweden), the amount of phytate in commonly consumed infant cereals was reduced. Healthy, term infants (n=300) were at 6 mo of age randomized to phytate-reduced infant cereals, conventional infant cereals, or infant formula and porridge. In a low income population (Purworejo, Indonesia), daily iron and zinc supplementation was given. Healthy, term infants (n=680) were at 6 mo randomized to supplementation with iron, zinc, a combination of iron and zinc, or placebo. Blood samples, anthropometrical measurements, and data on infant neurodevelopment and morbidity were collected. Also, in the Swedish study, detailed information on the dietary intake was recorded. Results: In the Swedish study, the reduction of phytate had little effect on iron and zinc status, growth, development or incidence of diarrhea or respiratory infections, possibly due to the presence of high contents of ascorbic acid, which may counteract the negative effects of phytate. In the Indonesian study, significant negative interaction between iron and zinc was evident for several of the outcomes; Hb and serum ferritin improved more in the iron only group compared to placebo or the combined iron and zinc group. Further, supplementation with iron alone improved infant psychomotor development and knee-heel length, whereas supplementation with zinc alone improved weight and knee-heel length compared to placebo. Combined iron and zinc supplementation did decrease the prevalence of iron deficiency anemia and low serum zinc, but had no other positive effects. Vomiting was more common in the combined group. Analyses of dietary intake from the Swedish study showed that dietary iron intake in the 6-11 mo period was significantly associated with Hb, but not serum ferritin at 9 and 12 mo, whereas the opposite was true in the 12-17 mo period, i.e. dietary iron intake was significantly associated with serum ferritin, but not Hb at 18 mo. Conclusions: The phytate content of commercial infant cereals does not seem to contribute to poor iron and zinc status of Swedish infants as feared. However, the current definitions of iron and zinc deficiency in infancy may overestimate the problem, and a change in the recommended cutoffs is suggested. These studies also indicate that dietary iron is preferably channeled towards erythropoiesis during infancy, but to an increasing amount channeled towards storage in early childhood. This suggests that in evaluating dietary programs, Hb may be superior in monitoring response to dietary iron in infancy, whereas S-Ft may respond better later in childhood. However, as shown in this study, increasing Hb may not necessarily be an indicator of iron deficiency, as more dietary iron increased Hb regardless of iron status. In the low-income setting combined supplementation with iron and zinc resulted in significant negative interaction. Thus, it is not possible to recommend routine iron-zinc supplementation at the molar concentration and mode used in this study. It is imperative that further research efforts are focused at finding cost-effective strategies to prevent iron and zinc deficiency in low-income populations.

BACKGROUND For many years, the Durban south community has raised concerns about ambient air pollution including particulate matter. The Durban South Industrial Basin (DSIB) may be high risk for exposure to significant levels ofPMI0 due to its geographic relationship with two major petroleum refineries, together with a pulp and paper manufacturing facility. While potential sources of elevated levels of PMlOin the south are industrial, the north is likely to be exposed to controlled burning of vacant fields and use ofbiomass fuels, particularly in informal settlements. Adverse health effects from particulate matter (PM) were well documented by extensive epidemiological observations by animal and human studies, following laboratory exposures. Studies across a variety of environmental settings have demonstrated a strong association between ambient air particulate matter (PMlO) and cardiopulmonary morbidity and mortality. Studies have reported that particulate matter is associated with adverse health effects resulting from inflammatory responses in the lower respiratory tract. Exposure to particulate matter may increase the risk of lung cancer. Some studies suggested that small temporal increases in ambient particulate matter are sufficient to cause health impacts. Other studies attributed strong seasonality to temperature inversions associated with temperature changes. Studies also illustrated the impact of temporal variation on PMl 0 levels across regions. OBJECTIVES The main objectives of this study were to determine and compare the levels of ambient PMIO in industry exposed and non-industry exposed communities, to determine temporal variation and to make recommendations. METHODS This study focused on determining the 24-hour ambient PMI0 levels in the Durban south community. The PMIO levels in Durban south (industry exposed) were compared with the PM10 levels in an area north of Durban (non-industry exposed). Relevant data obtained from the monitoring program of the South Durban Health Study (SDHS) was reviewed for the purposes of this study. The different techniques used to measure PMI0 are gravimetric sampling and tapered elemental oscillating microbalance (TEaM). Both methods were used to collect PMI0 data. The data comprised of quantitative and categorical variables. The dependent variable was the PM10 values and the independent variable was the sampling sites. Non-parametric tests were used to analyse the data. RESULTS PMI0 was recorded in all sites in north and south areas. The levels varied across all sites. Both the north and south areas recorded high PMI0 values at regular intervals. No particular trend was observed when the 24 hour PM10 concentration was compared against the standard. All sites recorded medians that were generally in the region of 40-S0,ug/m3. The site with the highest median (SIA,ug/m3 ) was Assegai. Briardale recorded the lowest median (34.9,ug/m3 ). Exceedances of the South African National Standard code 1929 maximum 24-hour concentrations of7S,ug/m3 were observed across all sites. Overall there were 163 (16.7 % of all samples) exceedances, and these ranged widely between the various sites, with no particular regional trend. Overall .June experienced the highest PMl 0 values. No differences in seasonal trends were observed in north and south. CONCLUSION On average the levels ofPMI0 do not exceed national or international standards. The findings did not reveal any statistical difference in exposure levels between the industry exposed and non-industry exposed areas. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2008.

The vast majority of paediatric HIV occurs in sub-Saharan Africa and could be averted through implementation of effective Prevention of Mother to Child Transmission (PMTCT) strategies. At the United Nations General Assembly Special Session on HIV/AIDS in 2001, members committed themselves to the goal of reducing paediatric HIV by 20% by 2005 and by 50% by 2010. In South Africa, rates of HIV infection range between 28% in KwaZulu-Natal and 16% in the Western Cape. The South African National Department of Health has, over the past few years, phased in a comprehensive package for PMTCT of HIV. KwaZulu-Natal implemented its programme in 2002. The South African private healthcare sector follows guidelines of those of developed countries for PMTCT. Not much data is available of the outcome of infants born to HIV positive mothers managed in private practice. In view of this, the present study aimed to assess success or otherwise of PMTCT in private paediatric practice in South Africa. Eight of the 20 private paediatricians, in the central region of Ethekweni Metro of KwaZulu-Natal (Durban Central Area), agreed to participate in a retrospective study. Data for all their HIV exposed infants between January 2004 and June 2005 were reviewed. One hundred and one Black African infants were born to 100 HIV positive women aged 29.85 years (SD 5.38; range 18-44 years). The median CD4 count was 426 (IQR 244-613). The median viral load at first presentation was 3.97 logs (IQR 1.6-5.8) or 11 391 copies/ml (IQR 2 013-41 502). Eighty six women had HAART, nine had other antiretroviral therapy and five had no prophylaxis. Treatment started before 34 weeks in 72 women. There were 93 caesarean sections. There were 20 low birth weight neonates, 18 were preterm and all had been formula fed and received AZT for six weeks. Of the 92 tested, two (one preterm) were positive. Although caesarean deliveries, both these mothers had not adhered to the optimal treatment protocol. Of the rest, eight did not return for HIV testing and one died (the only neonatal death). This death was unlikely to have been HIV related. The transmission rate of less than one percent in those women who followed the protocol optimally is much better than that in the SA public sector, and is consistent with transmission rates in the developed world. / Thesis (M. Med.)-University of KwaZulu-Natal, Durban, 2009.

This study aimed to review the use of lay counsellors and rapid HIV tests in a voluntary testing and counselling (VCT) service in the UGU South health district of KwaZulu Natal. The study ran from September 1999 to April 2001. In early 1999, UGU South was selected as a pilot site as part of an international initiative. This initiative aimed to promote testing for HIV by using VCT service as an entry point into a range of HIV/AIDS and TB prevention and care programmes and was termed the ProTEST Initiative. Four such ProTEST sites were developed in South Africa and all offered rapid HIV testing and prophylactic drugs (Isoniazid and Cotrimoxazole) for HIV infected people. VCT was prioritised at all sites, however UGU South was unique in providing lay counsellors. Traditionally a lay counsellor (who is not a trained health care worker), offered only pre and post- test counselling. Lay counsellors had been used in South Africa, however their impact had not been formally assessed. In accordance with the Health Professional Council ruling on testing blood, lay counsellors could not carry out a rapid HIV test procedure. The decision to use lay counsellors in UGU South, was based on a review of the capacity of existing health care workers to expand a VCT service. Ten female lay counsellors, who fulfilled pre-employment selection criteria, were employed. In 1999, VCT was prioritised by the South African Department of Health and a Strategic Plan on HIV/AIDS & STDs was developed. The aim was to test 12.5% of the adult population for HIV before the year 2005. The proposed VCT service was to be based at health facilities and was to utilize existing health care workers. The capacity of existing health care workers to cope with an expansion in VCT services had not been explored. The reasons why clients accessed VCT and the demographic profiles of such clients were poorly understood. The Department of Health also planned to use rapid HIV tests at health facilities. Literature on the use of rapid HIV tests in South Africa was limited. This study aimed to address gaps in knowledge around VCT in South Africa and specific objectives were to: * Assess the capacity of existing health care workers to expand a VCT service *Review the need for rapid HIV tests *Develop and evaluate a training, support and mentorship programme for lay counsellors *Review the reason why clients use a VCT service and the demographic profiles of such clients *Monitor the impact of lay counsellors on numbers of cases of TB diagnosed and treated *Make recommendations for the use of lay counsellors and rapid HIV tests in an expanded integrated HIV/TB Control Programme. The study was prospective, descriptive and was based at ten health facilities in UGU South. The health facilities offered counselling, rapid HIV tests and prophylaxis for HIV infected people (Isoniazid or Cotrimoxazole). The study population was all nurses, lay counsellors and clients involved with the VCT service at these sites. Both qualitative and quantitative methods of study were employed in this study including: *Postal survey * Interviews *Focus group discussion *Review of patient records, literature and questionnaires * Analysis of registers from the National TB Control Programme. Results from three independent reviews clearly indicated that nurses in UGU South did not have the capacity to offer an expanded VCT service due to a heavy workload commitment. The nurses considered that VCT was a necessary service and supported the introduction of lay counsellors. Quantitative reviews concluded that a third of people tested for HIV using a hospital based testing system never returned for their results and that the turn-around time for an HIV test result was as much as three weeks. Rapid HIV tests increased access to an HIV test result and were acceptable to health care workers. There was no review of the opinions of clients on the rapid HIV tests. A training, support and mentorship programme was developed for lay counsellors and both nurses and counsellors considered that the programme was largely effective. The lay counsellors were trained to offer a more comprehensive service than traditional lay counsellors; in particular lay counsellors were expected to screen clients for symptoms of TB disease and support clients taking TB medication. Evaluation of the programme concluded that the content should be more practical and there should be a dedicated supporter for the lay counsellors available at their place of work. Results suggested that access to VCT services increased due to the presence of lay counsellors. The lay counsellors were acceptable to health staff, however there was no review of the opinions of clients on the lay counsellors. Half of the 7 475 people tested were infected with HIV. Most clients were medically referred for VCT and had "AIDS defining" illnesses. The clients who self-referred were ill or knew someone who had died recently. The proportion of clients who self-referred increased and health education was the main reason why people self-presented. More women than men were tested and women were more likely to test HIV positive. Review of the TB registers indicated that the TB Control Programme in UGU South was not optimal. The impact of lay counsellors on numbers of TB cases diagnosed and on treatment could not be determined from this study. Before the use of lay counsellors is expanded, there should further review of the capacity of other health care workers to offer VCT. Issues such as conditions of employment, salaries and a job description for lay counsellors should be clarified. There should be an independent assessment of the quality of counselling offered and a review of the cost of the lay counsellors. The impact of using men and younger lay counsellors should be reviewed. VCT services should be based at clinics, rather than hospitals and consideration should be given to developing freestanding VCT sites. Education programmes on VCT should be expanded beyond health facilities. Prior to expanding the use of rapid HIV tests, there should be a review of the cost of rapid HIV tests and systems should be in place for ordering, delivery and for stock control. The opinions of clients on rapid HIV testing should be ascertained. Consideration should be given to lay counsellors performing the rapid HIV test or an alternative method of testing (not involving blood) should be introduced. There should be ongoing training in TB and monitoring of the TB Control Programme in UGU South. Specific indicators should be developed to monitor the impact of lay counsellors on the diagnosis and treatment of TB and to measure collaboration between HIV/AIDS and TB Control Programmes. / Thesis (M.Med.Sc.)-University of Natal, Durban, 2002.

Tuberculosis is a disease of global importance and remains the leading cause of death in the developing world. In South Africa a weak notification system and poor occupational health services for health care workers has resulted in little information being available about the incidence of tuberculosis and the groups at highest risk of contracting tuberculosis amongst health care workers, the clinical presentation and management of workers infected with tuberculosis. The purpose of this study was to describe the incidence of tuberculosis, and the clinical and public health aspects of the management of tuberculosis among health care workers in eight public sector hospitals in the Ethekwini Municipality of KwaZulu-Natal. Data was collected through a retrospective review of hospital records for the study period January 1999 to June 2004. Study findings: Five hundred and eighty three (N=583) health care workers were diagnosed with tuberculosis for the period under review. The mean age of the HCWs was 38 years (95% Cl: 37-39). The mean cumulative incidence for the study period was 1040/100 000 HCW population (95% Cl: 838-1242). The mean cumulative incidence of TB was highest in males (1544/100 000 HCW population; 95% Cl 1228 -1859), the age group 25 to 34 years (1043/100 000 HCW population; 95% CI: 650 -1436) and in paramedical staff (1675/100 000 HCW population; 95%CI: 880-2470). The majority of health care workers presented with pulmonary tuberculosis (77%, n=322) and 3% (n=13) had multidrug resistant tuberculosis. Successful treatment outcomes were achieved in 63% (n=334) of health care workers. Only one hospital has a work place policy with regard tuberculosis in health care workers. Compensation for this occupational disease was sought as follows. Submissions of a first medical report were made in 107 (18%) of the 583 health care workers. In the 107 cases initially reported submission of progress reports (n=75; 70%) and final reports (n=60; 56%) decreased considerably. In conclusion, the incidence of tuberculosis in health care workers has increased annually since 1999 and the treatment outcomes among health care workers do not reach the targets set by the National Tuberculosis Control Programme. Recommendations based on the study findings include establishing a uniform provincial policy for the prevention and reduction of tuberculosis infections among health care workers for implementation in hospitals; the implementation of a medical surveillance system for health care workers with respect to tuberculosis and a provincial training programme for staff on the clinical and administrative management of TB in health care workers. / Thesis (M.Med.)-University of KwaZulu-Natal, 2006.

No abstract available. / Thesis (M.Med.)-University of Natal, 1981.

It was suspected that about 2 cases of parasuicide were admitted daily to RK Khan Hospital and this suspicion was confirmed by this study. Most of the cases were female, and in the 15 - 24 year age group. Patients were admitted mainly in the evenings and on Sundays. The majority earned less than R500 per month and were mainly manual-skilled and semi-skilled workers predominantly from Chatsworth. Non-violent means were the common mode of parasuicide, the causes being family, marital and romantic problems. The hospital social worker dealt with the cases and referred patients to relevant organisations outside the hospital for management. Certain patients were referred to the Psychiatric Outpatient Clinic at the Hospital as there was no resident psychiatrist. / Thesis (MMed-Community Health)-University of Natal, 1984.