Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation

Introduction

We implemented a participatory quality improvement strategy in eight primary health care units of Ethiopia to improve use and quality of maternal and newborn health services.

Methods

We evaluated the effects of this strategy using mixed-methods research. We used before-and-after (March 2016 and November 2017) cross-sectional surveys of women who had children 0–11 months to compare changes in maternal and newborn health care indicators in the 39 communities that received the intervention and the 148 communities that did not. We used propensity scores to match the intervention with the comparison communities at baseline and difference-in-difference analyses to estimate intervention effects. The qualitative method included 51 in-depth interviews of community volunteers, health extension workers, health center directors and staff, and project specialists.

Results

The difference-in-difference analyses indicated that 7.9 percentage points (95% confidence interval [CI]: 1.8–13.9%) increase in receiving skilled delivery care between baseline and follow-up surveys in the intervention area that is attributable to the strategy. The intervention effect on postnatal care in 48 hours of the mother was 15.3% (95% CI: 7.4–23.2). However, there was no evidence that the strategy affected the seven other maternal and newborn health care indicators considered. Interview participants said that the participatory design and implementation strategy helped them to realize gaps, identify real problems, and design appropriate solutions, and created a sense of ownership and shared responsibility for implementing interventions.

Conclusions

Community participation in planning and monitoring maternal and newborn health service delivery improves use of some high-impact maternal and newborn health services. The study supports the notion that participatory community strategies should be considered to foster community-responsive health systems.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants' backgrounds, and contextual factors, estimated the intervention's effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics -the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral economics informed approaches to mitigate discontinuation of injectable contraceptives. Methods: Behavioral diagnosis was conducted to identify the primary drivers of discontinuation of injectable contraceptives. Using these insights, a user-centered behavioral design approach was implemented to create an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods adjusted for study design, participants' backgrounds, and contextual factors, were used to estimate the intervention's effect on discontinuation rates. Results: Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. This was not surprising as using appointment cards and the job aid was within the routine workflow of health extension workers, but using the planner was not. The injectable discontinuation rate was 10.8 % points lower in the intervention area compared to the control area during the post intervention follow-up survey. Conclusion: The use of two behavioral economics informed tools-the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics approaches have the potential to enhance family planning programs in Ethiopia and elsewhere. Trial registration: ISRCTN ISRCTN17390653 (10/04/2019).

Effects of a community-based data for decision-making intervention on maternal and newborn health care practices in Ethiopia: a dose-response study

BACKGROUND

Community participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women's Development Army (WDA), was added to extend Ethiopia's Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA's Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy.

METHODS

Using data from cross-sectional surveys in 2010-11 and 2014-15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys.

RESULTS

Kebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth.

CONCLUSIONS

This study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.

Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis

BACKGROUND

Maternal and newborn health care intervention coverage has increased in many low-income countries over the last decade, yet poor quality of care remains a challenge, limiting health gains. The World Health Organization envisions community engagement as a critical component of health care delivery systems to ensure quality services, responsive to community needs. Aligned with this, a Participatory Community Quality Improvement (PCQI) strategy was introduced in Ethiopia, in 14 of 91 rural woredas (districts) where the Last Ten Kilometers Project (L10 K) Platform activities were supporting national Basic Emergency Obstetric and Newborn Care (BEmONC) strengthening strategies. This paper examines the effects of the PCQI strategy in improving maternal and newborn care behaviors, and providers' and households' practices.

METHODS

PCQI engages communities in identifying barriers to access and quality of services, and developing, implementing and monitoring solutions. Thirty-four intervention kebeles (communities), which included the L10 K Platform, BEmONC, and PCQI, and 82 comparison kebeles, which included the L10 K Platform and BEmONC, were visited in December 2010-January 2011 and again 48 months later. Twelve women with children aged 0 to 11 months were interviewed in each kebele. Propensity score matching was used to estimate the program's average treatment effects (ATEs) on women's care seeking behavior, providers' service provision behavior and households' newborn care practices.

RESULTS

The ATEs of PCQI were statistically significant (p < 0.05) for two care seeking behaviors - four or more antenatal care (ANC) visits and institutional deliveries at 14% (95% CI: 6, 21) and 11% (95% CI: 4, 17), respectively - and one service provision behavior - complete ANC at 17% (95% CI: 11, 24). We found no evidence of an effect on remaining outcomes relating to household newborn care practices, and postnatal care performed by the provider.

CONCLUSIONS

National BEmONC strengthening and government initiatives to improve access and quality of maternal and newborn health services, together with L10 K Platform activities, appeared to work better for some care practices where communities were engaged in the PCQI strategy. Additional research with more robust measure of impact and cost-effectiveness analysis would be useful to establish effectiveness for a wider set of outcomes.

Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis

BACKGROUND

Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices.

METHODS

We used cross-sectional data from a representative sample of 4684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding.

RESULTS

About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05).

CONCLUSION

We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates.

Correlates of the Women's Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia

BACKGROUND

To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women's Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices.

METHODS

Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents' individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest.

RESULTS

Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category).

CONCLUSION

Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.

The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia

BACKGROUND

Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low- and middle-income countries to reduce maternal and newborn mortality. Tailored support, including BEmONC training to providers, mentoring and monitoring through supportive supervision, provision of equipment and supplies, strengthening referral linkages, and improving infection-prevention practice, was provided in a package of interventions to 134 health centers, covering 91 rural districts of Ethiopia to ensure timely BEmONC care. In recent years, there has been a growing interest in measuring program implementation strength to evaluate public health gains. To assess the effectiveness of the BEmONC initiative, this study measures its implementation strength and examines the effect of its variability across intervention health centers on the rate of facility deliveries and the met need for BEmONC.

METHODS

Before and after data from 134 intervention health centers were collected in April 2013 and July 2015. A BEmONC implementation strength index was constructed from seven input and five process indicators measured through observation, record review, and provider interview; while facility delivery rate and the met need for expected obstetric complications were measured from service statistics and patient records. We estimated the dose-response relationships between outcome and explanatory variables of interest using regression methods.

RESULTS

The BEmONC implementation strength index score, which ranged between zero and 10, increased statistically significantly from 4.3 at baseline to 6.7 at follow-up (p < .05). Correspondingly, the health center delivery rate significantly increased from 24% to 56% (p < .05). There was a dose-response relationship between the explanatory and outcome variables. For every unit increase in BEmONC implementation strength score there was a corresponding average of 4.5 percentage points (95% confidence interval: 2.1-6.9) increase in facility-based deliveries; while a higher score for BEmONC implementation strength of a health facility at follow-up was associated with a higher met need.

CONCLUSION

The BEmONC initiative was effective in improving institutional deliveries and may have also improved the met need for BEmONC services. The BEmONC implementation strength index can be potentially used to monitor the implementation of BEmONC interventions.

Changes in equity of maternal, newborn, and child health care practices in 115 districts of rural Ethiopia: implications for the health extension program

Background

Reducing within-country inequities in the coverage of maternal, newborn, and child health (MNCH) interventions is essential to improving a country’s maternal and child health and survival rates. The community-based health extension program (HEP) of Ethiopia, launched in 2003, aims to provide equitable primary health care services. Since 2008 the Last Ten Kilometers Project (L10K) has been supporting the HEP in promoting equitable MNCH interventions in 115 districts covering about 14 million people. We report the inequities in MNCH programmatic indicators in 2008 and in 2010 in the L10K areas, along with changes in equity between the two survey periods, and the implications of these results for the national program.

Methods

The study used cross-sectional surveys of 3932 and 3867 women from 129 representative kebeles (communities) conducted in December 2008 and December 2010, respectively. Nineteen HEP outreach activity coverage and MNCH care practice indicators were calculated for each survey period, stratified by the inequity factors considered (i.e. age, education, wealth and distance from the nearest health facility). We calculated relative inequities using concentration indices for each of the indicators and inequity factors. Ninety-five percent confidence intervals and survey design adjusted Wald’s statistics were used to assess differentials in equity.

Results

Education and age related inequities in the MNCH indicators were the most prominent (observed for 13 of the 19 outcomes analyzed), followed in order by wealth inequity (observed for eight indicators), and inequity due to distance from the nearest health facility (observed for seven indicators). Age inequities in six of the indicators increased between 2008 and 2010; nevertheless, there was no consistent pattern of changes in inequities during that period. Some related issues such as inequities due to wealth in household visits by the health extension workers and prevalence of modern family household; and inequities due to education in household visits by community health promoters showed improvement.

Conclusions

Addressing these inequities in MNCH interventions by age, education and wealth will contribute significantly toward achieving Ethiopia’s maternal health targets for the Millennium Development Goals and beyond. HEP will require more innovative strategies to achieve equitable MNCH services and outcomes and to routinely monitor the effectiveness of those strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0668-z) contains supplementary material, which is available to authorized users.

Effectiveness of supportive supervision on the consistency of integrated community cases management skills of the health extension workers in 113 districts of Ethiopia

BACKGROUND

Consistency in the adherence to integrated Community Case Management (iCCM) protocols for common childhood illnesses provided by Ethiopia's Health Extension Program (HEP) frontline workers. One approach is to provide regular clinical mentoring to the frontline health workers of the HEP at their health posts (HP) through supportive supervision (SS) following the initial training.

OBJECTIVE

To Assess the effectiveness of visits to improve the consistency of iCCM skills (CoS) of the HEWs in 113 districts in Ethiopia.

METHODS

We analyzed data from 3,909 supportive supervision visits between January 2011 and June 2013 in 113 districts in Ethiopia. From case assessment registers, a health post was classified as consistent in managing pneumonia, malaria, or diarrhea cases if the disease classification, treatment, and follow-up of the last two cases managed at the health posts were consistent with the protocol. We used regression models to assess the effects of SS on CoS.

RESULTS

All HPs (2,368) received at least one supportive supervision visit, 41% received two, and 15% received more than two. During the observation period, HP management consistency in pneumonia, malaria, and diarrhea increased by 3.0, 2.7 and 4.4-fold, respectively. After controlling for secular trend and other factors, significant dose-response relationships were observed between number of SS visits and CoS indicators.

CONCLUSIONS

The SS visits following the initial training were effective in improving the CoS.

Effect of the health extension program and other accessibility factors on care-seeking behaviors for common childhood illnesses in rural Ethiopia

BACKGROUND

In January 2011, Health Extension Workers (HEWs) of Ethiopia's Health Extension Program (HEP) began providing pneumonia case management for children less than five years of age through the integrated Community Case Management (iCCM) strategy.

OBJECTIVE

To report the effect of HEP, following the introduction of iCCM, and other accessibility factors on care-seeking behaviors for common childhood illnesses (acute respiratory infection [ARI], diarrhea, and fever).

METHODS

Three possible care-seeking outcomes for childhood illnesses were considered: not seeking appropriate care, seeking care from HEP sources, or seeking care from other appropriate sources. The baseline care-seeking outcomes from the Ethiopian Demographic and Health Survey, 2011, were compared with the care-seeking outcomes in a follow-up iCCM survey in December 2012. The effects of the HEP intensity and other factors on care-seeking outcomes were estimated using regression analyses.

RESULTS

Appropriate care-seeking for children with acute respiratory infection, ARI, diarrhea, or fever increased two-fold, from 19% at baseline to 38% at follow-up, mainly due to an increase in seeking care for common child- hood illnesses from HEWs. Higher intensity of the HEP and other accessibility factors were associated with higher care-seeking for childhood illnesses from HEP sources.

CONCLUSION

Incorporating iCCM within the HEP service package significantly improved the appropriate care-seeking behaviors for childhood illnesses in rural Ethiopia.

Cloning and characterization of a cDNA fragment encoding a Schistosoma mansoni actin-binding protein (Smfilamin)

To identify vaccine candidates for Schistosoma mansoni, the IgG fraction of rabbit antiserum raised against immature female worms affinity purified over a NP-40 extract of 3-h schistosomula was used to immunoscreen a cercarial lambdagt11 cDNA library. One clone with a 1.5-kb cDNA insert revealed an encoded peptide of 479 amino acids, which bears homology to human actin-binding protein (ABP-280=filamin). Northern blot analysis revealed a transcript of about 8.6 kb, indicating that the complete gene was not cloned. Overlapping clones, which encode a composite sequence of 983 amino acids (45% identity with filamin), were subsequently isolated from the cDNA library. The 1.5-kb insert was cloned into pGEX, overexpressed, and the 479 amino acid peptide purified. Western blot analysis using polyclonal antisera specific to the peptide identified a 280-kDa molecule in adult worm extracts. RT-PCR demonstrated that Smfilaimin is expressed in various stages. Immunofluorescence studies with specific antisera revealed a tegument-associated fluorescence in adult worms. IgG specific to the Smfilamin fragment showed 36.6% killing of schistosomules in an in vitro killing assay.

The impact of a reproductive health franchise on client satisfaction in rural Nepal

This study evaluates the impact of a nurse and paramedic reproductive health franchise in rural Nepal on client satisfaction and utilization of services. A quasi-experimental study design, with baseline and follow-up measurements on nonequivalent control groups, was used to assess the effects of the intervention. The study collected data from exit interviews with male and female clients at clinics and from household interviews with married women. Our assessment covers the project's performance for about a year of actual implementation. Client satisfaction with the quality of services increased across a range of indicators at intervention clinics but not at control clinics. Overall satisfaction with services also increased only at intervention clinics but not at control clinics. Consistent with these changes, loyalty increased among clients of franchised clinics. The analysis showed a positive relationship between client satisfaction and loyalty. Although the project's implementation was examined over a relatively short period of time, there appears to have been a net positive effect of the intervention on obtaining family planning products from medical stores/pharmacies. The study shows that franchising reproductive health services increases a provider's interest in delivering better quality services in rural areas of a developing country.

Molecular analysis of SMN1 and NAIP genes in Egyptian patients with spinal muscular atrophy

OBJECTIVES

The aim of this study is to provide preliminary molecular data on spinal muscular atrophy in Egyptian patients thus facilitating a rapid and conventional molecular assay for accurate diagnosis of SMA.

BACKGROUND

Childhood spinal muscular atrophy (SMA) is one of the most common autosomal recessive disorders. It is characterized by symmetrical muscle weakness and atrophy of limbs and trunk. At least four SMA related genes have been identified [survival motor neuron (SMN), neuronal apoptosis inhibitory protein (NAIP), the gene encoding the transcriptional factor p44 and H4F5 gene].

METHODS

Homozygous absence of exons 7 and 8 of the SMN1 gene was detected using PCR-SSCP analysis, while NAIP gene deletion was detected using multiplex PCR-agarose gel electrophoresis.

RESULTS

Homozygous absence of SMN1 exons 7 and 8, or exon 7 only, was found in 80% of patients. Of those patients, 45% were also deleted for NAIP exon 5.

CONCLUSION

The molecular basis of SMA in Egyptian patients has a similar pattern to that reported in most populations, but a larger study is recommended for more comprehensive characterization (Tab. 1, Fig. 2, Ref. 33).

The role of user charges and structural attributes of quality on the use of maternal health services in Morocco

Health care decision makers in settings with low levels of utilization of primary services are faced with the challenge of balancing the sometimes competing goals of increasing coverage and utilization of maternity services, particularly among the poor, with that of ensuring the financial viability of the health system. Morocco is a case in point where this policy dilemma is currently being played out. This study examines the role of household out-of-pocket costs and structural attributes of quality on the use of maternity care in Morocco using empirical data collected from both households and health care facilities. A nested logit model is estimated, and the coefficient estimates are used to carry out policy simulations of the impact of changes in the levels of out-of-pocket fees and structural attributes of quality in order to help guide policy makers responsible for the design of pending social insurance programs. The results of the paper suggest that social insurance strategies that involve increases in out-of-pocket charges in the form of copayments could be implemented without untoward effects on appropriate use of maternity care for non-poor women, but would be contraindicated for poorer and rural households.

Reproductive health risk and protective factors among unmarried youth in Ghana

CONTEXT

In Ghana, as in many other Sub-Saharan African countries, the behaviors of the current cohort of adolescents will strongly influence the course of the HIV/AIDS epidemic. This study sought to identify factors associated with elevated risks of pregnancy and sexually transmitted infection among unmarried Ghanaian youth.

METHODS

A nationally representative sample of 3,739 unmarried 12-24-year-olds were surveyed. Various regression techniques were used to assess the effects of individual and contextual factors on sexual behavior and condom use.

RESULTS

Forty-one percent of female and 36% of male youth reported being sexually experienced. On average, sexually experienced youth had had fewer than two partners; only 4% of these females and 11% of males had had more than one sexual partner in the three months before the survey. Although Ghanaian youth are knowledgeable about condoms, only 24% of sexually experienced males and 20% of females reported consistent condom use with their current or most recent partner. A sizable number of contextual factors and attributes of youth themselves were associated with sexual behaviors, while individual characteristics were stronger predictors of condom use.

CONCLUSIONS

The findings provide further justification for interventions targeting key contextual factors that influence youth behaviors in addition to providing youth with necessary communication, negotiation and other life skills.

Correlates of adolescent pregnancy in La Paz, Bolivia: findings from a quantitative-qualitative study

Recent data indicate that nearly one in three Bolivian adolescent females becomes pregnant prior to reaching age twenty. This article presents the results of a study undertaken to address the question of why some female adolescents in La Paz, Bolivia, become pregnant while others in similar circumstances avoid early pregnancy. The study utilized mixed qualitative-quantitative methods based on a case-control design. Among the potential explanatory factors considered were family structure, parental relationships, partner relationships, knowledge of pregnancy risks, self-esteem, and locus of control. Significant differences between girls experiencing a pregnancy and those who had not were observed on two of the six factors considered-relationships with parents and self-esteem. Girls who had experienced a pregnancy were less likely to have reported affectionate and supportive parents, more likely to have reported fighting in their home, and exhibited lower levels of self-esteem than those who had never been pregnant. Focus-group discussions suggested that adolescent females in La Paz lack trustworthy support networks that would empower them to seek information regarding sex and contraception and to act upon such information.

Reproductive health risk and protective factors among youth in Lusaka, Zambia

PURPOSE

To: (a) identify risk and protective factors for behaviors that expose Zambian youth to risk of HIV infection and, (b) assess whether research findings from the United States concerning protective factors in "high-risk" environments might apply to other settings.

METHODS

A community-based sample of 2328 youth ages 10-24 years residing in Lusaka, Zambia was interviewed. Multivariate statistical methods were used to isolate risk and protective factors for selected sexual and contraceptive behaviors. Seven categories of factors were considered: sociodemographic factors, sexual-reproductive health knowledge and perceptions, nonsexual risk behaviors, peer influence, connections with parents and social institutions, and communication with sexual partners.

RESULTS

A sizeable number of factors were associated with each outcome. Only two factors, school attendance and knowledge of AIDS, were associated with both lower levels of sexual activity and consistent use of condoms, and only engaging in higher-risk social activities with close friends was a risk factor for both. The effects of the other factors considered varied by outcome and gender. As in prior research, strong influences of peers were observed, but connections with parents and social institutions unexpectedly did not emerge as protective.

CONCLUSION

Because of the number and diverse nature of factors influencing adolescent behaviors, it is unlikely that a single intervention will be found to immediately change sexual risk-taking behaviors in Zambia.

Characterization of Sm20.8, a member of a family of schistosome tegumental antigens

Two cDNA clones each encoding a 20.8-kDa protein (Sm20.8) were identified from the human blood fluke Schistosoma mansoni sporocyst and adult worm cDNA expression libraries by antibodies derived from rabbits vaccinated with irradiated cercariae and purified over an NP-40 extract of 3h schistosomula. Each identified cDNA has an open reading frame encoding a protein of 181 amino acids and shows homology (29-30%) with Sm21.7, Sm22.6, and Sj22.6, previously identified as belonging to a family of soluble schistosome tegumental antigens. An EF-hand calcium-binding motif is found in Sm20.8 protein in two different positions. However, neither motif binds 45calcium (45Ca) Recombinant Sm20.8 showed immunoreactivity with sera from infected humans and rabbits vaccinated with irradiated cercariae. Polyclonal rabbit sera against the Sm20.8 recognized the native protein in an extract of infected snail (sporocyst), cercariae, 3 hour schistosomules (3 h NP-40) and an adult worm preparation but not in uninfected snail tissue or eggs. Further demonstration that Sm20.8 was expressed in the different developmental stages of the parasite was by RT-PCR. Confocal microscopy demonstrates that Sm20.8 localizes to the tegument of adult worms and 3 h np-40. The IgG fraction specific to Sm20.8 mediated complement killing of schistosomules in vitro by 34%. Vaccination of mice with naked DNA containing the Sm20.8 gene and subsequently challenged with cercariae showed 30% reduction in worm burden compared to controls.

Cloning and characterization of Schistosoma mansoni fructose-1,6-bisphosphate aldolase isoenzyme

A Schistosoma mansoni cercarial cDNA expression library, constructed in lambda gt11, was screened using the IgG fraction of sera taken from rabbits vaccinated with irradiated cercariae. A positive cDNA clone (1,431 base pairs) was selected and characterized. The amino acid sequence predicted from the cDNA sequence identified a polypeptide of 363 amino acids that showed significant homology to different family members of the enzyme fructose-1,6-bisphosphate aldolase (EC 1.4.2.13). The identity was 66% and 65% with human C and A isoenzymes, respectively. Active sites and substrate-binding determinant analysis suggest that the isolated enzyme in terms of function resembles type A aldolase. The recombinant protein expressed in the vector pGEX-2T was found to be active enzymatically. Antibodies raised against the purified recombinant protein recognized a 40-kDa band in extracts from cercariae, schistosomula (5 and 25 days), adult worms, and eggs. Using immunocytochemistry, aldolase localized to the tegumental region of the adult worms.

Reduced effects of L-carnitine on glucose and fatty acid metabolism in myocytes isolated from diabetic rats

Depressed glucose utilization and over-reliance of muscle tissues on fat represents a major metabolic disturbance in diabetes. This study was designed to investigate the relationship between fatty acid oxidation and glucose utilization in diabetic hearts and to examine the role of L-Carnitine on the utilization of these substrates in diabetes. 14CO2 release from [1-14C]pyruvate (an index of PDH activity), [2-14C]pyruvate and [6-14C]glucose (an index of acetyl-CoA flux through the Krebs cycle), [U-14C]glucose (an index of both PDH and acetyl-CoA flux through the Krebs cycle), and [1-14C]palmitate oxidation were studied in cardiac myocystes isolated from normal and streptozotocin-injected rats. Palmitate oxidation was increased twofold in diabetic myocytes compared to normal cells (5.4 +/- 1.45 vs 2.35 +/- 0.055 nmol/mg protein/30 min, p > 0.05). L-Carnitine (5 mM) significantly increased palmitate oxidation (60-70%) in normal cells but had no effect on diabetic cells. The activity of PDH and acetyl-CoA flux through the Krebs cycle was severely depressed in diabetes (58.14 +/- 20.27 and 8.63 +/- 0.62 in diabetes vs 128.75 +/- 11.47 and 24.84 +/- 7.81 nmol/mg protein/30 min in controls, p > 0.05, respectively). The efflux of acetylcarnitine, a by-product of PDH activity was also much lower in diabetic cells than in normal cells but had no effect in diabetes. L-Carnitine also had no effect on 14CO2 release from [U-14C]glucose but significantly decreased that from [6-14C]glucose, which reflects oxidative metabolism suggesting that L-Carnitine decreases oxidative glucose utilization. Thus, these data suggest that the overreliance on fat in diabetes may be in part secondary to a reduction of carbohydrate-generated acetyl-CoA through the Krebs cycle.

Synteny mapping in river buffalo

The cosegregation of ten coding loci has been investigated, in a panel of 37 somatic cell hybrids resulting from the fusion of a hamster cell line and river buffalo lymphocytes, by use of Southern hybridization technique. Five syntenic groups, TCRB-PGY3, ASS-ABL, FUCA1P-CRYG, MBP-YES1, and CGN1-ACTA1, previously assigned to cattle as U13, U16, U17, U28, and U29 respectively, were also found to be syntenic in buffalo. Based on the extensive syntenic conservation and banding homology between cattle and river buffalo, comparative mapping predicts the localization of these syntenic groups on river buffalo Chromosomes (Chrs) :BBU7, BBU12, BBU2q, BBU22, and BBU4q respectively as they have been previously localized on cattle Chrs BTA4, BTA11, BTA2, BTA24 & BTA28.

Cloning the gene encoding Schistosoma mansoni p50, an immunophilin

A 2.2-kb fragment of genomic DNA encoding Schistosoma mansoni immunophilin p50 (Smp50) was identified on a 14-kb genomic clone. The sequence of Smp50 reveals seven exons interrupted by six small introns ranging from 28-35 bp in size. The transcription start point, defined by primer extension analysis of schistosome RNA, begins at 30 bp upstream from the start AUG codon. Smp50 lacks a TATA box and appears to be a single-copy gene.

Identification and characterization of Schistosoma mansoni p17.7, a cyclophilin

Antibodies affinity purified against tegumental components of schistosomula were used to screen a Schistosoma mansoni lambda gt11 adult worm cDNA expression library. One of the reactive clones was determined by sequence analysis to encode a protein homologous to cyclophilins of other species, in particular cyclophilin A. The 0.8-kb cDNA clone contained an open reading frame of 483 nucleotides which corresponds to a translation product of 161 amino acids with a deduced molecular size of 17.7 kDa. We have chosen to designate this clone as S. mansoni p17.7 (Smp17.7). The overexpressed and purified recombinant Smp17.7 (rSmp17.7) was demonstrated to possess peptidylprolyl cis-trans isomerase (PPIase) or rotamase activity typical of cyclophilins. Western blot analysis of Nonidet P-40 and a total soluble extract of adult schistosomes probed with affinity-purified antisera to rSmp17.7, demonstrated the presence of this protein in the parasite. Immunofluorescence studies using the purified antisera indicates a localization in various tissues including the tegument and the gut. As cyclophilin is able to interact with cyclosporin A (CsA), which has been shown to be antischistosomal in mice infected with S. mansoni, the characterization of this S. mansoni cyclophilin homologue may allow a better understanding of the schistosomicidal nature of cyclosporin A and lead to a novel strategy of therapy for schistosomiasis.

Immune response to Schistosoma mansoni phosphoglycerate kinase during natural and experimental infection: identification of a schistosome-specific B-cell epitope

A cDNA clone encoding Schistosoma mansoni phosphoglycerate kinase (SmPGK) was previously identified by affinity-purified antibodies which are specific for 3-h-old schistosomula tegumental antigens. Antibodies to the recombinant SmPGK which has enzymatic activity were localized to various tissues including the tegument of the 3-h-old schistosomula and 42-day-old adult worms. In this study, we show that SmPGK is an immunogenic molecule in both natural infection in humans and experimental vaccination in animals. To understand the role that a highly conserved molecule like SmPGK played during schistosome infection, we affinity purified antibodies to SmPGK from patients with chronic schistosomiasis and demonstrated that they did not cross-react with human PGK. However, affinity-purified rabbit anti-SmPGK antibodies did show immunoreactivity to both human PGK and rabbit PGK. Thus, during natural infection antibodies that cross-react with human PGK are not produced; however, as a result of active immunization with an intact conserved molecule, such cross-reacting antibodies are produced. Immunological analysis of cyanogen bromide digests of SmPGK with monoclonal antibodies that recognize SmPGK but not human PGK identifies a B-cell epitope on a 12.2-kDa fragment represented by amino acids 61 to 174.

Cloning of the gene for phosphoglycerate kinase from Schistosoma mansoni and characterization of its gene product

As molecules on the surface or associated with the outer covering (tegument) of Schistosoma mansoni are a major focus as potential vaccine candidates, affinity purified antibodies which are specific to the tegumental antigens were used to immunoscreen a lambda gt11 S. mansoni cercarial cDNA library. One of the identified clones was found to encode the glycolytic enzyme phosphoglycerate kinase (PGK, EC 2.7.2.3). The 1.5-kb cDNA clone has a single open reading frame encoding 416 amino acids and exhibits over 60% identity to PGKs from a number of eukaryotic species. Recombinant S. mansoni PGK (SmPGK) was overexpressed in Escherichia coli, purified, and shown to have PGK enzyme activity. Native protein affinity purified from S. mansoni adult worms was shown by microsequencing to have the same amino-acid sequence as deduced from the cDNA sequence, thus confirming the cDNA clone we identified encodes S. mansoni phosphoglycerate kinase. Antibodies localize the native SmPGK to various tissues including the tegument of 3-h schistosomula and 42-day adult worms.

Schistosoma mansoni: characterization of p50, an immunophilin

A 1.4-kb cDNA clone encoding a 50-kDa homologue of p59, a heat shock binding immunophilin, has been isolated from a Schistosoma mansoni cercariae cDNA library. We have designated this clone S. mansoni p50 (Smp50). From the sequence comparison, we speculate that Smp50 is similar in structural organization to other p59 proteins. As with other p59s, Smp50 also shows homology to various FK binding proteins (FKBPs). The amino acids in human FKBP12 which are proposed to be important for FK506 interaction are conserved in the schistosome protein. We have expressed and purified the recombinant protein (rSmp50) from Escherichia coli. rSmp50 demonstrated peptidyl-prolyl cis-transisomerase (PPIase) activity, typical of immunophilins. Western blot analysis of extracts from S. mansoni adult worms probed with rabbit polyclonal antisera, generated against the recombinant polypeptide, has indicated the presence of Smp50 in the parasite. The antisera did not cross-react with proteins from E. coli or HeLa cell extracts. All of the p59s characterized to date have been from vertebrate species. Therefore, our finding represents the first identification of the protein in an invertebrate system.

The reaction of ribosomes with elongation factor Tu.GTP complexes. Aminoacyl-tRNA-independent reactions in the elongation cycle determine the accuracy of protein synthesis

The fidelity of protein synthesis depends on the rate constants for the reaction of ribosomes with ternary complexes of elongation factor Tu (EF-Tu), GTP, and aminoacyl (aa)-tRNA. By measuring the rate constants for the reaction of poly(U)-programmed ribosomes with a binary complex of elongation factor (EF-Tu) and GTP we have shown that two of the key rate constants in the former reaction are determined exclusively by ribosome-EF-Tu interactions and are not affected by the aa-tRNA. These are the rate constant for GTP hydrolysis, which plays an important role in the fidelity of ternary complex selection by the ribosome, and the rate constant for EF-Tu.GDP dissociation from the ribosome, which plays an equally important role in subsequent proofreading of the aa-tRNA. We conclude that the fidelities of ternary complex selection and proofreading are fundamentally dependent on ribosome-EF-Tu interactions. These interactions determine the absolute value of the rate constants for GTP hydrolysis and EF-Tu.GDP dissociation. The ribosome then uses these rate constants as internal standards to measure, respectively, the rate constants for ternary complex and aa-tRNA dissociation from the ribosome. These rates, in turn, are highly dependent on whether the ternary complex and aa-tRNA are cognate or near-cognate to the codon being translated.

Guanosine 5'-O-(3-thiotriphosphate) as an analog of GTP in protein biosynthesis. The effects of temperature and polycations on the accuracy of initial recognition of aminoacyl-tRNA ternary complexes by ribosomes

Guanosine 5'-O-(3-thio)triphosphate (GTP gamma S) is a good analog of GTP in the reactions leading to the formation of a peptide bond in protein biosynthesis. It forms binary and ternary complexes with elongation factor Tu (EF-Tu), and with EF-Tu and aminoacyl-tRNA (aa-tRNA). In addition, it stimulates aa-tRNA binding to ribosomes. Although GTP gamma S hydrolysis is more than three orders of magnitude slower than GTP hydrolysis, both reactions are dependent on the formation of a noncovalent complex (RS X TC) between mRNA-programmed ribosomes and ternary complex, and the complexes resulting from that hydrolysis are intermediates in peptide formation. The rate of dissociation of the ribosome X EF-Tu X GTP gamma S X aa-tRNA complex was determined from the rate of labeled peptide formation in the presence of an unlabeled ternary complex chase. This rate (2.2 X 10(-3) s-1) is similar to that determined previously (Thompson, R.C., and Karim, A.M. (1982) Proc. Natl. Acad. Sci. U.S.A. 79, 4922-4926) from the progress of GTP gamma S hydrolysis. The effects of temperature and polycation concentration on this rate constant and that for GTP gamma S hydrolysis are reported. The rate constants measured are consistent with a kinetic rather than thermodynamic limit on the accuracy of the aa-tRNA selection in vivo.

Mucosal antitoxic and antibacterial immunity after cholera disease and after immunization with a combined B subunit-whole cell vaccine

Mucosal and systemic immune responses to a new oral cholera vaccine, consisting of the B subunit plus killed vibrios, were studied in Bangladeshi volunteers and compared with those to clinical cholera. A single peroral dose of vaccine induced a local IgA antitoxin response in intestinal-lavage fluid of seven of eight vaccinees; the response closely mimicked that of patients convalescing from cholera, and evidence of the induction of local immunologic memory was found as well. Two peroral doses were needed for stimulation of an intestinal IgA immune response to the lipopolysaccharide of Vibrio cholerae that was comparable to the response obtained after clinical cholera. This response to peroral immunization was considerably stronger than that to parenteral vaccination, although the intramuscular route gave rise to the strongest IgG antitoxin and antilipolysaccharide responses in serum. The results suggest that B subunit-whole cell vaccine, when given in at least two oral doses, may be a good candidate for use in cholera prophylaxis.

The accuracy of protein biosynthesis is limited by its speed: high fidelity selection by ribosomes of aminoacyl-tRNA ternary complexes containing GTP[gamma S]

Guanosine 5'-[gamma-thio]triphosphate (GTP[gamma S] ) forms a stable ternary complex with polypeptide chain elongation factor Tu (EF-Tu) and aminoacyl-tRNA, and this complex binds rapidly and tightly to a properly programmed ribosome. However, the rate constant for the subsequent hydrolysis of the beta-gamma pyrophosphate bond (3.9 X 10(-3) s-1 at 5 degrees C) is less than 1/2,500th of that for the analogous reaction of GTP. We have taken advantage of this low rate to determine the rate constant for dissociation of the complex of poly(U)-programed ribosomes, EF-Tu, Phe-tRNAPhe, and GTP[gamma S] (2.7 X 10(-3) s-1) and the second-order rate constant for formation of this complex (3.3 X 10(6) M-1 s-1). Therefore, the Kd of the complex may be calculated to be 8.2 X 10(-10) M. An analogous near-cognate complex with Leu-tRNA2Leu in place of Phe-tRNAPhe has been determined by equilibrium methods to have a Kd greater than 1.7 X 10(-6) M. These results indicate that under equilibrium conditions the ribosome can distinguish cognate and near-cognate ternary complexes with great accuracy. Therefore, its failure to show this high specificity with the physiological ternary complexes containing GTP is due to the speed of GTP hydrolysis being similar to the speed of dissociation of the near-cognate complex. The low specificity of the physiological reaction is corrected by subsequent proofreading. The results reported here suggest that proofreading is necessary not simply for high accuracy but for the combination of speed and accuracy required in protein biosynthesis.

Effect of Mg2+ concentration, polyamines, streptomycin, and mutations in ribosomal proteins on the accuracy of the two-step selection of aminoacyl-tRNAs in protein biosynthesis

Discrimination against the binding of noncognate aminoacyl (aa)-tRNAs by mRNA-programmed ribosomes is the outcome of two selection steps, one involving an aa-tRNA.EFTu.GTP complex, which occurs prior to and includes GTP hydrolysis, the other involving the aa-tRNA alone, which follows GTP hydrolysis. Conditions which lead to errors in protein synthesis have been found to influence the accuracy of one or both selection steps in a system measuring poly(U)-directed binding of Leu-tRNA2Leu. Streptomycin has a large effect only on the discrimination process following GTP hydrolysis, but the other pertubations of recognition studied, high [Mg2+], polyamines, the strA1 and ram1 mutations, affect both discrimination processes. The general result is consistent with the view that proofreading of aa-tRNA by ribosomes for the most part uses the same specificity determinants used in the initial selection of a ternary complex.

A GTPase reaction accompanying the rejection of Leu-tRNA2 by UUU-programmed ribosomes. Proofreading of the codon-anticodon interaction by ribosomes

The characteristics of a GTPase reaction between poly(U)-programmed ribosomes, EFTu . GTP, and the near-cognate aminoacyl (aa)-tRNA, Leu-tRNA Leu 2, have been studied to assess the role of this reaction in proofreading of the codon-anticodon interaction. The reaction resembles the GTPase reaction with cognate aa-tRNAs and EFTu . GTP in its substrate requirements, in its involving EFTu . GTP . aa-tRNA ternary complexes, and in its requiring a free ribosomal A-site. The noncognate reaction differs from the cognate one in that aa-tRNA becomes stably bound to the ribosomes only 5% of the time; it therefore seems best characterized as an abortive enzymatic binding reaction. The rate of reaction is a significant fraction (4%) of that of the cognate aa-tRNA, indicating that recognition of ternary complexes by ribosomes involves a level of error greater than that of translation as a whole. The rejection of the noncognate aa-tRNA following GTP hydrolysis is therefore a vital step in the translation process and fulfills the criteria set for a proofreading reaction. Leu-tRNA Leu 2 which escapes rejection through proofreading, forms a stable complex with the ribosomal A-site, so it appears that the Leu-tRNA2 which was rejected never reached the A-site and that proofreading precedes full A-site binding.

Placement of two transvenous permanent pacemaker leads in a single vein. Report of two cases

In two cases of permanent transvenous pacemaker failure, the defective pacing electrode could not be removed. A second pacing electrode was placed in the same vein to avoid an additional operation. To our knowledge, this simple and effective procedure has not been previously reported.