HEALTH TRANSITION REVIEW

Australia (Canberra) 57

1994, VOLUME 4, SUPPLEMENT

AIDS Impact and Prevention in the Developing World:

Demographic and Social Science Perspectives

96.57.1 - English - John C. Caldwell and Pat CALDWELL, Health Transition Centre, National Centre for Epidemiology and Population Health, Australian National University, Canberra ( Australia) The neglect of an epidemiological explanation for the distribution of HIV/AIDS in Sub-Saharan Africa: Exploring the male circumcision hypothesis (p. 23-46)

It is now clear that there is a marked geographical distribution of the sub-Saharan African AIDS epidemic. In a belt from Uganda to Botswana the epidemic is characterized by high levels of seroprevalence even in low-risk populations, while elsewhere it is largely confined to high-risk groups and those in immediate contact with them. The only plausible explanation so far put forward for this pattern is that the AIDS belts largely coincide with areas where ethnic groups which do not practise male circumcision are found or to which migrants move from these areas. The role of male non-circumcision has been presented in epidemiological studies which claimed a level of statistical association usually accepted as approaching proof in other investigations. These studies have been largely ignored for reasons that may not be entirely scientific. This paper examines these studies, probes their data and methodology, and surveys possible alternative explanations for the geographical distribution of the sub-Saharan African heterosexually transmitted AIDS epidemic. (AFRICA SOUTH OF SAHARA, UGANDA, BOTSWANA, AIDS, CIRCUMCISION)

96.57.2 - English - John Stover, The Futures Group International, 80 Glastonbury Boulevard, Glastonbury, CT 06033 (U.S.A.) The impact of HIV/AIDS on adult and child mortality in the developing world (p. 47-63)

At the beginning of the AIDS epidemic some observers predicted that this disease would increase mortality so much that it would cause population decline in many countries. Others have said that the mortality impact of AIDS would not be large. This report reviews the evidence available to date in this issue and presents a simple methodology for assessing the magnitude of the impact at the country level, given a few pieces of readily available informtion. The paper also presents projections of the likely impact of HIV-AIDS on adult and child mortality in the developing world and for a number of specific developing countries. (DEVELOPING COUNTRIES, AIDS, ADULT MORTALITY, CHILD MORTALITY)

96.57.3 - English - Simon Gregson, Geoff P. Garnett, Centre for Epidemiology of Infectious Disease, Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS (U.K.), Ruth Shakespeare, Department of Public Medicine, Southampton Health Commission, Southampton (U.K.), Geoff Foster, Family AIDS Caring Trust, Mutare (Zimbabwe), and Roy M. Anderson, Centre for Epidemiology of Infectious Disease, University of Oxford (U.K.)

Determinants of the demographic impact of HIV-1 in sub-Saharan Africa: The effect of a shorter mean adult incubation period on trends in orphanhood (p. 65-92)

Recent evidence suggests that the adult HIV-1 incubation period may be shorter in some sub-Saharan African populations than in Western populations. In this article we use mathematical-model-based simulations to show that, other things being equal, a shorter incubation period can result in smaller but more pronounced HIV-1 epidemics and faster, more acute, changes in demographic features, such as adult mortality, orphanhood and population structure. Empirical studies of orphanhood reveal similar patterns to those found in the simulations, but suggest that migration patterns and structural factors can give rise to greater concentrations of orphans in areas of relatively low HIV-1 prevalence. (AFRICA SOUTH OF SAHARA, AIDS, ORPHANHOOD, SIMULATION)

96.57.4 - English - O.O. Dare, Department of Preventive and Social Medicine, University College Hospital, PMB 5116, Ibadan, Oyo State (Nigeria), and J.G. CLELAND, Centre for Population Studies, London School of Hygiene and Tropical Medicine, 99 Gower Street, Londres (U.K.)

Reliability and validity of survey data on sexual behaviour (p. 93-110)

The contribution of structured interview surveys to the monitoring of changes in risk behaviour is a crucial issue for the evaluation of HIV control programmes. A review is made of studies that have attempted to assess the reliability and validity of self-reported sexual behaviour. Evidence from developed-country studies is encouraging; in general the quality of responses appears to be as high as that found in studies of other topics. In developing countries, there have been fewer studies and results are more varied. One clear lesson is that survey execution must be of a very high standard; as in all survey research, but particularly in the case of sex surveys, poor standards of design and execution will yield untrustworthy data. (DEVELOPING COUNTRIES, DEVELOPED COUNTRIES, AIDS, SEXUAL BEHAVIOUR, SURVEYS, QUALITY OF DATA)

96.57.5 - English - Catherine Enel, Emmanuel Lagarde and Gilles PISON, MusŽum National d'Histoire Naturelle, Centre National de la Recherche Scientifique and Institut National d'Etudes DŽmographiques, Paris (France)

The evaluation of surveys of sexual behaviour: A study of couples in rural Senegal (p. 111-124)

The reliability of self-reported answers about sexual behaviour is assessed by means of a survey of couples in rural Senegal, Africa, carried out in 1992. A total of 51 married couples were followed weekly over a five-week period. Reports for a recall period of seven days are reliable: dates of sexual acts differed by no more than a day in 73% of cases. Reports over longer periods are less reliable. Retrospective recall of coital frequency for a four-week period yields much higher estimates than those obtained with a seven-day recall, particularly for men. (SENEGAL, COITAL FREQUENCY, COUPLE, SURVEYS, RELIABILITY)

96.57.6 - English - Kathleen Ford, Peter Fajans, Department of Population Planning and International Health, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109-2029 (U.S.A.), and Dewa NYOMAN WIRAWAN, Faculty of Medicine, Udayana University, Denpasar, Bali (Indonesia)

AIDS risk behaviours and sexual networks of male and female sex workers and clients in Bali, Indonesia (p. 125-152)

At the present early stage of the HIV epidemic in Indonesia, it is important to document risk behaviours and sexual networks for high-risk groups such as prostitutes and their customers to assist in the planning of programmes to prevent further spread of HIV infection. This study investigated the degree of AIDS knowledge, sexual practices and sexual networks of several groups of female and male sex workers and clients in Bali, Indonesia. AIDS knowledge is weak and condom use is low for many of these groups. Important prevention efforts are needed to improve the level of knowledge among the Indonesian prostitutes and their customers and to increase the use of condoms. In addition, the data demonstrated the wide range of sexual networks available for transmission of HIV and other sexually transmitted diseases among the multiple groups of sex workers, their clients, and their sexual partners. (INDONESIA, AIDS, PROSTITUTION, SEXUAL BEHAVIOUR, CONDOM)

96.57.7 - English - Michel Cara'l, Global Programme on AIDS, World Health Organization, 1211 Gen?ve 27 (Switzerland), John G. Cleland, Centre for Population Studies, London School of Hygiene and Tropical Medicine, 99 Gower Street, Londres (U.K.), and Roger Ingham, Department of Psychology, University of Southampton, Southampton (U.K.) Extramarital sex: Implications of survey results for STD/HIV transmission (p. 153-172)

Results are presented from 14 surveys on sexual behaviour and other topics related to HIV/AIDS. Reported levels of premarital and extramarital sex varied widely but, in all sites, these levels were much higher among men than among women. Educational attainment is positively related to the prevalence of non-marital sexual contacts but expected urban-rural differences largely disappear when related factors are controlled. The importance of sex in exchange for money or gifts also varied between the sites, being more prominent in the Asian than in the African populations. Regular use of condoms during such encounters was uncommon. (SURVEYS, AIDS, SEXUALLY TRANSMITTED DISEASES, SEXUAL RELATIONSHIPS, SEXUAL PERMISSIVENESS, CONDOM)

96.57.8 - English - Naomi Rutenberg, The Futures Group International, 1050 17th Street NW, Suite 1000, Washington D.C. (U.S.A.), Ann K. Blanc, Demographic and Health Surveys Program, Calverton, MD (U.S.A.), and Saidi Kapiga, Muhimbili Medical Centre, Dar es Salaam (Tanzania) Sexual behaviour, social change, and family planning among men and women in Tanzania (p. 173-196)

There is significant variation in sexual behaviour among different population subgroups in Tanzania. This study documents differences in sexual behaviour patterns between men and women, residents of urban and rural areas, by level of education, and between condom users and users of other methods of family planning and non-users. The results also suggest that marital status as conventionally defined in demographic surveys is an inadequate proxy for exposure to sexual intercourse and the likelihood of engaging in risky sexual behaviour. (TANZANIA, SEXUAL BEHAVIOUR, FAMILY PLANNING, CONDOM, SEX DIFFERENTIALS)

96.57.9 - English - Lisa J. MESSERSMITH, Department of International Health, Johns Hopkins University, Baltimore (U.S.A.), Thomas T. KANE, Department of Population Dynamics, School of Hygiene and Public Health, Johns Hopkins University, Baltimore (U.S.A.), Adetanwa I. ODEBIYI, Department of Sociology and Anthropology, Obafemi Awolowo University, Ile-Ife (Nigeria), and Alfred A.ADEWUYI, Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife (Nigeria)

Patterns of sexual behaviour and condom use in Ile-Ife, Nigeria€: Implications for AIDS/STD prevention and control (p. 197-216)

This paper presents results from a two-stage stratified random sample survey of sexual behaviour and reproductive health of 1,149 adult men and women living in Ile-Ife, Nigeria. Detailed information was collected on sexual behaviour, condom use, knowledge of and experience with sexually transmitted diseases (STDs), knowledge of AIDS, including knowledge of modes of transmission and means of prevention, and socio-demographic characteristics. Multivariate logistic regression for the sample of men was used to assess the simultaneous effects of socio-demographic and sexual behaviour variables on ever use of condoms to prevent an STD, and on the likelihood of ever contracting an STD. Results indicate that educational level, number of lifetime sexual partners, and the experience of an STD are significantly and positively associated with the use of condoms to prevent STDs. In the regression analysis of the covariates of experience of an STD, contact with a sex worker was the most significant variable associated with having had an STD, although among older men, educational level and number of lifetime sexual partners were also positively linked to the experience of an STD. Implications of these findings for STD/AIDS prevention programmes in Nigeria are discussed. (NIGERIA, SURVEYS, AIDS, SEXUALLY TRANSMITTED DISEASES, CONDOM, SEXUAL BEHAVIOUR)

96.57.10 - English - Karen OPPENHEIM MASON, Program on Population, East-West Center, 1777 East-West Road, Honolulu, Hawaii 96848 (U.S.A.) HIV transmission and the balance of power between women and men: A global view (p. 217-240)

This paper presents a logical analysis of the paths by which gender inequality is likely to affect the heterosexual transmission of HIV. Non-use of condoms, the combination of a sexual double standard and frequent use of female prostitutes, and a high prevalence of curable sexually transmitted diseases are considered. The 'circulation' of women as sexual and reproductive gifts, which is a near-universal feature of human societies, explains men's use of prostitutes and promiscuity, and contributes to high STD prevalence. It may also contribute to the non-use of condoms, although a separate analysis suggests this is not always the case. The empowerment of women thus might help to slow the spread of HIV/AIDS. Even more effective in countries with large commercial sex sectors would be the empowerment of female sex workers. (AIDS, SEXUALLY TRANSMITTED DISEASES, SEX DISCRIMINATION, WOMEN'S EMANCIPATION, PROSTITUTION)

96.57.11 - English - Eleanor PRESTON-WHYTE, Research Office, University of Natal, Durban (South Africa)

Gender and the lost generation€: The dynamics of HIV transmission among black South African teenagers in KwaZulu/Natal (p. 241-255)

Before 1987 HIV infection in the heterosexual population was absent or rare. Although it is now spreading in all race groups, the epidemic appears to be most advanced among black (African) South Africans. The seriousness of the situation is exacerbated by high levels of teenage fertility and the experience of widespread adolescent and premarital sexual activity in many African communities. It is argued that educational programmes which centre on chastity before marriage, partner reduction, and monogamy are unlikely to make major inroads in teenage behaviour in the near future. The discussion of intervention strategies highlights, instead, the problem of, and possibilities for, the promotion of barrier methods, and, in particular, the use of condoms among black teenagers in Durban, South Africa. (SOUTH AFRICA, BLACKS, AIDS, ADOLESCENTS, SEXUAL PERMISSIVENESS, CONDOM)

96.57.12 - English - Pamela A. GILLIES, Department of Public Health Medicine and Epidemiology, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH (U.K.), and Richard G. PARKER, Instituto de Medicina Social, State University of Rio de Janeiro (Brazil) Cross-cultural perspectives on sexual behaviour and prostitution (p. 257-271)

This paper describes the preliminary findings of a cross-cultural study of sexual behaviour and prostitution in the context of the prevention of sexually transmitted disease including HIV infection. Three hundred and sixty-six male and female prostitutes were involved in in-depth interviews and focus group discussions in sites in Brazil, the Dominican Republic and England. Findings on the heterogeneity of the category prostitute and on the shifting nature of sexual identity, roles and behaviours within as well as across cultures, stress the need for the development of understanding of local sexual culture to ensure that prevention programmes are relevant and practicable. (BRAZIL, DOMINICAN REPUBLIC, ENGLAND, SEXUAL BEHAVIOUR, PROSTITUTION, CULTURE, COMPARATIVE ANALYSIS)

96.57.13 - English - Kritaya ARCHAVANITKUL and Philip GUEST, Institute for Population and Social Research, Mahidol University at Salaya, Nakorn Pathom 73170 (Thailand) Migration and the commercial sex sector in Thailand (p. 273-296)

Migration in the Thai context is the crucial link between development and the expansion of prostitution. This paper examines the role that social networks and economic factors play in the migration of young women. Most female migrants are young and unmarried, have relatively low levels of education and migrate in search of employment: prostitution is one of the few occupations in which they can make relatively high incomes. Migration networks are more important than the socioeconomic status of families in determining the number and destination of young rural people seeking work outside the villages. These networks can facilitate the induction of young rural girls into prostitution and lead to a very clear geographical concentration of prostitutes in Thailand. Once in the industry, sex workers have relatively high incomes of which they can remit a large proportion; and they are often dependent on their employers. They provide a large contribution to overall household earnings and enable households to live quite well. Migration into the sex sector is intimately linked to family roles in Thailand: young women migrate to work in prostitution because they perceive a family need for the money that they earn. This gives them a great deal of responsibility, especially since in many cases, they are responsible for how their family spend the money. Remittances are often used to buy consumer items to show their community that the women have been successful; this compensates somewhat for the shame that they feel as prostitutes. (THAILAND, RURAL-URBAN MIGRATION, PROSTITUTION, WOMEN'S STATUS)

96.57.14 - English - Chai PODHISITA, Anthony PRAMUALRATANA, Uraiwan KANUNGSUKKASEM, Institute for Population and Social Research, Mahidol University, Salaya, Buddhamonthol, Nakhonpathom 73710 (Thailand), Maria J. WAWER and Regina McNAMARA, Center for Population and Family Health, Columbia University, 60 Haven Avenue, B-3, New York, NY 10032 (U.S.A.) Socio-cultural context of commercial sex workers in Thailand: An analysis of their family, employer and client relations (p. 297-320)

The rapid spread of HIV/AIDS in Thailand has recently led to increasing interest in prostitutes as the major source of the epidemic. This paper analyses the social and cultural context of female prostitutes. Survey and qualitative data from 678 women working in low-priced establishments reveal that most prostitutes entered the commercial sex sector from their own choice; about two-fifths did so when they were under 18 years of age. In most cases relationships with their families of origin are maintained through remittance of money and other contacts. The relationship with employers (brothel owners) is exploitative in nature and prostitutes are poorly treated. Use or non-use of condoms is seen as an important aspect of the relationship between prostitutes and their clients. Although reports on the number of clients in the night before the interview indicate an increase in condom use, there seems to be a wide gap with regard to consistency of use: much needs to be done towards safer sex for prostitutes and their clients. Adequate understanding of the sociocultural context of commercial sex should contribute to the success of intervention programmes aimed at slowing down the spread of AIDS as well as eventually reducing the number of prostitutes. (THAILAND, PROSTITUTION, AIDS, CONDOM, WOMEN'S STATUS, INTERPERSONAL RELATIONSHIPS)

96.57.15 - English - Saroj PACHAURI, The Ford Foundation, 55 Lodi Estate, New Delhi 110003 (India) Relationship between AIDS and family planning programmes€: A rationale for developing integrated reproductive health services (p. 321-347)

This paper examines the potential links between family planning and maternal and child health programmes and the emerging needs of the global AIDS epidemic; and assesses the feasibility of organizing comprehensive reproductive health programmes in developing countries to include the prevention and control of reproductive tract infections including sexually transmitted infections as well as HIV/AIDS. The paper discusses arguments opposing the integration of programmes against sexually transmitted infections within family planning and MCH programmes, as well as the programmatic and epidemiological reasons for considering such integration. It is important to determine what elements can be realistically integrated within programmes of varying organizational capacity without compromising their effectiveness. (DEVELOPING COUNTRIES, AIDS, FAMILY PLANNING PROGRAMMES, PUBLIC HEALTH)

96.57.16 - English - Eleanor MATICKA-TYNDALE, Department of Sociology and Anthropology, University of Windsor (Canada), Melissa HASWELL-ELKINS, Thicumporn KUYYAKANOND, Faculty of Medicine, Monthira KIEWYING, Faculty of Nursing, and David ELKINS, Faculty of Medicine, Khon Kaen University (Thailand)

A research-based HIV intervention in Northeast Thailand (p. 349-367)

This paper presents a case study of the development, implementation and evaluation of an HIV prevention strategy for rural, married women in the northeastern, Isan region of Thailand. The strategy is based on established principles of behaviour change, social learning, and community health promotion; grounded in baseline research, that identifies relevant contextual factors; community-based; evaluated; and applicable elsewhere. The methodology of the project includes four phases: data collection, strategy design, implementation, and evaluation. Baseline data were collected from an age-stratified sample of married women from 24 randomly chosen villages in Khon Kaen province in two waves. A total of 654 women participated in structured face-to-face interviews and 150 also participated in focus groups. Using the baseline data, a health promotion strategy including three components was designed: meetings with and training of village leaders and health workers; a five-part week long audio-drama, together with posters and other publicity conducted in villages; and village meetings to discuss the potential impact of HIV/AIDS on the village and to establish a village strategy to address this. This paper reports the results of the baseline data collection, how the data were used to produce an HIV prevention initiative for rural villages, results of the process evaluation and future development in HIV/AIDS prevention initiatives in this region. (THAILAND, AIDS, HEALTH SERVICES, PROGRAMME EVALUATION)

1995 - VOLUME 5, NUMBER 1

96.57.17 - anglais - Anne R. PEBLEY, Population Center, P.O. Box 2138, 1700 Main Street, Santa Monica, CA 90407-2138 (U.S.A.), and Noreen GOLDMAN, Office of Population Research, Princeton University, 21 Prospect Avenue, Princeton, NJ 08540 (U.S.A.)

Social inequality and children's growth in Guatemala (p. 1-20)

This paper is an investigation of the effects of social inequality in Guatemala on children's health and nutritional status as measured by attained height. Guatemala remains a highly stratified and poor society. We examine the association of land distribution, land tenure, occupation, and other aspects of family social and economic status with children's height between the ages of three months and 36 months, using data from a cross-sectional survey. An important consequence of the poverty and poor living conditions of the majority of the Guatemalan population is substantial deficits in children's growth. Our results suggest that children's growth is affected by ethnicity, their father's occupation, land distribution in the area where they live, and maternal education. Substantial growth deficits are observed among children living at altitudes above 1 500 metres; we hypothesize that this is because, in Guatemala, higher altitude is associated with land scarcity, poorer agricultural conditions, and greater remoteness from transport networks and other public services. (GUATEMALA, CHILD DEVELOPMENT, CHILD NUTRITION, AGRICULTURE)

96.57.18 - anglais - Jacob BAMIDELE ONI, Graduate Studies in Demography, National Centre for Development Studies, The Australian National University, Canberra, ACT 0200 (Australia) Fostered children's perception of their health care and illness treatment in Ekiti Yoruba households, Nigeria (p. 21-34)

This paper reports the findings from both quantitative and qualitative fieldwork conducted in six Ekiti Yoruba communities of southwestern Nigeria on the treatment of child illness within households. Relying heavily on data from focus group discussions, it shows how fostered children use local proverbs and day-to-day common sayings to describe their perception of the responses to and treatment of their illnesses in a very different way from that of the foster parents. Parents' responses and treatment of fostered and non-fostered children's illnesses were compared. Both the qualitative and quantitative evidence from the study showed that treatments were delayed for foster-children in comparison to own children, and foster-parents were found to be less sensitive to foster-child illness, which they often suspected was used to avoid housework. The different responses to, and treatment of, foster-children's illnesses are important for the understanding of the probable effects on differential morbidity, and possibly mortality, between fostered and nonfostered children. (NIGERIA, FOSTERING, CHILD REARING, MEDICAL CARE)

96.57.19 - anglais - Ricardo F. NEUPERT, Demography Program, Research School of Social Sciences, The Australian National University, Canberra (Australia)

Early-age mortality, socio-economic development and the health system in Mongolia (p. 35-57)

Since the 1920s Mongolia has developed an extensive and well-staffed health care system that has made modern health technologies accessible to most of its population. In addition, the country experienced rapid economic and social development whose benefits were equitably distributed among the population. In spite of this progress, infant and child mortality levels are high by contemporary standards and during the past 20 years these rates have remained virtually constant. The modern health care delivery system, externally imposed, failed to take into account the specific characteristics of the Mongolian culture; this fact is identified as one of the major determinants of the unexpected levels of early-age mortality. The excessive orientation toward curative medicine, the lack of health prevention and promotion activities and the lack of community participation have resulted in the people continuing to believe in traditional therapeutic patterns and self-care. They perceive the modern system exclusively in curative terms and not with regard to health preservation and disease prevention. Most Mongolians do not fully understand the health care system, and use its services mainly because they have no alternative, or because of coercion rather than conviction based on the learning and internalization of its basic principles. In practices and ideas of child care, preservation of health and disease prevention, people seem to identify more with the traditional health care system. Like other former socialist countries, Mongolia is experiencing deep economic and social transformations, whose implications for the health care system are discussed. An economic crisis whose end is nowhere in sight, emergent social inequalities, a vague health insurance model with unclear financing sources, and lack of concern by most policy-makers in strengthening the preventive component of the health system, are not positive factors for substantial infant and child mortality decline in the near future. A clear advantage is, however, the fact that there is a wide space for major improvements with existing internal and external resources. (MONGOLIA, INFANT MORTALITY, YOUTH MORTALITY, HEALTH SERVICES, ECONOMIC AND SOCIAL DEVELOPMENT)

96.57.20 - anglais - Dov FRIEDLANDER, Jona SCHELLEKENS and Refaela SHARASHOV COHEN, Department of Demography, The Hebrew University of Jerusalem, Mount Scopus, Jerusalem (Israel) Old-age mortality in Israel: Analysis of variation and change (p. 59-83)

This study analyses differentials in life expectancy and cause-specific death rates among the elderly Jewish population in Israel in the early 1970s and early 1980s. We find substantial inequality in old-age mortality levels across subpopulations in geographic units and show that this inequality increased between the two periods. Much of the variation in old-age mortality is explained by differences in economic and social status, ethnicity and religiosity. The importance of religiosity is of particular interest in the context of Israeli society. (ISRAEL, JEWS, RELIGIOUS PRACTICE, CAUSES OF DEATH, ADULT MORTALITY)

96.57.21 - anglais - D.H. BALMER, Department of Psychology, University of Nairobi, P.O. Box 30197, Nairobi (Kenya), E. GIKUNDI, M. KANYOTU and R. WAITHAKA, Kenya Association of Professional Counsellors, P.O. Box 55472, Nairobi (Kenya)

The negotiating strategies determining coitus in stable heterosexual relationships (p. 85-96)

Heterosexual behaviour is a complex subject and one which is aggravated by confounding variables. Few studies have investigated the way in which one variable, namely coitus, is initiated and negotiated in stable marital relationships. AS the HIV/AIDS pandemic spreads in sub-Saharan Africa, the subject of marital coitus becomes of increasing concern. This study tests a methodology of semi-structured interviews and diary-keeping techniques to investigate how the activity is initiated and negotiated. A research team monitored the study and evaluated the research techniques. The study concluded that the HIV/AIDS pandemic is affecting the initiation and negotiation of coitus between marital partners and that the partners wish to renegotiate the relationship, but the mechanisms for renegotiation are not at present available. (AFRICA SOUTH OF SAHARA, AIDS, SEXUAL BEHAVIOUR, COITUS, COUPLE)

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