Karl Krupp

Attitudes toward HPV vaccination among parents of adolescent girls in Mysore, India

This study investigates attitudes toward human papillomavirus (HPV) vaccination among parents of adolescent girls in Mysore, India. Seven focus group discussions were held among parents of adolescent girls stratified by sex, religion and region to explore attitudes about cervical cancer and HPV vaccination. The study found that while parents have limited knowledge about HPV or cervical cancer, most are still highly accepting an HPV vaccine. In addition, high acceptability levels appear to reflect positive attitudes toward the government universal immunization program in general, rather than to the HPV vaccine in particular. The results highlight the need for additional education and health promotion regarding HPV and cervical cancer prevention in India.

Empowering the people: Development of an HIV peer education model for low literacy rural communities in India

BackgroundDespite ample evidence that HIV has entered the general population, most HIV awareness programs in India continue to neglect rural areas. Low HIV awareness and high stigma, fueled by low literacy, seasonal migration, gender inequity, spatial dispersion, and cultural taboos pose extra challenges to implement much-needed HIV education programs in rural areas. This paper describes a peer education model developed to educate and empower low-literacy communities in the rural district of Perambalur (Tamil Nadu, India).MethodsFrom January to December 2005, six non-governmental organizations (NGOs) with good community rapport collaborated to build and pilot-test an HIV peer education model for rural communities. The program used participatory methods to train 20 NGO field staff (Outreach Workers), 102 womens self-help group (SHG) leaders, and 52 barbers to become peer educators. Cartoon-based educational materials were developed for low-literacy populations to convey simple, comprehensive messages on HIV transmission, prevention, support and care. In addition, street theatre cultural programs highlighted issues related to HIV and stigma in the community.ResultsThe program is estimated to have reached over 30 000 villagers in the district through 2051 interactive HIV awareness programs and one-on-one communication. Outreach workers (OWs) and peer educators distributed approximately 62 000 educational materials and 69 000 condoms, and also referred approximately 2844 people for services including voluntary counselling and testing (VCT), care and support for HIV, and diagnosis and treatment of sexually-transmitted infections (STI). At least 118 individuals were newly diagnosed as persons living with HIV (PLHIV); 129 PLHIV were referred to the Government Hospital for Thoracic Medicine (in Tambaram) for extra medical support. Focus group discussions indicate that the program was well received in the communities, led to improved health awareness, and also provided the peer educators with increased social status.ConclusionUsing established networks (such as community-based organizations already working on empowerment of women) and training womens SHG leaders and barbers as peer educators is an effective and culturally appropriate way to disseminate comprehensive information on HIV/AIDS to low-literacy communities. Similar models for reaching and empowering vulnerable populations should be expanded to other rural areas.

Determinants of domestic violence among women attending an Human Immunodeficiency Virus voluntary counseling and testing center in Bangalore, India

CONTEXT Violence against women is a global phenomenon that cuts across all social and economic classes. AIMS This study was designed to measure the prevalence and correlates of domestic violence (DV) among women seeking services at a voluntary counseling and testing (VCT) center in Bangalore, India. SETTINGS AND DESIGNS A cross-sectional survey was conducted among women visiting an human immunodeficiency virus (HIV) VCT center in Bangalore, between September and November 2005. MATERIALS AND METHODS An interviewer-administered questionnaire was used to collect information about violence and other variables. STATISTICAL ANALYSIS USED Univariable associations with DV were made using Pearson Chi-squared test for categorical variables and Student t-test or the Mann-Whitney test for continuous variables. RESULTS Forty-two percent of respondents reported DV, including physical abuse (29%), psychological abuse (69%) and sexual abuse (1%). Among the women who reported violence of any kind, 67% also reported that they were HIV seropositive. The most common reasons reported for DV included financial problems (38%), husbands alcohol use (29%) and womans HIV status (18%). Older women (P < 0.001) and those with low income levels were the most likely to have experienced DV (P = 0.02). Other factors included husbands education, HIV seropositivity and alcohol or tobacco use (P < 0.001). CONCLUSION This study found DV levels comparable to other studies from around the world. The findings highlight the need for additional training among health care providers in VCT centers in screening for DV, detection of signs of physical abuse and provisions and referrals for women suffering from domestic partner violence.

Acceptability of male circumcision among mothers with male children in Mysore India.

Objective:There is currently little information on the acceptability of male circumcision in India. This study investigated the acceptability of male circumcision among Indian mothers with male children. Design:A cross-sectional survey was conducted among a convenience sample of 795 women attending a reproductive health clinic in Mysore, India, between January and April 2007. Results:Of the 1012 invited eligible participants, 795 women agreed to participate (response rate = 78.5%). The majority of women were Hindus (78%), 18% were Muslims, and 4% were Christians. About 26% of respondents had no schooling, 29% had 7 years of schooling, 42% had 8–12 years, and 3% had more than 12 years. After women were informed about the risks and benefits of male circumcision, a majority of women with uncircumcised children (n = 564, 81%) said they would definitely circumcise their children if the procedure were offered in a safe hospital setting, free of charge, and a smaller number (n = 50, 7%) said they would probably consider the procedure. Only seven women (1%) said that they would definitely/probably not consider male circumcision, and 63 (9%) were unsure. Conclusion:Since male circumcision has been found to decrease risk of HIV infection among men, it is important to determine its acceptability as a potential HIV prevention strategy in India. This study found male circumcision to be highly acceptable among a broad range of mothers with male children in Mysore, India. Further studies of acceptability among fathers and other populations are warranted.

Simple and inexpensive point-of-care tests improve diagnosis of vaginal infections in resource constrained settings

Objective  Bacterial vaginosis (BV) and Trichomonas vaginalis infection (TV) have been associated with adverse birth outcomes and increased risk for HIV. We compare the performance of simple inexpensive point‐of‐care (POC) tests to laboratory diagnosis and syndromic management of BV and TV in poor settings.

Prevalence of Trichomonas vaginalis infection among young reproductive age women in India: implications for treatment and prevention.

BACKGROUND Trichomonas vaginalis infection is the most common curable sexually transmissible infection (STI) worldwide. The present study describes the burden and correlates of T. vaginalis infection among young reproductive age women in Mysore, India. METHODS Between November 2005 and March 2006, sexually active women aged 15-30 years were recruited from low-income peri-urban and rural neighbourhoods of Mysore, India. Participants were interviewed and offered a physical examination and testing for T. vaginalis, bacterial vaginosis, vaginal candidiasis, Neisseria gonorrheoea and herpes simplex virus type-2 antibodies. RESULTS Of the 898 participating women, 76 had a T. vaginalis infection (8.5%, 95% confidence interval [95% CI]: 6.7-10.5%). Nearly all (98%) participants were married and most reported their spouse as their main sex partner. The mean age at marriage was 16.9 years (s.d. 2.9 years) and two-thirds of the sample reported having first sexual intercourse before the age of 19 years. Risk factors independently associated with T. vaginalis infection included early age at first intercourse (adjusted odds ratio [OR] 2.09; 95% CI: 1.09-4.00), concurrent bacterial vaginosis (OR 8.21; 95% CI: 4.30-15.66), vaginal candidiasis (OR 2.40; 95% CI: 1.48-3.89) and herpes simplex virus type-2 infection (OR 3.44; 95% CI: 1.97-6.02). CONCLUSION The burden of T. vaginalis infection at 8.5% is relatively high among a community sample of young reproductive aged women. Because this infection increases the risk of HIV transmission and is associated with adverse pregnancy outcomes, there is a need for increased screening and treatment of this easily curable sexually transmissible infection in India.

Leveraging human capital to reduce maternal mortality in India: enhanced public health system or public-private partnership?

Developing countries are currently struggling to achieve the Millennium Development Goal Five of reducing maternal mortality by three quarters between 1990 and 2015. Many health systems are facing acute shortages of health workers needed to provide improved prenatal care, skilled birth attendance and emergency obstetric services – interventions crucial to reducing maternal death. The World Health Organization estimates a current deficit of almost 2.4 million doctors, nurses and midwives. Complicating matters further, health workforces are typically concentrated in large cities, while maternal mortality is generally higher in rural areas. Additionally, health care systems are faced with shortages of specialists such as anaesthesiologists, surgeons and obstetricians; a maldistribution of health care infrastructure; and imbalances between the public and private health care sectors. Increasingly, policy-makers have been turning to human resource strategies to cope with staff shortages. These include enhancement of existing work roles; substitution of one type of worker for another; delegation of functions up or down the traditional role ladder; innovation in designing new jobs;transfer or relocation of particular roles or services from one health care sector to another. Innovations have been funded through state investment, public-private partnerships and collaborations with nongovernmental organizations and quasi-governmental organizations such as the World Bank. This paper focuses on how two large health systems in India – Gujarat and Tamil Nadu – have successfully applied human resources strategies in uniquely different contexts to the challenges of achieving Millennium Development Goal Five.

Bacterial Vaginosis and Risk for trichomonas vaginalis Infection: A Longitudinal Analysis

Background: Bacterial vaginosis (BV) and Trichomonas vaginalis (TV) have been estimated to affect one-quarter to one-third of sexually active women worldwide, and are often found concurrently. Few studies have examined this relationship longitudinally to better understand the direction and temporality of this association. Methods: Between 2005 and 2006, a cohort of 853 young, sexually active women was followed in Mysore, India; participants were interviewed and tested for BV and TV at baseline, and at 3- and 6-month visit. Generalized estimating equations were used to estimate how changes in vaginal flora between consecutive visits—as defined by Nugent diagnostic criteria for BV—were related to the risk of TV infection at the latter visit, adjusted for sociodemographic and behavioral covariates. Treatment was offered to women with TV and/or symptomatic BV. Results: After adjustment for covariates, participants with abnormal vaginal flora at 2 consecutive visits had 9 times higher risk of TV (95% CI: 4.1, 20.0) at the latter visit, relative to those with persistently normal flora. An increased risk of TV was also observed for participants whose flora status changed from normal to abnormal (adjusted risk ratio: 7.11, 95% CI: 2.8, 18.2) and from abnormal to normal (adjusted risk ratio: 4.50, 95% CI: 1.7, 11.8). Conclusions: Women experiencing abnormal flora during a 3-month span appear to have significantly increased risk of acquiring TV infection. Women of reproductive age in low-resource settings found to have abnormal vaginal flora should be assessed for TV.

Are marginalized women being left behind? A population-based study of institutional deliveries in Karnataka, India

BackgroundWhile India has made significant progress in reducing maternal mortality, attaining further declines will require increased skilled birth attendance and institutional delivery among marginalized and difficult to reach populations.MethodsA population-based survey was carried out among 16 randomly selected rural villages in rural Mysore District in Karnataka, India between August and September 2008. All households in selected villages were enumerated and women with children 6 years of age or younger underwent an interviewer-administered questionnaire on antenatal care and institutional delivery.ResultsInstitutional deliveries in rural areas of Mysore District increased from 51% to 70% between 2002 and 2008. While increasing numbers of women were accessing antenatal care and delivering in hospitals, large disparities were found in uptake of these services among different castes. Mothers belonging to general castes were almost twice as likely to have an institutional birth as compared to scheduled castes and tribes. Mothers belonging to other backward caste or general castes had 1.8 times higher odds (95% CI: 1.21, 2.89) of having an institutional delivery as compared to scheduled castes and tribes. In multivariable analysis, which adjusted for inter- and intra-village variance, Below Poverty Line status, caste, and receiving antenatal care were all associated with institutional delivery.ConclusionThe results of the study suggest that while the Indian Government has made significant progress in increasing antenatal care and institutional deliveries among rural populations, further success in lowering maternal mortality will likely hinge on the success of NRHM programs focused on serving marginalized groups. Health interventions which target SC/ST may also have to address both perceived and actual stigma and discrimination, in addition to providing needed services. Strategies for overcoming these barriers may include sensitization of healthcare workers, targeted health education and outreach, and culturally appropriate community-level interventions. Addressing the needs of these communities will be critical to achieving Millennium Development Goal Five by 2015.

Novel recruitment strategies to increase participation of women in reproductive health research in India

Abstract In India, care seeking for reproductive health among women is inadequate. This poses a unique challenge to researchers recruiting cohorts for studies in clinic-based settings. The purpose of this paper is to describe the recruitment process used in a prospective cohort study investigating the relationship between bacterial vaginosis and acquisition of HSV-2 among sexually active women in Mysore, India. Participants were initially recruited from an obstetrics/gynaecology outpatient clinic. Results were compared with a ‘community supported’ enrolment process, which included community preparation and reproductive health education followed by screening of potential participants. During November 2005, 1,054 women were screened in the clinic. Of the total screened, 246 (23%) were eligible and only 78 (7%) enrolled. Between December 2005 and April 2006, investigators adopted a community supported enrolment process. During that period, 1,077 potential participants were screened, 947 were eligible, and 918 (85%) enrolled. Fifty-six (72%) participants recruited from the clinic returned for their first follow-up visit, compared with 795 (97%) participants recruited using the community supported enrolment process. Since obstetrics/gynaecology departments in India are poor places to recruit non-pregnant women of reproductive age, a community supported process yields more eligible potential participants to screen, and results in significantly better study retention.