http://repub.eur.nl/res/aut/12236/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/39507/ 2013-03-18T00:00:00Z Background: Although hand hygiene (HH) has proven to be an effective measure to prevent infections, HH compliance is generally low. We assessed sociocognitive determinants of caregivers' HH behavior in child day care centers (DCCs) to develop an effective HH intervention. Methods: Caregivers' compliance to HH guidelines was observed. Observed caregivers completed a questionnaire on self-reported HH compliance, sociocognitive determinants, and sociodemographic data. To determine sociocognitive determinants of observed compliance, multilevel logistic regression analyses were performed. Self-reported compliance was analyzed using linear regression. Results: In 122 participating DCCs, 350 caregivers and 2,003 HH opportunities were observed. The response rate on the questionnaire was 100%. Overall observed HH compliance was 42% (841/2,003). Overall mean self-reported HH compliance was 8.7 (scale, 0-10). Guideline knowledge (odds ratio [OR], 1.27; 95% confidence interval [CI]: 1.03-1.56) and perceived disease severity (OR, 0.93; 95% CI: 0.87-0.99) were associated with observed compliance. Guideline knowledge (β = 0.31; P < .001), guideline awareness (β = 0.16; P < .001), perceived importance (β = 0.20; P = .004), perceived behavioral control (β = 0.24; P < .001), habit (β = 0.27; P < .001), and children at home (β = 0.30; P = .002) were associated with self-reported compliance. Conclusion: When developing HH interventions for caregivers in DCCs, improving guideline knowledge should be considered as this was associated with both observed and self-reported HH compliance. Furthermore, increasing guideline awareness, perceived importance, and perceived behavioral control can contribute to better HH, as well as making HH a habitual behavior. http://repub.eur.nl/res/pub/38958/ 2013-01-29T00:00:00Z A key question for ecological studies with HIV as the outcome variable is what measure of HIV prevalence to use. In this study we compared the strengths and weaknesses of a variety of measures of HIV prevalence, focusing on peak HIV prevalence and HIV prevalence measured at the same time as the exposure variable. We explored the theoretical problems with each of the two measures of HIV prevalence. We then investigated the difference that substituting one variable for the other made to two published ecological studies. One published study found a strong relationship between migration intensity and HIV prevalence measured at the time the migration was measured. When we repeated the analysis using peak HIV prevalence as the outcome variable, there was no evidence of an association. The second study found evidence of a strong relationship between concurrency and peak HIV prevalence. On repetition of the analysis (but utilizing HIV prevalence at the time the concurrency was measured as the outcome variable) there was no longer a significant association. The choice of HIV measure as outcome variable in ecological studies makes a large difference to the study results. The choice of peak HIV prevalence as outcome variable offers the advantage of avoiding the HIV introduction time bias. http://repub.eur.nl/res/pub/37667/ 2012-12-01T00:00:00Z Background & Aims: Migrants born in countries where hepatitis B is endemic are a risk group for chronic hepatitis B virus (HBV) infection. Treatment options have improved, but due to the asymptomatic nature of chronic HBV infection, the majority of patients remain unidentified. Methods: In 2009, a campaign targeting the Chinese community was held in the city of Rotterdam, The Netherlands. The campaign combined disease awareness activities with free HBV testing at outreach locations. Chronically HBV infected patients were referred to specialist care based on a referral guideline. Before and after the campaign, knowledge of chronic hepatitis B was measured through questionnaires in a convenience sample of the target population (n = 285 and n = 277). Results: In a period of 3 months, 13 outreach activities took place and 1090 Chinese migrants were tested for HBV. Forty-nine percent had serological signs of a past or recent HBV infection and 8.5% (n = 92) were chronically infected. Thirty-eight percent (n = 35) of chronically infected patients were referred for evaluation by a specialist and of these, 15 started antiviral treatment within 1 year of follow-up. Before the campaign, 55% answered correctly to 6 or more out of 10 knowledge items. Knowledge was positively associated with educational level. After the campaign, an increase in knowledge was observed in participants with low levels of education. Conclusions: Chinese migrants could be reached with an outreach campaign, and on-site testing was well accepted. A high prevalence of chronic HBV infection was found and referral to specialist care and initiation of treatment was successful. http://repub.eur.nl/res/pub/33992/ 2011-12-01T00:00:00Z Mobility is associated with HIV due to more risky sexual behaviour of mobile groups such as travellers and migrants. Limited participation of such groups may reduce the effectiveness of HIV interventions disproportionally. The established STDSIM model, which simulates transmission and control of HIV and STD, was extended to simulate mobility patterns based on data from Tanzania. We explored the impact of non-participation of mobile groups (travellers and recent migrants) on the effectiveness of two interventions: condom promotion and health education aiming at partner reduction. If mobile groups do not participate, the effectiveness of both interventions could be reduced by 40%. The impact of targeting travellers with a combined HIV campaign is close to that of a general population intervention. In conclusion, it is important to account for possible non-participation of migrants and travellers. If non-participation is substantial, impact of interventions can be greatly improved by actively approaching these people. http://repub.eur.nl/res/pub/34345/ 2011-11-01T00:00:00Z The disappearance of traditional sex education during rites of passage in African societies has left many youth uncertain of where to look for information. Against this backcloth, the objectives of this study were to identify knowledge gaps amongst adolescents in Kenya regarding sexuality, HIV/AIDS and reproductive health. A thematic analysis was conducted of questions posed by 735 school youth aged 12-18 years from Meru and Kajiado Districts. Results show that many questions showed curiosity and anxiousness. Knowledge appeared to be fragmented and sometimes revealed misconceptions, which may put youth at risk. The raised themes differed by gender and age. Questions on saying no to sex, sexual violence and female circumcision were a great concern for girls. Boys were more concerned with managing boy-girl relationships, preventing STI/HIV infection, and condoms. Concern about transition to adulthood, sexuality, STI and HIV/AIDS, myths and misconceptions, and intergenerational communication cut across both genders. Older teens were more concerned with questions on boy-girl relationships, norms and values regarding sexuality, and STI. Younger teens (< 15 years) wanted to know about reproduction, saying no to sex, HIV/AIDS, condoms, sexual violence and female circumcision. Compounding these challenges was the lack of intergenerational communication. The study identified important knowledge and communication gaps in sexual and reproductive health among in-school adolescents in Kenya. There is a need for sex education interventions for different age groups and genders. These interventions should work with parents, teachers and health professionals. http://repub.eur.nl/res/pub/31125/ 2011-08-26T00:00:00Z Introduction: During the 2009 influenza A (H1N1) pandemic, parents in the Netherlands were recommended to vaccinate healthy children between six months and five years of age. The aim of this study was to examine reasons for (non-)acceptance, risk perception, feelings of doubt and regret, influence of the social network, and information-seeking behavior of parents who accepted or declined H1N1 vaccination. Methods: Data on accepters were collected via exit interviews following the second-dose vaccination round in December 2009 (n= 1227). Data on decliners were gathered in June and July 2010 with questionnaires (n= 1900); 25 parents participated in in-depth interviews. Results: The most reported reasons for parental acceptance of H1N1 vaccination were " I don't want my child to become sick" (43%), " Mexican flu can be severe" (10%), " the government advises it, so I do it" (6%), and " if I don't do it, I will regret it" (6%). The most reported reasons declining the vaccination were " fear of side effects/harmful consequences" (51%), " just having a bad feeling about it" (46%), and " the vaccine was not thoroughly tested" (39%). More decliners than accepters experienced feelings of doubt about the vaccination decision (decliners 63% versus accepters 51%, p< 0.001), and decliners reported more often information-seeking behavior (decliners 76% versus accepters 56%, p< 0.001). Decliners more frequently solicited advice from their social network than accepters (decliners 72% versus accepters 61%, p< 0.001). Furthermore, accepters more often reported social influence on their vaccination decision (accepters 58% versus decliners 38%, p< 0.001) and experienced more negative feelings after their vaccination decision (accepters 8% versus decliners 2%, p< 0.001). Immigrant accepters and decliners more often had feelings of doubt and regret about the vaccination decision, solicited advice more often from their social network, and were more often influenced by this advice compared to native Dutch parents. Conclusion: To optimize response rates in future vaccination campaigns, health authorities should provide more information on vaccine benefits and possible risks, tailoring this information to specific risk groups. Health authorities should also invest in the development and implementation of effective vaccine risk/benefit communication tools. http://repub.eur.nl/res/pub/31232/ 2011-08-10T00:00:00Z Background: Kisumu has shown a rising HIV prevalence over the past sentinel surveillance surveys, and most new infections are occurring among youth. We conducted a qualitative study to explore risk situations that can explain the high HIV prevalence among youth in Kisumu town, Kenya. Methods. We conducted in-depth interviews with 150 adolescents aged 15 to 20, held 4 focus group discussions, and made 48 observations at places where youth spend their free time. Results: Porn video shows and local brew dens were identified as popular events where unprotected multipartner, concurrent, coerced and transactional sex occurs between adolescents. Video halls - rooms with a TV and VCR - often show pornography at night for a very small fee, and minors are allowed. Forced sex, gang rape and multiple concurrent relationships characterised the sexual encounters of youth, frequently facilitated by the abuse of alcohol, which is available for minors at low cost in local brew dens. For many sexually active girls, their vulnerability to STI/HIV infection is enhanced due to financial inequality, gender-related power difference and cultural norms. The desire for love and sexual pleasure also contributed to their multiple concurrent partnerships. A substantial number of girls and young women engaged in transactional sex, often with much older working partners. These partners had a stronger socio-economic position than young women, enabling them to use money/gifts as leverage for sex. Condom use was irregular during all types of sexual encounters. Conclusions: In Kisumu, local brew dens and porn video halls facilitate risky sexual encounters between youth. These places should be regulated and monitored by the government. Our study strongly points to female vulnerabilities and the role of men in perpetuating the local epidemic. Young men should be targeted in prevention activities, to change their attitudes related to power and control in relationships. Girls should be empowered how to negotiate safe sex, and their poverty should be addressed through income-generating activities. http://repub.eur.nl/res/pub/22937/ 2011-01-05T00:00:00Z Background: Research into risk perception and behavioural responses in case of emerging infectious diseases is still relatively new. The aim of this study was to examine perceptions and behaviours of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands. Methods. Two cross-sectional and one follow-up online survey (survey 1, 30 April-4 May; survey 2, 15-19 June; survey 3, 11-20 August 2009). Adults aged 18 years and above participating in a representative Internet panel were invited (survey 1, n = 456; survey 2, n = 478; follow-up survey 3, n = 934). Main outcome measures were 1) time trends in risk perception, feelings of anxiety, and behavioural responses (survey 1-3) and 2) factors associated with taking preventive measures and strong intention to comply with government-advised preventive measures in the future (survey 3). Results. Between May and August 2009, the level of knowledge regarding Influenza A (H1N1) increased, while perceived severity of the new flu, perceived self-efficacy, and intention to comply with preventive measures decreased. The perceived reliability of information from the government decreased from May to August (62% versus 45%). Feelings of anxiety decreased from May to June, and remained stable afterwards. From June to August 2009, perceived vulnerability increased and more respondents took preventive measures (14% versus 38%). Taking preventive measures was associated with no children in the household, high anxiety, high self-efficacy, more agreement with statements on avoidance, and paying much attention to media information regarding Influenza A (H1N1). Having a strong intention to comply with government-advised preventive measures in the future was associated with higher age, high perceived severity, high anxiety, high perceived efficacy of measures, high self-efficacy, and finding governmental information to be reliable. Conclusions. Decreasing trends over time in perceived severity and anxiety are consistent with the reality: the clinical picture of influenza turned out to be mild in course of time. Although (inter)national health authorities initially overestimated the case fatality rate, the public stayed calm and remained to have a relatively high intention to comply with preventive measures. http://repub.eur.nl/res/pub/28489/ 2010-08-26T00:00:00Z Background: Hepatitis B virus infection is an important health problem in the Turkish community in the Netherlands. To prevent transmission and progression of the disease in this community, increased screening is necessary. This study aimed to determine 1) the levels of awareness and knowledge regarding hepatitis B, comparing these in tested and non-tested Turkish-Dutch in Rotterdam; 2) the self-reported hepatitis B test status in this population, and how this is related to demographic characteristics, knowledge and awareness. Methods: We conducted a postal survey amongst first and second generation migrants, aged 16 - 40 years. Results: The response rate was 30.2% (n = 355 respondents). Levels of awareness and knowledge regarding hepatitis B were low, as the majority of respondents (73%) never thought about the disease and 58% of the respondents scored 5 or less out of ten knowledge items. Weighted analysis of self-reports showed a test rate of 15%, and a vaccination rate of 3%. Regression analysis showed that having been tested for hepatitis B was related to being married and higher levels of awareness and knowledge. Conclusions: This study shows low levels of hepatitis B awareness and knowledge in the Turkish community in Rotterdam. Self-reported test rates are lower in people who are not currently married, and in those who have low levels of awareness and knowledge. Especially, knowledge about the consequences of hepatitis B, such as liver cancer, was lacking. Therefore, a health promotion intervention should foremost raise awareness, and increase knowledge on the seriousness of this disease. http://repub.eur.nl/res/pub/24954/ 2009-11-02T00:00:00Z Background. Hepatitis B is an important health problem in the Turkish community in the Netherlands. Increased voluntary screening is necessary in this community, to detect individuals eligible for treatment and to prevent further transmission of the disease. Methods. We investigated socio-cultural determinants associated with hepatitis B screening in male and female, first and second generation Turkish migrants, by means of Focus Group Discussions. Results. Socio-cultural themes related to hepatitis B screening were identified; these were social norm, social support, sensitivity regarding sexuality, reputation, responsiveness to authority, religious responsibility, cleanliness and religious doctrine regarding health and disease, and the perceived efficacy of Dutch health care services. Motivating factors were the (religious) responsibility for one's health, the perceived obligation when being invited for screening, and social support to get tested for hepatitis B. Perceived barriers were the association of hepatitis B screening with STDs or sexual activity, the perception of low control over one's health, and the perceived low efficacy of the Dutch health care services. Reputation could act as either a motivator or barrier. Conclusion. This study identified relevant socio-cultural themes related to hepatitis B screening, which may serve to customize interventions aimed at the promotion of voluntary hepatitis B screening in the Turkish-Dutch population in the Netherlands. http://repub.eur.nl/res/pub/16179/ 2009-06-26T00:00:00Z OBJECTIVE: We investigated the so-called 'disco funeral' phenomenon in Kisumu, Kenya, whereby community members including adolescents congregate at the home of the deceased for several days, accompanied by music and dancing. We explored whether disco funerals are a risk situation for HIV/sexually transmitted infection infection among youth. DESIGN:: Cross-sectional qualitative study. METHODS: We conducted 44 in-depth interviews with male and female adolescents aged 15-20 years in Kisumu municipality in Nyanza Province, Kenya. We also made observations during six disco funerals. RESULTS: Disco funerals were an important place for young people to hang out; they increased the opportunities to meet and engage in (risky) sexual activities. Many adolescents reported having casual sex on these occasions, sometimes with multiple partners, and mostly without condoms. Some girls were forced into sex, and there were several accounts of gang rape. Sex in exchange for money was reported frequently. Drugs and alcohol seemed to facilitate unprotected, multiple-partner, coerced, and transactional sex. CONCLUSION: In Kisumu, a town with a generalized HIV/AIDS epidemic, the high AIDS mortality leads to frequent disco funerals. Because many adolescents are having unprotected, transactional, or coerced sex at these occasions, disco funerals might contribute to the high HIV prevalence among youth, especially among adolescent girls. HIV interventions urgently need to include outreach actions to youth who hang out at disco funerals and link up with parents and funeral organizers to reduce risk situations http://repub.eur.nl/res/pub/25397/ 2009-04-01T00:00:00Z We explored constraints of implementing AIDS education in public schools in Kenya. Sixty interviews with teachers and 60 focus group discussions with students were conducted in 21 primary and nine secondary schools. System/school-level constraints included lack of time in the curriculum, limited reach of secondary-school students (because AIDS education is embedded in biology, which is not compulsory), and disapproval of openness about sex and condoms by the Ministry of Education and parents. Alternative strategies to teach about AIDS had their own constraints. Teachers lacked training and support and felt uncomfortable with the topic. They were not used to interactive teaching methods and sometimes breached confidentiality. Teachers' negative attitudes constrained students from seeking information. Training interventions should be provided to teachers to increase their self-confidence, foster more positive attitudes, and stimulate interactive teaching methods. The Ministry of Education needs to have a clear policy toward the promotion of condoms. http://repub.eur.nl/res/pub/18233/ 2009-03-01T00:00:00Z Background: Ethnic minorities in Europe such as the Chinese may need a special strategy with regard to risk communication about emerging infectious diseases. To engage them in precautionary actions, it is important to know their information sources, knowledge, and health beliefs. Purpose: This study's purpose is to study the use of information sources, knowledge, and health beliefs related to SARS and avian flu of Chinese people in the UK and The Netherlands, and to make comparisons with the general population in these countries. Method: Results of a self-administered questionnaire among 300 British/Dutch Chinese were compared to data obtained from a computer-assisted phone survey among the general population (n∈=∈800). Results: British/Dutch Chinese got most information about emerging diseases from family and friends, followed by Chinese media and British/Dutch TV. They had less confidence than general groups in their doctor, government agencies, and consumer/patient interest groups. Their knowledge of SARS was high. They had a lower perceived threat than general populations with regard to SARS and avian flu due to a lower perceived severity. They had higher self-efficacy beliefs regarding SARS and avian flu. Conclusion: In case of new outbreaks of SARS/avian flu in China, local authorities in the UK and The Netherlands can best reach Chinese people through informal networks and British/Dutch TV, while trying to improve confidence in information from the government. In communications, the severity of the disease rather than the susceptibility appears to need most attention. http://repub.eur.nl/res/pub/18234/ 2009-03-01T00:00:00Z Background: Although the SARS outbreak involved few probable cases of infection in Europe, swift international spread of infections raised the possibility of outbreaks. In particular, SARS presented a sociopsychological and economic threat to European Chinese communities because of their close links with the outbreak's origins. Methods: A qualitative study was conducted among Chinese residents in the United Kingdom and the Netherlands to identify the origins of SARS risk perceptions and their impact on precautionary actions and adverse consequences from the perspective of vulnerable communities living in unaffected regions. Analysis was informed by protection motivation theory. Results: Results revealed that information from affected Asia influenced risk perceptions and protective behavior among the Chinese in Europe when more relevant local information was absent. When high risk perceptions were combined with low efficacy regarding precautionary measures, avoidance-based precautionary action appeared to dominate responses to SARS. These actions may have contributed to the adverse impacts of SARS on the communities. Conclusions: Experiences of European Chinese communities suggest that practical and timely information, and consistent implementation of protective measures from central governments are essential to protect vulnerable populations in unaffected regions from unnecessary alarm and harm during outbreaks of emerging infections. http://repub.eur.nl/res/pub/18236/ 2009-03-01T00:00:00Z Purpose: To study the levels of perceived threat, perceived severity, perceived vulnerability, response efficacy, and self-efficacy for severe acute respiratory syndrome (SARS) and eight other diseases in five European and three Asian countries. Method: A computer-assisted phone survey was conducted among 3,436 respondents. The questionnaire focused on perceived threat, vulnerability, severity, response efficacy, and self-efficacy related to SARS and eight other diseases. Results: Perceived threat of SARS in case of an outbreak in the country was higher than that of other diseases. Perceived vulnerability of SARS was at an intermediate level and perceived severity was high compared to other diseases. Perceived threat for SARS varied between countries in Europe and Asia with a higher perceived severity of SARS in Europe and a higher perceived vulnerability in Asia. Response efficacy and self-efficacy for SARS were higher in Asia compared to Europe. In multiple linear regression analyses, country was strongly associated with perceived threat. Conclusions: The relatively high perceived threat for SARS indicates that it is seen as a public health risk and offers a basis for communication in case of an outbreak. The strong association between perceived threat and country and different regional patterns require further research. http://repub.eur.nl/res/pub/18089/ 2009-02-20T00:00:00Z Objective: We investigated the so-called 'disco funeral' phenomenon in Kisumu, Kenya, whereby community members including adolescents congregate at the home of the deceased for several days, accompanied by music and dancing. We explored whether disco funerals are a risk situation for HIV/sexually transmitted infection infection among youth. Design: Cross-sectional qualitative study. Methods: We conducted 44 in-depth interviews with male and female adolescents aged 15-20 years in Kisumu municipality in Nyanza Province, Kenya. We also made observations during six disco funerals. Results: Disco funerals were an important place for young people to hang out; they increased the opportunities to meet and engage in (risky) sexual activities. Many adolescents reported having casual sex on these occasions, sometimes with multiple partners, and mostly without condoms. Some girls were forced into sex, and there were several accounts of gang rape. Sex in exchange for money was reported frequently. Drugs and alcohol seemed to facilitate unprotected, multiple-partner, coerced, and transactional sex. Conclusion: In Kisumu, a town with a generalized HIV/AIDS epidemic, the high AIDS mortality leads to frequent disco funerals. Because many adolescents are having unprotected, transactional, or coerced sex at these occasions, disco funerals might contribute to the high HIV prevalence among youth, especially among adolescent girls. HIV interventions urgently need to include outreach actions to youth who hang out at disco funerals and link up with parents and funeral organizers to reduce risk situations. http://repub.eur.nl/res/pub/30539/ 2008-05-07T00:00:00Z Background: Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, especially for women. An urgent demand for implementation of PrEP is expected at the moment efficacy has been demonstrated in clinical trials. We explored the long-term impact of PrEP on HIV transmission in different HIV epidemics. Methodology/Principal Findings: We used a mathematical model that distinguishes the general population, sex workers and their clients. PrEP scenarios varying in effectiveness, coverage and target group were modeled in the epidemiological settings of Botswana, Nyanza Province in Kenya, and Southern India. We also studied the effect of condom addition or condom substitution during PrEP use. Main outcome was number of HIV infections averted over ten years of PrEP use. PrEP strategies with high effectiveness and high coverage can have a substantial impact in African settings. In Southern India, by contrast, the number of averted HIV infections in different PrEP scenarios would be much lower. The impact of PrEP may be strongly diminished or even reversed by behavioral disinhibition, especially in scenarios with low coverage and low effectiveness. However, additional condom use during low coverage and low effective PrEP doubled the amount of averted HIV infections. Conclusions/Significance: The public health impact of PrEP can be substantial. However, this impact may be diminished, or even reversed, by changes in risk behavior. Implementation of PrEP strategies should therefore come on top of current condom campaigns, not as a substitution. http://repub.eur.nl/res/pub/14459/ 2008-01-01T00:00:00Z BACKGROUND: Persons with absent partners may be more vulnerable to risky sexual behavior and therefore HIV. Partner absence can be due to traveling (e.g., family visits or funerals) or to living apart (e.g., work-related or in polygamous marriages). We investigated to what extent partner absence leads to more risky sexual behavior in Tanzanian couples. METHODS: We compared 95 men and 85 women living apart with 283 men and 331 women living together. Only persons who were still married were included, either living apart or cohabiting at the time of the interview. Subjects were classified into 4 groups: coresidents being either nonmobile or mobile, and people living apart either frequently or infrequently seeing each other. RESULTS: Most people living apart were polygamously married. Men living apart did not report more extramarital sex than coresident men. However, among coresident men, extramarital sex was reported by 35% of those being mobile compared with 15% of those nonmobile. Among women, those living apart reported extramarital sex more often than coresidents (14% vs. 7%), and this was mainly due to women living apart who infrequently saw their husbands. CONCLUSIONS: Risky sexual behavior occurs more often in mobile coresident men, and in women living apart infrequently seeing their spouses. These groups are relatively easy to identify and need extra attention in HIV prevention campaigns. http://repub.eur.nl/res/pub/36827/ 2007-02-01T00:00:00Z Objectives: To compare the sexual behaviour of female sex workers in urban and rural areas in Nyanza province in Kenya, and to compare their unsafe sex with clients and with regular partners. Methods: In a cross-sectional study among 64 sex workers (32/32 in urban/rural areas), sex workers kept a sexual diary for 14 days after being interviewed face-to-face. Results: Most sex workers were separated/divorced and had one or two regular partners, who were mostly married to someone else. Sex workers in Kisumu town were younger, had started sex work at an earlier age, and had more clients in the past 14 days than rural women (6.6 vs. 2.4). Both groups had an equal number of sex contacts with regular partners (4.7). With clients, condom use was fairly frequent (75%) but with regular partners, it was rather infrequent (<40%). For both urban and rural areas, the mean number of sex acts in which no condom was used was greater for regular partners (3.2 and 2.8 respectively) than for clients (1.9 and 1.0 respectively). Conclusions: Sex workers in urban and rural areas of Nyanza province practise more unsafe sex with regular partners than with clients. Interventions for sex workers should also focus on condom use in regular partnerships. http://repub.eur.nl/res/pub/10693/ 2006-05-01T00:00:00Z objectives Migration is associated with HIV infection, but the relationship has been mostly assessed in cross-sectional studies. In a prospective study, we investigated whether out-migrants are a selection of high-risk individuals and whether rural-to-urban migration results in risky sexual behaviour for HIV incidence. methods A population cohort was enrolled in a stratified household census in four different community types in Manicaland, east Zimbabwe, between July 1998 and February 2000, and followed-up after 3 years. Out-migrants to the national capital (Harare), the provincial capital (Mutare) and other study areas were followed-up. A structured questionnaire was administered and an HIV test was conducted at each interview. HIV prevalence and sexual risk behaviour at baseline, and HIV incidence and sexual behaviour during follow-up were compared for out-migrants and residents. results At baseline, future migrants were significantly younger, better educated and more likely to be single than residents. For males, migration was highest from subsistence farming areas and roadside trading centres and lowest from estates. After adjusting for age, education, marital status and location, there were no differences in HIV prevalence and sexual risk behaviour between future migrants and residents at baseline, for either sex. No significant differences in HIV incidence or sexual behaviour during follow-up were detected between rural-to-urban out-migrants and residents. conclusions Out-migrants from rural Zimbabwe did not have higher levels of HIV infection or sexual risk behaviour than residents either before or after they moved. These findings may be related to the mature stage of the HIV epidemic and the social and living conditions of migrants in Zimbabwean cities. http://repub.eur.nl/res/pub/7583/ 2006-03-15T00:00:00Z This thesis describes three important determinants of HIV spread in Kenya: 1. Sexual behaviour of female sex workers, their clients, and young adults 2. Health care seeking behaviour for sexually transmitted diseases (STD) 3. Quality of STD care in the public and private health sector The first determinant was studied in urban and rural areas of Nyanza, the province in the west of Kenya which has the highest HIV prevalence. The latter two determinants were studied in the capital of Kenya, Nairobi. The main conclusions are: - HIV interventions regarding commercial sex should target clients of sex workers, and they should be implemented in bars, nightclubs and lodges in Nyanza. - HIV prevention programmes in Nyanza should promote condom use in regular sex worker-client relationships. - Long-term sex worker-client relationships are very important for the transmission of HIV in urban and rural Nyanza. - Sexual behaviour is high-risk especially in the rural areas of Nyanza. - Half of women in Nairobi who have STD complaints do not seek any care at all or wait very long before seeking care. - The majority of STD patients in Nairobi visit the private sector, in spite of its rather low quality of care and its high costs. - Providers in Nairobi insufficiently educate their STD patients on condom use and on the risk to contract HIV. - Attending an in-service course on STD management significantly improves the quality of STD treatment and STD health education in Nairobi. http://repub.eur.nl/res/pub/10692/ 2006-02-01T00:00:00Z Objective: To investigate how mobility is related to sexual risk behavior and HIV infection, with special reference to partners staying behind in mobile couples. Methods: HIV status, sexual behavior and demographic data of 2800 couples were collected in a longitudinal study in Kisesa, rural Tanzania. People were considered short-term mobile if they had slept outside the household at least once the night before one of the five demographic interviews, and long-term mobile if they were living elsewhere at least once at the time of a demographic round. Results: Overall, while long-term mobile men did not report more risk behavior than resident men, short-term mobile men reported significantly more often two or more sex partners in the last year (47.8% vs 40.0%, p=0.006). In contrast, long-term mobile women reported more often multiple sex partners than resident women (6.8% vs 2.4%, p=0.001), and also had a higher HIV prevalence (7.7% vs 2.7%, p=0.02). In couples, men and women who were resident and had a long-term mobile partner both reported more sexual risk behavior and also showed higher HIV prevalence than people with resident/short-term mobile partners. Remarkably, risk behavior of men increased more when their wives moved than when they were mobile themselves. Conclusions: More sexual risk behavior and an increased risk of HIV infection was not only seen in mobile persons, but also in partners staying behind. Interventions aiming at reducing risk behavior due to mobility should therefore include partners staying behind.