Newsletter July 2013

ICRH Global Newsletter

8th of July, 2013

 

ICRH Activity Report 2012
The ICRH 2012 Activity Report was officially presented on 30 May and is available online.

The report contains an overview of all projects conducted by ICRH in the course of 2012, as well as a complete list of publications and some information on general functioning and staff of the organisation. A PDF version of the Activity Report can be downloaded at http://icrhb.org/sites/default/files/ICRH%20Annual%20report%202012%20final%2020130604.pdf.

 

ICRH internship programme
ICRH launched a research internship programme for postgraduates considering a career in repro­ductive health research.

The programme aims at exposing junior researchers to the various aspects of research with a focus on themes such as sexually transmitted infections, maternal and child health, sexual violence and family planning. The trainee will be super­vised by ICRH’s Scienti?c Director and will be involved together with other researchers in the centre’s normal research activities including proposal writing, project management, scienti?c analysis and article writing. The internship consists of a six months stay in Gent, followed by a six months stay in Africa, during which the intern will have the opportunity to experience the implementation of ?eld research in one of ICRH’s sister-organizations in Kenya (ICRH-K) and Mozambique (ICRH-M).

The first intern in this programme is Emilomo Ogbe (see below). She started her internship mid-June.

More information: Olivier.degomme@ugent.be

ICRH re-designated as WHO Collaborating Centre
The recognition of ICRH as WHO collaborating centre for research on sexual and reproductive health has been renewed for another four years term.

 

The new terms of reference are:

-To conduct epidemiological, operations and implementation research on family planning, STIs (including HIV), gender-based violence and harmful practices;
-To support WHO’s capacity building efforts in the area of reproductive health;
-To communicate the results of research relevant policy-making.

For each of these terms of reference, specific activities have been put forward, which will be implemented in the course of the next years.

The new re-designation period expires in June 2017.
More information:
dirk.vanbraeckel@ugent.be


PROJECTS

Post-abortion family planning in China
The INPAC project (INtegrating Post-Abortion family planning services into existing abortion services in hospital settings in China) has completed its critical review of China policy and practice of family planning and now started the qualitative and quantitative situation analysis.

The review results were presented by dr. Xu Jieshuang on behalf of the INPAC consortium during an oral presentation at the ESC Conference in Copenhagen, entitled Critical review of FP and PAFP policy, situation in China and practice and lessons learned to integrate PAFP into existing health system worldwide. The presentation also included recommendations on the INPAC interventions design, as well as on Post Abortion Family Planning policy and practices.

At the same conference, there was also a poster presentation on ‘Post-abortion contraception in China: two EC-funded collaborative research projects’, with reporting on the INPAC project, but also on the earlier PAFP (Post-Abortion Family Planning in China) project. The results of both projects will contribute to standardizing the post-abortion family planning services and to decreasing the long-term costs related to abortion in China. The research results will also be of interest to other countries with high abortion rates.

Currently, a detailed situation analysis on abortion services in China is being prepared, based on quantitative and qualitative data that are being collected in over 30 provinces and regions in China. The next stage is the development and testing of a post-abortion family planning service intervention.

More information: weihong.zhang@ugent.be and shuchen.wang@ugent.be

EVENTS

Opening new night clinic in Mozambique
The health services for Moatize key populations are now provided in a new building

The night clinic was inaugurated in Moatize, Tete Province, on 3 March 2013 by the Provincial Governor. According to the District Health Director who was present in the ceremony, «the support of our partners will galvanize our efforts, as health professionals, because with the means provided we have to improve the conditions of service to citizens».

Tete province is intersected by a major transport route between Mozambique, Malawi and Zimbabwe and is also witnessing a rapidly growing mining industry, attracting travellers, migrant workers and sex workers, mostly female. A cross- sectional survey among 350 female sex workers (FSW) in 2006 showed relatively low STI prevalence but a high HIV prevalence (49.7%, compared to 13.7% at national level) and inconsistent condom use.

Access to public health services for sex workers is hampered by stigmatizing attitudes of providers and patients, inadequate opening times and inappropriate services. The stand-alone night clinic of Moatize that has been receiving support from ICRH since 2004 opens from 4 to 10 pm and offers sexual and reproductive health services for key populations, such as STI care, HIV counselling and testing and contraceptives. Services are also offered to victims of sexual and gender-based violence since February 2013.

ICRH-M is working with the provincial and district health officials to improve the current SRH services for female sex workers and male clients of FSW. Within the Tete-MARP project, funded by the Flemish International Cooperation Agency, USAID and with support from Vale, and the DIFFER project , funded by the European Commission’s 7th Framework Programme, the range of SRH services targeted to FSW and male clients, as well as the SRH services at public health facilities, in the Tete-Moatize area is broadened and improved, and linkages between the two are strengthened.

ICRH at the ESC conference in Copenhagen
The European Society of Contraception and Reproductive Health (ESC) organized the 1st Global Conference on Contraception, Reproductive and Sexual Health in Copenhagen, from 22 to25 May.
The focus was on empowering of women and on all aspects of sexual and reproductive health. ICRH was present at the conference with the following presentations and posters:
-High frequency of genital HPV infections and related cervical dysplasia in underage girls in Belgium (Mireille Merckx, Ina Benoy, Joris Meys, Christophe Depuydt, Marleen Temmerman, Steven Weyers, Davy Vanden Broeck;

-Post-abortion contraception in China: two EC-funded collaborative research projects (Wei-Hong Zhang, Shuchen Wang, Yimin Cheng, Marleen Temmerman, PAFP consortium and INPAC consortium);
-Community embedded reproductive health interventions for adolescents in Latin America: development of a complex intervention. (Peter Decat, Sara De Meyer, Lina Jaruseviciene, Marcia Ibarra, Nancy Auquilla, Joel Medina, Arnold Hagens);
-Joining forces across sectors to meet the unmet need for family planning. (Dirk Van Braeckel, Peter Decat, Olivier Degomme).

ICRH PEOPLE

Emilome Ogbe
Emilomo Ogbe came to ICRH in June, to become the first trainee in the newly launched ICRH research internship programme.

Emilomo Ogbe (M.B.B.S., M.A) is a recent graduate from the Masters in Gender and Development at the Institute of Development Studies, University of Sussex (2012). Her dissertation on Pelvic Inflammatory Disease explored the political and moral economy around the prioritisation and management of sexually transmitted diseases. Prior to pursuing a Master’s degree, she obtained a Bachelor of Medicine, Bachelor of Surgery from the College of Medicine at the University of Lagos, and worked in clinical medicine. She also worked on gender analysis and mainstreaming of health policies and programmes with the Department of Gender, Women and Health at the World Health Organisation in Geneva and with the Women’s Global Network for Reproductive Rights in Manila. Her research interests include bioethics, exploring the influence of biopolitics in constructing ‘heteronormative sexual identities’, as well as how these factors influence access to sexual and reproductive health services for sexual minorities.

More information: emilomo.ogbe@ugent.be

Dirk Schelstraete leaves, Chris Moreel arrives
From mid-June on, Chris Moreel replaces Dirk Schelstraete as ICRH’s accountant.

Dirk Schelstraete, who started working at ICRH in June 2012, will return to his previous profession of financial consultant. His successor, Chris Moreel started working for ICRH in the beginning of June. Chris Moreel started working for ICRH on June 1. Before coming to ICRH, he worked for a transport company with headquarters in Ghent and subsidiaries around Europe. In his spare time Chris likes spending time with his family, cycling, football, watching movies and listening to music. He is also involved in the organization of a music festival near Ghent. More information: Chris.moreel@ugent.be

Marlise Richter’s Ph.D. defence
On 18 June, ICRH scholar Marlise Richter successfully defended her Ph.D. thesis on Characteristics, sexual behaviour and access to health care services for sex workers in South Africa and Kenya’.

Marlise’s research indicates the diversity of the sex industry and the people who work in it. Sex work is an important livelihood strategy that provides an income for sex workers and their extended network of dependents. Migration is a vital component for exploring and understanding how many sex worker lives and work are structured in South Africa. Sex workers are subject to violence from police and their non-commercial partners, while unprotected sex with non-commercial partners emerges as an important risk factor for HIV.

 

Moreover, this thesis highlights the shortcomings of health care services in responding to the needs of sex workers. It recommends the rolling-out of specialised, sex work-specific health care services in areas of sex work concentration, and sex work-friendly services in mainstream health care facilities in areas of lower sex work concentration. Non-judgemental and empathetic health workers are a key

component of responsive services. Lastly and perhaps most importantly, it underscores the importance of decriminalising sex work in order to safeguard sex worker rights and to protect individual and public health.

Marlise’s work was supervised by prof. Marleen Temmerman and prof. Matthew Chersich. More information: marlise.richter@ugent.be.

De thesis can be downloaded from the ICRH website at: http://icrhb.org/sites/default/files/PhD%20thesis%20Marlise%20Richter%209%20june%202013%20monograph%20final.pdf

Birgit is leaving, and will be replaced by Aurore
Birgit, health economist, has been working part-time for ICRH since October 2011 as MOMI Consortium project administrator. From July on, she will leave ICRH to resume her previous occupation as an independent consultant in health financing and economics.
Her responsibilities for the FP7 project MOMI (Missed Opportunities in Maternal and Infant Heatlh) will be taken over by Aurore Guieu, who was already working part-time at ICRH for support to another FP7 project: DIFFER (Diagonal Interventions to Fast-Forward Enhanced Reproductive health).

 


Inge Tency’s PhD defence
On June 28, Inge Tency successfully defended her Ph.D. thesis on Inflammatory response in maternal serum during preterm labour.

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality worldwide. Despite significant advances in perinatal care and advancing knowledge of risk factors and mechanisms associated with PTB, there has been little progress in reducing the PTB rate. Diagnosis of preterm labour as well as accurate prediction of PTB is notoriously difficult, because of the heterogeneity of the condition. A tremendous amount of efforts has been expended to identify markers to predict PTB and to improve our understanding of the mechanisms and pathways leading to PTB. The best studied site of infection is amniotic fluid, but obtaining this sample requires an invasive and sometimes risky procedure (e.g. amniocentesis). A non-invasive approach seems to be more relevant to clinical practice because of the feasibility and accessibility. Therefore, the overall objective of Inge’s study was to determine several inflammatory markers in maternal serum from pregnant women in labour (either term or preterm) vs. non-labouring controls.

Inge conducted a nested case control study in which singleton pregnancies were recruited at the obstetric department of Ghent University Hospital and divided into groups according to gestational age and labour status. The study showed that serum levels of sTRE M-1 were elevated during spontaneous term and preterm labour vs. non-labouring women. In line with previous studies, MMP-9 concentrations were elevated during preterm labour. TIMP-1 and TIMP-2 were lower in preterm gestation, irrespective of labour, while TIMP-4 concentrations were raised in labour. One of the most intriguing findings of the study is that MMP-9:TIMP-1 and MMP-9:TIMP-2 balances in maternal serum were tilting in favour of matrix degradation (gelatinolysis) in women with preterm labour. This observation suggests that aberrant serum expression of MMP:TIMP ratios may provide a far less invasive method to determine enzymes essential in the degradation of extracellular matrix (EC M) during pregnancy and parturition.

More information: inge.tency@kahosl.be

De thesis can be downloaded from the ICRH website at: http://icrhb.org/sites/default/files/Inge%20Tency_PhDThesis_180x240_Def_Spreads.pdf

 

PUBLICATIONS

Sex workers in South Africa
This article describes characteristics and sexual behaviour of female, male and transgender sex workers, and assesses their risk factors for unprotected sex.

In South Africa, information on sex workers' characteristics, sexual behaviour and health needs is limited. Current social, legal and institutional factors impede a safe working environment for sex workers and their clients. Repeat cross-sectional surveys among sex workers were conducted in Hillbrow, Sandton, Rustenburg and Cape Town in 2010. Trained sex workers interviewed 1 799 sex workers. Sex work was a full-time profession for most participants. About 8% (126/1 594) of women, 33% (22/75) of men, and 25% (12/50) of transgender people had unprotected sex. A quarter of anal sex was unprotected. Unprotected sex was 2.1 times (adjusted odds ratio (AOR), 95% CI 1.2 - 3.7; p=0.011) more likely in participants reporting daily or weekly binge drinking than non-binge drinkers. Male sex workers were 2.9 times (AOR, 95%CI 1.6 - 5.3; p<0.001) more likely, and transgender people 2.4 times (AOR, 95% CI 1.1 - 4.9; p=0.021) more likely, than females to have unprotected sex. Sex workers in Hillbrow, where the only sex work-specific clinic was operational, were less likely to have unprotected sex than those in other sites.
The authors conclude that tailored sex work interventions should explicitly include male and transgender sex workers, sex work-specific clinics, focus on the risks of unprotected anal sex, and include interventions to reduce alcohol harm.

Link to full text: http://samj.org.za/index.php/samj/article/view/6170/4999.

M L Richter, M Chersich, M Temmerman, S Luchters. Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa. South African Medical Journal, Vol 103, No 4 (2013).

Abandonment of FGM
What Works and What Does Not: A Discussion of Popular Approaches for the Abandonment of Female Genital Mutilation

The prevalence of Female Genital Mutilation (FGM) is reducing in almost all countries in which it is a traditional practice. There are huge variations between countries and communities though, ranging from no change at all to countries and communities where the practice has been more than halved from one generation to the next. Various interventions implemented over the last 30–40 years are believed to have been instrumental in stimulating this reduction, even though in most cases the decrease in prevalence has been slow. This raises questions about the efficacy of interventions to eliminate FGM and an urgent need to channel the limited resources available, where it can make the most difference in the abandonment of FGM. This paper is intended to contribute to the design of more effective interventions by assessing existing knowledge of what works and what does not and discusses some of the most common approaches that have been evaluated: health risk approaches, conversion of excisers, training of health professionals as change agents, alternative rituals, community-led approaches, public statements, and legal measures.

Link to the full text: http://dx.doi.org/10.1155/2013/348248

R. Elise B. Johansen, Nafissatou J. Diop, Glenn Laverack, and Els Leye. What Works and What Does Not: A Discussion of Popular Approaches for the Abandonment of Female Genital Mutilation. Obstetrics and Gynecology International, Volume 2013 (2013), Article ID 348248.

The effect of concurrency on the frequency of unprotected sex
Coital frequency and condom use in monogamous and concurrent sexual relationships in Cape Town, South Africa.

A decreased frequency of unprotected sex during episodes of concurrent relationships may dramatically reduce the role of concurrency in accelerating the spread of HIV.

Such a decrease could be the result of coital dilution - the reduction in per-partner coital frequency from additional partners -_and/or increased condom use during concurrency. To study the effect of concurrency on the frequency of unprotected sex, the autors examined sexual behaviour data from three communities with high HIV prevalence around Cape Town, South Africa. They conducted a cross-sectional survey from June 2011 to February 2012 using audio computer-assisted selfinterviewing to reconstruct one-year sexual histories, with a focus on coital frequency and condom use. Participants were randomly sampled from a previous TB and HIV prevalence survey. Mixed effects logistic and Poisson regression models were fitted to data from 527 sexually active adults reporting on 1210 relationship episodes to evaluate the effect of concurrency status on consistent condom use and coital frequency.
Results: The median of the per-partner weekly average coital frequency was 2 (IQR: 1_3), and consistent condom use was reported for 36% of the relationship episodes. Neither per-partner coital frequency nor consistent condom use changed significantly during episodes of concurrency (aIRR_1.05; 95% confidence interval (CI): 0.99_1.24 and aOR_1.01; 95% CI: 0.38_25 2.68, respectively). Being male, coloured, having a tertiary education, and having a relationship between 2 and 39 weeks were associated with higher coital frequencies. Being coloured, and having a relationship lasting for 40 week or more, was associated with inconsistent condom use.
Conclusions: No evidence was found for coital dilution or for increased condom use during concurrent relationship episodes in three communities around Cape Town with high HIV prevalence. Given the low levels of self-reported consistent condom use, the findings suggest that if the frequency of unprotected sex with each of the sexual partners is sustained during concurrent relationships, HIV-positive individuals with concurrent partners may disproportionately contribute to onward HIV transmission.

Link to full text: http://www.jiasociety.org/index.php/jias/article/view/18034

Wim Delva, Fei Meng, Roxanne Beauclair, Nele Deprez, Marleen Temmerman, Alex Welte and

Niel Hens. Coital frequency and condom use in monogamous and concurrent sexual relationships in Cape Town, South Africa. Journal of the International AIDS Society 2013, 16:18034.

High-risk sexual behaviour among female adolescent sex workers in China
This study assessed social and behavioural predictors for sexual risk taking and sexually transmitted infections (STIs) including HIV among adolescent female sex workers (FSWs) from Kunming, China. Additionally, health services needs and use were assessed.

A cross-sectional survey was conducted in 2010. Using snowball and convenience sampling, self-identified FSWs were recruited from four urban areas in Kunming. Women consenting to participate were administered a semi-structured questionnaire by trained interviewers identified from local peer-support organisations. Following interview, a gynaecological examination and biological sampling to identify potential STIs were undertaken. Descriptive and multivariable logistic regression analyses were performed.
Adolescent FSWs had a mean age of 18.2?years and reported numerous non-paying sexual partners with very low rate of consistent condom use (22.2%). Half (50.3%)of the respondents had sex while feeling drunk at least once in the past week, of whom 56.4% did not use condom protection. STI prevalence was high overall (30.4%) among this group. Younger age, early sexual debut, being isolated from schools and family, short duration in sex work, and use of illicit drugs were found to be strong predictors for unprotected sex and presence of an STI. Conversely, having access to condom promotion, free HIV counselling and testing, and peer education were associated with less unprotected sex. The majority reported a need for health knowledge, free condoms and low-cost STI diagnosis and treatment.
The authors conclude that there is an urgent need to improve coverage, accessibility and efficiency of existing interventions targeting adolescent FSWs.

Xu-Dong Zhang, Marleen Temmerman, Yan Li, Wei Luo, Stanley Luchters. Vulnerabilities, health needs and predictors of high-risk sexual behaviour among female adolescent sex workers in Kunming, China. Sex Transm Infect 2013;89:237-244 doi:10.1136/sextrans-2012-050690

Contraceptive practices in China
A review of contraceptive practices among married and unmarried women in China from 1982 to 2010.

Data concerning married women were collected from national surveys conducted by the Chinese government. Those pertaining to unmarried women were obtained by searching the China Academic Journal Network Publishing database and PubMed.

Contraception Prevalence Rate (CPR) among married women in China was 89% in 2010, the highest in the world. Most married women use long-acting reversible contraceptives, particularly intrauterine devices, and sterilisation. CPR among sexually active unmarried women has fluctuated between 17 and 70% since 1988, although the frequency of condom use has. More than 25% of unmarried women rely since at least 1982 on less effective contraceptive methods, including rhythm and withdrawal. This has led to an annual induced abortion rate of approximately 20% among those women.The authors conclude that in sharp contrast to the high CPR among married women, the rate among sexually active unmarried women in China has remained extremely low since 1988. More efforts should be directed at raising contraception awareness among this population to improve their reproductive health and reduce the rate of unwanted pregnancy.

Jinke Li, Marleen Temmerman, Qiuju Chen, Jialin Xu, Lina Hu and Wei-Hong Zhang. A review of contraceptive practices among married and unmarried women in China from 1982 to 2010. The European Journal of Contraception and Reproductive Health Care, 2013; Early Online: 1–11

Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia
Understanding why people do not use family planning is critical to address unmet needs and to increase contraceptive use.

According to the Ethiopian Demographic and Health Survey 2011, most women and men had knowledge on some family planning methods but only about 29% of married women were using contraceptives. 20% women had an unmet need for family planning. We examined knowledge, attitudes and contraceptive practice as well as factors related to contraceptive use in Jimma zone, Ethiopia. Data were collected from March to May 2010 among 854 married couples using a multi-stage sampling design. Quantitative data based on semi-structured questionnaires was triangulated with qualitative data collected during focus group discussions. We compared proportions and performed logistic regression analysis.

The concept of family planning was well known in the studied population. Sex-stratified analysis showed pills and injectables were commonly known by both sexes, while long-term contraceptive methods were better known by women, and traditional methods as well as emergency contraception by men. Formal education was the most important factor associated with better knowledge about contraceptive methods (aOR = 2.07, p,0.001), in particular among women (aORwomen = 2.77 vs. aORmen = 1.49; p,0.001). In general only 4 out of 811 men ever used contraception, while 64% and 43% females ever used and were currently using contraception respectively.

Conclusion: The high knowledge on contraceptives did not match with the high contraceptive practice in the study area. The study demonstrates that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. Thus, projects aiming at increasing contraceptive use should contemplate and establish better counseling about contraceptive side effects and method switch. Furthermore in all family planning activities both wives’ and husbands’ participation should be considered.

Tilahun T, Coene G, Luchters S, Kassahun W, Leye E, et al. (2013) Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia. PLoS ONE 8(4): e61335. doi:10.1371/journal.pone.0061335.

Integrated maternal and child health services in Mozambique
Results of a study testing the viability of integrated care for mother and infant after birth, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique.

Between April 2009 and September 2010, a mixed-method, intervention-control study was conducted in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually.

Results: One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. In both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing) was observed, but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups.

The authors conclude that, despite improvement in various aspects of the follow-up of HIV-exposed infants, they observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

Geelhoed Diederike, Lafort Yves, Chissale √Člder, Candrinho Baltazar, Degomme Olivier. Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants.BMC Health Services Research.2013, 13:207.

SRH healthcare for adolescents in Latin America
A study on primary healthcare providers’ views on how to improve adolescent sexual and reproductive health (ASRH)
services in Bolivia, Ecuador, and Nicaragua

Overall, 126 healthcare providers (46 from Bolivia, 39 from Ecuador, and 41 from Nicaragua) took part in this qualitative study. During a series of moderated discussions, they provided written opinions about the accessibility and appropriateness of ASRH services and suggestions for its improvement. The data were analyzed by employing a content analysis methodology. Study participants emphasized managerial issues such as the prioritization of adolescents as a patient group and increased healthcare providers’ awareness about adolescent-friendly approaches.
They noted that such an approach needs to be extended beyond primary healthcare centers.
Schools, parents, and the community in general should be encouraged to integrate issues related to ASRH in the everyday life of adolescents and become ‘gate-openers’ to ASRH services. To ensure the success of such measures, action at the policy level would be required.
For example, decision-makers could call for developing clinical guidelines for this population group and coordinate multisectoral efforts.
The authors conclude that to improve ASRH services within primary healthcare institutions
in the three Latin American countries, primary healthcare providers call for focusing on improving the youth-friendliness of health settings.
To facilitate this, they suggested engaging with key stakeholders, such as parents, schools, and decision-makers at the policy level
Link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3656216/
L. Jaruseviciene, M. Orozco, M. Ibarra, F. Cordova , B Vega, N. Auquilla, J. Medina, A. Gorter, P. Decat, S. De Meyer, M. Temmerman, A. B. Edmonds, L. Valius and J. V. Lazarus.
Primary healthcare providers’ views on improving sexual and reproductive healthcare for adolescents in Bolivia, Ecuador, and Nicaragua. Glob Health Action. 2013 May 6; 20444