Gender differences in the prevalence of sexually transmitted infections and genital symptoms in an urban setting in southern India.

OBJECTIVES: To examine gender differences in sexual behaviour, the prevalence of laboratory-detected sexually transmitted infections (STIs) and self-reported genital symptoms in urban Chennai, Tamil Nadu, India. STUDY DESIGN: The data were based on a cross-sectional survey (n = 1649) of residents from low-income communities in Chennai. Data were collected during community-wide health camps comprising physical examinations, interviews and laboratory testing between March and June 2001. RESULTS: The population was young, sexually active, with a low prevalence of STI. The most commonly detected STI was Herpes simplex virus type 2 (HSV2; 13.2%). Women had a higher prevalence of HSV2, but were more likely than men to be asymptomatic. Most of the self-reported genital symptoms could not be linked to a laboratory-detected STI. >10% of the cohort had a history of an ulcerative STI and >5% had an inflammatory STI. CONCLUSIONS: Given a high prevalence of HSV2 in the study population, interventions targeting HSV2 transmission may be particularly relevant for this population.

The burden of anemia among women in India.

OBJECTIVE: This research investigates the prevalence and determinants of anemia among women in Andhra Pradesh. We examined differences in anemia related to social class, urban/rural location and nutrition status body mass index (BMI). We hypothesized that rural women would have higher prevalence of anemia compared to urban women, particularly among the lower income groups, and that women with low body mass index (BMI; <18.5 kg/m(2)) would have a higher risk compared to normal or overweight women. DESIGN: The National Family Health Survey 1998/99 (NFHS-2) provides nationally representative cross-sectional survey data on women's hemoglobin status, body weight, diet, social, demographic and other household and individual level factors. Ordered logit regression analyses were applied to identify socio-economic, regional and demographic determinants of anemia. SETTING: Andhra Pradesh, a southern Indian state. SUBJECTS: A total of 4032 ever-married women aged 15-49 from 3872 households. RESULTS: Prevalence of anemia was high among all women. In all 32.4% of women had mild (100-109.99 g/l for pregnant women, 100-119.99 for non-pregnant women), 14.19% had moderate (70-99.99 g/l), and 2.2% had severe anemia (<70 g/l). Protective factors include Muslim religion, reported consumption of alcohol or pulses, and high socioeconomic status, particularly in urban areas. Poor urban women had the highest rates and odds of being anemic. Fifty-two percent of thin, 50% of normal BMI, and 41% of overweight women were anemic. CONCLUSIONS: New program strategies are needed, particularly those that improve the overall nutrition status of women of reproductive ages. This will require tailored programs across socio-economic groups and within both rural and urban areas, but particularly among the urban and rural poor.

The nutrition transition is underway in India.

Nutrition research in India has previously focused on the serious problem of undernutrition related to nutrient deficit and high rates of infection. Recent data from the National Family Health Survey 1998/99 (NFHS 2), however, identified a significant proportion of Indian women as overweight, coexisting with high rates of malnutrition. This paper examines the emerging nutrition transition for women living in rural and urban communities of Andhra Pradesh, India. NFHS 2 provides nationally representative data on women's weight and height. In this paper, we examine representative data from the state of Andhra Pradesh (n = 4032 women). Logistic regression analyses are applied to the data to identify socioeconomic, regional and demographic determinants of overweight and thinness. The major nutrition problem facing women continues to be undernutrition, with 37% having a low body mass index [(BMI) < 18.5 kg/m(2)]; 8% of these women are severely malnourished (BMI < 16 kg/m(2)). However, 12% of the women can be classified as overweight (BMI > 25 kg/m(2)) and 2% are obese (BMI > 30 kg/m(2)). Furthermore, in the large cities of the state in which 4% of the sample live, 37% of women are overweight or obese, whereas in the rural areas in which 74% reside, 43% have a low BMI. Women from lower socioeconomic groups are also significantly more likely to have a low BMI. Findings from the logistic regression models reveal socioeconomic status to be a more important predictor of both over- and underweight than location of residence.

Home and videotape intervention delays early complementary feeding among adolescent mothers.

BACKGROUND: The American Academy of Pediatrics, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the World Health Organization recommend that infants receive only breast milk or formula for the first 4 to 6 months of life, followed by the introduction of complementary foods. Despite these recommendations, many infants, particularly those with adolescent mothers, receive solid foods (often cereal mixed with formula in a bottle) and liquids other than formula or breast milk in the first few weeks of life. Decisions on early feeding are often guided by grandmothers and influenced by beliefs that infants need complementary food to counteract signals of hunger, reduce crying, and sleep through the night. OBJECTIVE: This investigation evaluated the efficacy of an intervention to delay the early introduction of complementary feeding among first-time, black, adolescent mothers living in multigenerational households. The intervention focused on reducing the cultural barriers to the acceptance of the recommendations of the American Academy of Pediatrics, WIC, and World Health Organization on complementary feeding by highlighting 3 topics: 1) recognition of infants' cues; 2) nonfood strategies for managing infant behavior; and 3) mother-grandmother negotiation strategies. The intervention was delivered through a mentorship model in which a videotape made by an advisory group of black adolescent mothers was incorporated into a home-visiting program and evaluated through a randomized, controlled trial. METHODS: One hundred eighty-one first-time, low-income, black mothers <18 years old, living in multigenerational households were recruited from 3 urban hospitals. Infants were born at term, with birth weight appropriate for gestational age and no congenital problems. Shortly after delivery, mothers and grandmothers completed a baseline assessment and mothers were randomized into an intervention or control group. Intervention group mothers received home visitation every other week for 1 year. At 3 months, a subset of 121 adolescent mothers reported on their infant's intake through a food frequency questionnaire. Mothers who fed their infant only breast milk, formula, or water were classified as optimal feeders. Mothers who provided complementary foods other than breast milk, formula, or water were classified as less optimal feeders. RESULTS: Sixty-one percent of the infants received complementary foods before 3 months old. Multivariate hierarchical logistic regression was used to evaluate the determinants of being in the optimal versus less optimal feeders group. After controlling for infant age and family income, mothers of infants in the optimal feeders group were more likely to report accurate messages from WIC regarding the timing of complementary food and nearly 4 times more likely to be in the intervention group. The most common complementary food was cereal mixed with formula in the bottle. CONCLUSIONS: The success of this relatively brief intervention demonstrates the importance of using ecological theory and ethnographic research to design interventions that enable participants to alter their behavior in the face of contradictory cultural norms. The intervention focused on interpreting infants' cues, nonfood methods of managing infant behavior, and mother-grandmother negotiations. It was delivered through methods that were familiar and acceptable to adolescent mothers-a mentorship model incorporating home visits and videotape. The skill-oriented aspects of the intervention delivered in a culturally sensitive context may have enabled the young mothers to follow the guidelines that they received from WIC and from their pediatricians. Strategies, such as those used in this intervention, may be effective in promoting other caregiving recommendations, thereby enabling providers to meet the increasing demands from parents for advice regarding children's early growth and development.

Acceptability of a novel vaginal microbicide during a safety trial among low-risk women.

CONTEXT: The increasing recognition that women who are unable or unwilling to discuss or use condoms with their sexual partners need female-controlled methods for preventing sexually transmitted diseases (STDs), including HIV, has led to considerable focus on the development of vaginal microbicides. While many such products are being tested for safety and effectiveness, clinical trials generally overlook another key factor in a product's impact on infection rates-its acceptability to users. METHODS: A Phase I clinical trial of a microbicidal gel included an assessment of the product's acceptability among 27 low-risk participants. Information on acceptability was gathered from structured interviews, participants' daily diaries and unstructured exit interviews. RESULTS: Participants reported only minor side effects of product use, such as itching, burning and difficulty urinating; two women developed candida infections while participating in the study. None of the side effects could be conclusively linked to use of the gel. Some women noted product discharge and messiness as drawbacks of the method, but this experience varied according to how often the women applied the gel. For example, one-third of those who used it once daily said that at least some of the time, it was too "wet or drippy," compared with two-thirds of women who inserted the gel twice a day. However, participants considered these "nuisance factors" that could be outweighed by the potential protective characteristics of the product. The majority reported that they would use the product if it were available and proven efficacious, and if they perceived that they were at risk of STD infection. CONCLUSIONS: Additional testing of this product is urgently needed. Furthermore, as other products approach Phase I testing, acceptability assessments should be a key component of clinical trials.

Improving dietary intake to prevent anemia in adolescent girls through community kitchens in a periurban population of Lima, Peru.

Peru has high rates of iron deficiency anemia. The prevalence is 35% in nonpregnant women of fertile age and 24.7% in adolescent girls in slums of periurban Lima. The major cause of anemia is low intake of dietary iron. A community-based, randomized behavioral and dietary intervention trial was conducted to improve dietary iron intake and iron bioavailability of adolescent girls living in periurban areas of Lima, Peru. Results show that there was a change in knowledge about anemia and improved dietary iron intake in the 71 girls who completed the study compared with the 66 girls in the control group. Although the 9-mo. intervention was not sufficient to improve hemoglobin levels significantly, there appeared to be a protective effect in maintaining the iron status of girls in comparison with the control group.

Sources of influence on intention to breastfeed among African-American women at entry to WIC.

To examine how individuals within a woman's life influence her infant feeding intention, we interviewed 441 African-American women on the breastfeeding attitudes and experiences of their friends, relatives, mother, and the baby's father. Women were interviewed at entry into prenatal care at clinics associated with one of four Baltimore WIC clinics chosen for a breastfeeding promotion project. Qualitative data were also collected among 80 women. Friends and "other" relatives were not influential. Grandmothers' opinions and experiences were important, but their influence was reduced after considering the opinion of the baby's father. The opinion of the woman's doctor was an independent predictor of infant feeding intention. Breastfeeding promotion programs should recognize the separate influence of fathers, health providers, and grandmothers in women's infant feeding decisions.

Early introduction of solid foods among urban African-American participants in WIC.

OBJECTIVE: To compare infant feeding practices among low-income, urban, African-American women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with current recommendations for infant feeding. DESIGN: Longitudinal follow-up of women and their infants who participated in a WIC-based breast-feeding promotion project. Women enrolled prenatally at or before 24 weeks of gestation were followed up until 16 weeks postpartum. SUBJECTS/SETTING: Two hundred seventeen African-American WIC participants in an urban area. METHODS: Data related to infant feeding practices were collected by interviewers who used a structured questionnaire to determine when nonmilk liquids or solids were introduced to the infant. Reported practices were compared with current recommendations. STATISTICAL ANALYSIS PERFORMED: Contingency table analysis, including chi 2 tests, and multivariate analysis using logistic regression. RESULTS: By 7 to 10 days postpartum, approximately a third of infants were receiving some nonmilk liquids or solids; this escalated to 77% by 8 weeks and 93% by 16 weeks postpartum. Women breast-feeding exclusively (i.e., not adding nonmilk liquids or solids) were least likely, and women providing mixed feeding (breast milk and formula) were more likely, than women feeding formula exclusively to introduce nonmilk liquids and solids at each data collection time period. APPLICATIONS/CONCLUSIONS: WIC participants who receive instruction about infant feeding nutrition are no more likely than mothers who do not participate in WIC to follow infant feeding guidelines recommended by the American Academy of Pediatrics in regard to the time when solids should be introduced to infants' diet. Our findings suggest the need for WIC to implement more powerful and innovative educational and motivational strategies to help mothers delay the introduction of nonmilk liquids and solid foods until their infants are 4 to 6 months old, as recommended.

HIV testing and counseling among men attending sexually transmitted disease clinics in Pune, India: changes in condom use and sexual behavior over time.

OBJECTIVES: To describe changes in sexual behavior and condom use among male heterosexual clients at two public sexually transmitted disease (STD) clinics in Pune, after exposure to HIV testing, counseling, and condom promotion. DESIGN: From 13 May 1993 to 11 April 1997, 6819 heterosexual men were screened for HIV infection as part of the HIV Network for Prevention Trials study. A total of 1628 HIV-seronegative men agreed to return at 3-month intervals for repeated HIV counseling and testing. Counseling at each visit focused on reinforcing messages of monogamy, condom use with sexual partners, and provision of government-provided condoms. METHODS: Data were collected at baseline and at subsequent 3-month intervals, on demographics, previous STD diagnoses, medical history, sexual behavior, knowledge of HIV/AIDS, and practices related to the prevention of HIV. STD were assessed through physical examination and specimen collection, and blood was drawn for HIV-1 and HIV-2 antibody testing. RESULTS: The level of consistent condom use with sex workers increased proportionately with follow-up time: at 6 months men were 2.8 times more likely to consistently use condoms (P < 0.001), at 18 months they were 3.6 times more likely (P < 0.001), and after 24 months they were 4.7 times more likely to be using condoms every time. The risk of HIV seroconversion in men was lowest for those who reported 'always' using condoms (adjusted relative risk, 0.68; P = 0.42; HIV incidence, 4.0) compared with those who reported 'never' using a condom (adjusted relative risk, 2.94; P < 0.001; HIV incidence, 14.0). CONCLUSION: Ongoing counseling and testing was positively associated with risk-reduction behaviors amongst a large proportion of men recruited for this study.

Working after the sun goes down: exploring how night blindness impairs women's work activities in rural Nepal.

OBJECTIVE: To explore the influence of night blindness during pregnancy on nighttime work activities of women. DESIGN AND SUBJECTS: A community based case-control study was used to compare nighttime activities of night blind (cases) and non-night blind pregnant women (controls) using a 24h recall method to measure work activities (n=116 pairs). SETTING: Rural South-Eastern district in the plains of Nepal. RESULTS: Approximately one third of the night blind women reported being 'inactive' the previous night, not participating in any of the inquired work activities, as compared with only 15% of the control group (P < 0.031). The type of work that was significantly affected was the outdoor kind such as fetching water and washing dishes. Logistic regression analysis showed that night blind women were half as likely (odds ratio=0.49, 95% confidence interval=0.25-0.98) to work at night than women without night blindness after controlling for the effects of confounding variables including gestational age, season, and protein energy malnutrition which were significantly associated with nighttime work activity. CONCLUSIONS: Night blindness during pregnancy, an indicator of vitamin A deficiency, reduces the number and type of work activities women perform at night, thus impairing women's ability to participate in normal subsistence activities by reducing their 'work day'.

Ethical challenges in efficacy trials of vaginal microbicides for HIV prevention.

This paper discusses some of the ethical challenges raised by advanced clinical trials designed to assess the safety and efficacy of vaginal microbicides in protecting women from HIV infection. The ethical principles that guide clinical research involving human subjects require that all participants in such trials be provided available measures known to reduce the risk of HIV infection. However, this will reduce the ability of the study to assess the protective effect of the test microbicide. In addition, providing extensive services to trial participants may be construed as an undue inducement if the study is being conducted among vulnerable groups such as sex workers or women from disadvantaged communities. Suggestions are provided to resolve this dilemma in the planning and implementation of HIV prevention services for trial participants.

An ethnographic study of night blindness "ratauni" among women in the Terai of Nepal.

Night blindness is the most common ocular condition representing moderate-to-severe vitamin A deficiency in children. Very little, however, is known about maternal night blindness, which has recently been reported to occur frequently during pregnancy in parts of south-east Asia. In Nepal, the prevalence of night blindness is reported to be 16%. We carried out an ethnographic study of night blindness during pregnancy in the south-eastern, rural plains of Nepal as preliminary research for a case-control study of the determinants of this condition. The purpose of the research was to identify local terms and concepts of night blindness and to examine women's perceptions of its causes, symptoms, severity, and consequences during pregnancy. Data collection involved in-depth interviews, case studies, unstructured observations and structured anthropologic methods, such as free listing and quick sort ranking. Women considered night blindness to be an important illness of pregnancy, ranking it second (to vaginal bleeding) in perceived severity from a list of 15 "women's illnesses". Local terms for night blindness were identified in three different languages from the region. Informants described a complex ethnomedical model of night blindness that included causes, symptomatology, and treatment alternatives. However, there was no perceived link between food intake and the occurrence of night blindness. The major causes of night blindness were attributed to pregnancy, weakness, or "hotness". Some women sought treatment for the condition but most women chose not to treat it since they believed that it was a transient condition of pregnancy. Interviews with women who had previously experienced night blindness and home-based observations of women exhibiting concurrent night blindness showed that it adversely affected their activity patterns, especially those related to child care and food preparation. Night blindness increased reliance on family members to perform various domestic chores and was also associated with personal injury and accidents. The findings of this study have relevance for women's reproductive health and nutrition throughout the Indian sub-continent. A simple history of night blindness may be a practical tool to identify women with nutritional and health risks. Maternal night blindness should be more routinely investigated in vitamin A deficient areas of the world, both to define the magnitude of the problem, and to develop programs/interventions that specifically target this population.

WIC-based interventions to promote breastfeeding among African-American Women in Baltimore: effects on breastfeeding initiation and continuation.

We evaluated the single and combined effects of introducing a motivational video and peer counseling into four matched WIC clinics on breastfeeding initiation and continuation at 7-10 days among African-American WIC participants. Of the 242 women with complete data, 48% initiated breastfeeding, but only 31% were still breastfeeding at 7-10 days. Initiation was associated with cesarean delivery, infant feeding instruction, no artificial milk discharge pack, attending the peer counselor only-intervention site, and intention to breastfeed. Continuation was influenced by infant feeding instruction, no artificial milk discharge pack, and intention to breastfeed. Overall, trends toward a positive impact of the breastfeeding promotion activities were evident but weak, and largely gone by 7-10 days postpartum.

Counseling and motivational videotapes increase duration of breast-feeding in African-American WIC participants who initiate breast-feeding.

OBJECTIVE: To evaluate the relative effects introducing motivational videotapes and/or peer counseling in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics serving African-American women have on breast-feeding duration. DESIGN: Experimental intervention study. Pregnant women were enrolled at or before 24 weeks gestation and were followed up until postpartum week 16. Women were interviewed at enrollment, 7 to 10 days, 8 weeks, and 16 weeks postpartum. SUNJECTS/SETTING: One hundred fifteen African-American WIC participants who initiated breast-feeding and who had been enrolled in 1 of 4 clinics. INTERVENTION: Two-by-two factorial design, in which 4 clinics were randomly assigned to receive either no intervention, a motivational video package intervention, a peer-counseling intervention, or both interventions. MAIN OUTCOME MEASURES: Breast-feeding duration in weeks and relative risk ratios for breast-feeding cessation before 16 weeks postpartum. STATISTICAL ANALYSIS PERFORMED: Contingency table analysis, including chi2 tests and log-rank tests; multivariate analysis using Cox proportional hazards regression analysis. RESULTS: A higher proportion of women were breast-feeding at 8 and 16 weeks postpartum in the intervention clinics than in the control clinic. The proportion of women reporting breast-feeding declined at 8 and 16 weeks postpartum, but the rate of decline was slower in the 3 intervention clinics than in the control clinic. Being younger than 19 years of age or older than 25 years of age, having a male infant, and returning to work or school all negatively affected breastfeeding duration, whereas previous breast-feeding experience positively influenced breast-feeding duration. APPLICATIONS/CONCLUSIONS: WIC-based peer counselor support and motivational videos can positively affect the duration of breast-feeding among African-American women. WIC nutritionists and other health professionals in contact with this population should expand their efforts toward promoting increased duration of breast-feeding.

Spread of HIV infection in married monogamous women in India.

CONTEXT: A high prevalence of human immunodeficiency virus (HIV) infection in female sex workers (FSWs) and men who attend sexually transmitted disease (STD) clinics poses a risk for spread of infection to other populations. OBJECTIVE: To examine spread of HIV to a low-risk population by comparing prevalence of, and risk factors for, HIV and STDs in FSWs and non-FSWs. METHODS: Women attending STD clinics in Pune, India, were assessed for STDs and HIV from May 13, 1993, to July 11, 1996. Demographic and behavioral information was collected, and clinical and laboratory assessment was performed. MAIN OUTCOME MEASURE: Prevalence and risk determinants of HIV infection. RESULTS: Of 916 women enrolled, 525 were FSWs and 391 were non-FSWs. Prevalence of HIV in FSWs and non-FSWs was 49.9% and 13.6%, respectively (P<.001). In multivariate analysis, inconsistent condom use and genital ulcer disease or genital warts were associated with prevalent HIV in FSWs. History of sexual contact with a partner with an STD was associated with HIV in non-FSWs. CONCLUSIONS: Infection with HIV is increasing in non-FSWs, previously thought to be at low risk in India. Since history of sexual contact with their only sex partner was the only risk factor significantly associated with HIV infection, it is likely that these women are being infected by their spouses. This underscores the need for strengthening partner-notification strategies and counseling facilities in India.

Zinc supplementation affects the activity patterns of rural Guatemalan infants.

Zinc deficiency has been associated with growth deficits, reduced dietary intake and appetite, and has been hypothesized to result in reduced activity. This randomized, double-blind, placebo-controlled study examined whether 10 mg of oral zinc as zinc sulfate, given daily for up to 7 mo, affected activity patterns of 85 Guatemalan infants recruited at 6-9 mo of age. Infant activity was assessed by time sampling-observation method at 10-min intervals during a 12-h data collection period, at base line, 3 and 7 mo follow-up. Motor development and the percentage of time infants were observed in various positions (being carried, lying down, sitting, crawling, standing or walking) and engaged in various activities (eating, sleeping, resting, crying/whining or playing) were compared by treatment group. No differences in motor development were observed by treatment group. However, at follow-up 2 (after 7 mo of supplementation), zinc-supplemented infants were significantly more frequently observed sitting up compared with lying down, and were playing during 4.18 +/- 1.95% (P < 0.05) more observations than unsupplemented infants. They were also somewhat less likely to be observed crying or whining (P < 0.10) compared with those receiving the placebo. These effects are independent of other factors including infant age, motor development, sex, maternal education, family socioeconomic status and nutritional status at base line. Further research must be conducted to determine the long-term developmental importance of these differences in activity patterns associated with zinc supplementation in this setting.

Is prolonged breastfeeding associated with malnutrition? Evidence from nineteen demographic and health surveys.

BACKGROUND: A growing body of literature suggests that prolonged breastfeeding (typically defined as beyond the first year of life) may be a risk factor for malnutrition. METHODS: To examine the extent to which continued breastfeeding is a risk factor for malnutrition, we used multiple regression techniques to relate current breastfeeding status to weight and stature in children < 36 months old whose mothers participated in one of 19 Demographic and Health Surveys (DHS) conducted between 1987 and 1989. RESULTS: The data from 9 of 11 countries outside sub-Saharan Africa (SSA) indicated that among older children, those still breastfed are shorter and lighter than those no longer breastfed. These differences, which reached statistical significance in five countries, become apparent at 12-18 months of age. In contrast, in five of eight SSA countries, younger still breastfed children are significantly shorter and lighter than those no longer breastfed, but, the differences are largely diminished among older children. These basic patterns were not altered by adjustment for family sociodemographic characteristics, health care utilization, and recent child illness. CONCLUSIONS: Important differences in nutritional status associated with continued breastfeeding are observed throughout the developing world, and are not likely due to confounding by family sociodemographic characteristics, health care utilization or recent child illness. A unifying interpretation of the observed relationships is that child size is somehow related to the decision to wean, and that whereas in SSA, the biggest children are weaned first, in non-SSA countries, the smallest children are weaned last.

PIP: A growing body of literature suggests that prolonged breast feeding, typically defined as breast feeding beyond age one year, may be a risk factor for malnutrition. The authors therefore investigated the extent to which prolonged breast feeding is a risk factor for malnutrition. Findings are based upon the use of multiple regression to relate current breast feeding status to weight and stature in children younger than age 36 months whose mothers participated in one of 19 Demographic and Health Surveys (DHS) conducted during 1987-89. The data from 9 of 11 countries outside of sub-Saharan Africa (SSA) indicate that among older children, those still breastfed are shorter and lighter than those no longer breastfed. These differences, which reached statistical significance in five countries, become apparent at age 12-18 months. In five of eight SSA countries, younger still breastfed children are significantly shorter and lighter than those no longer breastfed, but the differences are largely diminished among older children. These basic patterns did not change once adjustments were made for family sociodemographic characteristics, health care use, and recent child illness.

Acute childhood diarrhoea and maternal time allocation in the northern central Sierra of Peru.

Interventions to improve child health depend, at least implicitly, on changing maternal knowledge and behaviour and a reallocation of maternal time. There have been few studies, however, of the time cost involved in the adoption of new health technologies and even fewer that examine changes in maternal activities in response to child illness. The present study examines maternal daytime activities and investigates changes that occur when children are ill. We examine the impact of acute childhood diarrhoea episodes on the activity patterns of the mother/caretaker in this setting. The results show that mothers alter their usual activity patterns only slightly in response to acute diarrhoea episodes in their children. They continue to perform the same variety of activities as when the children are healthy, although they are more likely to perform them with the child 'carried' on their back. There is some indication that diarrhoea perceived to be more severe did result in the mother acting as caretaker more frequently. These findings have important implications for health interventions that depend on changing the amount of maternal or caretaker time spent for child health technologies, but the implications may vary depending on the reasons for the observed lack of changes in caretaker activities.

PIP: During the daytime in the rural village of Macashca in the Callejon de Huaylas, Peru, data collecters conducted 30 minute interval spot check observations on the activities of 45 children aged 4-36 months and their mothers/caretakers to examine the effect of acute childhood diarrhea episodes on the activities of the mothers/caretakers. The mothers/caretakers took more than 2 hours/day to prepare meals and 0.13 hours/day to collect fuel and water. Mothers were the caretakers for about 70% of all observations. Overall, time spent on child care duties increased only slightly during acute diarrhea episodes. It increased markedly for children aged 12-18 months, however (230 vs. 415 minutes/day; p = 0.006). When mothers perceived diarrhea to be severe, the amount of time spent in caretaker activities increased (72% vs. 62% during health; p = 0.1). Time spent on productive activities (e.g., gardening, food preparation, and work for wages) did not change greatly during acute diarrhea episodes. Possible explanations why mothers did not change their activity patterns during acute diarrhea episodes include: lack of flexibility to change their activity patterns; diarrhea may not be perceived as a threat; and lack of knowledge of, or access to, diarrheal treatments other than herbal tea. These findings demonstrate the need for public health specialists to consider the amount of time spent on child health technologies when designing health interventions. Realistic assessments of the practice and efficacy of traditional caretaker patterns during diarrheal episodes should be conducted to design feasible, culturally appropriate, effective case management programs.