An investigation of the role of fathers in immunization uptake.

BACKGROUND: Mothers, but not fathers, are the usual focus of strategies to maximize immunization coverage in low income countries. METHODS: A study of the immunization determinants of children aged 12-18 months was conducted in 1991 in the Eastern Region of Ghana using structured interviews of a population sample of 294 mothers and 170 (67%) of the children's fathers. RESULTS: Fathers were more likely than mothers to perceive that the fathers had participated in the decision to send children for immunizations. Where both parents reported that the father had participated in the decision, and he could speak English, the child was more likely to have completed the immunization schedule by 12 months (OR = 5.7, 95% confidence interval [CI]: 1.5-21.7), independently of other factors. Neither the father's participation, nor his ability to speak English, was independently associated with the child's immunization status. CONCLUSIONS: The results of the study suggest that, where fathers have a higher level of education, programmes which are designed to involve them in decisions about their children's use of preventive health services have the potential to increase timely immunization coverage levels.

PIP: Programs and strategies to maximize immunization coverage in low income countries generally focus upon mothers. 294 mothers of children aged 12-18 months and 170 (67%) of the children's fathers were interviewed in a 1991 study of immunization determinants in the Eastern Region of Ghana. Fathers were more likely than mothers to perceive that the fathers had participated in the decision to send children for immunizations. Where both parents reported the father's involvement in the decision making process, and the father could speak English, the child was more likely to have completed the immunization schedule by 12 months, independently of other factors. Neither the father's participation, nor his ability to speak English, was independently associated with the child's immunization status. These findings suggest that where fathers have a relatively higher level of education, programs involving them in decision making about their children's use of preventive health services may increase timely immunization coverage levels.

A WHO Collaborative Study of Maternal Anthropometry and Pregnancy Outcomes.

OBJECTIVES: To evaluate to what degree anthropometric measurements are useful and efficient in predicting maternal and fetal outcomes in different country settings and to develop appropriate reference curves for maternal weight gain. METHODS: A meta-analysis of 25 data sets providing information on over 111,000 births worldwide. RESULTS: Attained weight indicators from pre-pregnancy (Pp) through 9 lunar months demonstrated high odds ratios (O.R.) for both low birth weight (LBW) and intra-uterine growth retardation (IUGR). The strongest effect size (O.R. = 4.0) was provided by attained weight at 7 lunar months for IUGR, when applied to women of below average pre-pregnancy weight. The study indicators showed only minor and inconsistent O.R. for preterm birth (PTB). The ability of study indicators to predict the three maternal outcomes was much weaker. Maternal height as a predictor of assisted delivery showed the highest positive O.R. (1.6), but did not meet the screening criteria. CONCLUSIONS: A single measurement of attained weight at 5 or 7 lunar months (16-20 or 24-28 weeks) is the most practical screening instrument for LBW and IUGR in most primary health care settings and provides warning of the need for intervention. The operational value of these findings should be demonstrated through their successful large-scale application in service settings.

Maximizing immunization coverage through home visits: a controlled trial in an urban area of Ghana.

A strategy of home visits to maximize children's immunization coverage was implemented in three towns in Ghana. The strategy was tested in town 1 in a controlled trial where clusters of children were allocated to the intervention and control groups. A total of 200 mothers in the intervention group were visited at home by non-health workers and their children were referred to a routine under-fives' clinic. Subsequent home visits targeted at those who failed to complete immunization schedules were made by nurses. After 6 months, coverage had risen from 60% to 85%, which was 20% higher than in the town 1 control group of 219 age-matched children (P < 0.005). A similar home-visiting strategy in a neighbouring town resulted in a rise in coverage from 38% to 91% (n = 55), mainly through home immunizations. Children were more likely to complete the schedule if their fathers were interviewed and participated in the decision to send them to the clinic. Countries with national service programmes can use a home-visiting strategy to supplement and strengthen their routine immunization programmes. A wide range of other community-based primary health care interventions could also be tested and implemented using this methodology.

PIP: The strategy of home visits to maximize children's immunization coverage was evaluated in three towns in Eastern Ghana in 1991-92. Mothers were visited by a non-health worker and referred to an under-fives clinic; if they failed to follow through, a second home visit was made by a nurse. After 6 months, the proportion of completed schedules was significantly higher among the 200 intervention group children than the 219 controls, whether measured by card only (85.5% vs. 62.6%) or by card and history (86.0% vs. 66.7%). Complete coverage was most likely when the mother followed the advice of the interviewer and, without further prompting, brought the child to the health clinic (relative risk (RR), 1.43; 95% confidence interval (CI), 1.17-1.75), when a nurse met the mother at a subsequent home visit (RR, 0.40; 95% CI, 1.00-1.96), and if fathers were interviewed and participated in the decision to send the child to the clinic (RR, 1.85; 95% CI, 1.10-3.12). During the home visit period, 70.2% of previously uncompleted immunization schedules were completed. Other potential advantages of home visits include disaggregated data collection, identification of pockets of low immunization coverage, information on health service users' perspectives, and the involvement of fathers in health care decision making. However, home visiting should be viewed as a means of strengthening routine primary health care service provision and not as a substitute for clinic services.

Immunization determinants in the eastern region of Ghana.

A study of the immunization determinants of children aged 12 to 18 months was conducted in 1991 in the Eastern Region of Ghana, using structured interviews of mothers and fathers. The completion of immunization schedules by one year, among the 294 children, was positively associated (P < 0.005) with the town of residence of the child and mother, the ability of the mother to speak English, the target child having been treated for illness at the local hospital, the child's mother having given birth to less than 5 children, the possession of a sewing machine by the mother, and the birth of the child in the current town of residence. Significantly higher immunization coverage levels were achieved where the Under Fives' Clinic was an affordable and acceptable service, integrating preventive and curative care, and where measures were implemented by the community to increase attendance levels at the Clinic. This was achieved among a target group who were otherwise at a relatively high risk of failing to complete immunization schedules on-time.

PIP: The study of immunization determinants was conducted in July and August 1991 in 3 towns in the eastern region of Ghana using structure interviews of mothers and fathers. Town 1 had weekly Under Fives' Clinics; Town 2 had a monthly Under Fives' Clinic; and Town 3 had monthly outreach clinic provided by a team from the mission hospital. The target group was 12-18 month old children who numbered 296 including 2 sets of twins. The responses of 294 female caretakers were analyzed. The completion of immunization schedules by 1 year was positively associated (p 0.005) with the town of residence of the child and mother (adjusted odds ratio [OR] = 7.7) in Town 1 and 3; the ability of the mother to speak English (OR = 2.8); the child having been treated at the local hospital (OR = 4.1); the mother's parity of less than 5 births (OR = 6.6); the possession of a sewing machine by the mother (OR = 2.0); and the birth of the child right in the respective town (OR = 4.6). In bivariate analyses the best fit logistic repression equations included: mother from local ethnic group (OR = 3.7); mother earns money (OR = 2.4); assisted birth (OR = 2.3); and mother's economic level exclusive of owning a sewing machine (OR = 1.9). In addition, significantly higher coverage of immunization was achieved where the Under Fives' Clinic was affordable, integrating preventive and curative care, and where measures by the community increased attendance levels among the target group who were otherwise at relatively high risk of failing to complete immunization on time. These results support the hypothesis that higher female literacy, or perhaps more effective education of parental and Under Fives' Clinic attenders, improved economic status, and lower parity may contribute to the better use of primary health care services by mothers.

Determinants of nutrition status among children in the eastern region of Ghana.

A cross-sectional survey of children's weights was included in a population study which was designed to identify and measure the determinants of immunization status of 12-18-month-old children of 294 mothers in the Eastern Region of Ghana. Birth weight, among a subgroup of 91 children where this information was available from the mothers' Road To Health cards, was the variable with which current weight-for-age Z scores was most strongly associated (r = 0.38). Associations of current weight-for-age with certain socio-economic variables, at or close to statistically significant levels, corresponded with similar or stronger associations of birth weight with these same socio-economic variables. Cross-sectional studies of young children, to identify associations and possible determinants of nutrition status, are more informative where there is a high Road To Health card coverage and where birth weights have been recorded on these cards.

Nutrient intakes in long-stay mentally handicapped persons.

A study of the dietary intake of 115 male and 217 female mentally handicapped persons aged 15-64 years in five long-stay institutions was carried out using a semi-weighed technique over 4 d. Nineteen per cent of males and 5% of females were classified as being underweight and 15% of males and 27% of females were classified as being obese. The average daily intakes of nutrients were: energy 8.8 MJ, protein 92 g, carbohydrate 218 g, fat 101 g, dietary fibre 18 g, calcium 1024 mg, iron 12.5 mg, vitamin B6 1.4 mg, vitamin B12 10.8 micrograms, ascorbic acid 68 mg. The distribution of energy between protein, carbohydrate and fat was 18, 39 and 43% respectively. Energy intakes were not related to ambulatory status, degree of mental handicap, the level of drug usage or body mass index. Energy intakes varied significantly between hospitals and between the sexes.

A case-control study of dietary intake of renal stone patients. I. Preliminary analysis.

The average daily dietary intake of 88 idiopathic renal stone cases and 88 age and sex matched controls was assessed by history using a standardised questionnaire. Statistical analysis was undertaken on the whole group and on male and female subgroups, to establish if there were any significant differences between cases and controls. There were statistically significant differences in dietary intake between the whole group, the female cases and the control group. Male cases showed only a significantly lower intake of thiamine compared to controls. There was little difference between cases and controls intake of iron or multivitamin supplements but vitamin C supplements (greater than 1 g/day) were taken more than twice as frequently by cases than controls. These results suggest that control dietary studies of renal stone patients without regard to their sex may conceal many differences in dietary intake between cases and controls.

A case-control study of dietary intake of renal stone patients. II. Urine biochemistry and stone analysis.

The dietary intakes of 88 renal stone cases and 88 age and sex matched controls were assessed by dietary history using a standardised questionnaire. The stone cases were divided into six subgroups established on the basis of urine biochemistry (calcium, oxalate and uric acid) and stone composition. The average intake of each group was then compared with that of their controls using standard statistical procedures. Cases with idiopathic calcium oxalate stones had significantly lower intakes of dietary fibre, non-cellulose polysaccharide, phytate, magnesium, phosphate and thiamine than controls. No significant difference in dietary intake was found between cases with high urinary calcium and uric acid and their respective controls. All cases with a high urinary oxalate had a significantly higher intake of vitamin C than controls. Our results support the belief that dietary intake is an important pre-urinary risk factor of idiopathic renal stone disease.

Diet and primary prevention of cancer.

Various assessments have been made of the contribution of diet to the risk of developing cancer in industrialized societies. The evidence available for a causal relationship between diet factors and cancer of specific sites is still incomplete and further research is needed to fill gaps in knowledge. Nevertheless given the limited effectiveness of available therapy in the treatment of established disease, preventive measures based on available evidence should receive active consideration, particularly as they are unlikely to be hazardous in other respects and as they approximate to changes in food supply and diet recommended for general health maintenance. Prevention must address itself to the nature of the food supply, to the choice of the foods that constitute the normal diet and the way in which these are stored and prepared both domestically and industrially. The objectives of a primary prevention programme would be to develop dietary intake patterns that would meet established requirements for health maintenance, would minimize the intake of carcinogens and optimize the intake of inhibitors. The feasibility of public health measures in respect of these objectives is examined and the cost effectiveness assessed. Potential problems arising from the implementations are considered. Measures include the modification of agricultural practices and of food processing techniques as well as various approaches to nutrition education, and modification of food intake patterns. It is concluded that considerable experience exists in other areas of nutrition intervention to suggest that primary prevention of cancer in respect of dietary factors is feasible and would complement other public health activities in this area.