Did point-of-use drinking water strategies for children change in the Dominican Republic during a cholera epidemic?

OBJECTIVE: Point-of-use (POU) strategies to improve drinking water, particularly chlorination, are promoted within cholera epidemics when centrally delivered safe drinking water is lacking. Most studies examining POU practices during cholera epidemics have relied on single cross-sectional studies which are limited for assessing behavioural changes. This study examined POU practices in a community over time during a cholera outbreak. STUDY DESIGN: Secondary data analysis of existing dataset. METHODS: During attendance at well-baby clinics serving a low-income peri-urban community in the Dominican Republic, mothers had been routinely asked, using a structured questionnaire, about POU strategies used for drinking water for their children. Frequency distribution of reported practices was determined over a 21 month period during the cholera outbreak on the island of Hispaniola. RESULTS: An estimated 27.8% of children were reported to have had some exposure to untreated tap water. Unsustained reductions in exposure to untreated tap water were noted early in the epidemic. POU chlorination was infrequent and showed no significant or sustained increases over the study time period. CONCLUSION: High reliance on bottled water, consistent with national household patterns prior to the cholera outbreak, may have reduced the perceived need for POU chlorination. Examination of the safety of relying on bottled water during cholera outbreaks is needed. Additionally, further inquiries are needed to understand variation in POU practices both during and beyond cholera outbreaks.

Participation in a parent education programme in the Dominican Republic: utilization and barriers.

There has been a limited assessment of the extent of participation in parent education programmes and the factors influencing attendance. This is particularly the case for low- and middle-income countries. Experiences with an eight-session education programme offered to caregivers of malnourished children in the Dominican Republic were examined. Overall, 57% of a total of 143 caregivers completed more than half of the programme. This value increased from 41% to 79% following a midstream change in service delivery, which entailed concentrating the programme into a shorter period of time and pairing it with a more intensive child nutrition component. Other hypothesized variables did not predict attendance. Key barriers to attendance identified in qualitative interviews included lack of money for transportation, lack of an acceptable babysitter for other children and competing demands on the caregivers' time. Efforts to eliminate caregiver identified barriers may improve participation levels.

Early termination of breast-feeding in periurban Santo Domingo, Dominican Republic: mothers' community perceptions and personal practices.

OBJECTIVES: The objectives of this study were to determine: 1) whether mothers' perceptions of typical community practice for breast-feeding duration influence their personal practices and 2) whether the mothers' reports of community reasons for terminating breast-feeding identify barriers not elicited through self-report. METHODS: The study was conducted in 1997 in a sample of poor neighborhoods in a periurban district of Santo Domingo, the capital of the Dominican Republic. A representative sample of 220 mothers from these neighborhoods was interviewed with a structured questionnaire. RESULTS: While the duration of breast-feeding was similar for self-report and for mothers' perceptions of typical community practice, there was no statistically significant correlation between these two variables. "Mother-driven" reasons for early termination of breast-feeding, such as "fear of loss of figure or of breast shape" and "not wanting to breast-feed," were frequently perceived as community reasons but rarely given as personal reasons. Personal reasons were predominately "child-driven," including "the child not wanting the breast," or reasons beyond the mother's control such as having "insufficient" milk. CONCLUSIONS: Maternal report of community reasons for early termination may be a useful way to identify factors that would not otherwise be revealed on self-report. These additional reasons may guide health promotion efforts aimed at increasing breast-feeding duration.

Prevention of diarrhoea in a poor District of Santo Domingo, Dominican Republic: practices, knowledge, and barriers.

The study, conducted in a poor periurban community of Santo Domingo, Dominican Republic, assessed the practices, knowledge, and barriers relating to prevention of diarrhoea. A total of 582 caregivers of children, aged less than 5 years, were systematically sampled from four barrios. Results of the study showed that 55% of the caregivers did not boil drinking water for children; 38% did not always wash hands of the children prior to meals; 87% of the children did not always wear shoes outside their house; and 54% were breastfed for less than one year. Biomedical knowledge about these practices was high among the caregivers, and was not related to the reported behaviours. However, several barriers were significantly related to practices, including lapse in caregiving, limited resources, erroneous beliefs, and non-compliance by children. Health education, based on a biomedical knowledge-deficit model, may have little impact on improving the diarrhoea-prevention practices in these communities. Greater attention should, therefore, be directed toward the barriers experienced by caregivers of children.

To boil or not: drinking water for children in a periurban barrio.

Boiling water, or other water purification methods, are common recommendations of health promoters in developing countries to improve the quality of drinking water in an attempt to decrease the incidence of childhood diarrhea. Health education programs frequently employ an approach based on knowledge deficits to promote this practice. However, there has been little published about water purification practices or associated variables such as knowledge deficits. We interviewed 266 randomly selected child caregivers about water purification in a poor periurban district of Santo Domingo, Dominican Republic. Though most reported that they provided purified drinking water for their children when they were babies, only half of the children five years of age and under were regularly drinking purified water at the time of the study. Only one knowledge variable remained significantly related to purifying drinking water in the final multivariate model. Other factors that remained in the final model were level of maternal education, endorsing being too tired to boil water and a global measure of social support. Several other hypothesized variables were not related to purifying water. Knowledge deficits may play only a limited role in determining this prevention practice. Further work is required to better identify key factors to improve this practice and hence guide health promotion efforts.

Knowledge and practices of preventing diarrhoea in malnourished children.

Instructions for preventing diarrhoea, based on a knowledge-deficit model, are a common health-promotion approach aimed at the providers of child care attending nutritional rehabilitation centres. However, there is rarely an assessment of baseline knowledge to justify the need for this type of intervention and to guide its form. This study investigated the practice and knowledge of recommended diarrhoea-prevention behaviours of caregivers of 78 malnourished children consecutively admitted to a realimentation programme. Major deficits included: 39% not boiling (or not planning on boiling) drinking water after the child reached two years of age; 35% not always washing children's hands before meals; only 17% reporting that it was rare for their children to go barefoot; and the majority breastfeeding for less than one year. However, almost all measures of knowledge, based on open and closed questions, were not related to the corresponding practice. Several types of barriers to preventive practices were reported on open questions, including, "beliefs," "children as barriers," and "time." This information may be helpful in designing more effective health-promotion programmes.

Infant feeding practices in a poor district of Santo Domingo.

PIP: During August-December 1989, in the Dominican Republic, local health promoters interviewed 103 primary caretakers and took anthropometric measurements from 103 children aged 3 years and under during home visits in three poor neighborhoods of Los Alcarrizos (Alto de Chavon, Barrio Landia, and Pueblo Nuevo) to examine infant feeding practices. 95% of the mothers had started breast feeding. The median duration of breast feeding was 7.5 months. Almost 33% had quit breast feeding by 3 months. Perception of insufficient milk was the leading reason for early discontinuation of exclusive breast feeding. The local pharmacies in all three communities offered powdered milk. About 25% of mothers began using breast milk substitutes within the first week. A non-infant formula milk powder was the most commonly used breast milk substitute. 30% of mothers stored prepared milk for later feeds, as long as half a day. Only 13% of households had a refrigerator. The most frequently used first weaning foods were orange juice, lime juice, and beans. 76% of mothers had used or were currently using baby bottles. 95% of them reported washing the bottle in boiling water. The median age of introducing the baby bottle was 3 days. Only 44% of mother covered prepared food during storage. The most commonly eaten foods among children aged at least 1 year were milk, beans, rice, and citrus fruits. Yet the children did not eat all these foods daily. 18% of 1-2 year olds and 13% of 2-3 year olds did not eat meats and alternatives regularly. 7% of 1-2 year olds and 10% of 2-3 year olds did not eat fruits and vegetables regularly. 4% of 1-2 year olds and 3% of 2-3 year olds did not eat breads and cereals regularly. About 14% of all children were not consuming any milk at the time of the survey. These findings will be used to refine nutrition education programs in the district to make them more effective.^ieng