Group Antenatal Care: A Paradigm Shift to Explore for Positive Impacts in Resource-poor Settings.

The delivery of high-quality antenatal care is a perennial global concern for improving maternal and neonatal outcomes. Antenatal care is currently provided mainly on a one-to-one basis, but growing evidence has emerged to support the effectiveness of group antenatal care. Providing care in a small group gives expectant mothers the opportunity to have discussions with their peers about certain issues and concerns that are unique to them and to form a support system that will improve the quality and utilization of antenatal care services. The aim of this article is to promote group antenatal care as a means to increase utilization of healthcare.

Uncovering Multidimensional Poverty Experiences in Shaping Children's Socioemotional Trajectories during the First 6 Years of Schooling.

The extant literature has attested to the importance of poverty on child well-being generally using a unidimensional approach. Researchers have yet to establish solid evidence on how multiple dimensions of poverty (e.g., depth, volatility, and spells of exposure) might be associated with children's socioemotional well-being during their early school years. Building upon Bronfenbrenner's bioecological systems theory, this study used latent class analysis to identify poverty patterns by incorporating multiple dimensions of poverty and investigated the relationship between multidimensional poverty patterns and children's socioemotional trajectories from kindergarten through fifth grade. Using the Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (ECLS-K), a longitudinal dataset featuring a nationally representative cohort of children in the United States (N ≈ 20,090), the analysis identified seven poverty groups. Each group exhibited a unique poverty or economic pattern that incorporates the three poverty dimensions. Growth-curve results indicate that multidimensional poverty patterns were significantly associated with externalizing and internalizing behaviors both at kindergarten and over time by fifth grade. Children with the acutest form of economic deprivation-extreme poverty, volatile income, and multiple spells of poverty exposure-were reported to have the worst outcomes. The significant variations in children's socioemotional trajectories due to different poverty patterns highlight the importance of poverty reduction and prevention strategies corresponding to those patterns for optimal effect. This study suggests a focus not just on helping families exit poverty temporarily, but on improving their economic security as a way to nurture children's socioemotional well-being.

La bibliografía existente ha avalado la importancia de la pobreza en el bienestar de los niños, generalmente usando un enfoque unidimensional. Los investigadores aun tienen que demostrar con pruebas sólidas cómo las múltiples dimensiones de la pobreza (p. ej.: la profundidad, la volatilidad y los periodos de exposición) podrían estar asociadas con el bienestar socioemocional de los niños durante sus primeros años de escolarización. Basándose en la teoría bioecológica de sistemas de Bronfenbrenner, este estudio utilizó el análisis de clases latentes para identificar patrones de pobreza incorporando varias dimensiones de pobreza e investigó la relación entre los patrones multidimensionales de pobreza y las trayectorias socioemocionales de los niños desde el jardín de infantes hasta quinto grado. Utilizando el Estudio longitudinal de la primera infancia, promoción de jardín de infantes de 1998-99 (ECLS-K), un conjunto de datos longitudinales que presenta una cohorte de niños de los Estados Unidos representativa a nivel nacional (N ≈ 20,090), el análisis identificó siete grupos de pobreza. Cada grupo expuso un patrón económico o de pobreza único que incorporó las tres dimensiones de pobreza. Los resultados de la curva de crecimiento indican que los patrones multidimensionales de pobreza estuvieron asociados significativamente con conductas exteriorizadas e interiorizadas tanto en el jardín de infantes como en transcurso del tiempo hasta quinto grado. Se informó que los niños con la forma más aguda de privación económica-pobreza extrema, ingresos volátiles y varios periodos de exposición a la pobreza-tuvieron los peores resultados. Las variaciones significativas en las trayectorias socioemocionales de los niños debido a diferentes patrones de pobreza destacan la importancia de la reducción de la pobreza y de las estrategias de prevención correspondientes a esos patrones para lograr un efecto óptimo. Este estudio sugiere enfocarse no solo en ayudar a las familias a salir de la pobreza temporariamente, sino en mejorar su seguridad económica como forma de promover el bienestar socioemocional de los niños.

Many Kinds of Poverty: Three Dimensions of Economic Hardship, Their Combinations, and Children's Behavior Problems.

Income poverty, material deprivation, and subjective financial stress are three distinct dimensions of economic hardship. The majority of the theoretical and empirical literature on the effects of economic hardship on children has treated material deprivation and subjective financial stress as only mediators of the effects of income poverty, not considering the independent effects of each dimension or the effects of their combinations. Using nationally representative, longitudinal data from the Millennium Cohort Study on more than 18,000 families in the United Kingdom, we propose seven distinct experiences of economic hardship, based on the possible combinations of income poverty, material deprivation, and subjective financial stress. We use mixed- and fixed-effects linear regression models to identify whether these different economic hardship combinations are differentially associated with children's behavior problems between ages 3 and 7. We find that all economic hardship combinations, including those without income poverty, are associated with higher levels of children's behavior problems. The combination of material deprivation and subjective financial stress and the combination of all three dimensions of economic hardship are associated with the highest levels of behavior problems. Based on these findings, we argue that income poverty is an important but insufficient measure of economic hardship for children and that theory and research on the effects of economic hardship on children should consider the multidimensional nature of economic stressors for families.

Spatial distribution of Robson 10-group classification system and poverty in southern and southeastern Brazil.

OBJECTIVE: To assess the spatial distribution of the Robson 10-group classification system (TGCS) and poverty in southeastern and southern regions of Brazil in 2016. METHODS: An ecologic study based on public data from the Brazilian Information System on Live Births and the Brazilian Institute of Geography and Statistics, including 1 519 289 (53.2%) of all live-born neonates in Brazil between January and December 2016. Statistical analysis used Bayesian modelling with spatial distribution following an autoregressive conditional structure, and Moran index. RESULTS: In 2016, the percentage of live-born neonates delivered by cesarean was 58.8% and 60.7% in the southeastern and southern regions, respectively. Robson groups 1 and 3, involving spontaneous labor, were related to regions with higher poverty (Moran index, 0.36 and 0.44, respectively), whereas groups 2 and 5, involving cesarean delivery, were related to poorer regions (Moran index, 0.56 and 0.45, respectively). CONCLUSION: The frequencies of each group of the Robson TGCS were heterogeneously distributed in the geographic space owing to important associations with the proportion of poverty in the different regions. Actions are needed to develop the poorest regions in order to minimize existing disparities.

Analysis of population-level determinants of legionellosis: spatial and geovisual methods for enhancing classification of high-risk areas.

BACKGROUND: Although the incidence of legionellosis throughout North America and Europe continues to increase, public health investigations have not been able to identify a common exposure in most cases. Over 80% of cases are sporadic with no known source. To better understand the role of the macro-environment in legionellosis risk, a retrospective ecological study assessed associations between population-level measures of demographic, socioeconomic, and environmental factors and high-risk areas. METHODS: Geographic variability and clustering of legionellosis was explored in our study setting using the following methods: unadjusted and standardized incidence rate and SaTScan™ cluster detection methods using default scanning window of 1 and 50% as well as a reliability score methodology. Methods for classification of "high-risk" census tracts (areas roughly equivalent to a neighborhood with average population of 4000) for each of the spatial methods are presented. Univariate and multivariate logistic regression analyses were used to estimate associations with sociodemographic factors: population ≥ 65 years of age, non-white race, Hispanic ethnicity, poverty, less than or some high school education; housing factors: housing vacant, renter-occupied, and built pre-1950 and pre-1970; and whether drinking water is groundwater or surface water source. RESULTS: Census tracts with high percentages of poverty, Hispanic population, and non-white population were more likely to be classified as high-risk for legionellosis versus a low-risk census tract. Vacant housing, renter-occupied housing, and homes built pre-1970 were also important positively associated risk factors. Drinking water source was not found to be associated with legionellosis incidence. DISCUSSION: Census tract level demographic, socioeconomic, and environmental characteristics are important risk factors of legionellosis and add to our understanding of the macro-environment for legionellosis occurrence. Our findings can be used by public health professionals to target disease prevention communication to vulnerable populations. Future studies are needed to explore the exact mechanisms by which these risk factors may influence legionellosis clustering.

Correlates of school dropout and absenteeism among adolescent girls from marginalized community in north Karnataka, south India.

Secondary education among lower caste adolescent girls living in rural Karnataka, South India, is characterized by high rates of school drop-out and absenteeism. A cross-sectional baseline survey (N=2275) was conducted in 2014 as part of a cluster-randomized control trial among adolescent girls (13-14 year) and their families from marginalized communities in two districts of north Karnataka. Bivariate and multivariate logistic regression models were used. Overall, 8.7% girls reported secondary school dropout and 8.1% reported frequent absenteeism (past month). In adjusted analyses, economic factors (household poverty; girls' work-related migration), social norms and practices (child marriage; value of girls' education), and school-related factors (poor learning environment and bullying/harassment at school) were associated with an increased odds of school dropout and absenteeism. Interventions aiming to increase secondary school retention among marginalized girls may require a multi-level approach, with synergistic components that address social, structural and economic determinants of school absenteeism and dropout.

Including health insurance in poverty measurement: The impact of Massachusetts health reform on poverty.

We develop and implement what we believe is the first conceptually valid health-inclusive poverty measure (HIPM) - a measure that includes health care or insurance in the poverty needs threshold and health insurance benefits in family resources - and we discuss its limitations. Building on the Census Bureau's Supplemental Poverty Measure, we construct a pilot HIPM for the under-65 population under ACA-like health reform in Massachusetts. This pilot demonstrates the practicality, face validity and value of a HIPM. Results suggest that public health insurance benefits and premium subsidies accounted for a substantial, one-third reduction in the health inclusive poverty rate.

Measuring Poverty in Southern India: A Comparison of Socio-Economic Scales Evaluated against Childhood Stunting.

INTRODUCTION: Socioeconomic status (SES) scales measure poverty, wealth and economic inequality in a population to guide appropriate economic and public health policies. Measurement of poverty and comparison of material deprivation across nations is a challenge. This study compared four SES scales which have been used locally and internationally and evaluated them against childhood stunting, used as an indicator of chronic deprivation, in urban southern India. METHODS: A door-to-door survey collected information on socio-demographic indicators such as education, occupation, assets, income and living conditions in a semi-urban slum area in Vellore, Tamil Nadu in southern India. A total of 7925 households were categorized by four SES scales-Kuppuswamy scale, Below Poverty Line scale (BPL), the modified Kuppuswamy scale, and the multidimensional poverty index (MDPI) and the level of agreement compared between scales. Logistic regression was used to test the association of SES scales with stunting. FINDINGS: The Kuppuswamy, BPL, MDPI and modified Kuppuswamy scales classified 7.1%, 1%, 5.5%, and 55.3% of families as low SES respectively, indicating conservative estimation of low SES by the BPL and MDPI scales in comparison with the modified Kuppuswamy scale, which had the highest sensitivity (89%). Children from low SES classified by all scales had higher odds of stunting, but the level of agreement between scales was very poor ranging from 1%-15%. CONCLUSION: There is great non-uniformity between existing SES scales and cautious interpretation of SES scales is needed in the context of social, cultural, and economic realities.

Poverty and fatalism: Impacts on the community dynamics and on hope in Brazilian residents.

The aim of this study was to analyze the consequences of poverty on expressions of fatalism, hope, and sense of community of two Brazilian States: Ceará and Rio Grande do Sul. Seven-hundred and thirty-one people, divided in four groups (extreme poverty, poverty, median income, and adequate income) answered a questionnaire. The variables sense of community and hope were found to be predictors of fatalism. Individuals in situations of poverty and extreme poverty showed high indices of fatalism, pessimism, divinity control, and luck, and low indices of hope and sense of community. Individuals with adequate income have low levels of fatalism, pessimism, and divinity control. It is concluded that poverty has consequences on the life of those who experience it, and that attitudes of pessimism, hopelessness, and belief in luck as well as the weakening of community networks, articulate and support the maintenance of the status quo.

[Poverty and Health: The Living Standard Approach as a Supplementary Concept to Measure Relative Poverty. Results from the German Socio-Economic Panel (GSOEP 2011)]. / Armut und Gesundheit: Der Lebensstandardansatz als ergänzendes Messinstrument relativer Armut. Ergebnisse aus dem Sozio-ökonomischen Panel (SOEP 2011).

BACKGROUND: A common indicator of the measurement of relative poverty is the disposable income of a household. Current research introduces the living standard approach as an alternative concept for describing and measuring relative poverty. This study compares both approaches with regard to subjective health status of the German population, and provides theoretical implications for the utilisation of the income and living standard approach in health research. METHODS: Analyses are based on the German Socio-Economic Panel (GSOEP) from the year 2011 that includes 12 290 private households and 21106 survey members. Self-rated health was based on a subjective assessment of general health status. Income poverty is based on the equalised disposable income and is applied to a threshold of 60% of the median-based average income. A person will be denoted as deprived (inadequate living standard) if 3 or more out of 11 living standard items are lacking due to financial reasons. To calculate the discriminate power of both poverty indicators, descriptive analyses and stepwise logistic regression models were applied separately for men and women adjusted for age, residence, nationality, educational level, occupational status and marital status. RESULTS: The results of the stepwise regression revealed a stronger poverty-health relationship for the living standard indicator. After adjusting for all control variables and the respective poverty indicator, income poverty was statistically not significantly associated with a poor subjective health status among men (OR Men: 1.33; 95% CI: 1.00-1.77) and women (OR Women: 0.98; 95% CI: 0.78-1.22). In contrast, the association between deprivation and subjective health status was statistically significant for men (OR Men: 2.00; 95% CI: 1.57-2.52) and women (OR Women: 2.11; 95% CI: 1.76-2.64). CONCLUSIONS: The results of the present study indicate that the income and standard of living approach measure different dimensions of poverty. In comparison to the income approach, the living standard approach measures stronger shortages of wealth and is relatively robust towards gender differences. This study expands the current debate about complementary research on the association between poverty and health.

Poverty identification for a pro-poor health insurance scheme in Tanzania: reliability and multi-level stakeholder perceptions.

BACKGROUND: Many low income countries have policies to exempt the poor from user charges in public facilities. Reliably identifying the poor is a challenge when implementing such policies. In Tanzania, a scorecard system was established in 2011, within a programme providing free national health insurance fund (NHIF) cards, to identify poor pregnant women and their families, based on eight components. Using a series of reliability tests on a 2012 dataset of 2,621 households in two districts, this study compares household poverty levels using the scorecard, a wealth index, and monthly consumption expenditures. METHODS: We compared the distributions of the three wealth measures, and the consistency of household poverty classification using cross-tabulations and the Kappa statistic. We measured errors of inclusion and exclusion of the scorecard relative to the other methods. We also gathered perceptions of the scorecard criteria through qualitative interviews with stakeholders at multiple levels of the health system. FINDINGS: The distribution of the scorecard was less skewed than other wealth measures and not truncated, but demonstrated clumping. There was a higher level of agreement between the scorecard and the wealth index than consumption expenditure. The scorecard identified a similar number of poor households as the "basic needs" poverty line based on monthly consumption expenditure, with only 45 % errors of inclusion. However, it failed to pick up half of those living below the "basic needs" poverty line as being poor. Stakeholders supported the inclusion of water sources, income, food security and disability measures but had reservations about other items on the scorecard. CONCLUSION: In choosing poverty identification strategies for programmes seeking to enhance health equity it's necessary to balance between community acceptability, local relevance and the need for such a strategy. It is important to ensure the strategy is efficient and less costly than alternatives in order to effectively reduce health disparities.

6000 días más: evidencia neurocientífica acerca del impacto de la pobreza infantil / 6000 more days: Neuroscientific evidence about the impact of childhood poverty

El estudio neurocientífico de la pobreza infantil realizado por diferentes grupos de investigación durante las últimas dos décadas ha permitido acumular evidencia que indica que el impacto de las carencias materiales y simbólicas por pobreza, desde la concepción, puede limitar las oportunidades de desarrollo e inclusión social de las personas durante todo su ciclo vital. No obstante, la potencialidad de cambio inherente a la plasticidad neural, las diferencias individuales y las posibilidades de modificación del desarrollo autorregulatorio por intervención ambiental (i.e., familiar, escolar y comunitaria) también indican que los impactos no son iguales en todos los casos, que no hay un período crítico para el desarrollo cognitivo y las competencias de aprendizaje que se limite a los primeros 1000 días, que la irreversibilidad del impacto de la pobreza no es un fenómeno que afecte a todos los niños que la padecen y que la pobreza no implica necesariamente déficit del desarrollo

Neuroscientific study on child poverty carried out by several research groups over the last two decades has allowed us to gather evidence showing that the impact of material and symbolic needs from poverty, may from the onset limit opportunities of development and social inclusion of people throughout their life cycle. Nevertheless, the potential shift inherent to neural plasticity, individual differences, and the potential change of self-regulatory development by means of environment intervention (i.e., family, school, and community) also show that impacts are not the same for every child, that there is no critical period for cognitive development and learning competencies that is limited to the first 1,000 days, that irreversibility of poverty impact is not a fact that affects every child exposed to it, and that poverty does not necessary means developmental déficit

Patient delay factors in women presenting with breast cancer in a low income country.

BACKGROUND: In low income countries, many patients with breast cancer present with advanced disease which is majorly attributed to late presentation and this is associated with poor survival rates. The aim of this study was to determine the magnitude of patient delay and the factors that influence, delay in seeking health care in female breast cancer patients. METHODS: A cross-sectional study was done between January and April 2014 at a tertiary breast unit. Female patients with breast cancer above the age of 18 years were interviewed. Ethical approval was obtained. RESULTS: In total 162 patients were recruited, the mean patient delay in months was 22.6 (SD = 26.4), median delay was 13 months and range was 1-127 months. 139 (89 %) patients delayed by more than 3 months after noticing symptoms of breast anomaly. Patients with no social support from spouses and family were more likely to delay (OR = 7.1, 95 % CI 2.4-21.5, p = 0.001), those who perceived the symptoms as very serious were less likely to delay (OR = 0.2, 95 % CI 0.1-0.6, p = 0.007). There was a significant association between delayed presentation and advanced stage at presentation (p = 0.006). CONCLUSION: Most women (89 %) with breast cancer delayed by more than 3 months to seek the first medical consultation after noticing symptoms. Patients who had no social support from their families were more likely to delay.

Free solar lanterns to below poverty line girls in India: a step toward achieving millennium development goals.

Development sectors like health cannot function in isolation. Intersectoral coordination between various departments helps in bringing a positive change in the health-seeking behavior of society in the long run. The decision by the Government of India to provide free solar lanterns (lamps) to the school-going girls of below poverty line families is a welcome step in this context. This initiative would help in reducing the number of school dropout girls and thus help in improving the health indicators that are directly related to women's education. Thus it is an initiative that will help in attainment of Millennium Development Goals through women's education and empowerment. Along with that, the environment-friendly approach will definitely have an impact on health of the girls by switching from kerosene/wood stoves to solar lantern light. Also this initiative would pave the path of real "intersectoral coordination" in the health sector in India that is marred with watertight functioning of various departments. There is an urgent need to popularize the scheme and involve different stakeholders like corporate houses, media, nongovernment organizations, multinational welfare agencies, and local governing bodies for ensuring the availability and utilization of solar lanterns in India.

Older adults need twice the federal poverty level to make ends meet in California.

New calculations using the Elder Economic Security Standard (TM) Index (Elder Index) for California show that both singles and couples age 65 or older who rent need more than twice the amount established by the Federal Poverty Level (FPL) Guideline to meet basic living expenses. The gap is greater for elders who own their home and are paying a mortgage than for renters. The gap between basic expenses and the FPL is smaller for owners without a mortgage, but still exists. Housing and health care are the primary drivers of the high costs. This policy brief documents that the Elder Index provides a better measure of income adequacy than the FPL for older adults because it accounts for those costs at the county level. The growing number of public and nonprofit organizations using the Elder Index will aid the quality of planning and programs that improve income security for California's rapidly growing older population.

The Canadian elder standard - pricing the cost of basic needs for the Canadian elderly.

We determined the after-tax income required to finance basic needs for Canadian elders living with different circumstances in terms of age, gender, city of residence, household size, homeowner or renter status, means of transportation, and health status. Using 2001 as our base year, we priced the typical expenses for food, shelter, medical, transportation, miscellaneous basic living items and home-based long-term care for elders living in five Canadian cities. This is the first Canadian study of basic living expenses tailored to elders instead of adults in general, prepared on an absolute rather than a relative basis. We also accounted for an individual's unique life circumstances and established the varying effect that they have on the cost of basic expenses, particularly for home care. We found that the maximum Guaranteed Income Supplement and Old Age Security benefit did not meet the cost of basic needs for an elder living in poor circumstances.

Gendered Moral Dimensions of Childhood Vulnerability

Community; state; and international definitions of childhood and vulnerability play a central role in determining which people and families receive the limited resources available to support vulnerable children's survival and thriving. International definitions of childhood and vulnerability are often assumed by international development organizations (IDOs) to embody universal human rights and equality norms; and thus to serve as an appropriate basis for creating universal categorization frameworks to identify vulnerable children across communities and states. Community definitions; on the other hand; may be viewed as particular and potentially biased; embedded as they are in local power dynamics and social relations. Nonetheless; IDOs increasingly rely on communities to identify and distribute support to vulnerable children. This paper utilizes vertical ethnographic approaches to map and compare the gendered moral assumptions that shaped community; state; and international conceptions of childhood and vulnerability and responses to vulnerable children in border communities in Malawi and Mozambique. It argues that a gendered lens on childhood and vulnerability reveals both the gender inequitable assumptions underlying international and community childhood and vulnerability frameworks; and the urgent need for gendered analyses of childhood and vulnerability that engage honestly with people's lived realities; opportunities; and social relations. These analyses would explicitly link efforts to improve children's lives to gendered analyses of the local; national; and international social and political economic systems that differentially shape survival strategies and opportunities-and people's judgments of the morality of these strategies-for females and males

[Access to social networks and health care among extremely poor people]. / Acceso a redes sociales y de salud de población en extrema pobreza.

BACKGROUND: Extremely poor people have more problems to have access to social networks and health care. AIM: To evaluate the access to health services and the perception about these services of adults living in conditions of extreme poverty. MATERIAL AND METHODS: A survey was applied to 361 people living in slums aged 15 to 77 years (83% females), that were living in these conditions for a mean of 11 years. Twenty six in-depth interviews were also performed to prototypical subjects living in extreme poverty. RESULTS: Ten percent of subjects were illiterate. Sixty two percent were unsatisfied with their access to health services and 32% were not registered in primary health clinics. Among children of less than 6 years of age, 22% were delayed in their vaccination schedule and 32% were not withdrawing the milk delivered by the complementary feeding program of the clinic. The qualitative analysis revealed that the lack of access to health care is associated with the feeling of exclusion, mutual distrust and lack of resolution of health problems. CONCLUSIONS: People living in extreme poverty are distrustful and perceive obstacles to have access to the health care system.