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.

'Jumping through hoops': parents' experiences with seeking respite care for children with special needs.

BACKGROUND: Respite care may act as a means to reduce stress and fatigue in people caring for a dependent who has a disability. Despite this, a variety of barriers may exist to obtaining such services. This study explored caregivers' experiences seeking respite care for their children with special needs within a province in Canada. METHODS: Caregivers were recruited from two agencies providing respite care for children with fetal alcohol spectrum disorders and other mental health and developmental difficulties. In total, 10 caregivers participated in in-depth individual interviews. A constructivist grounded theory approach was employed in the design and analysis of the data. RESULTS: Caregivers discussed their frustrations with the process of finding and obtaining respite care, a course of action described as 'jumping through hoops'. This construct was composed of subcategories emphasizing the complexity of 'navigating the system', the bidirectional process of 'meeting the requirements' and the challenges of 'getting help'. CONCLUSIONS: The collective experiences of these caregivers point to the need for more flexibility and co-ordination of respite care services for children with special needs.

Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers.

OBJECTIVES: To examine the prevalence, persistence, and correlates of depressive symptoms in mothers of toddlers in a nationally representative sample. METHOD: The self-report components of two linked databases were used for this study, the 1988 National Maternal and Infant Health Survey and the 1991 Longitudinal Followup. Depressive symptoms of 7,537 mothers were measured by the Center for Epidemiologic Studies-Depression Scale (CES-D) at both time points. Weighted bivariate and multivariate analyses were used to assess the stability of maternal depressive symptoms across two time points and maternal and child predictors of elevated depressive symptoms. RESULTS: Twenty-four percent of mothers at time 1 (mean child age 17 months) and 17% at time 2 (mean child age 35 months) had elevated depressive symptoms (CES-D score > or =16). Thirty-six percent of those with elevated scores at time 1 also had elevated scores at time 2. Not having breast-fed, a mistimed or unwanted pregnancy, and poor child health status were related to elevated depressive symptoms but not persistence. CONCLUSIONS: Elevated depressive symptoms are common in mothers of toddlers. Given the potential magnitude of need, a systematic clinical and public health approach may be required.

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.

Parental prevention practices for young children in the context of maternal depression.

OBJECTIVE: To assess the relationship between maternal depression and 4 parent-based prevention practices (use of car seats and electrical plug covers, presence of syrup of ipecac in the home, and reading to their child), using a large nationally representative follow-back sample. METHODS: The maternal self-report components of 2 databases were used for this study, the 1988 National Maternal and Infant Health Survey and the linked companion 1991 Longitudinal Follow-Up Survey. A total of 7537 mothers with newborns in 1988 served as the subjects. Measures of the 4 prevention practices were extracted from the 1991 survey. Depressive symptom measures were derived from both surveys using the Center for Epidemiologic Studies-Depression Scale. Weighted bivariate and multivariate logistic analyses were used to assess the relationship between maternal depressive symptoms (trichotomized to depression at both time points, at 1 time point, and at neither time point) and parental prevention practices, while controlling for a wide variety of sociodemographic variables. RESULTS: Mothers reporting a high level of depressive symptoms (Center for Epidemiologic Studies-Depression Scale score >/=16) reported significantly poorer prevention practices for car seat use, covering electrical plugs, and having syrup of ipecac in the home. High depressive symptoms were also related to a lower likelihood of daily reading, but only for those mothers presently living with a male partner. Engagement in all prevention practices, except having syrup of ipecac in the home, were less likely if the mother reported high levels of depressive symptoms at both time points versus a single time point. CONCLUSION: Maternal depression may significantly impede parental prevention practices. As maternal depression is a treatable condition, screening and treating this disorder may contribute to improvement in childhood prevention practices and ultimately child health.

Family planning and parenthood needs of women with severe mental illness: clinicians' perspective.

Family planning and parenthood are important issues for women with severe and persistent mental illness (SPMI). The role of adult mental health clinicians with regard to these issues has been under investigated. Clinicians treating patients with SPMI at a large community health center completed survey forms on 419 women. Clinicians reported that a large fraction of sexually active women were not thought to be using birth control. Despite this, many clinicians had not discussed birth control with these patients. Clinicians had concerns about childcare in 72% of cases where the patient with SPMI was the primary custodian of a younger child; however, the majority of these families were not receiving child or family services. Further consideration of the role of the adult mental health clinician in addressing issues of family planning and parenting is required.

The Physician Belief Scale and psychosocial problems in children: a report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network.

Clinicians' management of children with psychosocial problems may vary with their attitudes and beliefs. However, we lack sound instruments to assess these factors. This study examined the psychometric properties of the Physician Belief Scale (PBS). A modified version of the PBS was sent to clinicians who participated in two primary care research networks. Using factor analysis, we reduced the PBS to 14 items and 2 subscales. Cronbach's alpha values were high. Female clinicians, those using DSM-IV, and those having completed training earlier rated themselves as more psychosocially oriented. Identification and treatment of psychosocial problems were significantly related to scores on the Belief and Feeling subscale. The PBS provided only a modest amount of information regarding primary care practices. It is not clear if these limitations are attributable to the instrument or the many other barriers to effective psychosocial care.

Adolescents' insight in heavy drinking.

PURPOSE: Because so few adolescents with alcohol problems seek treatment, this study examined the factors associated with adolescents' recognition or insight into having a substance use problem. METHOD: Data were extracted from a self-report questionnaire used in an epidemiological study of public middle school students on substance abuse in Arkansas. Those drinking heavily were divided into "admitters" and "deniers" based on their response to the question of having a substance use problem. Odds ratios were calculated to measure the association of several variables with admitting a problem. RESULTS: Of 3395 adolescents, 13.4% (455) met or exceeded our threshold for heavy drinking. Only 15.9% (65) of these heavy drinkers acknowledged having a substance use problem. Reporting more types of negative social events related to alcohol use and scoring higher on a measure of positive alcohol expectancies were significantly related to admitting to a substance use problem. Recent health care contact and perceived environmental factors did not independently contribute to insight. CONCLUSIONS: If these results are generalizable, treatment and educational interventions should emphasize linking alcohol use and negative social consequences.

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

Sex differences in higher functioning people with autism.

Though a sex difference in the incidence of autism has frequently been reported, few studies have considered sex differences in the severity of features associated with autism. The Autism Diagnostic Interview was used to assess the difference between a group of 21 females and 21 males with autism with equivalent chronological nonverbal IQ greater than 60. Males were rated to be more severely autistic than females on several measures of early social development, but not in any other areas. Results are discussed in relationship to hypotheses based on sex differences in other populations.