"Birth weakness": cultural meanings of maternal impressions for infant health in Northeast Brazil

Pregnancy encompasses socio-cultural, historical, and affective dimensions that process various meanings in women's bodies. Each society constructs popular concepts, practices, and explanatory models that differ from the biomedical model and aim to protect the mother and fetus and foster a healthy pregnancy. This qualitative study, based on interpretative anthropology, unveils the experiences of 27 poor women and their repercussions on the malnutrition of their infants, treated at a Childhood Malnutrition Treatment Center in Fortaleza, Northeast Brazil. From January to June 2004, ethnographic and narrative interviews were conducted on so-called "birth weakness", in addition to participant observation of outpatient, nursing, and home childcare. The mothers believed that their own physical and emotional suffering and precarious nutritional status were "imprinted" on the fetus, resulting in the child's malnutrition. While the ethno-etiology of "weakness" points to factors outside the body that involuntarily affect the pregnant mother, the medical view tended to incriminate the mother herself. It is necessary to understand the mothers' narratives, sympathize with their suffering, and spawn a closer approach between the popular and biomedical concepts.     

The costs of a community-based intervention to promote maternal health

The costs of community-level interventions are rarely reported, although such insights are needed if intervention research is to be useful to practitioners seeking to understand what might be involved in replicating interventions in different contexts. We report the costs of a 2-year community-based intervention to promote the health of recent mothers in Victoria, Australia. Program of Resources, Information and Support for Mothers was an integrated programme of primary care and community-based strategies. It had health care professional training, health education and community development components as well as an emphasis on creating 'mother-friendly' environments. Costs included the programme costs [primarily the salaries of the community development officers (CDO) in the field] and also 'induced' costs that relate to the CDOs' successes in attracting additional resources to the intervention from the local community. The total cost averaged A$272,490 per rural community and A$313,900 per urban community, equivalent to A$172.40 and A$128.70 per mother, respectively. For every A$10 of public funds initially invested in the project, the CDOs were able to attract a further A$1-2 worth of local resources, predominantly in the form of volunteer time or donated services.     

The unified health system of Brazil and the effectiveness of health services

Journal of Public Health - The public health sector in Brazil covers approximately 75% of the population, yet accounts for just 45% of total health expenditure, while the private sector, covering...     

High risk channeling to improve Medicaid maternal and infant care

To improve the medical care access of the poorest women and newborns, South Carolina began a High Risk Channeling Project since April 1986. The Project directs physicians to screen all Medicaid-eligible pregnant women and newborns for specified clinical high risk factors. High risk patients are channeled to designated clinics for prenatal and newborn care. Channeled pregnant women are directed to deliver their babies at regional referral hospitals. For the first two years of the Project, about two-thirds of pregnancies and 60% of newborns were actually screened. Channeled women were much more likely than the non-channeled to deliver at higher level hospitals. In counties where relatively few women were channeled, the rate of prematurity among Medicaid newborns was significantly higher than in other counties.     

The importance of community mobilization in interventions to improve sexual,reproductive, and maternal health outcomes: A review of the evidence

Community participation, engagement, and mobilization are common components of many sexual, reproductive, and maternal health (SRMH) programs, but little consensus exists among researchers on how critical these program components are. Using principles of realist review, we reviewed a spectrum of community mobilization interventions to evaluate their use in improving five SRMH areas. Consistent with theoretical assumptions, we found that actively involving community members in leading intervention activities and/or taking ownership tends to produce better SRMH outcomes than simply relying on community members as implementers. Despite this, many fewer programs exist with this meaningful level of engagement than with more cursory engagement.     

Public health impact of community-based nutrition and lifestyle interventions

Community-based interventions have increasingly received attention since researchers and public health professionals have come to acknowledge the importance of an environment that makes the healthy choice the easy choice. All stakeholders including the target community are involved to achieve changes in legislation, in people's social and physical context, and in individual characteristics that support healthy diets and other lifestyles. Some early large-scale community-based heart health interventions showed promising results. The Stanford Five City Project, for example, showed net improvements in knowledge of coronary heart disease risk factors of approximately 12%. Net declines in smoking prevalence (14%), cholesterol (2%), and systolic (3%) and diastolic (5%) blood pressure were also observed. Most later studies did not replicate these findings and it was therefore suggested that community-based interventions, which require substantial commitment and resources, may be less effective than approaches targeting high-risk groups. We present the rationale and theories for community-based interventions, and then elaborate on the methodological challenges in the design and the outcome and process evaluation of community-based interventions. We provide an overview of some of the evidence on the effectiveness of community-based heart health interventions and conclude with the perspectives for community-based interventions in future research and practice.     

Strengthening health care systems to improve infant health in rural Nepal

The functioning of the government primary health care system as it affects infant health in the Baglung District of Nepal, is discussed. the Baglung District is a remote rural area of 232,000 population in the western Himalayan foothills, entirely based on subsistence farming, and without drivable roads. The government has a 15-bed hospital in the district capital, 11 health posts and 80 village-based community workers (VHWs). The Save the Children Fund also has a Maternal-Child Health Clinic with an expatriot doctor and 35 staff, funded by US $88,000 in 1984-5, and caring for about 10% of the district. District health administration could be improved by setting up communication links between the district capital, health posts and VHWs. The SCF funded a newsletter publicizing immunization and family planning campaigns, which were previously unannounced. The government has also tried to decentralize the control of staffing, pay, and health campaign scheduling from the national to the district level since 1985, with mixed success. Since the hospital runs out of drugs and supplies, and the health posts lack these as well as diagnostic equipment, water and sanitation, the public usually resorts to traditional healers. It is suggested that staff rotations be made during monsoons when people cannot travel, and that supplies be upgraded during the pre-monsoon when food is limited and morbidity is higher, VHWs are usually young men with little training, supplies or respect from the community. It would be best to strengthen health posts initially, then train VHWs by associating them with the health posts. Other suggestions are to gain the respect of the traditional healers for referrals, and to emphasize cost-effective ways to improve female education and literacy.     

Evaluation of the effectiveness of a community-based prenatal health education program.

This study demonstrated the importance of outlining evaluation criteria for newly implemented programs. An educational program should have measurable program objectives with which the goals of the program can be evaluated. Along with a clearly defined set of program objectives, new educational programs should be implemented with the appropriate record keeping systems to facilitate information retrieval. With a measurable set of objectives and accurate data collection, ongoing evaluation of programs would enable developers to identify the programs' strengths and weaknesses as a basis for revisions to best meet the needs of the population served.     

Improving health and energy efficiency through community-based housing interventions

Objectives  

Houses designed for one climate and cultural group may not be appropriate for other places and people. Our aim is to find cost-effective ways to improve the characteristics of older homes, ill-fitted for New Zealand’s climate, in order to improve the occupants’ health.     

Designing and implementing behaviour change interventions to improve population health

Improved population health depends on changing behaviour: of those who are healthy (e.g. stopping smoking), those who are ill (e.g. adhering to health advice) and those delivering health care. To design more effective behaviour change interventions, we need more investment in developing the scientific methods for studying behaviour change. Behavioural science is relevant to all phases of the process of implementing evidence-based health care: developing evidence through primary studies, synthesizing the findings in systematic reviews, translating evidence into guidelines and practice recommendations, and implementing these in practice. 'Behaviour change: Implementation and Health', the last research programme to be funded within the MRC HSRC, aimed to develop innovative ways of applying theories and techniques of behaviour change to understand and improve the implementation of evidence-based practice, as a key step to improving health. It focused on four areas of study that apply behaviour change theory:defining and developing a taxonomy of behaviour change techniques to allow replication of studies and the possibility of accumulating evidence; conducting systematic reviews, by categorizing and synthesizing interventions on the basis of behaviour change theory; investigating the process by which evidence is translated into guideline recommendations for practice; developing a theoretical framework to apply to understanding implementation problems and designing interventions. This work will contribute to advancing the science of behaviour change by providing tools for conceptualizing and defining intervention content, and linking techniques of behaviour change to their theoretical base.     

Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004

This article assesses the effects of an integrated community-based primary care program (Brazil's Family Health Program, known as the PSF) on microregional variations in infant mortality (IMR), neonatal mortality, and post-neonatal mortality rates from 1999 to 2004. The study utilized a pooled cross-sectional ecological analysis using panel data from Brazilian microregions, and controlled for measures of physicians and hospital beds per 1000 population, Hepatitis B coverage, the proportion of women without prenatal care and with no formal education, low birth weight births, population size, and poverty rates. The data covered all the 557 Brazilian microregions over a 6-year period (1999-2004). Results show that IMR declined about 13 percent from 1999 to 2004, while Family Health Program coverage increased from an average of about 14 to nearly 60 percent. Controlling for other health determinants, a 10 percent increase in Family Health Program coverage was associated with a 0.45 percent decrease in IMR, a 0.6 percent decline in post-neonatal mortality, and a 1 percent decline in diarrhea mortality (p<0.05). PSF program coverage was not associated with neonatal mortality rates. Lessons learned from the Brazilian experience may be helpful as other countries consider adopting community-based primary care approaches.     

Microbiome-based stratification to guide dietary interventions to improve human health

Diverse evidence has suggested that the gut microbiome is closely associated with overall human health. Modulation of the gut microbiome through nutritional intervention is recognized as a robust and attainable strategy to prevent disorders/diseases and improve human health. However, universal dietary recommendations demonstrated to have different, sometimes even opposite, effects due to the considerable inter-individual variability between subjects, especially in the gut microbiome. Hence, implementation of personalized nutrition or other treatment strategies have been suggested to tackle the individuality problem. A first step into this direction includes the stratification of subjects into specific groups based on their gut microbiome. The gut microbiome could serve as a pool of potential biomarkers for distinguishing “responders” and “non-responders” to specific treatments, which subsequently can be used to classify subjects with ambition to increase treatment efficacy. In this review, we explain the need for human gut microbiome stratification, introduce the concepts and show with specific examples potential options of microbiome-based stratifications. Finally, we propose a strategy for how microbiome-based stratification can be introduced to obtain improvements in dietary efficacy that can be implemented in real-life settings.     

Evidence on the effectiveness of occupational health interventions

BACKGROUND: At present there exists no overview of the range of evidence currently available regarding the effectiveness of occupational health interventions (OHI). METHODS: Articles published in 2000 and 2001 in 16 general and specialized biomedical journals were searched for evaluations of OHI studies. RESULTS: Out of 8,687 articles searched there were 148 OHI studies. In 21% of the studies the study design was a randomized controlled trial, in 28% it was a controlled trial, an interrupted time-series in 7% and a different design in 44%. The occupational health outcome was exposure in 27% of the studies, worker behavior in 12%, disease symptoms in 30%, disability or sickness absence in 24%, injuries in 4%, and quality of care in 3%. CONCLUSIONS: High quality evaluation studies are conducted in all areas of occupational health. However, it is clear that more are needed and the methodology used could be improved.     

Alternative accounting in maternal and infant global health

Efforts to augment accountability through the use of metrics, and especially randomised controlled trial or other statistical methods place an increased burden on small nongovernmental organisations (NGOs) doing global health. In this paper, we explore how one small NGO works to generate forms of accountability and evidence that may not conform to new metrics trends but nevertheless deserve attention and scrutiny for being effective, practical and reliable in the area of maternal and infant health. Through an analysis of one NGO and, in particular, its organisational and ethical principles for creating a network of safety for maternal and child health, we argue that alternative forms of (ac)counting like these might provide useful evidence of another kind of successful global health work.     

An overview of maternal and infant health services in rural America.

Economically disadvantaged rural families, like their urban counterparts, face significant difficulties obtaining adequate maternity and infant health care resulting, in part, from an unequal distribution of resources as well as economic and racial barriers to health care nationwide. Rural women and infants must contend with additional access problems that reflect the inherent constraints of rural existence as well as specific state policies that exacerbate the barriers associated with isolation. This article provides an overview of the availability and accessibility of maternal and infant health services in nonmetropolitan America and identifies policy reforms to improve access to care.     

Integration of social epidemiology and community-engaged interventions to improve health equity

The past quarter century has seen an explosion of concern about widening health inequities in the United States and worldwide. These inequities are central to the research mission in 2 arenas of public health: social epidemiology and community-engaged interventions. Yet only modest success has been achieved in eliminating health inequities. We advocate dialogue and reciprocal learning between researchers with these 2 perspectives to enhance emerging transdisciplinary language, support new approaches to identifying research questions, and apply integrated theories and methods. We recommend ways to promote transdisciplinary training, practice, and research through creative academic opportunities as well as new funding and structural mechanisms.     

Comparison of static and dynamic models of maternal immunization to prevent infant pertussis in Brazil

BackgroundThis paper compares cost-effectiveness results from two models of maternal immunization to prevent pertussis in infants in Brazil, one static, one dynamic, to explore when static models are adequate for public health decisions and when the extra effort required by dynamic models is worthwhile.MethodsWe defined two scenarios to explore key differences between static and dynamic models, herd immunity and time horizon. Scenario 1 evaluates the incremental cost/DALY of maternal acellular pertussis (aP) immunization as routine infant vaccination coverage ranges from low/moderate up to, and above, the threshold at which herd immunity begins to eliminate pertussis. Scenario 2 compares cost-effectiveness estimates over the models’ different time horizons. Maternal vaccine prices of $9.55/dose (base case) and $1/dose were evaluated.ResultsThe dynamic model shows that maternal immunization could be cost-saving as well as life-saving at low levels of infant vaccination coverage. When infant coverage reaches the threshold range (90–95%), it is expensive: the dynamic model estimates that maternal immunization costs $2 million/DALY at infant coverage > 95% and maternal vaccine price of $9.55/dose; at $1/dose, cost/DALY is $200,000. By contrast, the static model estimates costs/DALY only modestly higher at high than at low infant coverage. When the models’ estimates over their different time horizons are compared at infant coverage < 90–95%, their projections fall in the same range.ConclusionsStatic models may serve to explore an intervention’s cost-effectiveness against infectious disease: the direction and principal drivers of change were the same in both models. When, however, an intervention too small to have significant herd immunity effects itself, such as maternal aP immunization, takes place against a background of vaccination in the rest of the population, a dynamic model is crucial to accurate estimates of cost-effectiveness. This finding is particularly important in the context of widely varying routine infant vaccination rates globally.Clinical Trial registryClinical Trial registry name and registration number: Not applicable.