The household management of childhood diarrhea in rural north India

An in-depth anthropological study of child diarrhea in 3 villages in rural North India investigated the variation in the household management of child diarrhea. Qualitative and quantitative methodologies were used to collect data on a series of variables, including maternal knowledge, beliefs, and practices during diarrhea, feeding and fluid intake during diarrhea, treatment choices, and knowledge and use of oral rehydration therapy (ORT). The results showed both positive and negative diarrhea management behaviors. Almost all mothers continued to breastfeed normally, and did not decrease fluids during diarrhea. A shift in the child's diet toward 'softer' and 'cooler' foods rather than the withholding of food was the norm. The use of anti-diarrheals was widespread. Acceptance and sustained use of ORT was found to be inversely related to an understanding of the function of ORT. Eighty-one percent of mothers who had previously used ORT but who do not plan to use it again were dissatisfied because it 'did not stop the diarrhea'. These mothers thought that ORT was a medicine that would cure the diarrhea. Therefore, in ORT interventions there is a need to explain that the function of ORT is to replace lost fluids, and not to stop the diarrhea. Anthropological research of household diarrhea management can provide important information that will result in improved intervention design. Messages that are meant to change behavior must be based upon the target group's perception.     

The evolution of health administration education for public health: responding to a changing environment

Health administration education in schools of public health has undergone a steady but remarkable evolution over the last five decades. What was once taught was simply an enumeration of statutory requirements and programs managed by public health agencies. This changed dramatically in the 1960s with the incorporation of both theoretical concepts and skills from the fields of public administration and business administration. In the 1990s, the differentiation between training required for public health administration and for health services administration has become increasingly blurred as institutional responsibility for the health of defined populations has necessitated the adoption of the community epidemiology perspective, long the centerpiece of public health programs, by all health services administration programs. The future challenge for programs located in schools of public health is to identify the unique characteristics of public health practice and to prepare graduates to assure that core public health functions are met adequately in the communities in which they will serve.     

Women's health and the environment: innovations in science and policy

Current scientific findings indicate that environmental factors affect women's health. Specifically, evidence has accumulated on the effects of the environment on reproductive health, cancer, injury, respiratory problems, autoimmune diseases, and other health problems. To review the current state of the science and policies related to women's health and the environment, the Federal Interagency Working Group on Women's Health and the Environment of the Department of Health and Human Services and the Society for Women's Health Research jointly sponsored a conference in 1998 entitled Women's Health and the Environment: Innovations in Science and Policy. The aim of the conference was to provide a forum for scientists to share recent findings, promising avenues of research, methodological barriers, and data gaps about women's susceptibility to environmental agents. The conference generated 22 recommendations for policy, 17 recommendations for communication and training, and 48 recommendations for research to be considered by the federal government. The purpose of this review is to bring to the attention of the scientific community and policymakers the breadth of the women's health implications associated with environmental factors by highlighting key research findings presented at the conference. This review summarizes the current status of science in women's health, it describes relevant activities by the federal government, and it suggests recommendations for future research and policy initiatives in the context of women's health and the environment.     

Mothers' concepts of childhood diarrhea in rural Pakistan: what ORT program planners should know

Diarrhea is the leading cause of infant and child death in Pakistan. Appropriately, the development of oral rehydration therapy (ORT) programs has become a major priority of the Pakistan Ministry of Health and of international funding agencies. Paradoxically, however, there is virtually no published anthropological literature on diarrhea-related traditional health beliefs and practices among the rural and illiterate people who make up 90% of the nation's population. The study reported on here focuses on these matters and suggests important implications for the multimillion-dollar ORT programs currently being launched. Mothers' ethnomedical models of diarrheal disease and concepts of appropriate treatment are discussed, as are practical problems relating to the effective implementation of ORT in such a setting. The results underline the need for anthropological studies as an adjunct to health interventions involving behavioral modification.     

Innovation in health policy: responding to the health society

The 21st century health society is characterized by 2 major social processes: the expansion of the territory of health and the expansion of the reflexivity of health. The boundaries of what we call the are becoming increasingly fluid and health has become integral to how we live our everyday life. Health itself has become a major economic and social driving force in society. This shifts the pressure for policy innovation from a focus on the existing health system to a reorganization of how we approach health in 21st century societies. The dynamics of the health society challenge the way we conceptualize and locate health in the policy arena, the mechanisms through which we conduct health policy and they redefine who should be involved in the policy process. This concern is beginning to be addressed within government through joined up government approaches, beyond government through making health everybody's business and beyond nation states as a new interface between domestic and foreign policy.     

Women's childhood and adult adverse experiences,mental health,and binge drinking: The California Women's Health Survey

Background  

This study examined sociodemographic, physical and mental health, and adult and childhood adverse experiences associated with binge drinking in a representative sample of women in the State of California.     

Assessing management training needs: a study in the Punjab health services,Pakistan

Pakistan's public sector is organized in a federal system with many management and planning functions devolved to the 4 provincial governments. Provincial health secretariats lead on most policy and planning decisions for health services. The provinces employ health personnel, although the national Public Service Commission controls some key aspects of human resources management. Reporting the findings of a training needs assessment (TNA) for health personnel in the provincial health services of Punjab, the authors show how TNA can be used systematically to improve the quality of health professional training. They also discuss the extent to which better training could contribute to improved health management capacity in Pakistan, and describe the context and problems of Pakistan's health services, focusing upon management capacity, and the methods and results of a training needs assessment conducted to address the problems. A final section covers the usefulness of the TNA method in Pakistan and its applicability to other countries. Moreover, the implications of decentralization and the problems of preparing training plans in the absence of decentralized structures are discussed.     

Targeted doctors,missing patients: Obstetric health services and sectarian conflict in Northern Pakistan

The spectre of exclusionary medical service provision, restricted clinic access and physician targeting in sectarian-divided Iraq underscores the crucial and timely need for qualitative research into the inter-relationship between conflict, identity and health. In response, this paper provides a critical ethnography of obstetric service provision and patient access during Shia-Sunni hostilities in Gilgit Town, capital of Pakistan's Northern Areas (2005). I analyse how services were embedded in and constrained by sectarian affiliation in ways that detrimentally impacted Sunni women patients and hospital staff, resulting in profoundly diminished clinic access, reduced physician coverage and a higher observed incidence of maternal morbidity and mortality. The paper first situates obstetric medicine at the interstices of contested sectarian terrain and competing historical projects of sectarian identity. Gilgiti Sunnis' high clinical reliance is argued to be a response to and consequence of, inter-sectarian dissonance and the ascendance of biomedicine during three decades of regional development. In 2005, conflict-incurred service deprivations and the enactment and strategic use of sectarian identity in clinical settings were associated with differential treatment and patient-perceived adverse health outcomes, leading Sunnis to generate alternative sect-specific health services. Obstetric morbidity and mortality during sectarian conflict are analyzed as distinctive manifestations of the wide range of direct harms routinely associated with violence and political strife.     

Diet supplemented with MCT oil in the management of childhood diarrhea

This study was undertaken to determine the effect of medium-chain triglyceride (MCT) oil supplementation on the duration and episodes of diarrhea attacks, and specifically its effect on the clinical manifestations of patients. Seventeen children aged 6 months to 47 months old with a mean age of 19.6 months, suffering from acute diarrhea at the Pediatric Ward of the Philippine General Hospital Medical Center and other neighboring health centers were studied. A double-blind randomized design was employed. Physical and clinical assessment was performed by a physician prior to enrolment in the study. Dietary, anthropometric, and biochemical assessment were undertaken by clinical investigators before and after the supplementation. The subjects were randomly assigned to either the MCT oil- supplemented diet or the non-MCT oil diet. Daily monitoring of food intake and the frequency or episodes of diarrhea attacks was done. Subjects were closely monitored for any possible adverse reactions. The baseline characteristics of the subjects were not significantly different for any of age, height, weight, cholesterol or triglyceride concentrations between the two groups. Nutrient intakes at baseline and during intervention were also not significantly different. There were no differences in cholesterol and triglyceride between the two groups after supplementation. Stool frequencies of the MCT group and the non-MCT group at baseline, after the 6th hr, and at 12th hour, were not different. No subject developed fat malabsorption during the intervention, as assessed with Sudan Black stain. There was statistical significant difference in the rate of weight gain among subjects in the MCT group compared to subjects in the non-MCT group , but a trend in this direction (0.22 + 0.22 kg/day vs -.048 + .26 kg/day), (p=.042). MCT oil may promote weight gain (although what this constitutes in body compositional terms is uncertain) and shows a trend towards shorter duration of intervention among children with acute diarrhea. Limited sample size precludes conclusions on these possibilities. MCT oil did not cause vomiting, dehydration, or fat intolerance. MCT oil did not cause an elevation in cholesterol and triglyceride levels. More studies, with larger sample size, and longer duration will be worthwhile to assess the effect of MCT oil on childhood diarrhea.     

Medicines and the maintenance of ordinariness in the household management of childhood asthma

This paper applies and extends the 'adaption' perspective on chronic illness by arguing that, in the case of moderate child-hood asthma, an important aspect of the process may be found in the ways in which children and parents construct a sense of their ordinariness. It is suggested that medicines may play a role in this process. Reporting an intensive and detailed qualitative study of the management strategies of nine English families, it is shown that household members did not generally regard asthma as a major problem. Regular medication, usually in the form of inhaled drugs, was their main response. Few other strategies were followed and little attention was paid to the non-medicinal preventive actions recommended in asthma management guidelines and educational material. Parents' and children's accounts suggest that they were involved not only in managing a disease but also in maintaining a sense of their own ordinariness. Paradoxically, medicines, especially inhalers, were the main resource for accomplishing this goal because they supported the ordinariness of the child and the family far more readily than other preventive measures.     

Use of satellite imagery in constructing a household GIS database for health studies in Karachi,Pakistan

Background  

Household-level geographic information systems (GIS) database are usually constructed using the geographic positioning system (GPS). In some research settings, GPS receivers may fail to capture accurate readings due to structural barriers such as tall buildings. We faced this problem when constructing a household GIS database for research sites in Karachi, Pakistan because the sites are comprised of congested groups of multi-storied building and narrow lanes. In order to overcome this problem, we used high resolution satellite imagery (IKONOS) to extract relevant geographic information.     

The cost of treatment for child pneumonias and meningitis in the Northern Areas of Pakistan

Pneumonia, meningitis, and sepsis place a significant economic burden on health care systems, particularly in developing countries. This study estimates treatment costs for these diseases in health facilities in the Northern Areas of Pakistan. Health facility resources are organized by categories--including salaries, capital costs, utilities, overhead, maintenance and supplies--and quantified using activity-based costing (ABC) techniques. The average cost of treatment for an outpatient case of child pneumonia is dollar 13.44. For hospitalized care, the health system spent an average of dollar 71 per episode for pneumonia, dollar 235 for severe pneumonia, and dollar 2,043 for meningitis. These costs provide important background information for the potential introduction of the conjugate Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae vaccines in Pakistan.     

The relationship between household income and childhood respiratory health in the United Kingdom

Growing empirical evidence on the association between household income and adverse child health outcomes has generated mixed results with some North-American studies showing a significant inverse relationship and some British studies identifying a much weaker association. We use data from the rich UK Millennium Cohort Study (MCS) dataset and check the robustness of these recent findings by focusing on the impact of household income on adverse childhood respiratory outcomes (i.e. asthma and wheezing). We also identify pathways, such as mother's child-health-related behaviours, parental health and grandparental socioeconomic status, through which income might influence child health. Our econometric strategy is to use, both in a cross-sectional and in a panel data context, detailed information in the MCS dataset to directly account for as many potential confounding factors as possible that might bias the income-child health nexus. Overall our results show that household income has a weak direct effect on child health after we control for potential mechanisms that mediate the income-child health association. We argue that our evidence should inform government health and broader fiscal policies aimed at reducing health inequalities in childhood.     

Finding synergies among food,health, care and environment as determinants of malnutrition in Pakistan

Aim

Pakistan has one of the highest proportions of stunted children in the world, and the prevalence of stunting has been quite persistent over the years. This study aims to identify the factors behind the persistent prevalence of under-5 stunting in Pakistan, focusing on a child’s access to food, health, care, and environment and the synergies among them.

Subjects and methods

This study uses the country-representative data from the Demographic and Health Survey (2012–2013) for Pakistan. The estimations of the econometric models are carried out using ordinary least squares in STATA software.

Results

Systematic synergies are found for the combination of food and environment when the sample is split into B40 (bottom 40%) and T60 (top 60%) wealth categories. For urban households, “food and environment” has a positive and significant coefficient under both definitions, showing the presence of synergies among food and environment sectors, as coefficients of their individual effects are insignificant. Under definition 2, synergies are also found for urban households in “care, environment and health”. Under definition 1, the four-way interaction is significant for rural areas and at 3.5 it is significantly higher than the sum of the individual components, i.e., 2.3.

Conclusions

We can conclude from the results that simultaneous improvements in multiple sectors are likely to have a much stronger impact on height-for-age than improvements in individual components. Therefore, the interventions aiming at stunting reduction should target multiple sectors instead of isolated interventions targeting one of the components. In particular, the results show that interventions aiming at stunting reduction should simultaneously consider access to adequate food and the environment, even if the primary sector of intervention is related to care or health.

     

Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review

Background

Current WHO guidelines on the management and treatment of diarrhea in children strongly recommend continued feeding alongside the administration of oral rehydration solution and zinc therapy, but there remains some debate regarding the optimal diet or dietary ingredients for feeding children with diarrhea.

Methods

We conducted a systematic search for all published randomized controlled trials evaluating food-based interventions among children under five years old with diarrhea in low- and middle-income countries. We classified 29 eligible studies into one or more comparisons: reduced versus regular lactose liquid feeds, lactose-free versus lactose-containing liquid feeds, lactose-free liquid feeds versus lactose-containing mixed diets, and commercial/specialized ingredients versus home-available ingredients. We used all available outcome data to conduct random-effects meta-analyses to estimate the average effect of each intervention on diarrhea duration, stool output, weight gain and treatment failure risk for studies on acute and persistent diarrhea separately.

Results

Evidence of low-to-moderate quality suggests that among children with acute diarrhea, diluting or fermenting lactose-containing liquid feeds does not affect any outcome when compared with an ordinary lactose-containing liquid feeds. In contrast, moderate quality evidence suggests that lactose-free liquid feeds reduce duration and the risk of treatment failure compared to lactose-containing liquid feeds in acute diarrhea. Only limited evidence of low quality was available to assess either of these two approaches in persistent diarrhea, or to assess lactose-free liquid feeds compared to lactose-containing mixed diets in either acute or persistent diarrhea. For commercially prepared or specialized ingredients compared to home-available ingredients, we found low-to-moderate quality evidence of no effect on any outcome in either acute or persistent diarrhea, though when we restricted these analyses to studies where both intervention and control diets were lactose-free, weight gain in children with acute diarrhea was shown to be greater among those fed with a home-available diet.

Conclusions

Among children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.

     

Lowering the barriers to consumer-directed health care: responding to concerns

Consumer-directed health care is a potentially promising tool for moving toward more efficient use of health care resources. Tax policy has long been biased against health plans with significant patient cost sharing. Tax advantages created by health savings accounts (HSAs) began to change that, and proposed tax reforms could go even further. We assess various critiques of these plans, focusing on why they benefit not just the healthy and wealthy. Lower costs and more efficient health spending would help all patients and reduce uninsurance. Potential negative distributional effects are important but can be remedied more efficiently without distorting insurance design.     

Women's health, men's health, and gender and health: implications of intersectionality

Although intersectionality is now recognized in the context of women's health, men's health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each field to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the field of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging benefits of de-centering gender through intersectional analyses.