Social context of work injury among undocumented day laborers in San Francisco

OBJECTIVE

To identify ways in which undocumented day laborers' social context affects their risk for occupational injury, and to characterize the ways in which these workers' social context influences their experience of disability.

DESIGN

Qualitative study employing ethnographic techniques of participant-observation, supplemented by semistructured in-depth interviews.

SETTINGS

Street corners in San Francisco's Mission District, a homeless shelter, and a nonprofit day labor hiring hall.

PARTICIPANTS

Thirty-eight Mexican and Central American male day laborers, 11 of whom had been injured. PRIMARY THEMES: Anxiety over the potential for work injury is omnipresent for day laborers. They work in dangerous settings, and a variety of factors such as lack of training, inadequate safety equipment, and economic pressures further increase their risk for work injury. The day laborers are isolated from family and community support, living in a local context of homelessness, competition, and violence. Injuries tend to have severe emotional, social, and economic ramifications. Day laborers frequently perceive injury as a personal failure that threatens their masculinity and their status as patriarch of the family. Their shame and disappointment at failing to fulfill culturally defined masculine responsibilities leads to intense personal stress and can break family bonds. Despite the high incidence of work injuries and prevalence of work-related health conditions, day laborers are frequently reluctant to use health services due to anxiety regarding immigration status, communication barriers, and economic pressure.

IMPLICATIONS

On the basis of these ethnographic data, we recommend strategies to improve ambulatory care services to day laborers in 3 areas: structural changes in ambulatory care delivery, clinical interactions with individual day laborers, and policymaking around immigration and health care issues.

Drinking in adulthood: similarities and differences in effects of adult roles for Hispanic ethnic groups and Anglos

OBJECTIVE

This study examines whether the adult social roles perspective. an approach that explains drinking behaviors for Anglos, similarly affects alcohol use by Cubans, Mexican Americans, Puerto Ricans and Other Hispanics (Central and South Americans).

METHOD

The 1993 National Household Survey on Drug Abuse, a national probability sample of the household population in the United States, is used. The sample utilized here (N= 13,822; 56.2% female) consisted of 9,388 Anglos, 611 Cubans, 2,459 Mexican Americans, 611 Puerto Ricans and 753 Central/South Americans age 18 and older. The outcome measures include past-year drinking, and for drinkers, heavy drinking and alcohol-related problems. Logistic regression analyses are conducted using Stata.

RESULTS

The results show that there are some ethnic differences in the effects of the adult social roles. Of particular importance is the finding that being married has anomalous effects for Cubans (heavy drinking), Mexican Americans (problems) and Other Hispanics (problems) compared with Anglos and the other Hispanic ethnic groups.

CONCLUSIONS

The adult social roles perspective has some utility for explaining Hispanic drinking patterns. Future research should consider not only traditional predictors of drinking but also such socio-cultural factors as acculturation and familism, to better understand adult alcohol use by members of Hispanic ethnic groups.

Contributors to depression in Latino and European-American patients with type 2 diabetes

OBJECTIVE

To determine the independent and cumulative contributions of diabetes and other life stresses on depression and anxiety in Latino and European-American (EA) patients with diabetes.

RESEARCH DESIGN AND METHODS

A total of 75 Latino and 113 EA patients with type 2 diabetes, recruited from managed care settings, were assessed regarding three groups of potential stresses: demographics (age, sex, and education), disease status (functional impact, time since diagnosis, comorbidities, HbA(1c), and BMI), and family stress (financial stress, spouse conflict resolution, and family closeness). Dependent variables were depression (Center for Epidemiological Studies-Depression scale [CES-D]) and anxiety (Symptom Checklist [SCL-90]). Multiple regression equations assessed the independent contribution of each predictor on depression and anxiety.

RESULTS

For both ethnic groups, education, functional impact, and financial stress significantly and independently predicted depression; poor spouse conflict resolution was a fourth significant predictor for EA patients only. The equations accounted for a high percentage of variance (43- 55%). Excluding education, the same variables predicted anxiety for both ethnic groups. The disease status and family stress variable groups significantly predicted outcomes independently. The relationships among these variables and depression and anxiety generally occurred for all patients, not only for those classified as likely depressed.

CONCLUSIONS

The findings suggest the utility of considering many life stresses, not just diabetes alone, that combine to affect depression and anxiety. We suggest that these effects are experienced cumulatively as general psychological distress for all patients with diabetes, not just those classified as likely depressed. Taken together, the findings emphasize a life-centered, patient-focused approach to the treatment of depression, rather than an exclusive disease-related perspective.

Latino AIDS immigrants in the Western Gulf states: a different population and the need for innovative prevention strategies

Immigrant HIV infected Latinos, and those at highest risk for infection, demonstrate strikingly different patterns of risk behaviors and origins. This complicates the already complex acculturation process impacting their lives. By weaving together immigration and AIDS epidemiological patterns, the impact of tightening immigration policy, and masked sexual behaviors, the authors express concern for a lack of communication with, and lack of health care access for, Latinos in the Western Gulf Coast. To combat this deficit, health care and social workers need to be aware of different social, cultural, and behavioral contexts in Latino populations. Policy makers should support efforts to provide health care workers with skills through appropriate language and cultural sensitivity workshops. HIV prevention strategies specific to Latinos are also discussed.

Living conditions and emotional profiles of Cambodian, Central American, and Québécois youth

OBJECTIVE

To compare Cambodian and Central American adolescent refugees to Quebec with their Quebec-born peers in regard to emotional and behavioural problems, feelings of competence, and risk-behaviour profiles, and to examine relations between emotional variables and living conditions in the 3 groups.

METHOD

The sample consisted of 76 Cambodian, 82 Central American and 67 Québécois youth living in the Montreal area. The teenagers' internalization and externalization symptoms were assessed using the Child Behaviour Checklist (CBCL) and the Youth Self-Report (YSR); the YSR also provided a measure of their feelings of competence. Risk behaviour was reported by the teenagers. The socioeconomic status of the teenagers' households was taken into account in multiple regression analyses conducted for each group.

RESULTS

The level of emotional and behavioural problems reported by teenagers was lowest in Central Americans and highest in Québécois; the latter group also reported more risk behaviours than did either refugee group. The socioeconomic status of the Cambodian and Central American refugee households was lower than that of the Québécois. Living conditions were not a major determinant of emotional distress in young Cambodians, but low annual income was associated with internalizing symptoms among Central American youth. The most powerful predictor of externalizing symptoms among the Québécois youth was having a single-parent household.

CONCLUSION

This study underscores the contrast between the living conditions of young Cambodian and Central American refugees to Quebec and those of Quebec-born youth. These refugees' precarious socioeconomic status is not accompanied by an increase in adolescents' emotional and behavioural problems.

Prenatal risk factors among foreign-born Central American women: a comparative study

The purpose of this study was to compare the incidence of empirically established prenatal risk factors for low birthweight (LBW) outcomes among two groups of low-income mothers: foreign-born Central American women and nonimmigrant, non-Hispanic women. Two hundred ninety-six women who were part of a larger study of maternal role sufficiency were included in the present study: 127 Central American women and 169 nonimmigrant, non-Hispanic women who identified themselves as Black (n = 59) or White (n = 110). Data were collected by public health nurses (PHNs) during home visits and by research nurses in prenatal health department clinics. Comparisons were made between the two groups in areas of demographic characteristics, prenatal health behaviors, and prenatal stressful life-events. Foreign-born Central American mothers were found to be less educated, more likely to be living with their partners, less likely to engage in prenatal health risk behaviors, and less likely to identify stressors in their lives. The initiation of prenatal PHN services by the target group was similar to the comparison group. Their rate of LBW deliveries did not reflect the protective effect often attributed to foreign-born Hispanic mothers. Findings are discussed in light of the paradox of LBW and Hispanic heritage. Recommendations for practice, clinical research, and public policy are also addressed.

Social networks and cancer screening in four U.S. Hispanic groups

BACKGROUND

Evidence shows that social relationships play an important role in health and health behavior. We examined the relationship between social networks and cancer screening among four U.S. Hispanic groups.

METHODS

We used telephone surveys to collect data in eight U.S. regions that have concentrations of diverse Hispanic-origin populations. We interviewed 8903 Hispanic adults, for a response rate of 83%; analysis was restricted to the 2383 women aged > or =40. As a measure of social integration, we formed a social network index from items on the number of close relatives and friends, frequency of contact, and church membership. We used logistic regression to estimate the effects of social integration on screening, adjusting for sociodemographic factors.

RESULTS

Among Mexican, Cuban, and Central-American women, the effect of social integration on mammography screening was slight. The odds ratios (OR) per unit change in social integration category ranged from 1.16 to 1.22 with confidence intervals (CI) that overlapped with the null. For Pap smear screening, the effect was strongest among Mexican-American women (OR=1.44, 95% CI=1.21 to 1.72), but also evident among Central-American women (OR=1.22, 95% CI=0.72 to 2.06) and Cuban women (OR = 1.25, 95% CI = 0.81 to 1.93). Among Puerto Rican women, social integration had no effect on either mammography (OR=1.03) or Pap smear screening (OR=1.08).

CONCLUSIONS

Independent of socioeconomic factors, social integration appears to influence cancer screening participation of Hispanic women. The modest effect is not universal across Hispanic groups and was stronger for Pap smear than for mammography screening behavior. Researchers should recognize Hispanic group differences in social network characteristics and the potential of social networks to change screening behavior.

Psychosocial predictors of depression among Central American immigrants

The present study investigated the relationship between stress and depression associated with acculturation among Central American immigrants (64 women, 14 men) and identified the best predictors of depression among Central American immigrants. Elevated acculturative stress was significantly associated with higher depression. Family dysfunction, ineffective social support, lack of hopefulness toward the future, and low socioeconomic status were also significantly associated with high depression. The overall findings suggest that Central American immigrants who report high acculturative stress may be "at risk" for experiencing depression and that effective family and social support, hopefulness toward the future, and socioeconomic status may serve to protect against depression during acculturation.

Patient centeredness in medical encounters requiring an interpreter

PURPOSE

Patient-centered interviewing is associated with greater patient satisfaction and better medical outcomes than traditional encounters, but actively seeking patients' views of their illnesses and encouraging patients to express expectations, thoughts, and feelings is difficult in encounters that require an interpreter. We sought to examine physicians' use of the patient-centered approach with patients who required the assistance of an interpreter.

SUBJECTS AND METHODS

A cross-sectional sample of patients was videorecorded during visits with physicians at a multi-ethnic, university-affiliated, primary care clinic. Nineteen medical encounters of Spanish-speaking patients who required an interpreter and 19 matched English-speaking encounters were coded for frequency that patients mentioned symptoms, feelings, expectations, and thoughts (collectively called "offers"). Physicians' responses were coded as ignoring, closed, open, or facilitative of further discussion.

RESULTS

English-speaking patients made a mean (+/- SD) of 20 +/- 11 offers, compared with 7 +/- 4 for Spanish-speaking patients (P = 0.001). Spanish-speaking patients also were less likely to receive facilitation from their physicians and were more likely to have their comments ignored (P <0.005). English-speaking patients usually received an answer or acknowledgment to their questions even if the physicians did not encourage further discussion on the topic.

CONCLUSION

Spanish-speaking patients are at a double disadvantage in encounters with English-speaking physicians: these patients make fewer comments, and the ones they do make are more likely to be ignored. The communication difficulties may result in lower adherence rates and poorer medical outcomes among Spanish-speaking patients.

Psychosocial adjustment among Central American immigrants with disabilities: an exploratory study

This is an exploratory study that investigated factors influencing the psychosocial adjustment of Central American immigrants with disabilities. The relationships between stress, and perception of disability severity and (a) depression and (b) anxiety were assessed. Furthermore, this study investigated whether social support moderated the impact of stress and severity of disability on depression and anxiety. Stress, severity of disability, and social support explained a high percentage (54%) of the variance in depression. High levels of stress, increased perceptions of severity of disability, and low social support were associated with increased depression. The interactions between support and stress and between support and disability severity did not significantly add to the original model which predicted depression. Main effects were found for stress, disability severity, and the interaction between support and disability severity. Stress and social support significantly accounted for 31% of the variance in anxiety. Increased stress and decreased social support were associated with greater levels of anxiety. The interaction between support and stress did not significantly predict anxiety. Implications of the study in terms of future research and intervention programs targeting mental health outcomes for Latino immigrants with disabilities are discussed.

Elevated blood lead levels among internationally adopted children--United States, 1998

Lead poisoning has been reported recently among Chinese children adopted by U.S. citizens. However, little is known about the prevalence of elevated blood lead levels (BLLs) among adoptees from China and other countries. Persistent sources of lead exposure outside the United States include leaded gasoline exhaust; industrial emissions; cottage industries (e.g., battery breaking and recycling plants); traditional medicines; and some cosmetics, ceramic ware, and foods. In 1998, approximately 15,000 orphans from countries outside the United States who were adopted abroad or were to be adopted in the United States by U.S. citizens were issued U.S. immigrant visas-a nearly two-fold increase over 1988 (L. Lewis, Immigrant and Visa Control and Reporting Division, VISA Office, Bureau of Consular Affairs, U.S. State Department, personal communication, August 1999). Some orphans have been abandoned for extended periods and have no obtainable medical history. Immigrants aged <15 years are not required to have serologic or blood tests either in their country of origin or on entry into the United States unless exposure to syphilis or human immunodeficiency virus is suspected. To obtain reports on the prevalence of elevated BLLs (> or =10 microg/dL) among international adoptees, CDC contacted 12 international adoption medical specialists identified through the Joint Council on International Children's Services and two collaborating medical specialists. This report summarizes the results of that investigation, which suggest that international adoptees may arrive in the United States with elevated BLLs.

Acculturative stress, depression, and suicidal ideation among Central American immigrants

No previous studies have examined suicide risk among Central American immigrants. The present study explored the relationship between acculturative stress, depression, and suicidal ideation among Central American immigrants. Also examined were variables that predict depression and suicidal ideation. Elevated levels of acculturative stress were significantly correlated with high levels of depression and suicidal ideation. Family dysfunction, ineffective social support, nonpositive expectations concerning the future, low levels of religiosity, low levels of education and income, and lack of agreement with the decision to immigrate were significantly associated with high levels of depression and suicidal ideation. The overall findings suggest that Central American immigrants who experience elevated levels of acculturative stress may be at risk for experiencing heightened levels of depression and suicidal ideation. The findings highlight the importance of using culturally relevant clinical methods when assessing and treating depressed and potentially suicidal acculturating individuals.

Infestations and chronic infections in foreign pediatric patients with burns: is there a role for specific protocols?

Infestations by parasites such as Mycobacterium tuberculosis and other viral infections are common in third world countries. Consequently, the admission of a significant number of foreign patients to burn centers in the United States may pose new problems, not only for inpatients but also for health care workers. To document infestations in patients from third world countries and to determine the need for specific protocols, we studied 62 consecutive foreign patients admitted to our pediatric burn reconstruction service between July 1997 and December 1998. All patients were evaluated with chest X-ray, hemogram with differential count, clinical and laboratory nutritional assessment, and skin test for tuberculosis, and stool samples were evaluated for ova and parasites. No pathologic findings were seen on chest radiographs. Only 1 patient had a positive skin test for tuberculosis, as a result of previous bacille Calmette-Guérin vaccine. Yet, 10 patients (16%) had positive stool cultures for ova and parasites that contained 29 isolates. The most frequently identified organism was Blastocystis hominis. All amoebas identified were nonpathogenic according to Centers for Disease Control criteria. Ascaris lumbricoides and 1 case of cysticercosis were found. None of the patients with parasites had clinical manifestations of parasitosis or chronic infections. However, parasite infestations had a positive correlation with eosinophilia, altered nutritional status, and altered mean corpuscular hemoglobin concentration, as defined by multiple linear regression. Although foreign patients admitted to burn centers from third world countries have a low rate of infestations, patients at risk can be identified by laboratory findings and studies of nutritional status. Simple hand washing prevents the spread of disease and protects health providers.

The impact of cultural and familial context on behavioral and emotional problems of preschool Latino children

This study examined the impact of financial, cultural, and family variables on the incidence of behavioral and emotional problems in a group of two- and three-year-old Latino children. The vulnerability of these children to mental health problems stems from the many challenges faced by their families, especially those associated with acculturation and poverty. Results indicate that most problems experienced by the children were related to depression and social withdrawal. Children were at greatest risk whose parents had immigrated from Central America, whose families relied more extensively on internal coping strategies such as passive resignation, and whose parents were dissatisfied with their family's interactions.

Immigration and tuberculosis among children on the United States-Mexico border, County of San Diego, California

OBJECTIVE

To identify factors contributing to a 400% increase in tuberculosis among children in San Diego County, California, from 1985 to 1993.

DESIGN

Review of medical records of reported cases in 1989, 1991, and 1993 and their source case.

RESULTS

Of 192 children with tuberculosis, the largest increase was observed in children younger than 5 years old, of whom 77.4% were born in the United States, 67.8% had a foreign-born parent, 73.1% came from a non-English-speaking household, and 46.2% were known to visit Mexico. Of 28 source cases, 82.1% were born outside the United States, primarily in Mexico (67.9%). Resistance to at least one first-line antituberculous drug was identified in 27.5% of isolates from children and in 33.3% of isolates from source cases.

CONCLUSIONS

The increase in tuberculosis and high level of drug-resistance among children born in the United States may be attributed to transmission outside of the United States or within the United States from household contacts born in countries in which tuberculosis is highly endemic.

The public health care of Central Americans in Houston

In recent years, Americans have witnessed a marked change in the source of immigrant groups. Current immigrants are more likely to be former residents of the less developed world (nations such as Guatemala, Nigeria, India, and Viet Nam) than were earlier immigrants. In urban Texas, the influx of peoples from Central America is particularly striking and is largely a consequence of homeland political and economic instability. The new immigrants tend to be young and sexually active. We analyzed utilization patterns of Central Americans at our district health care facilities over 18 months and compared results with those of our non-Central American health care recipients. The 30,000 annual visits by Central Americans accounted for 4% of all visits. Disproportionately large amounts of care were given for sexually transmitted diseases and obstetric problems; conversely, small amounts were given for chronic illnesses, infectious diseases, acquired immunodeficiency syndrome, mental health problems, and adverse fetal outcomes. Few exotic tropical diseases were recognized or treated.

Impact of maternal nativity on the prevalence of diabetes during pregnancy among U.S. ethnic groups

OBJECTIVE

This study examines the impact of maternal nativity (birthplace) on the overall prevalence of diabetes during pregnancy and among 15 racial and ethnic groups in the U.S.

RESEARCH DESIGN AND METHODS

Birth certificate data for all resident single live births in the U.S. from 1994 to 1996 were used to calculate reported diabetes prevalence during pregnancy and to assess the impact of maternal birthplace outside of the 50 states and Washington, DC, on the risk of diabetes before and after adjustment for differences in maternal age, other sociodemographic characteristics, and late or no initiation of prenatal care overall and for each racial and ethnic group.

RESULTS

Mothers born outside of the U.S. are significantly more likely to have diabetes during pregnancy. The impact of maternal nativity on diabetes prevalence is largely explained by the older childbearing age of immigrant mothers. However, adjusted diabetes risk remains elevated for Asian-Indian, non-Hispanic black, Filipino, Puerto Rican, and Central and South American mothers who were born outside the U.S. Conversely, birthplace outside the U.S. significantly reduces diabetes risk for Japanese, Mexican, and Native American women.

CONCLUSIONS

Identification, treatment, and follow-up of immigrant mothers with diabetes during pregnancy may require special attention to language and sociocultural barriers to effective care. Systematic surveillance of the prevalence and impact of diabetes during pregnancy for immigrant and nonimmigrant women, particularly in racial and ethnic minority groups, and more detailed studies on the impact of acculturation on diabetes may increase understanding of the epidemiology of diabetes during pregnancy in our increasingly diverse society.

Elevated maternal age-specific rates of Down syndrome liveborn offspring of women of Mexican and Central American origin in California

BACKGROUND

Maternal age-specific rates of Down syndrome livebirths are widely utilized in personal and policy decisions concerning provision of and election of prenatal cytogenetic diagnostic services. The only extensive reference data available are on those of primarily European ancestral origin. In the absence of definitive evidence of any ethnic, racial or environmental influence upon rates (other than those associated with age) these rate schedules have been widely applied to those of all national origins.

METHODS

Available material age-specific data on livebirths from intensive studies on those of Hispanic (primarily of Mexican and Central American background) and of other origin in populations in the U.S.A. with likely complete ascertainment were analysed. The numbers observed were compared with (i) those predicted from established published rate schedules in those of primarily European origin, and (ii) with the observations on livebirths of non-Hispanic European origin in the same population as the Hispanic live births.

RESULTS

In comparisons with the numbers predicted from published rates, observed numbers of case among Hispanic live births were increased by 19 per cent (SE 0.06) in younger mothers, 23 per cent in older mothers (SE 0.07) and 20 per cent (SE 0.04) in those of all ages. Comparisons with observed rates in those of Hispanic origin with those observed in non-Hispanic births in the same time intervals and populations indicated that the excess rates in Hispanics were not attributable to some local factor increasing rates in all ethnic groups at least among those under 35.

CONCLUSIONS

Data on mothers of Mexican and Central American origin residing in the U.S.A. indicate maternal age-specific rates of Down syndrome in live births about 20 per cent greater than those in published rate schedules on Down syndrome, widely used in decisions concerning election or provison of prenatal diagnostic services. The reason for this difference remains unknown.

A study of tuberculosis among foreign-born Hispanic persons in the U.S. States bordering Mexico

In 1996, 10% of the 20,973 U.S. tuberculosis (TB) cases were among foreign-born (FB) Hispanic persons, with the four states bordering Mexico accounting for 83% of FBH cases. Limited information is available on this population's health care seeking and migration practices and on differences between FB Hispanic patients in border and nonborder areas. Therefore, we conducted interviews and record reviews for all consenting FB Hispanic TB patients from eight counties bordering Mexico (BC; n = 167) and seven urban nonborder counties (NBC; n = 158) in these States during 1995-1997. BC patients had resided in the U.S. longer than NBC patients (17.4 versus 10.8 yr; p < 0.01), had immigrated more often from Mexican border communities (62.4% versus 25.4%; p < 0.01), and had returned to Mexico more often in the past 12 mo (71.5% versus 47.3%; p < 0. 01). TB symptoms were present for >/= 6 mo in 37% of BC and 34% of NBC patients. Binational collaboration is essential for improving TB control in both countries and should extend beyond border areas of Mexico.

Correlates of alcohol and drug use among low-income Hispanic immigrant childbearing women living in the USA

Alcohol and drug use is a widespread and serious problem with deleterious consequences for the health and well-being of childbearing-age women and their children. Little information exists regarding etiological factors for substance use among Hispanic childbearing-age women immigrating to the United States (USA). This research provides a correlational analysis of factors associated with alcohol and drug use. The Social Stress Model for Substance Use Prevention provided the conceptual framework for this cross-sectional, interview-administered survey of 60 low-income predominantly Mexican-American women. The outcome variable was alcohol and drug use (alcohol, cigarettes, marijuana, cocaine and opiates). Independent variables included the major constructs of the model: stress, social support, social influences, personal competencies and community resource utilization patterns. Findings suggested that the levels of drug use were lower among this study sample than in the general USA population regardless of pregnancy status. Bivariate correlations demonstrate that women with higher drug use indices had more lenient attitudes regarding drug use and were more likely to have family and friends that used alcohol and drugs. Although drug use was relatively low among this sample of women, both women who used alcohol themselves and women whose partners used alcohol and drugs reported significantly higher levels of stress, weaker social support and poorer levels of self esteem. Implications for practice and future research are suggested.

Caries conditions among 2-5-year-old immigrant Latino children related to parents' oral health knowledge, opinions and practices

OBJECTIVES

To collect baseline data prior to initiating a community-based, oral health promotion program in an inner city Latino community in Washington DC, populated by Central American immigrants.

METHODS

In 1995, an oral survey of a convenience sample of children 2-5 years of age (n = 142) and a survey of the knowledge, opinions and practices (KOP) of their parents (n = 121) were completed. Clinical data of children were matched with parent respondents of the KOP survey. Data were analyzed for statistical associations using univariate odds ratios, Fisher's exact tests, and multiple logistic regression.

RESULTS

Only 53% of the children were caries free. Eighteen percent of all children were in need of immediate dental care and 26% were in need of early or non-urgent dental care. Only 7% of the parents knew the purpose of sealants and 52% knew the purpose of fluorides. Further, only 9% thought that brushing with toothpaste can prevent tooth decay The strongest predictors of dental caries in this population, after adjusting for child's age and mother's education, were recency of mother's residence in the United States and report of an uncooperative child when attempting toothbrushing.

CONCLUSIONS

Regimens of caries prevention have been successful in reducing dental decay for a large segment of the US population, yet this disease remains prevalent especially among low socioeconomic groups. The oral health status of the children and the oral health KOP of the parents in this community are disturbingly deficient.