Infant mortality in Sri Lankan households: a causal model

Community intervention for cardiovascular disease risk factors in Kalutara, Sri Lanka

BACKGROUND

The effectiveness of a 2015-17 community intervention to reduce cardiovascular disease (CVD) and type 2 diabetes (T2DM) risk factors is assessed in a Sri Lanka adult population, using a before-and-after study design.

METHODS

Four contiguous Public Health Midwife (PHM) areas in Kalutara district (Western Province) were exposed to a Sri Lankan designed community health promotion initiatives (without screening) to lower CVD and T2DM risk factors. Pre- and post-intervention surveys (2014, n=1,019; 2017, n=908) were of 25-64 year males (M) and females (F) from dissimilar randomly selected clusters (villages or settlements) from PHMs, with probability of selection proportional to population size, followed by household sampling, then individual selection to yield equal-probability samples. Differences in resting blood pressure (BP), fasting plasma glucose (FPG), total cholesterol, body mass index and tobacco smoking, adjusting for cluster sampling, age and socio-economic differences, were examined.

RESULTS

Hypertension prevalence declined from 25% to 16% (F) (p<.0001), and 21% to 17% (M). Both mean systolic and diastolic BP declined. T2DM declined from 18% to 13% (F), and 18% to 15% (M), as did mean fasting plasma glucose. Elevated total cholesterol declined from 21% to 15% in women (p=0.003) and mean cholesterol declined. Frequency distributions, medians and means of these continuous CVD risk factors shifted to lower levels, and were mostly statistically significant (p< 0.05).

CONCLUSIONS

Community health promotion can lower key CVD and T2DM risk factors. Lowering tobacco consumption in males and obesity remain challenges in Sri Lanka.

The effect of poverty, social inequity, and maternal education on infant mortality in Nicaragua, 1988-1993

OBJECTIVES

This study assessed the effect of poverty and social inequity on infant mortality risks in Nicaragua from 1988 to 1993 and the preventive role of maternal education.

METHODS

A cohort analysis of infant survival, based on reproductive histories of a representative sample of 10,867 women aged 15 to 49 years in León, Nicaragua, was conducted. A total of 7073 infants were studied; 342 deaths occurred during 6394 infant-years of follow-up. Outcome measures were infant mortality rate (IMR) and relative mortality risks for different groups.

RESULTS

IMR was 50 per 1000 live births. Poverty, expressed as unsatisfied basic needs (UBN) of the household, increased the risk of infant death (adjusted relative risk [RR] = 1.49; 95% confidence interval [CI] = 1.15, 1.92). Social inequity, expressed as the contrast between the household UBN and the predominant UBN of the neighborhood, further increased the risk (adjusted RR = 1.74; 95% CI = 1.12, 2.71). A protective effect of the mother's educational level was seen only in poor households.

CONCLUSIONS

Apart from absolute level of poverty, social inequity may be an independent risk factor for infant mortality in a low-income country. In poor households, female education may contribute to preventing infant mortality.

Relação entre saúde e saneamento na perspectiva do desenvolvimento

Discute-se a relação entre saúde e saneamento, situando-a no contexto do processo de desenvolvimento social. É defendida inicialmente a inserção dessa relação no atual enfoque saúde e ambiente, reconhecendo que esta nova área não elimina a pertinência da abordagem saúde-saneamento, na verdade sua precursora. Apresenta-se a conceituação de saneamento e sua atual situação no país, além dos marcos conceituais da relação saúde-saneamento. Indicadores de desenvolvimento dos países, enfatizando os brasileiros, são confrontados com indicadores sanitários, mostrando-se que, para o grau de desenvolvimento econômico e a cobertura por serviços de saneamento no Brasil, melhor desempenho dos indicadores de saúde seria esperado. Avaliam-se as assertivas que podem ser extraídas dos estudos epidemiológicos desenvolvidos na área de saneamento e, por fim, discutem-se as perspectivas que se apresentam no campo da relação saúde-saneamento.

A causal model of high rates of child mortality

The distribution of child mortality has often been misunderstood because of insufficient attention to its context. High rates of child mortality in developing countries have variously been attributed to child neglect, cultural traditions of child care, population pressure, low maternal educational levels, lack of medical care, and insufficient basic resources. The model proposed in this article organizes factors leading to high child mortality rates onto three tiers to contextualize the medical causes of death and the debate over traditions of child care. The proximate tier includes the immediate biomedical conditions that result in death, typically involving interactions of malnutrition and infection. The intermediate tier includes child care practices and other behavior that increase the exposure of children to causes of death on the proximate tier. The ultimate tier encompasses the broad social, economic, and cultural processes and structures that lead to the differential distribution of basic necessities, especially food, shelter, and sanitation. The ultimate tier thus forms the context of causes located on the other tiers. Research from rural Mexico, Central America, and Africa supports various parts of the model, particularly concerning traditional parental behavior, which has often been interpreted as child neglect but appears in many cases to result ultimately from economic scarcity. Links from tier to tier in the model especially warrant further attention from both researchers and policy makers.

Early child health in Lahore, Pakistan: III. Maternal and family situation

The family situation for mothers, in three areas differing in degree of urbanization and an upper middle class control group, in Lahore, Pakistan was described. Area differences in socio-economic, family composition, and housing and sanitary conditions were investigated. Data from a longitudinal sample (n = 1476 newborns) were compared with data from a cross-sectional population survey (n = 2998 families). Risk factors for child mortality and morbidity were common in the village and periurban slum area; conditions were somewhat better in the urban slum community. The sample was concluded to be representative of the population in the three areas and also for Pakistan in general. Two indices for cross-study comparisons were proposed, one for socio-economic background and the other for housing standard. The two indices were shown to be related to maternal weight for height at 9 months of pregnancy in the urban slum area; the socio-economic level was also functionally related to the weight for height measure in the village. The lower socio-economic and housing standard level, the lower was the mothers' relative weight just before childbirth. The findings were discussed in terms of risk factors for infant mortality, morbidity and psychological development.

Early child health in Lahore, Pakistan: X. Mortality

Mortality during the first two years of life among 1476 Pakistani infants born between September 1984 and March 1987 is described according to age, causes of death, area of living, season of the year and sex. The mortality rate (deaths under two years/1000 live births) projected over the whole population of Pakistan was 127 and under one year 114. During the first two years of life, the mortality rate was 133/1000 in the village, 159 in the periurban slum, 107 in the urban slum and 17 in the upper middle class group. In the latter group all deaths had occurred within 72 hours after birth. The overall major causes of death were acute and prolonged diarrhoea (36%), asphyxia neonatorum (13%), respiratory infections (13%), septicaemia (11%) and tetanus (9%). A clear age dependency was noted with 14% of deaths occurring during the first 24 hours of life (asphyxia neonatorum in 86%), and 57% dying within the first 28 days of life. In the later age groups, infections were mainly responsible for 82% of total deaths. Early mortality was therefore extremely high in the poorer areas studied and the cause of death was highly age dependent. Any interventions for reducing mortality must therefore be directed towards better antenatal care and safe delivery and postnatally, towards preventing infections, especially during the first six months of life.

Early child health in Lahore, Pakistan: IV. Child care practices

Child care practices and hygiene measures were studied at 6 months of age in a longitudinally followed cohort of 1476 infants born between September 1984 to March 1987 in four socio-economically different areas in and around Lahore, Pakistan. Although, 76-98% of the mothers looked after their infants during health and 96-98% during a diarrhoeal illness, child care practices and hygiene measures differed significantly between the four areas. During a diarrhoeal episode, the mothers from the upper middle class took timely medical help, fed ample food and Oral Rehydration Salts (ORS) to the sick infants and provided uncontaminated food to them in clean surroundings. The mothers from the village and the periurban slum took their sick child, mostly after the second day of illness, to a doctor, but preferred home remedies. Fourteen percent of the mothers in the village and 6% in the periurban slum did not seek any medical help at all. One-third of the families, from these two areas, fed food to children 12 hours after cooking; the surroundings of the child were dirty with large numbers of flies present throughout the year, though the food was commonly kept covered with a lid. We constructed a simple measure of the surroundings of the child, rated as dirty, medium or clean; it was found to be associated to both parental illiteracy and child growth, but not with housing standard. The main conclusion is that any attempt to improve child-care practices and the hygienic environment for the child, should focus on maternal literacy and simple health messages.

Socio-cultural determinants of child mortality in southern Peru: including some methodological considerations

Among Amerindian children living at high altitude in the Andes in southern Peru, high child mortality rates have been reported in the literature, especially in the perinatal and neonatal period. We compared mortality rates in children calculated from retrospective survey data in 86 rural families from 2 Aymara and 3 Quechua peasant communities living at the same level of altitude (3825 m) in southern Peru. Relations between land tenure, socio-cultural factors and child mortality were studied, and methodological considerations in this field of interest are discussed. Checks on consistency of empirical data showed evidence for underreporting of neonatal female deaths with birth order 3 and more. Perinatal (124 vs 34 per 1000 births) and infant mortality (223 vs 111 per 1000 live births) was significantly higher in Aymara compared with Quechua children, but no difference was found after the first year of life. A short pregnancy interval was associated with an elevated perinatal and infant mortality rate, and a similar albeit insignificant association was found with increased maternal age. Amount of land owned and birth order were not related with child mortality. Although levels of maternal education are generally low in both cultures, a consistent decline in infant and child mortality was found with the amount of years mothers had attended school. However, the results suggest a U-shaped relationship between the amount of years of parental education and perinatal mortality in offspring. Late fetal and early neonatal mortality were particularly high in one Aymara community where mothers were found to have more years of education. Infanticide, a known phenomenon in the highlands of the Andes, is discussed in relation with the findings of the study. Although maternal and child health services are utilized by the majority of families in 4 of 5 study communities, 43 of 51 mothers under the age of 45 years reported that they delivered their last baby in the absence of traditional midwives or official medical supervision.

Sociocultural determinants of infant and child mortality in Turkey

This paper is an attempt to review and integrate international and Turkish research on infant and child mortality. Recent research and multivariate analyses in African, Latin American and Asian countries have revealed that in many countries mother's education is a powerful predictor of child survival. The present review of research in Turkey has indicated that urban/rural and regional differentials in infant mortality have been clearly established as by-products of fertility, contraception, and health surveys covering nationally representative samples. However, there are only a few multivariate explanatory models of infant/child mortality in Turkey to isolate and measure the effects of mother's education in relation to other variables. Nevertheless, existing studies in Turkey seem to suggest that mother's and father's education might link socio-economic, psychocultural, and biomedical variables with each other at community, household, and individual levels, providing clue for the formulation of future research designs and policy decisions.

Infant mortality and socioeconomic development: Evidence from Malaysian household data

Household data from Malaysia are used to assess the roles of a number of mortality correlates in explaining the inverse relationship between the infant mortality rate (IMR) and socioeconomic development. Increases in mothers’ education and improvements in water and sanitation are the most important household-level changes that accompany regional and temporal development and contribute to the inverse relationship between the IMR and development. One concomitant of development—reduced breastfeeding—has kept the relationship from being even stronger. Continued prevalence of extended breastfeeding in the poorer states of Peninsular Malaysia and a narrowing of educational and sanitation differentials helped close the IMR gap between the richer and the poorer states.

Plural medicine in Sri Lanka: do Ayurvedic and Western medical practices differ?

In Sri Lanka, as in India, two formally structured systems of medicine exist side by side. While Western-style biomedicine is believed to be useful, Ayurvedic medicine is well established and commonly used. Underlying one explanation for the persistence of such plural medical systems is a functional theory, suggesting that each system is used for different treatments, diseases, or for the ideological, linguistic or social characteristics of the physician. In part, Ayurvedic and Western medicine may persist because their practitioners provide distinctly different services. We tested part of this functional explanation by sending trained 'pseudo-patients' to 764 Ayurvedic and allopathic physicians across Sri Lanka. 'Patients' reported symptoms of common cold, diarrhea or back pain, and recorded after leaving the clinic many aspects of history-taking, diagnostic procedures and physician-patient interaction. Medicines prescribed were later analyzed by a laboratory. We found, basically, no significant differences between the medical practices of sampled Ayurvedic and Western-style physicians, with one exception. While both types spend 3-4 min asking four questions and doing two or three physical examination procedures, and while both prescribe, overwhelmingly, only Western medicines, the allopathic physicians give drugs, that, from the point of view of Western medicine, either 'help' or 'harm' and Ayurvedic physicians prescribe 'neutral' medicines. While we have not directly tested the entire functional explanation we suggest that a structural explanation of the persistence of two systems of medicine may be more valid. Ayurvedic and Western medicine continue in Sri Lanka because they, as institutions, are linked to the social, economic and political structure of the society. Thus, survival is based, not on what a physician does in his practice but upon the power of his medical profession to control medical territory.

Jakarta kampung morbidity variations: some policy implications

Urban growth in the developing world is likely to be accompanied by health problems in crowded zones where services are not available. Geographical analyses of aggregated data may prove interesting, but reliability and utility of spatial correlations are greater when microscale data are acquired. In this study data for households in 11 Jakarta neighborhoods were collected in interviews. Malaria and diarrheal disease patterns have been correlated with environmental and socioeconomic variables at the household level. Several environmental characteristics seem to be closely associated with the incidence of malaria and diarrheal diseases.

From aralu to ORS: Sinhalese perceptions of digestion, diarrhea, and dehydration

This paper explores popular Sinhalese perceptions of diarrheal diseases and related health care behavior. Also addressed are cultural interpretations of dehydration and perceptions of oral rehydration solution (ORS). The social marketing of ORS is considered. It is suggested that the marketing of ORS be more closely linked to education programs which promote appropriate conceptualization of dehydration. The need to more closely integrate nutrition education and diarrheal management programs is discussed.