Pneumonia perceptions and management: an ethnographic study in urban squatter settlements of Karachi, Pakistan

Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Epidemiological studies on lower respiratory tract infection in children in the District Bannu, Khyber Pakhtunkhwa, Pakistan

Background

Lower respiratory tract infections are the leading cause of death in children globally and are transmitted by inhaling airborne droplets. The study demonstrated the prevalence of lower respiratory tract infections in children admitted to the Women and Children Hospital Bannu from February through November 2019. The cross-sectional study was conducted by obtaining indoor data from the official record maintained in the children’s wards.

Results

Males accounted for 649 (61.6%) and females 405 (38.4%) cases out of 1054 cases of the disease. Age group of ≤ 6 months showed 36.2% prevalence, followed by > 6 m ≤ 1 y (25.6%), > 1 y ≤ 2 y (17.1%), > 2 y ≤ 5 y (14.3%), > 5 ≤ 10 y (6.0%), and > 10 y ≤ 15 y (0.8%). Pediatric patients of age ≤ 2 y and ≤ 5 y contributed 78.9% and 93.3% to overall disease, respectively. The disease was at its peak in February (17.9%) while lowest in May (5.5%). The age group (≤ 6 m) was the dominant group in all months except August when replaced by the age group (> 6 m ≤ 1 y). The disease revealed higher prevalence during February-April and October-November.

Conclusions

Different age groups showed variation in the prevalence of the disease with an age group of ≤ 5 y contributing the largest share and seasonal peaks in the disease occurred. The present findings help in adopting strategies for effective control of the disease in different age groups of the children for their peak season.

A Community-Based Survey on Health-Care Utilization for Pneumonia in Children in Peri-Urban Slums of Karachi, Pakistan

Pneumonia, as defined by WHO, is a syndromic diagnosis characterized by presence of cough or difficult breathing. Presentation to health-care provider depends on timely identification of signs and symptoms by caretakers. We explored patterns of health-care utilization among caretakers of a randomly selected sample of 1,152 children aged 2-59 months, residing in low-income settlements of Karachi, Pakistan. Information on household demographics, occurrence of pneumonia-specific symptoms, care seeking, air quality, and knowledge regarding preventive measures for pneumonia was collected. Predictors of care seeking were estimated using weighted logistic regression. Prevalence of pneumonia with cough and rapid or difficulty in breathing was found to be 40.8% and 37.1% in infants (2-11 months) and children (12-59 months), respectively. Ninety-five percentage of caretakers sought care, 68.5% privately. Odds ratios (ORs) for independent predictors of care-seeking were as follows: younger age of child (infants compared with children), 3.60 (95% CI = 2.65-4.87); caretaker with primary education compared with none, 3.40 (2.46-4.70); vaccine awareness, 1.65 (1.45-1.87); and breastfeeding awareness, 1.32 (1.13-1.53). Presence of symptoms such as fever OR, 1.51 (1.30-1.76); tachypnea, 1.57 (1.35-1.83); chest indrawing, 2.56 (2.05-3.18); persistent vomiting, 1.69 (1.37-2.09); and recurrent illness, 2.57 (2.23-2.97) were also predictive. There is high health-care utilization for pneumonia with the skewed presentation toward private services. Strategies should be focused on making pneumonia care standardized, efficient and affordable, especially in the private sector.

To assess the effectiveness of various communication strategies for improving childhood pneumonia case management: study protocol of a community based behavioral open labeled trial in rural Lucknow, Uttar Pradesh, India

BACKGROUND

Community Acquired Pneumonia (CAP) is the leading cause of childhood morbidity and mortality worldwide including India. Many of these deaths can be averted by creating awareness in community about early symptoms of CAP and by ensuring availability of round the clock, quality health care. The objective was to assess the effectiveness of an innovative package of orienting doctors and community health workers about community perceptions on CAP barriers to qualified health care seeking, plus infrastructural strengthening by (i) providing "Pneumonia Drug Kit" (PDK) (ii) establishing "Pneumonia Management Corner" (PMC) at additional primary health center (PHCs) and (iii) "Pneumonia Management Unit" (PMU) at Community health center (CHCs) along with one of 4 different behavior change communication interventions: 1. Organizing Childhood Pneumonia Awareness Sessions (PAS) for caregivers of children < 5 years of age during a routine immunization day at PHCs and CHCs by Auxillary Nurse Midwives (ANM) 2. Organizing PAS on Village Health and Nutrition Day only once a month in villages by Accredited Social Health Activist (ASHA) 3. Combination of both Interventions 1 & 2 4. Usual Care as measured by number of clinical pneumonia cases-treated by ANM/doctors with PDK or treated at either PMC or PMU.

METHODS

Prospective community based open labeled behavioral trial (2 by 2 factorial design) conducted in 8 rural blocks of Lucknow district. Community survey will be done by multistage cluster sampling to collect information on changes in types of health care providers' service utilization for ARI/CAP pre and post intervention.

DISCUSSION

CAP is one of the leading killers of childhood deaths worldwide. Studies have reported that recognition of pneumonia and its danger signs is poor among caregivers. The proposed study will assess effectiveness of various communication strategies for improving childhood pneumonia case management interventions at mother/community level, health worker and health center level. The project will generate demand and improve supply of quality of care of CAP and thus result in reduced mortality in Lucknow district. Since the work will be done in partnership with government, it can be scaled up.

TRIAL REGISTRATION

This study has been registered retrospectively in the AEARCT Registry and the registration number is: AEARCTR-0003137 .

Exploring health care seeking knowledge, perceptions and practices for childhood diarrhea and pneumonia and their context in a rural Pakistani community

Background

Where access to facilities for childhood diarrhea and pneumonia is inadequate, community case management (CCM) is an effective way of improving access to care. In Pakistan, utilization of CCM for these diseases through the Lady Health Worker Program remains low. Challenges of access to facilities persist leading to delayed care and poor outcomes. Estimating caregiver knowledge, understanding their perceptions and practices, and recognizing how these are related to care seeking decisions about childhood diarrhea and pneumonia is crucial to bring about coherence between supply and demand-side practices.

Methods

Data was collected from family caregivers to explore their knowledge, perceptions and practices regarding childhood diarrhea and pneumonia. Data from a household survey with 7025 caregivers, seven focus group discussion (FGDs), seven in-depth interviews (IDIs), and 20 detailed narrative interviews are used to explore caregiver knowledge, perceptions and practices.

Results

Household survey shows that most family caregivers recognize main signs and symptoms of diarrhea such as loose stools (76%). Fewer recognize signs and symptoms of pneumonia such as breathing problems (21%). Few caregivers (18%) have confidence in lady health workers’ (LHWs) ability to treat childhood diarrhea and pneumonia. Care seeking from LHWs remains negligible (< 1%). Caregivers overwhelmingly prefer to seek care from doctors (97%). Seventy-five percent caregivers sought care from private providers and 45% from public providers.

FGDs, IDIs, and narrative interviews show that care mostly begins with home remedies and sometimes self-prescribed medicines. Treatment delays occur because of caregiver inability to recognize disease, use of home remedies, financial constraints, and low utilization of community based LHW services. Caregivers do not seek care from LHWs because of lack of trust and LHWs’ inability to provide medicines. If finances allow, private doctors, who caregivers perceive as more responsive, are preferred over public sector doctors. Financial resources, availability of time, support for household chores by family and community determine whether, when, and from whom caregivers seek care.

Conclusions

Many children do not receive recommended diarrhea and pneumonia treatment on time. Taking into consideration caregiver concerns, adequate supply of medicines to LHWs, improved facility level care could improve care seeking practices and child health outcomes.

Trial registration

The trial is registered with ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707. Registered 18 November 2013.

Predictors of diarrheal mortality and patterns of caregiver health seeking behavior in in Karachi, Pakistan

Background

Pakistan is unfortunately among the five countries that contributed to the most deaths due to diarrhea and pneumonia in 2010. To explore factors associated with diarrheal deaths we assessed care–seeking behavior and other predictors of diarrhea–related mortality in children in selected low–income peri–urban communities of Karachi, Pakistan.

Methods

A mixed methods study (qualitative and quantitative) using matched case–control design and focus group discussions with parents of children with moderate to severe diarrhea (MSD) was undertaken. Cases were children  <5 years of age who died within 60 days of developing an episode of MSD. Controls were age–matched children who survived after 60 days of an episode of MSD. Demographic, clinical, and care–related behavioral predictors of mortality were assessed. Conditional logistic regression was performed, matched adjusted odds ratios (mOR) are reported.

Results

Parents of 77 cases and 154 controls were interviewed. Cases were less likely to receive appropriate care compared to controls (mOR = 0.2, 95% confidence interval (CI) 0.05–0.91). Refusal for hospital admission (OR = 8.9, 95% CI 2.6–30.8), and delays in reaching the health facility (OR = 3.6, 95% CI 1.0–12.9) were significant independent predictors of mortality. We found strong beliefs in traditional and spiritual healing in the population; use of both modern and traditional/spiritual treatments concurrently was common.

Conclusion

Appropriate care seeking behavior predicts survival in children with diarrhea in Pakistan. There is a complex belief system relating to traditional and standard therapies. Health education for appropriate health care seeking should be implemented in order to achieve a substantial decline in diarrheal disease mortality in Pakistan.

Community perceptions and practices of treatment seeking for childhood pneumonia: a mixed methods study in a rural district, Ghana

Background

The World Health Organization recommends community case management of malaria and pneumonia for reduction of under-five mortality in developing countries. Caregivers’ perception and understanding of the illness influences the care a sick child receives. Studies in Ghana and elsewhere have routinely shown adequate recognition of malaria by caregivers. Similarly, evidence from Asia and some African countries have shown adequate knowledge on pneumonia. However, in Ghana, little has been documented about community awareness, knowledge, perceptions and management of childhood pneumonia particularly in the Dangme West district. Therefore this formative study was conducted to determine community perceptions of pneumonia for the purpose of informing the design and implementation of context specific health communication strategies to promote early and appropriate care seeking behaviour for childhood pneumonia.

Methods

A mixed method approach was adopted. Data were obtained from structured interviews (N = 501) and eight focus group discussions made up of 56 caregivers of under-fives and eight community Key Informants. Descriptive and inference statistics were used for the quantitative data and grounded theory to guide the analysis of the qualitative data.

Results

Two-thirds of the respondents had never heard the name pneumonia. Most respondents did not know about the signs and symptoms of pneumonia. For the few who have heard about pneumonia, causes were largely attributed to coming into contact with cold temperature in various forms. Management practices mostly were self-treatment with home remedies and allopathic care.

Conclusion

The low awareness and inadequate recognition of pneumonia implies that affected children may not receive prompt and appropriate treatment as their caregivers may misdiagnose the illness. Adequate measures need to be taken to create the needed awareness to improve care seeking behaviour.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3513-z) contains supplementary material, which is available to authorized users.

Effect of community mobilization on appropriate care seeking for pneumonia in Haripur, Pakistan

BACKGROUND

Appropriate and timely care seeking reduces mortality for childhood illnesses including pneumonia. Despite over 90 000 Lady Health Workers (LHWs) deployed in Pakistan, whose tasks included management of pneumonia, only 16% of care takers sought care from them for respiratory infections. As part of a community case management trial for childhood pneumonia, community mobilization interventions were implemented to improve care seeking from LHWs in Haripur district, Pakistan. The objective of the study was to increase the number of children receiving treatment for pneumonia and severe pneumonia by Lady Health Workers (LHWs) through community mobilization approaches for prompt recognition and care seeking in 2 to 59 month-old children.

METHODS

To assess pneumonia care seeking practices, pre and post-intervention household surveys were conducted in 28 target Union Councils. Formative research to improve existing LHW training materials, job aids and other materials was carried out. Advocacy events were organized, LHWs and male health promoters were trained in community mobilization, non-functional women and male health committees were revitalized and LHWs and male health promoters conducted community awareness sessions.

RESULTS

The community mobilization interventions were implemented from April 2008 - December 2009. Project and LHW program staff organized 113 sensitization meetings for opinion leaders, which were attended by 2262 males and 3288 females. The 511 trained LHWs organized 6132 community awareness sessions attended by 50 056 women and 511 male promoters conducted 523 sessions attended by 7845 males. In one year period, the number of LHWs treating pneumonia increased from 11 in April 2008 to 505 in March 2009. The care seeking from LHWs for suspected pneumonia increased from 0.7% in pre-intervention survey to 49.2% in post-intervention survey.

CONCLUSION

The increase in care seeking from LHWs benefited the community through bringing inexpensive appropriate care closer to home and reducing burden on overstretched health facilities. The community mobilization interventions led to improvements in appropriate care seeking that would not have been achievable just by strengthening pneumonia case management skills of LHWs. In addition to strengthening skills, community mobilization and behavior change activities should also be included in community case management programmes.

Revisiting community case management of childhood pneumonia: perceptions of caregivers and grass root health providers in Uttar Pradesh and Bihar, northern India

Background

Community-acquired pneumonia (CAP) is the leading cause of under-five mortality globally with almost one-quarter of deaths occurring in India.

Objectives

To identify predisposing, enabling and service-related factors influencing treatment delay for CAP in rural communities of two states in India. Factors investigated included recognition of danger signs of CAP, health care decision making, self-medication, treatment and referral by local practitioners, and perceptions about quality of care.

Methods

Qualitative research employing case studies (CS) of care-seeking, key informant interviews (KII), semi-structured interviews (SSI) and focus group discussions (FGD) with both video presentations of CAP signs, and case scenarios. Interviews and FGDs were conducted with parents of under-five children who had suffered CAP, community health workers (CHW), and rural medical practitioners (RMP).

Results

From September 2013 to January 2014, 30 CS, 43 KIIs, 42 SSIs, and 42 FGDs were conducted. Recognition of danger signs of CAP among caregivers was poor. Fast breathing, an early sign of CAP, was not commonly recognized. Chest in-drawing was recognized as a sign of serious illness, but not commonly monitored by removing a child’s clothing. Most cases of mild to moderate CAP were brought to RMP, and more severe cases taken to private clinics in towns. Mothers consulted local RMP directly, but decisions to visit doctors outside the village required consultation with husband or mother-in-law. By the time most cases reached a public tertiary-care hospital, children had been ill for a week and treated by 2-3 providers. Quality of care at government facilities was deemed poor by caregivers.

Conclusion

To reduce CAP-associated mortality, recognition of its danger signs and the consequences of treatment delay needed to be better recognized by caregivers, and confidence in government facilities increased. The involvement of RMP in community based CAP programs needs to be investigated further given their widespread popularity.

The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review

BACKGROUND

Pneumonia, diarrhoea, and malaria are among the leading causes of death in children. These deaths are largely preventable if appropriate care is sought early. This review aimed to determine the percentage of caregivers in low- and middle-income countries (LMICs) with a child less than 5 years who were able to recognise illness in their child and subsequently sought care from different types of healthcare providers.

METHODS AND FINDINGS

We conducted a systematic literature review of studies that reported recognition of, and/or care seeking for episodes of diarrhoea, pneumonia or malaria in LMICs. The review is registered with PROSPERO (registration number: CRD42011001654). Ninety-one studies met the inclusion criteria. Eighteen studies reported data on caregiver recognition of disease and seventy-seven studies on care seeking. The median sensitivity of recognition of diarrhoea, malaria and pneumonia was low (36.0%, 37.4%, and 45.8%, respectively). A median of 73.0% of caregivers sought care outside the home. Care seeking from community health workers (median: 5.4% for diarrhoea, 4.2% for pneumonia, and 1.3% for malaria) and the use of oral rehydration therapy (median: 34%) was low.

CONCLUSIONS

Given the importance of this topic to child survival programmes there are few published studies. Recognition of diarrhoea, malaria and pneumonia by caregivers is generally poor and represents a key factor to address in attempts to improve health care utilisation. In addition, considering that oral rehydration therapy has been widely recommended for over forty years, its use remains disappointingly low. Similarly, the reported levels of care seeking from community health workers in the included studies are low even though global action plans to address these illnesses promote community case management. Giving greater priority to research on care seeking could provide crucial evidence to inform child mortality programmes.

Measuring coverage in MNCH: a prospective validation study in Pakistan and Bangladesh on measuring correct treatment of childhood pneumonia

BACKGROUND

Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh.

METHODS AND FINDINGS

Caregivers of 950 children under 5 y with pneumonia and 980 with "no pneumonia" were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated. Results at both sites showed suboptimal discriminative power, with no difference between 2- or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry.

CONCLUSIONS

Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time.

Understanding community perceptions, social norms and current practice related to respiratory infection in Bangladesh during 2009: a qualitative formative study

Background

Respiratory infections are the leading cause of childhood deaths in Bangladesh. Promoting respiratory hygiene may reduce infection transmission. This formative research explored community perceptions about respiratory infections.

Methods

We conducted 34 in-depth interviews and 16 focus group discussions with community members and school children to explore respiratory hygiene related perceptions, practices, and social norms in an urban and a rural setting. We conducted unstructured observations on respiratory hygiene practices in public markets.

Results

Informants were not familiar with the term "respiratory infection"; most named diseases that had no relation to respiratory dysfunction. Informants reported that their community identified a number of 'good behaviors' related to respiratory hygiene, but they also noted, and we observed, that very few people practiced these. All informants cited hot/cold weather changes or using cold water as causes for catching cold. They associated transmission of respiratory infections with close contact with a sick person's breath, cough droplets, or spit; sharing a sick person's utensils and food. Informants suggested that avoiding such contact was the most effective method to prevent respiratory infection. Although informants perceived that handwashing after coughing or sneezing might prevent illness, they felt this was not typically feasible or practical.

Conclusion

Community perceptions of respiratory infections include both concerns with imbalances between hot and cold, and with person-to-person transmission. Many people were aware of measures that could prevent respiratory infection, but did not practice them. Interventions that leverage community understanding of person-to-person transmission and that encourage the practice of their identified 'good behaviors' related to respiratory hygiene may reduce respiratory disease transmission.

Community case management of severe pneumonia with oral amoxicillin in children aged 2-59 months in Haripur district, Pakistan: a cluster randomised trial

BACKGROUND

First dose oral co-trimoxazole and referral are recommended for WHO-defined severe pneumonia. Difficulties with referral compliance are reported in many low-resource settings, resulting in low access to appropriate treatment. The objective in this study was to assess whether community case management by lady health workers (LHWs) with oral amoxicillin in children with severe pneumonia was equivalent to current standard of care.

METHODS

In Haripur district, Pakistan, 28 clusters were randomly assigned with stratification in a 1:1 ratio to intervention and control clusters by use of a computer-generated randomisation sequence. Children were included in the study if they were aged 2-59 months with WHO-defined severe pneumonia and living in the study area. In the intervention clusters, community-based LHWs provided mothers with oral amoxicillin (80-90 mg/kg per day or 375 mg twice a day for infants aged 2-11 months and 625 mg twice a day for those aged 12-59 months) with specific guidance on its use. In control clusters, LHWs gave the first dose of oral co-trimoxazole (age 2-11 months, sulfamethoxazole 200 mg plus trimethoprim 40 mg; age 12 months to 5 years, sulfamethoxazole 300 mg plus trimethoprim 60 mg) and referred the children to a health facility for standard of care. Participants, carers, and assessors were not masked to treatment assignment. The primary outcome was treatment failure by day 6. Analysis was per protocol with adjustment for clustering within groups by use of generalised estimating equations. This study is registered, number ISRCTN10618300.

FINDINGS

We assigned 1995 children to treatment in 14 intervention clusters and 1477 in 14 control clusters, and we analysed 1857 and 1354 children, respectively. Cluster-adjusted treatment failure rates by day 6 were significantly reduced in the intervention clusters (165 [9%] vs 241 [18%], risk difference -8·9%, 95% CI -12·4 to -5·4). Further adjustment for baseline covariates made little difference (-7·3%, -10·1 to -4·5). Two deaths were reported in the control clusters and one in the intervention cluster. Most of the risk reduction was in the occurrence of fever and lower chest indrawing on day 3 (-6·7%, -10·0 to -3·3). Adverse events were diarrhoea (n=4) and skin rash (n=1) in the intervention clusters and diarrhoea (n=3) in the control clusters.

INTERPRETATION

Community case management could result in a standardised treatment for children with severe pneumonia, reduce delay in treatment initiation, and reduce the costs for families and health-care systems.

FUNDING

United States Agency for International Development (USAID).

Inherent illnesses and attacks: an ethnographic study of interpretations of childhood Acute Respiratory Infections (ARIs) in Manhiça, southern Mozambique

Background

Pneumonia is a leading cause of childhood hospitalisation and child mortality in Africa. This study explores local interpretations of Acute Respiratory Infections (ARIs), focusing on caretakers of children under five in the context of hospital care seeking.

Methods

The study took place in Manhiça, southern Mozambique and used Focused Ethnographic Study tools (FES) including field exercises and interviews.

Results

Understandings of terms used to describe ARIs differed between caretakers and hospital staff. Children's sicknesses that hospital staff diagnosed as ARIs were interpreted by caretakers as intermittent "attacks" of xifuva, a permanent, inherent and incurable chest illness. Caretakers thought that it was possible to manage and treat the attacks, which were caused by immediate natural factors such as food or the weather, but not the underlying illness, which was seen as having more indirect and social causes. Explanations of illness could not be neatly separated into pluralistic categories, but were characterised by syncretism, with "lay" and "biomedical" terms and concepts intermingling in practical care-seeking interactions between caretakers and health staff.

Conclusions

Health promotion should take into account the syncretism involved in explanations of ARIs in the context of practical care seeking for children. In doing so, it should draw upon lay interpretations and terminologies in order to stress the importance of seeking hospital care for all xifuva-type illnesses as well as seeking care for any subsequent attacks of an already diagnosed xifuva. However, this should be undertaken with awareness that the meanings of the terms used in practical care-seeking interactions may change over time. Health communication about ARIs should therefore be ongoing and evidence-based, even if ARIs appear to be well understood.

Zinc modifies the association between nasopharyngeal Streptococcus pneumoniae carriage and risk of acute lower respiratory infection among young children in rural Nepal

Nasopharyngeal (NP) carriage is necessary for Streptococcus pneumoniae (Spn) transmission and invasive infection. This study evaluated the effect of zinc prophylaxis on the association between NP colonization with Spn and acute lower respiratory infection (ALRI) in children aged 1-35 mo living in a rural district in southern Nepal. We compared carriage prevalence of Spn in 550 ALRI cases with that of healthy age- and season-matched controls. This study, conducted from December 2003 to July 2005, was nested in a community-randomized trial designed to evaluate the effect of zinc on morbidity and mortality in 1- to 36-mo-old children. They were randomized to receive either 10-mg tablets of zinc or placebo daily until discharge. Approximately 75% of cases and controls were Spn carriers. There was an interaction between zinc and Spn carriage (P = 0.091). Spn carriage increased the risk of ALRI in the placebo group [adjusted matched odds ratio (AMOR) = 2.57; P = 0.025] but not in the zinc group (AMOR = 0.95; P = 0.890). Among the subset of symptomatic cases and their controls, the odds of ALRI for Spn carriers in the placebo group was 30 times greater (AMOR = 78.09; P = 0.006) than in the zinc group (AMOR = 2.77; P = 0.288). These findings suggest that zinc prophylaxis may protect children against ALRI associated with carriage of Spn and that the effect may differ by infectious etiology.

The role of polyamines in glucagon-like peptide-2 prevention of TPN-induced gut hypoplasia

Total parenteral nutrition (TPN) of rats has been demonstrated to produce hypoplasia of gut mucosa, and to be associated with reduced immune response and elevated translocation of bacteria from gut to mesenteric lymph nodes, spleen and liver. Treatment of rats being maintained on TPN with the proglucagon fragment, glucagon-like peptide-2 (GLP-2), has been shown to totally prevent small intestine mucosal hypoplasia. In the present study, we found that depletion of polyamines with alpha-difluromethylornithine (DFMO) significantly reduced the efficacy of GLP-2 in preserving gut mucosa in rats maintained on TPN for 8 days. Co-infusion of GLP-2 with TPN prevented loss of protein and mucosa in duodenum, jejunum and ileum, but not in colon. Addition of DFMO to the infusate prevented the protective effects of GLP-2 in the duodenum and jejunum. In the jejunum, putrescine and spermidine were reduced in DFMO-treated rats, while the ileum exhibited reductions of these polyamines in rats infused with TPN or TPN plus GLP-2. DFMO infusion further reduced these polyamines in the ileum, while levels of spermine were increased. Concentrations of ornithine decarboxylase were elevated in jejunum of rats infused with TPN or TPN plus GLP-2, but were reduced significantly in DFMO-treated rats. These results suggest that normal levels of polyamines are necessary for the expression of GLP-2-induced hyperplasia. Differential effects of GLP-2 and DFMO across gut segments may relate to regional differences in proliferative and anti-apoptotic effects of the treatments.

Women's management of the household health environment: responding to childhood diarrhea in the Northern Areas, Pakistan

This paper examines mothers' management of water, sanitation, hygiene, and childhood diarrhea in a mountain community in the Northern Areas, Pakistan. It draws upon qualitative data obtained from 65 in-depth interviews and other ethnographic field methods. The analysis shows that respondents were familiar with diarrhea control interventions carried out in the study site, and associated childhood diarrhea with oral-fecal transmission routes such as poor water quality, unhygienic behaviors, contaminated food, and inadequate sanitation practices. Findings also demonstrate the continuance of long-established cultural patterns of perception and behavior with regard to childhood diarrhea and the influence of socio-economic constraints to instituting new management practices.

Recognizing childhood illnesses and their traditional explanations: exploring options for care-seeking interventions in the context of the IMCI strategy in rural Ghana

OBJECTIVES

Interventions that promote appropriate care-seeking for severely ill children have the potential to substantially reduce child mortality in developing countries, but little is known about the best approach to address the issue. This paper explores the relative importance of illness recognition as a barrier to care-seeking and the feasibility and potential impact of improving recognition.

METHODS

The study combined qualitative and quantitative methods including in-depth interviews exploring the local illness classification system, a Rapid Anthropological Assessment (RAA) recording narratives of recent episodes of child illness and a survey designed to test the hypotheses that emerged from the RAA.

RESULTS

Several danger symptoms were not recognized by caregivers. There were recognition problems which may not be feasibly addressed in an intervention. Other significant care-seeking barriers included classifying certain illnesses as 'not-for-hospital' and untreatable by modern medicine; problems of access; and frequent use of traditional medicines.

CONCLUSION

The recognition component of any care-seeking intervention should identify the type of recognition problem present in the community. Many of the care-seeking barriers identified in the study revolved around the local illness classification system, which should be explored and built on as part of any care-seeking intervention.

Respiratory illness in the Dominican Republic: what are the predictors for health services utilization of young children?

Respiratory illness and diarrhoea continue to be the leading causes of paediatric morbidity and mortality in the Dominican Republic. An important first step in alleviating this disease burden is to understand patterns and predictors of health services utilization for these conditions. This study examines the predictors of (a) health services utilization, and (b) public versus private sector use, for respiratory illness in the under-five population in the Dominican Republic. The DHS-2 dataset (1991) was utilized for analysis. Logistic regression models for predicting use and non-use, and for predicting private versus public sector use, were constructed using the Andersen Behavioural Model as the conceptual framework. Our findings indicate that sex, location and possession index quartile are factors that influence the decision to seek care or not for respiratory illness in under-fives. In contrast, the choice between the public and private sector is determined by location and insurance status. From the policy perspective, if the Dominican Republic were to undertake steps to increase private insurance coverage, our results indicate that this would lead to increased utilization of private sector providers for respiratory illness by children having private insurance, but would not have an impact on overall utilization (i.e. use vs. non-use). On the other hand, one of the ways to deliver cost-effective interventions by the publicly financed system would be to improve facilities in the rural areas.

Choices about treatment for ARI and diarrhea in rural Guatemala

This paper uses the 1995 Guatemalan Survey of Family Health (EGSF) to analyze the relationship between child illness and health seeking behavior. The EGSF contains detailed calendar data on the nature and timing of illness and treatment behavior for children age five and below; extensive information about the characteristics of mothers, families and communities; and data on the accessibility of traditional and biomedical providers within and near the community. The analysis is based on 870 children who began a diarrheal or respiratory illness during a 2-week period prior to interview. Estimates are derived from a multinomial logit model of the probability of seeing a specific type of provider on a given day of illness, as a function of characteristics of the illness, child, mother, and community. The results indicate that modern medical care plays a major role in the treatment of infectious illness among children in rural Guatemala. The symptoms associated with the illness, their perceived severity, and mother's beliefs about their causes are important determinants of whether a child is brought to a provider and the type of provider visited. Poverty is a serious constraint on a family's choices about how to treat children's illnesses, whereas education and ethnicity have little effect on treatment behavior when income is held constant. In addition, the availability of modern health facilities within the community-both government-sponsored facilities and private doctors-has a substantial impact on the type of providers sought to treat children's illnesses.

Lay perceptions of genetic risks attributable to inbreeding in Pakistan

Pakistan along with many other West and South Asian countries has a very high prevalence of consanguineous, especially close cousin, marriages. Although there is substantial empirical information on offspring morbidity and mortality attributable to parental consanguinity, population-based information on how communities in general, and women in particular, perceive the health risks associated with consanguineous unions is limited. This paper considers community perceptions of health effects associated with consanguineous marriages using qualitative data from 15 focus group discussions and 294 in-depth interviews. The study was conducted in four low-income, multi-ethnic, and multi-religious communities in Karachi, the principal commercial center of Pakistan. The results show a general lack of awareness of the possible adverse health effects of consanguineous marriage. In cases where a link between consanguinity and ill health was acknowledged, it often centered on the familial origins of non-communicable disorders such as diabetes and hypertension or infectious diseases such as tuberculosis. Belief in fate and the "evil eye" was widespread across all ethnic and religious groups. Many respondents did not agree with medical explanations of a genetic mode of disease inheritance, even in cases where there was an affected child in the family. The absence of a uniform manifestation of disease among all children of a couple who were identified as carriers of a specific mutation added to the confusion among participants. The study highlights the need for further quantification of risks associated with consanguinity and a need for provision of appropriate information to primary-care clinicians and also to communities. The likely impact of increasing morbidity attributable to inbreeding on the health care system in resource poor settings is also discussed.

Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers' health care-seeking behaviors during their infants' fatal illness

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995-May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care: and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants' chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.

Cultural basics and chronic illness

Cultural factors have significant impact on the clinical encounter between health care professionals and their patient-families. A good continuing relationship is essential for successful management of chronic disease. Misunderstandings predicated on implicit cultural assumptions are a frequent potential hazard. This review outlines some possible problems and concludes by making eight suggestions for culturally sensitive and medically effective communication.