Newborn care: the effect of a traditional illness, asram, in Ghana

AIMS

To explore the role of a traditional illness of the newborn, asram, in care-seeking in rural Ghana.

METHODS

Data are from formative research into newborn care which included collecting qualitative data from 14 villages in Brong Ahafo region of Ghana through 25 birth narratives, 30 in-depth interviews and two focus groups with recently delivered/pregnant women, 20 in-depth interviews and six focus groups with birth attendants/grandmothers, 12 in-depth interviews and two focus groups with husbands, and six in-depth interviews with asram healers.

RESULTS

The study confirmed that asram is characterised by symptoms which include green/black veins, a big head and the newborn growing lean. However, a complex classification of 14 types of asram covering a wide array of symptoms was identified. Asram was perceived as a common illness which cannot be treated at health facilities and to which many danger signs in the newborn are attributed, and thus it affects care-seeking. Asram treatment includes frequent cold herbal baths and air-drying; however, oral treatments and preventive bathing are also used. Any modification of asram treatment was reported to require the sanction of a healer.

CONCLUSION

Understanding traditional illnesses as a potential barrier to newborn care-seeking is essential for designing care-seeking interventions. An asram diagnosis can prevent sick newborns being taken to health facilities and traditional treatment exposes them to the risk of hypothermia.

Detecting common mental disorders in primary care in India: a comparison of five screening questionnaires

BACKGROUND

Screening of patients for common mental disorders (CMDs) is needed in primary-care management programmes. This study aimed to compare the screening properties of five widely used questionnaires.

METHOD

Adult attenders in five primary-care settings in India were recruited through systematic sampling. Four questionnaires were administered, in pairs, in random order to participants: the General Health Questionnaire (GHQ, 12 items); the Primary Health Questionnaire (PHQ, nine items); the Kessler Psychological Distress Scale (K10, 10 items), and from which we could extract the score of the shorter 6-item K6; and the Self-Reporting Questionnaire (SRQ, 20 items). All participants were interviewed with a structured lay diagnostic interview, the Revised Clinical Interview Schedule (CIS-R).

RESULTS

Complete data were available for 598 participants (participation rate 99.3%). All five questionnaires showed moderate to high discriminating ability; the GHQ and SRQ showed the best results. All five showed moderate to high degrees of correlation with one another, the poorest being between the two shortest questionnaires, K6 and PHQ. All five had relatively good internal consistency. However, the positive predictive value (PPV) of the questionnaires compared with the diagnostic interview ranged from 51% to 77% at the optimal cut-off scores.

CONCLUSIONS

There is little difference in the ability of these questionnaires to identify cases accurately, but none showed high PPVs without a considerable compromise on sensitivity. Hence, the choice of an optimum cut-off score that yields the best balance between sensitivity and PPV may need to be tailored to individual settings, with a higher cut-off being recommended in resource-limited primary-care settings.

Informed consent in Ghana: what do participants really understand?

OBJECTIVES

To explore how subjects in a placebo-controlled vitamin A supplementation trial among Ghanaian women aged 15-45 years perceive the trial and whether they know that not all trial capsules are the same, and to identify factors associated with this knowledge.

METHODS

60 semistructured interviews and 12 focus groups were conducted to explore subjects' perceptions of the trial. Steps were taken to address areas of low comprehension, including retraining fieldworkers. 1971 trial subjects were randomly selected for a survey measuring their knowledge that not all trial capsules are the same. The subjects' fieldworkers were also interviewed about their characteristics and trial knowledge. Factors associated with knowledge were explored using multi-level modeling.

RESULTS

Although subjects knew they were taking part in research, most thought they were receiving an active and beneficial medication. Variables associated with knowledge were education and district of residence. Radio broadcasts benefited those with some schooling. Fieldworkers' characteristics were not associated with subjects' knowledge.

CONCLUSIONS

Research and debate on new or improved consent procedures are urgently required, particularly for subjects with little education.

Technical aspects and complications of laparoscopic banding for morbid obesity—a radiological perspective

Morbid obesity is a significant clinical problem in the western world. Various surgical restrictive procedures have been described as an aid to weight reduction when conservative treatments fail. Adjustable laparoscopic gastric banding (LAPBAND) has been popularized as an effective, safe, minimally invasive, yet reversible technique for the treatment of morbid obesity. Radiological input is necessary in the follow-up of these patients and the diagnosis of complications peculiar to this type of surgery. In this review we will highlight the technical aspects of radiological follow-up and the lessons learnt over the last 5 years.

Oral nutritional supplementation is effective in the maintenance of remission in Crohn's disease

BACKGROUND

Enteral feeding with either elemental or polymeric diets is an established primary therapy for active Crohn's disease. However, the role of supplementing normal food with elemental diet in the long-term management of Crohn's disease has hitherto not been explored.

PATIENTS AND METHODS

A series of 39 consecutive patients with Crohn's disease in clinical remission were studied. Of these, 21 patients (Group 1) received oral nutritional supplementation, taken in addition to their normal diet. Their outcome (relapse rate, Crohn's disease activity index, inflammatory markers) was compared with that of 18 patients (Group 2), who were maintained on a normal unrestricted diet over an observation period of 12 months.

RESULTS

A total of 17 patients (81%) tolerated the nutritional supplementation. On an intention-to-treat basis, 10 patients (48%) remained in remission for 12 months, compared to 4/18 (22%) patients in Group 2, p<0.0003. Their Crohn's disease activity index and CRP remained stable while their weight and body mass index improved during the period of nutrition therapy Seven patients in Group 1 and 14 in Group 2 relapsed at a mean of 7.4+/-0.9 and 6.2+/-0.4 months, respectively. The response to nutrition supplement was independent of age, sex, disease duration or location. Four patients (19%) were intolerant to enteral feeding.

CONCLUSIONS

Nutritional supplementation is safe, well tolerated and effective in the long-term management of patients with quiescent Crohn's disease.

The Multidimensional Health Behavior Inventory

Gaps in knowledge about what constitutes healthy and risky behaviors for young people hinder successful health promotion intervention strategies. With the development of appropriate instruments, behaviors can be measured and interventions can be implemented to improve health outcomes. The structure of a new health behavior instrument, the Multidimensional Health Behavior Inventory (MHBI), was explored with data from 1,077 college students, ages 18 to 24 years. Factor analysis of 116 health behavior questions yielded 7 factor-based scales with 57 items: diet (13 items), substance use (10 items), safety (9 items), checkup (9 items), social (6 items), stress (6 items), and exercise (4 items). Evaluation of the 7 behavior scales of the MHBI using subgroups defined by age, gender, and race will contribute to an understanding of health behaviors of older adolescents and young adults and will provide directions for research and clinical interventions.

Polymeric versus elemental diet as primary treatment in active Crohn's disease: a randomized, double-blind trial

OBJECTIVE

Enteral feeding is now an established primary therapy for active Crohn's disease. This first-double blind randomized trial was designed to compare the therapeutic efficacy of a polymeric diet (PD) with an elemental diet (ED).

METHODS

Patients with active Crohn's disease (Crohn's disease activity index [CDAI] > 150, increased bowel uptake of Tc-HMPAO-labeled leukocytes, and abnormal C-reactive protein [CRP]), were randomized to receive either an ED or a PD. The two preparations were identical except for the nitrogen source, which was amino acid based in ED and intact protein in PD. Enteral feeding was considered successful if clinical remission was achieved as defined by a final CDAI of < or = 150, a reduction in the CDAI by at least 100 points from baseline level, and a normal CRP.

RESULTS

Twenty-one patients were enrolled of whom 11 were randomized to PD and 10 to ED. The two groups were comparable at entry. Clinical remission was obtained in eight (80%) patients receiving ED and six (55%) patients receiving PD, p = 0.1. The treatment failed in three and two patients in the PD and ED groups, respectively. Another two patients were intolerant to the feed (PD). Reduction in the CDAI after treatment with ED (359 +/- 67 to 112 +/- 19) was similar to that seen with PD (303 +/- 27 to 97 +/- 11). Similar changes in the CRP were also observed (16 +/- 5 to 4 +/- 1.6) and (62 +/- 20 to 9 +/- 6), respectively. Overall, enteral feeding was successful in 14 patients (63%).

CONCLUSIONS

Enteral nutrition is effective in treatment of active Crohn's disease. Differences in nitrogen sources of enteral feeds are not relevant to their therapeutic efficacy, as polymeric and elemental diets are equally effective.

Polymeric versus elemental diet as primary treatment in active Crohn's disease: a randomized, double-blind trial

OBJECTIVE

Enteral feeding is now an established primary therapy for active Crohn's disease. This first-double blind randomized trial was designed to compare the therapeutic efficacy of a polymeric diet (PD) with an elemental diet (ED).

METHODS

Patients with active Crohn's disease (Crohn's disease activity index [CDAI] > 150, increased bowel uptake of Tc-HMPAO-labeled leukocytes, and abnormal C-reactive protein [CRP]), were randomized to receive either an ED or a PD. The two preparations were identical except for the nitrogen source, which was amino acid based in ED and intact protein in PD. Enteral feeding was considered successful if clinical remission was achieved as defined by a final CDAI of < or = 150, a reduction in the CDAI by at least 100 points from baseline level, and a normal CRP.

RESULTS

Twenty-one patients were enrolled of whom 11 were randomized to PD and 10 to ED. The two groups were comparable at entry. Clinical remission was obtained in eight (80%) patients receiving ED and six (55%) patients receiving PD, p = 0.1. The treatment failed in three and two patients in the PD and ED groups, respectively. Another two patients were intolerant to the feed (PD). Reduction in the CDAI after treatment with ED (359 +/- 67 to 112 +/- 19) was similar to that seen with PD (303 +/- 27 to 97 +/- 11). Similar changes in the CRP were also observed (16 +/- 5 to 4 +/- 1.6) and (62 +/- 20 to 9 +/- 6), respectively. Overall, enteral feeding was successful in 14 patients (63%).

CONCLUSIONS

Enteral nutrition is effective in treatment of active Crohn's disease. Differences in nitrogen sources of enteral feeds are not relevant to their therapeutic efficacy, as polymeric and elemental diets are equally effective.

Measuring hygiene practices: a comparison of questionnaires with direct observations in rural Zaïre

To date questionnaire surveys have been the most commonly used instruments to measure hygiene behaviours related to water and sanitation. More recently, a number of studies have used structured observations to study practices related to diarrhoea. During a trial of a hygiene education intervention to reduce diarrhoea among young children in Bandundu, Zaire, both instruments were used to measure the disposal of child faeces and various hand-washing practices. Three hundred families were observed and follow-up interviews performed with 274 (91%) mothers. At the individual level, agreement between observed and reported behaviour was little better than might be expected by chance. There was evidence of over-reporting of hand-washing before food preparation (44% vs 33%; P = 0.03), hand-washing before eating (76% vs 60%; P < 0.001) and disposal of the child's faeces in a latrine (75% vs 40%; P < 0.001). On the other hand, hand-washing before feeding the child was reported less often than it was observed (7% vs 64%; P < 0.001). Our data are consistent with the hypothesis that, in general, mothers over-report 'desirable' behaviours. At the same time, our data indicate that open questions may lead to under-reporting of certain behaviours. The repeatability of observations at both the individual and population levels remains to be established.

Risk factors for pneumonia among children in a Brazilian metropolitan area

OBJECTIVE

To investigate risk factors for pneumonia for infants < 2 years of age.

DESIGN

Hospital-based, case-control study with neighborhood control subjects.

SETTING

Urban area in southern Brazil.

SUBJECTS

Five hundred ten infants with radiologically confirmed pneumonia who were admitted to a pediatric hospital. One age-matched neighborhood control subject was selected for each case.

RESULTS

Multiple conditional regression modeling was used to control for confounding, taking into account the hierarchical relationships between risk factors. The incidence of radiologically confirmed pneumonia was associated with low paternal education, the number of persons in the household, young maternal age, attendance at day-care centers, low birth weight and weight-for-age, lack of breast-feeding and of non-milk supplements, and a history of previous pneumonia or wheezing. Day-care center attendance showed the highest risk, with an adjusted odds ratio of 11.75.

CONCLUSIONS

In addition to continued efforts toward appropriate case management, actions directed against the above risk factors may help prevent the major cause of deaths of children younger than 5 years.

Breast-feeding among the urban poor in southern Brazil: reasons for termination in the first 6 months of life

A study of breast-feeding practices over the first 6 months of life among a cohort of urban poor infants in southern Brazil indicated that the median duration of breast-feeding was 18 weeks, and at 6 months 41% of the infants were still being breast-fed. The duration of breast-feeding was significantly associated with the following: the infant's sex, mother's colour, type of first feed, timing of the first breast-feed, breast-feeding regimen and frequency of breast-feeding at 1 month, and the use of hormonal contraceptives by the mother. The following were significant risk factors for early termination of breast-feeding: the infant's sex, type of first feed, use of supplementary feeds, frequency of breast-feeding, feeding regimen, weight-for-age, and weight-for-age after controlling for birth weight. Dissatisfaction with their infant's growth rate was the most frequent reason given by mothers for supplementing the diets of infants who were exclusively breast-fed in the first 3 months of life. Also, the mothers' perception that their milk output was inadequate was the most frequent reason expressed for stopping breast-feeding in the first 4 months. The roles of health services and family support in providing favourable conditions for increasing the duration of breast-feeding in the study population are discussed, as well as the possibility of bias being introduced into studies of the relationship between infant feeding and growth by the effect of the infant's rate of growth on the mother's decision to continue breast-feeding.

Home-based oral rehydration therapy in rural Zimbabwe

A study was carried out in four rural areas of Zimbabwe to assess the acceptability, feasibility and accuracy of sugar-salt solutions and to investigate the action taken during a recalled episode of diarrhoea in a child. Only 5% of respondents gave the child a sugar-salt solution at home during the described illness yet a majority (52%) claimed knowledge of oral rehydration techniques. A great variety of recipes were described; 46% of respondents knew a recipe for a solution containing sugar and salt and 12% were able to describe the standard recipe for sugar-salt solutions. Those who knew a recipe for a sugar-salt solution were asked to prepare a sample for chemical analysis; of those who prepared a sample, 26% prepared a solution having both sucrose and sodium concentrations within the safe and effective ranges. Surprisingly therefore, 12% (26% X 46%) of rural adults were able to prepare a safe and effective oral rehydration solution, despite the fact that there is as yet no concerted programme for the promotion of home-based oral rehydration therapy in Zimbabwe. The standard method of preparation was taught to all respondents who had no previous knowledge of sugar-salt solutions. Recall of the standard method was good; after a period of 11 to 26 days 64% of respondents remembered the correct recipe and 84% prepared a solution having both sucrose and sodium concentrations in the safe and effective ranges. 92% of all households had a teaspoon, sugar and salt and 88% had all the required items: a 750 ml bottle, a teaspoon, sugar and salt. It is concluded that home-based oral rehydration therapy using sugar-salt solutions is an acceptable and feasible strategy for the early management of acute diarrhoea in rural Zimbabwe.

Preparation of sugar-salt solutions

Correct measurement techniques are essential for the preparation of oral rehydration solutions but dangerous or ineffective solutions may also result from the inherent variability of the method and ingredients. This paper describes an experimental study conducted in Zimbabwe to compare the reliability of three methods for measuring sugar and salt in a 750 ml bottle of water: (i) 6 level teaspoons of sugar and half a level teaspoon of salt, (ii) 3 heaped teaspoons of sugar and half a level teaspoon of salt and (iii) 3 level measures of sugar and salt with a double-ended spoon. The teaspoon and 750 ml bottle methods produced reliable results. Heaped teaspoons of sugar gave more reproducible sucrose concentrations than level teaspoons . The double-ended spoon was not more reliable and gave disquietingly high sodium concentrations with refined salt. Under field conditions the level teaspoon method gave more variable results but still within acceptable limits. It is concluded that a domestic teaspoon and a standard 750 ml bottle can be recommended for the preparation of home-based oral rehydration solutions in rural Zimbabwe.

Perceptions of childhood diarrhoea and its treatment in rural Zimbabwe

In the course of a study on the acceptability and feasibility of home-based oral rehydration therapy in rural Zimbabwe, information was collected on attitudes and beliefs about diarrhoea and on action taken in response to an episode of diarrhoea in a child. Diarrhoea was found to be a perceived threat at community and family level and numerous possible causes of diarrhoea were described which were assigned to two broad classes: (1) 'physical' causes, such as a polluted environment, diet and teething and (2) 'social and spiritual' causes such as those associated with a depressed fontanelle. These domains were not, however, mutually exclusive; 76% of the described episodes of diarrhoea were attributed to 'physical' causes, 15% to 'social and spiritual' causes and 8% to a combination of both. Reported utilization rates of the formal health services were unexpectedly high. In contrast, we recorded a low demand for indigenous herbalists (n'angas). Home management was common and comprised the administration of indigenous herbal remedies, of sugar and salt solutions, of over-the-counter drugs or of enemas. These remedies were given on their own or alongside the treatment prescribed by a health worker. A number of variables were examined to assess their influence on health-seeking behaviour: perceived cause and severity of the illness, socio-demographic characteristics of the respondent or child and accessibility of the health services.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationships between mortality, visual acuity and microfilarial load in the area of the Onchocerciasis Control Programme

The relationships between onchocercal infection, visual acuity and mortality have been examined using epidemiological data gathered by the Onchocerciasis Control Programme from 66 villages in West Africa. All of these villages were surveyed at least twice. 18,778 persons were registered at the first surveys which were conducted around the time when control activities started. The second surveys were conducted two to five years later. 14,961 persons (79.7%) were alive and registered again, 786 (4.2%) had died, 2776 (14.8%) had moved and 255 (1.4%) could not be traced. The prevalence of blindness and of visual damage other than blindness both increased markedly with age, and the degree of visual damage was strongly associated with level of microfilarial infection. Among adults, the prevalence of blindness was higher for males than for females at all ages. The prevalence and intensity of microfilarial infection were also higher among males but this was not sufficient to explain their excess blindness. Logistic regression analysis showed that males were 1.5 times more likely to be blind than females of the same age and same level of microfilarial infection. The presence of visual damage at the first survey considerably increased the risk of mortality between the first and second surveys for both males and females. Mortality rates were three to four times higher among the blind and about 1.5 times higher among those with visual damage other than blindness compared with those with no visual damage. There was some evidence, for males but not for females, that mortality was also directly related to microfilarial load.(ABSTRACT TRUNCATED AT 250 WORDS)

Variations in the prevalence and intensity of microfilarial infections by age, sex, place and time in the area of the Onchocerciasis Control Programme

Epidemiological data gathered by the Onchocerciasis Control Programme from 66 villages in West Africa have been analysed. All of these villages were surveyed twice and 10 a third time. The first surveys were conducted around the time when control activities started and provide baseline data against which to assess the effectiveness of control. The second and third surveys were conducted two to five years later. 18,778 persons were registered in the first surveys and 15,783 (84.1%) were examined for microfilariae. The prevalence of microfilarial infection was higher among males, increased rapidly with age in both sexes until about 25 years and levelled off at about 90% in males and 85% in females. The age-sex adjusted prevalence rates in different villages varied from 5% to 93% but were above 60% in three quarters of the villages. After two to five years of control there was an over-all fall in the prevalence of infection of about 4 to 5% a year. Among children born since control started, only seven of 1871 examined were found to be infected with microfilariae compared to an expected number of 79, had there been no change in prevalence rates.

Controlled trial of chlorpromazine as antisecretory agent in patients with cholera hydrated intravenously

A randomised controlled trial was conducted to investigate the ability of chlorpromazine to reduce intestinal secretion in cholera. Chlorpromazine had reduced loss of intestinal fluid in animals with diarrhoea induced by cholera toxin, and in a preliminary study the drug had reduced purging in patients with cholera. Forty-six adults with cholera were included in the randomised trial. Of these, 34 were treated with chlorpromazine (1 mg/kg or 4 mg/kg either by mouth or intramuscularly) and 12 served as controls. After treatment with the drug there was a significantly greater reduction in the rate of fluid loss in the treated patients than in the controls during the first (p less than 0.005), second (p less than 0.05), and fourth (p less than 0.01) eight-hour periods, but not during the third eight-hour period; the dose of 4 mg/kg was only marginally more effective than 1 mg/kg. The effect of chlorpromazine was strikingly biphasic, with one peak during the first eight hours and another 24-32 hours after administration. Chlorpromazine also significantly reduced the duration of diarrhoea, frequency of vomiting, and amount of intravenous fluid required. The drug induced mild sedation and no hypotension in these well-hydrated patients. These findings confirm the effectiveness of chlorpromazine in reducing fluid loss in cholera. A sedative effect, however, especially in children, may limit its usefulness and requires further study.

Sickle-cell disease in a British urban community

Seventy cases of sickle-cell disease were identified in the London Borough of Brent from records dating back to 1962. All but three were still alive and, with one exception, were recalled for confirmation of the diagnosis and to provide personal and family histories. The group consisted of 22 individuals with homozygous sickle-cell anaemia (Hb SS), 12 with sickle-cell/beta-thalassaemia double heterozygosity, 34 with sickle-cell/haemoglobin C disease (Hb SC), and two with the combination of haemoglobin S and hereditary persistence of fetal haemoglobin. They were predominantly of West Indian origin, more than half had been born in Britain, and most were aged under 25. The records for 304 patient admissions between 1962 and 1979 were analysed. There were 199 sickle-cell-disease-related admissions, 61 unrelated to sickle-cell disease, and 44 for pregnancy or its complications. Admissions per patient-year averaged less than one, except for children with Hb SS under the age of 5 years, who were admitted more frequently. The commonest reasons for admission were painful crises (74% of all admissions) and the "chest syndrome" (21%). There were four pneumococcal infections, all in children with Hb SS under the age of 8 years; all recovered. Three patients, aged 10, 15, and 50 years, died. The two children with Hb SS died in their sleep without gross evidence of sickling at necropsy. Multiple brain infarcts were found at necropsy in the 50-year-old woman with Hb SC who, having survived nine uneventful pregnancies, succumbed to an infection after cryosurgery to the cervix. Obstetric records were available for 18 term pregnancies in 11 women. Three antenatal sickling crises and three postpartum thromboembolic complications were encountered. There were no maternal or perinatal deaths. Fifteen asymptomatic individuals with sickle-cell disease were diagnosed as a result of routine screening procedures. There are likely to be many such individuals currently undiagnosed in the community. They urgently need identification because of their increased risks from pregnancy, surgery, and infection.

The derivation of a minimum immune titre of rubella haemagglutination-inhibition (HI) antibody. A Public Health Laboratory Service collaborative survey

Ten laboratories collaborated in a study of minimum immune titre (MIT) of rubella haemagglutination-inhibiting (HI) antibody with one laboratory acting as a reference laboratory to provide a uniform basis for comparison of the HI results. The international unitage equivalent to the MIT used by the ten laboratories was found to vary from 24 to 98 units. Testing of the sera by immunofluorescence and by HI after flotation centrifugation indicated that residual non-specific inhibitors may interfere with HI antibody testing to an extent equivalent to 12-15 units. An acceptable MIT would therefore be equivalent to 24-48 units of rubella HI antibody. The single radial haemolysis (SRH) results on the sera indicate that this is a sensitive and specific test for rubella antibody.

Estimation of glomerular filtration rate from plasma creatinine concentration in children

The relation between the true plasma creatinine concentration (Pc) and the glomerular filtration rate corrected for body surface area (GFR/SA) was investigated in 108 individuals, and the following formula was derived: GFR/SA (ml/min per 1-73m2SA) = 0-43 Ht (cm)/Pc (mg/100 ml). This formula was tested in a second group of 83 children, and its accuracy and precision was compared to the 24-hour creatinine clearance. It was found to be superior to the creatinine clearance overall, and was as good, even if all results involving suspect 24-hour-urine collections were eliminated from analysis. The formula in SI usage is: GFR/SA (ml/min per 1-73 m2SA) = 38 Ht (cm)1Pc (mumol/l).

Experimental high density optical memory using the dichroic absorption of the m(a) color center

An experimental, high density optical memory using M(A) color centers in KCI has been built to study the application of color centers as read, write, and erase computer bulk memories. M(A) centers are employed as a binary indicator by making use of their ability to reorient in the KCI lattice when excited with either [110] or [110] polarized 531-nm light. Information is read out with circularly polarized 531-nm light. Results indicate that writing times of less than 5 microsec and packing densities exceeding 10(6) bits/cm(2) will be possible in a fully developed system.