Prolonged institutional rearing is associated with atypically large amygdala volume and difficulties in emotion regulation.

Early adversity, for example poor caregiving, can have profound effects on emotional development. Orphanage rearing, even in the best circumstances, lies outside of the bounds of a species-typical caregiving environment. The long-term effects of this early adversity on the neurobiological development associated with socio-emotional behaviors are not well understood. Seventy-eight children, who include those who have experienced orphanage care and a comparison group, were assessed. Magnetic resonance imaging (MRI) was used to measure volumes of whole brain and limbic structures (e.g. amygdala, hippocampus). Emotion regulation was assessed with an emotional go-nogo paradigm, and anxiety and internalizing behaviors were assessed using the Screen for Child Anxiety Related Emotional Disorders, the Child Behavior Checklist, and a structured clinical interview. Late adoption was associated with larger corrected amygdala volumes, poorer emotion regulation, and increased anxiety. Although more than 50% of the children who experienced orphanage rearing met criteria for a psychiatric disorder, with a third having an anxiety disorder, the group differences observed in amygdala volume were not driven by the presence of an anxiety disorder. The findings are consistent with previous reports describing negative effects of prolonged orphanage care on emotional behavior and with animal models that show long-term changes in the amygdala and emotional behavior following early postnatal stress. These changes in limbic circuitry may underlie residual emotional and social problems experienced by children who have been internationally adopted.

"Below their notice": exploring women's subjective experiences of cancer system exclusion.

BACKGROUND: The experiences that marginalized breast cancer populations have in common are rarely considered. METHODS: The authors look across 3 qualitative studies to explore the experiences of older, lower-income, and Aboriginal women diagnosed with cancer and treated by the cancer care system in Ontario, Canada. RESULTS: The research examines critical moments in participants' narratives that parallel one another and are categorized within 2 themes: Not Getting Cancer Care and Not Getting Supportive Care. CONCLUSIONS: Although exploratory, the findings merit attention both for what they tell us about women's experiences, and because they suggest disparities in access to treatment and psychosocial support.

Silenced complaints, suppressed expectations: the cumulative effects of home care rationing.

In many Western welfare jurisdictions, publicly provided home care is being eroded and its provision increasingly individualized. These shifts are of a particular significance for older women, a group for whom supportive home care has been an important buttress against the social and physical jeopardies of old age. A longitudinal, qualitative study of such women in Ontario, Canada, spanned the implementation of managed competition in home care and a period of rapid privatization and service rationing. Study participants experienced cuts and, stemming from increasingly precarious employment conditions in the home care workforce, inconsistent care providers. These changes generated distress, insecurity, and isolation in participants' lives. This article explores how their complaints about insufficient care were silenced: by fear, hopelessness, and the cultural injunction to put a stoic and selfless face on the limitations of old age. Their accounts reveal how large material and discursive shifts and state restructuring come to penetrate identity, feeling, and speech. This examination of the silencing of complaint at home care's front lines reveals the cumulative effects of rationing; it also illuminates how, if heard, service users' voices can inform collective struggles to resist the degradation of home care and reposition older people in relation to the state.

Oral health status, knowledge, attitudes and behaviours among marginalized children in Addis Ababa, Ethiopia.

Data on oral health status in Ethiopia are scarce. We assessed the prevalence of dental decay and gum disease and oral health practices and its barriers. We performed a cross-sectional study using comprehensive questionnaires and oral examination of 132 children aged 6-15 years in Addis Ababa. Mean age was 10 years and 50% were females. A significant number of children were HIV positive and orphaned. Forty-eight percent did not brush teeth and 43% brushed only once daily. The majority consumed sugary food despite knowing its relationship with dental decay. Seventy-four percent had between 1 and 13 dental caries and 52% showed evidence of bleeding upon brushing. Seventy-eight percent did not clean between teeth and were more likely to consume sugary food (p < 0.05) with oral pain within past six months (p < 0.01). In logistic regression, bleeding upon brushing and caries were not predicted by age or gender. We provided oral health trainings with illustrative flip-book, games and interactive discussions. Marginalized children suffer from poor oral health. We recommend national oral health strategies, targeted health education tailored towards Ethiopian societal norms and resources, improving access to local preventive tools and provision of oral care by training community health workers in the World Health Organization basic oral care package.

'You Need Them to Know Your Ways': Service Users' Views About Valued Dimensions of Home Care.

Dominant approaches to evaluating supportive home care tend to be 'top-down,' undertaken from the vantage points of funding bodies and professionals, rather than from the perspectives of service users. A longitudinal, qualitative study of women receiving home care in Ontario, Canada explored their accounts of what constitutes good and responsive care. Participants identified four dimensions of care that they particularly valued: Minimized exposure, being known, staying in charge, and being able to speak. The implications of their perspectives for home care practice, evaluation and organization are discussed.

Community perception, misconception, and discord regarding prevention and treatment of infection with human immunodeficiency virus in Addis Ababa, Ethiopia.

Approximately one million persons infected with human immunodeficiency virus (HIV) live in Ethiopia. Socio-cultural factors influence prevention and treatment adherence. We applied a qualitative descriptive approach to evaluate community perception, knowledge, and the role of spiritual factors in regard to HIV. We conducted 14 focus groups with sampling of HIV+ and HIV- participants (n = 52) by using open-ended questions. We coded and analyzed data for major themes. There are misconceptions, including transmission via casual contact, and pervasive beliefs of holy water as a cure. Many HIV-participants believe treatment is ineffective or incompatible with holy water. Most HIV+ participants believe treatment and holy water can be taken together, but experienced either pressure to stop treatment or stigma when taking medications. Participants emphasized the role of spiritual leaders in directing and shaping community perspectives on HIV. Ongoing community education via local initiatives, nation-wide structural and environmental strategies, and efforts tailored toward Ethiopian society to reconcile treatment with faith are crucial.

"I like to be an informed person but..." negotiating responsibility for treatment decisions in cancer care.

Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients' roles and responsibilities do not however always map neatly onto patients' actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants' complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients' expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine.

Cancer care from the perspectives of older women.

PURPOSE/OBJECTIVES: To understand how older age affects cancer care, from the perspectives of older women. RESEARCH APPROACH: Qualitative, participatory. SETTING: Urban southern region of Ontario, Canada. PARTICIPANTS: Purposive sample (age groups and income) of 15 women diagnosed with cancer at age 70 or older; 10 women were diagnosed with breast cancer, 5 with gynecologic cancer. METHODOLOGIC APPROACH: Two face-to-face interviews, with data analysis in collaboration with the project team based on constructivist grounded theory, including negative case analysis. MAIN RESEARCH VARIABLES: Age, experience of cancer care. FINDINGS: Age-related life and health circumstances intersect with professional practice and wider social contexts and are implicated in treatment decision making, including decisions against treatment, as well as in the day-to-day "getting around" that cancer care requires. CONCLUSIONS: The nursing history should be holistic in scope, attending to the supportive care domains to elicit older women's physical, social, practical, informational, psychological, and spiritual needs after a diagnosis of cancer. History taking should draw forward older women's life contexts and examine these contexts in relation to cancer care, including treatment decision making. INTERPRETATION: Individual-level care and systems advocacy are required to ensure that older women's worries about sustaining independence, including worries generated by inadequacies in home-based care, do not act as determinants of treatment choices.

'You need them to know your ways': service users' views about valued dimensions of home care.

Dominant approaches to evaluating supportive home care tend to be 'top-down,' undertaken from the vantage points of funding bodies and professionals, rather than from the perspectives of service users. A longitudinal, qualitative study of women receiving home care in Ontario, Canada explored their accounts of what constitutes good and responsive care. Participants identified four dimensions of care that they particularly valued: Minimized exposure, being known, staying in charge, and being able to speak. The implications of their perspectives for home care practice, evaluation and organization are discussed.

Elderly people's accounts of home care rationing: missing voices in long-term care policy debates.

Fundamental shifts in state intervention in recent years have resulted in steady curtailment in public provision of community and social care. A longitudinal study of elderly women receiving home care in Ontario explored the reverberations of these shifts in the texture of frail elderly people's lives. Three distinct accounts of negotiating unstable and rationed home care were discernible. "Taking charge" was an active account of women successfully impressing their particular needs and identities on home care provision. "Pushed over the edge" was a vulnerable account of insufficient and depersonalized care in which participants felt themselves practically and emotionally out of control. In "Restraining expectations", women adjusted silently to the shortcomings of home care, stoically making themselves smaller as they found their previous orbits and identities unsupported. Home care's front line emerged as a complex site of struggle for identity and agency--a struggle in which elderly people engage with inventiveness and determination but also with dwindling support, few witnesses and in mounting isolation.

Evaluating acceptability and completeness of overseas immunization records of internationally adopted children.

BACKGROUND: Increasing numbers of families in the United States are adopting children who were born in other countries. Appropriate immunization of internationally adopted children provides a challenge to pediatricians who must evaluate documentation of vaccines administered overseas and fulfill the recommended US childhood immunization schedule. The acceptability of vaccinations received outside the United States was addressed by the Advisory Committee on Immunization Practices in 1994, but few population-based studies assessing these vaccinations have been reported. METHODS: We performed a retrospective cohort study of 504 children who were adopted from other countries and evaluated in 1997 and 1998. Our goal was to determine the acceptability of overseas vaccinations for meeting US immunization requirements. We assessed immunization records for both valid documentation of receipt of vaccine and comparability with the recommended US schedule. We also determined the number of children who were up to date (UTD) for diphtheria-tetanus-pertussis, polio, hepatitis B, and measles-mumps-rubella vaccines under the US schedule. RESULTS: The children's mean age at initial US evaluation was 19 months; 71% were girls, and most (88%) had resided in orphanages. They were adopted from 16 countries, most frequently from China (48%) and Russia (31%). Thirty-five percent (178) of children had overseas immunization records, 167 (94%) of which were considered valid. Most children with valid records (112 [67%] of 167) were UTD for 1 or more vaccine series under the US schedule. CONCLUSION: The majority (65%) of internationally adopted children had no written records of overseas immunizations. Among the 178 children with documented overseas immunizations, 167 (94%) had valid records and some vaccine doses that were acceptable and UTD under the US schedule. Additional research and more specific guidance in the most cost-effective approaches to evaluation of overseas vaccinations are needed to ensure appropriate state-side vaccination and to improve the health of these children and their communities.