Using behavior change to reduce child lead exposure in resource-poor settings: a formative study.

The objective of this formative research was to explore the acceptability and feasibility of changing housekeeping behaviors as a low-cost approach that may reduce childhood lead exposure in Johannesburg, South Africa. Using the Trials of Improved Practices (TIPs) methodology, modified housekeeping behaviors were negotiated with participants who chose the behaviors they wanted to try and then performed them in their homes over 4 weeks. Researchers interviewed them at the end of the month to understand their experience of trying out the behaviors. The modified behaviors offered to each participant were as follows: cleaning window sills with detergent and water, cleaning window sills more frequently, mopping floors with two buckets (one with soapy water for washing and one with clean water for rinsing), mopping floors more frequently, dusting surfaces with detergent and water and dusting surfaces more frequently. Participants found cleaning window sills with soap and water and cleaning them more often the most acceptable and feasible of behavior modifications. Environmental samples showed a significant reduction in lead dust on window sills. These findings can assist in the development of acceptable and feasible medium-term interventions to reduce childhood lead exposure in resource-poor settings until more robust health policies are implemented.

Family violence and its 'adversity package': a community survey of family violence and adverse mental outcomes among young people.

BACKGROUND: Limited research has examined the relationship between common forms of family violence and their impacts. We (1) examine the co-occurrence of exposure to domestic violence (EDV) and physical abuse (PA) in childhood and their relations to intimate partner violence (IPV) in adulthood among the young Thai people, and (2) describe their associations with common adverse mental outcomes. METHODS: A population-based cross-sectional survey was conducted in a community in Bangkok on a representative sample of 1,052 young residents, aged 16-25 years. Measurements were as follows: (1) exposures--the Conflict Tactics Scales were used to assess EDV and PA in childhood and IPV in adulthood, and (2) outcomes--common mental disorder and suicidal ideation were assessed with Clinical Interview Schedule-Revised, illicit drug use with Diagnostic Interview Schedule, and problem drinking with Alcohol Use Disorder Identification Test. RESULTS: Those who reported EDV and PA were highly likely to report IPV (OR 9.3, 95% CI 4.4-19.4). In general, strong associations were found between exposure to each form of the violent experiences and all the adverse outcomes (adjusted odds ratios ranged from 1.7 to 5.7). Those who had been exposed to the three types of violence, compared to none, were most likely to report all the adverse outcomes (odds ratios ranged from 4.3 to 17.3). CONCLUSION: Those who had experienced both kinds of the childhood violence were particularly likely to get re-victimised later in their life. A dose-response relationship was observed between the extent of exposure to violence and the adverse outcomes. There is a need to identify and prevent these experiences and their impact on children and young people.

Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists.

Urbanization in developing countries involves changes in social support and life events which have been shown to affect mental health; mainly depression and anxiety, particularly among low income women. Although depressive and anxiety disorders have a high prevalence and account for a large proportion of visits to primary health services there is little international health research in this field. The determinants, extent and outcome of the association between urbanization and mental health requires multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods is required before effective research can begin. Other issues such as the avoidance of environmental determinism; the separation of macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of research, all need consideration in the development of research into this rapidly emerging, but relatively neglected problem.

Policy directions in urban health in developing countries--the slum improvement approach.

The urban development, or housing, sector has a longer experience of addressing the problems of the urban poor in developing countries than the health sector. In recent years the policy of 'slum improvement', which involves both sectors, has attracted the support of international donors. This article documents the development of the slum improvement approach and addresses key issues of the approach which have implications for health planning: covering the poorest dwellers; relocation; land tenure; gentrification; debt burdens and the impact on women. Questions about the approach which still need answering are defined and a summary of the constraints in slum improvement and potential solutions is presented.

Child malaria treatment practices among mothers in Kenya.

A study of 883 mothers with children aged 0-9 years was undertaken in Kilifi district on the Kenyan coast in order to examine child malaria treatment practices. Quantitative and qualitative methods were used to investigate: whether complications of childhood malaria were recognized; decision-making dynamics in treatment-seeking; and the extent and reasons for the use of proprietary treatment. Childhood malaria was perceived as a mild, everyday illness, not preventable but treatable. The link between malaria and mosquitoes was not recognized. Mothers recognized convulsions, anaemia and splenomegaly but did not link them to malaria. Antimalarial drugs were not given or were withdrawn from children suffering from these conditions. Ill children were treated promptly by purchase of over-the-counter drugs at retail outlets. The health education implications of these findings are discussed.

Health surveys in developing countries: the objectives and design of an international programme.

There have been calls recently for a major international effort to collect epidemiological information in developing countries. One approach to a World Health Survey is considered, namely single-round retrospective interview surveys. Surveys can contribute to the improvement of national health information systems by providing person-based, rather than episode-based, measures related to health that apply to the entire population. A programme of health interview surveys could be used to ascertain patterns of morbidity and mortality, to measure access to and use of health services and to develop and disseminate methodologies for collecting and analysing health related data. Single-round surveys could not be used to evaluate the impact of investments on health and would be of limited use for improving our understanding of the determinants of ill health. Attention is drawn to a number of conceptual, technical and logistic issues to be considered in the design of a World Health Survey.

Private practitioners in the slums of Karachi: what quality of care do they offer?

Private health services have expanded in many developing countries over the last 10 yr. Qualified private practitioners provide basic health care for poorer groups in urban areas, although health care planners frequently criticize them for providing poor quality of care, charging high fees and failing to provide preventive health advice. In Karachi, a large city with more than 400 slums, private practitioners are important providers of care to the poor. This study assessed the nature and quality of care provided by 201 practitioners selected from four districts of the city. Vignettes of specific medical problems were used to assess their knowledge and their practice was measured by observing 658 doctor-patient contacts. The results show that knowledge was closer to accepted medical management than was their actual prescribing practice. On the other hand, their manners and interpersonal behaviour were good. Thus poor prescribing practice, which might equally stem from market influences as lack of knowledge, is the cause of low standards of care. In these circumstances, didactic in-service training to improve prescribing practice is unlikely to be successful.

Evaluation of medical rehabilitation in community based rehabilitation.

Almost all governments and non-governmental organisations in developing countries use a community-based rehabilitation (CBR) approach to work with disabled people. Although disabled people's organisations reject the categorisation of disability in individual terms, 'medical rehabilitation' is still regarded as an important but time limited process within rehabilitation. The paper lists measures and methods used in a comprehensive evaluation, and presents a practical method to examine the quality of medical rehabilitation. The method was developed and applied in an evaluation of service needs and service provision for disabled people in low-income communities, for the Ministry of Welfare, Government of India. The method described is a tracer approach. It assesses quality in three aspects of medical rehabilitation: (i) Technical quality, based on application of minimum technical standards for each impairment. (ii) Interpersonal quality, by observation of service sessions and interviews with service users. (iii) Management (structural) quality, by comparing the rehabilitation goals of service users and service providers. The method differs from most others in that it is process oriented, as opposed to output oriented. The method meets the challenges of providing low-cost assessment of a difficult outcome measure (the quality of medical rehabilitation), within a complex process (CBR). It is anticipated that the tracer method will be useful to the objective evaluation of disability services throughout the developing world.

The referral process and urban health care in sub-Saharan Africa: the case of Lusaka, Zambia.

Much of the current reform of urban health systems in sub-Saharan Africa focuses upon the referral system between different levels of care. It is often assumed that patients are by-passing primary facilities which leads to congestion at hospital outpatient departments. Zambia is well advanced in its health sector reform and this case study from the capital, Lusaka, explores the patterns of health seeking behaviour of the urban population, the reasons behind health care choices, the functioning of the referral system and the users' evaluations of the care received. Data were collected across three levels of the system: the community, local health centres and the main hospital (both in- and out-patients). Results showed those who by-passed health centres were doing so because they believed the hospital outpatient department to be cheaper and/or better supplied with drugs (not because they believed they would receive better technical care). Few users were given information about their diagnosis or reason for referral. The most striking result was the degree of unmet need for health services and the large number of individuals who were self-medicating due to lack of money rather than the minor nature of their illness. The current upgrading of urban health centres into 'reference centres' may provide a capacity for unmet need rather than decongesting the hospital outpatient department as originally intended.

Urbanization and mental health in Brazil: social and economic dimensions.

While there have been attempts to examine urbanization and the quality of urban life as special risk factors in the generation of mental illness, the issue is controversial and remains largely unresolved. In this article particular consideration is given to the process of contemporary structural transformation in the Brazilian society leading to urbanization. Selected Brazilian studies of mental illness in urban areas are described. Economic displacement, or unemployment, emerges as the most significant risk factor for mental ill-health and is more important than, for example, rural to urban migration. Current studies are then criticized for focusing too much on the search for single risk factors instead of taking the social, structural context into account.

From chronic emergency to development: an analysis of the health of the urban poor in Luanda, Angola.

There is a dearth of published literature on health care systems in Angola. Like many sub-Saharan African countries, Angola is experiencing rapid urbanization. The authors provide an analysis of the health status, environmental health conditions, and health-related behavior of the urban poor in Luanda, Angola. Although data are patchy and rarely disaggregated to reveal severe conditions in the shanty towns, a grave picture emerges. An average infant mortality rate of 104/1,000, with malaria and intestinal infections the main causes of death in children under 1 year old, reflects the poor environmental conditions, which are worsening as urbanization continues at a rapid rate. Use of health services is limited; for example, 50 percent of women give birth at home, mainly unassisted, and only 28 percent of children are covered by measles immunization (as validated by card). A discussion of existing health strategies, programs, and their constraints is set in the context of the future possibilities of the ending of the 15-year war and the introduction of structural adjustment policies.

[An intra-community profile of nutritional deficiency: a study of children under 5 years of age in a low-income community in Rio de Janeiro (Brazil)]. / Perfil intracomunitário da deficiência nutricional: estudo de crianças abaixo de 5 anos numa comunidade de baixa renda do Rio de Janeiro (Brasil).

This study is part of a larger epidemiological study concerned with the health status of children under the age of five carried out in the squatter settlement of Rocinha, and focuses on the nutritional profile of a representative sample of 591 children. According to the weight-for-age criteria (Gomez's classification), 23.9% and 2.0% were, respectively, mildly and moderately malnourished. This finding is in agreement with the assessment using weight-for-height and height-for-age as anthropometric indicators: (a) absence of acute malnutrition (wasting) indicated by a pattern overlapping that of an expected normal population, and (b) growth deficiency (stunting) indicated by 7% and 15% of children exceeding the proportion normally expected to be, respectively, below the -1 and -2 standard deviate limits. So far as growth failure was concerned, the following variables remained associated even when controlling for economic status (indicated by the environmental conditions of the household): low birth weight, number of siblings equal to or above three, male gender, a history of never having breastfed and a family history of previous sibling death. Each variable is discussed separately, as well as the overall nutritional profile and the marked social intra-community stratification related to growth deficit.

Maternal mobility across the rural-urban divide: empirical data from coastal Kenya.

This paper describes the mobility patterns, rural-urban linkages and household structures for a low-income neighbourhood on the outskirts of Mombasa, Kenya's main port, and a rural settlement 60 kilometres away. Drawing on interviews with a sample of mothers resident in each location, it documents their perceptions of the advantages and disadvantages of rural and urban life, and shows the continuous interchange between the two areas. It also highlights how most rural to urban migrants are familiar with urban environments before moving and how, having moved, many maintain strong rural ties. The ways in which households are split across rural and urban areas is influenced by intra-household relations and by household efforts to balance the income-earning opportunities in town, the relatively low cost of living in rural areas and future family security. This produces dramatic differences between and among rural and urban mothers and suggests a need for policy makers and planners to recognize diversity and to build upon complex livelihood strategies that span the rural-urban divide.

The implementation of the healthy cities project in developing countries: lessons from Chittagong.

PIP: The Chittagong Healthy City Project was carried out in late 1994 in Chittagong, Bangladesh. This paper presents findings of an evaluation of the project based upon internationally generated process indicators related to the institutional aspects of the project. The following issues are discussed with regard to project implementation: the institutional organization of local authorities, institutions' conceptual understanding of the project, formal insertion of the project into public authorities' activities, institutional leadership of the project, central-local relations, the lack of interministerial coordination, the project's office, international projects, and community organization. Giving consideration to these issues may help program planners detect problems in forthcoming projects prior to their implementation.^ieng

From research evidence to policy: Mental health care in Viet Nam.

PROBLEM: The use of evidence-based policy is gaining attention in developing countries. Frameworks to analyse the process of developing policy and to assess whether evidence is likely to influence policy-makers are now available. However, the use of evidence in policies on caring for people with mental illness in developing countries has rarely been analysed. APPROACH: This case study from Viet Nam illustrates how evidence can be used to influence policy. We summarize evidence on the burden of mental illness in Viet Nam and describe attempts to influence policy-makers. We also interviewed key stakeholders to ascertain their views on how policy could be affected. We then applied an analytical framework to the case study; this framework included an assessment of the political context in which the policy was developed, the links between organizations needed to influence policy, external influences on policy-makers and the nature of evidence required to influence policy-makers. LOCAL SETTING: The burden of mental illness among various population groups was large but there were few policies aimed at providing care for people with mental illness, apart from policies for providing hospital-based care for people with severe mental illness. RELEVANT CHANGES: The national plan proposes to incorporate screening for mental illness among women and children in order to implement early detection and treatment. LESSONS LEARNED: Evidence on the burden of mental ill-health in Viet Nam is patchy and research in this area is still relatively undeveloped. Nonetheless the policy process was influenced by the evidence from research because key links between organizations and policy-makers were established at an early stage, the evidence was regarded as rigorous and the timing was opportune.

Health of the urban poor in developing countries.

The urban poor are at the interface between underdevelopment and industrialization and their disease patterns reflect the problems of both. From the first they carry a heavy burden of infectious diseases and malnutrition, while from the second they suffer the typical spectrum of chronic and social diseases.

Urbanization and health in developing countries.

In developing countries the level of urbanization is expected to increase to 39.5% by the end of this century and to 56.9% by 2025. The number of people living in slums and shanty towns represent about one-third of the people living in cities in developing countries. This article focuses upon these poor urban populations and comments upon their lifestyle and their exposure to hazardous environmental conditions which are associated with particular patterns of morbidity and mortality. The concept of marginality has been used to describe the lifestyle of the urban poor in developing countries. This concept is critically examined and it is argued that any concept of the urban poor in developing countries being socially, economically or politically marginal is a myth. However, it can certainly be claimed that in health terms the urban poor are marginal as demonstrated by some of the studies reviewed in this article. Most studies of the health of the urban poor in developing countries concentrate on the environmental conditions in which they live. The environmental conditions of the urban poor are one of the main hazards of the lifestyle of poor urban residents. However, other aspects of their way of life, or lifestyle, have implications for their health. Issues such as smoking, diet, alcohol and drug abuse, and exposure to occupational hazards, have received much less attention in the literature and there is an urgent need for more research in these areas.

PIP: This article reviews some of the literature of the health of the urban poor in developing countries. Some studies focus on environmental conditions, others on personal lifestyles such as smoking, diet, alcohol and drug abuse, and most are descriptive. Poverty is the prevalent condition. The characterization of the urban poor, particularly those in squatter settlements, is one of the being socially and politically marginal with lack of skills and education. This stereotype belies the economic conditions that drive the poor to migrate to urban areas. This population also is integrated in the economic and political life in the informal sector. Their health however is marginal. Studies in Manila, Philippines and Buenos Aires, Quito, Colombo, and Pelotas, Brazil have demonstrated that mortality rates are associated with socioeconomic status or geographical areas as a proxy for status (slums, squatter areas). Intermediate variables are rarely incorporated in the models. There are also studies of intraurban differentials in mortality and morbidity, particularly due to infectious diseases, but not necessarily airborne diseases. Nutritional status studies also receive attention since measurement guidelines are available. Cause of death studies are problematic because of classification problems. The picture presented is one of the urban poor suffering the worst of both the developed and the developing world, chronic diseases such as cardiovascular disease and infectious diseases and neonatal deaths. Studies also investigate the at risk populations. The 5 population suffer similar mortality and morbidity as rural areas, but there is little available on 5-19 year olds. Also missing is data on women and workers in particular occupations. Presently, 33% of urban city dwellers live in slums or shantytowns. Urbanization is expected to increase from 33.9% in 1990 to 39.5% by 2000 and 56.9% by 2025. A summary table or urban poverty research is provided which indicated the author, the year, the location, the population investigated, and findings and comments.

The explanatory models of mental health amongst low-income women and health care practitioners in Lusaka, Zambia.

There is currently much debate about the cultural construction and specificity of mental health. It is thus not surprising that explanatory models, which look at the meaning of illness for those suffering from it, have been widely used within the mental health field. This paper considers the significance of explanatory models and presents a study comparing the explanatory models of mental ill health used by urban women in low-income groups and local health care practitioners in ZAMBIA: To measure mental ill-health status, an instrument recommended by the World Health Organization was used - the Self Reporting Questionnaire, 20 items (SRQ 20). To obtain explanatory models, Kleinman's classic eight questions were adapted. The terms used by the practitioners to define and explain the mental health problems of women in low-income groups were 'stress and depression', with these two concepts being used interchangeably. In contrast, the phrase most frequently used by the women was 'problems of the mind'. The professionals regarded the experience of depression itself as a manifestation of ill health. For the women, however, only the physical symptoms were defined as ill health. There was a common agreement, however, that the women's socioeconomic situation as a major causal factor. Both groups identified the home environment as a key determinant, particularly the quality of marital relationships. Greater awareness of explanatory models may have beneficial effects on mental health policy and planning, both at national levels (where recognition of the true prevalence and burden of mental ill health should have an impact on public health policy) and at the level of local implementation (where training of health professionals to take patients' explanatory models into account might contribute towards the diagnosis of mental health problems).

Urbanization and mental health in developing countries.

PIP: It is expected that the urban population in developing countries will double in the next 30 years. While urbanization is accompanied by health problems, population density can lower public health costs. Common mental disorders, such as anxiety, depression, insomnia, fatigue, irritability, and poor memory, account for 90% of all mental disorders, cause behavioral problems in offspring, and impede recovery from physical ailments. Those who suffer most from common mental disorders include women, those between 15 and 49 years old, and low-income populations. Strong links have been established between socioenvironmental factors and common mental disorders, and an urban environment has been associated with many possible risk factors for such disorders. Only a small percentage of people with mental disorders seek primary health care and even less receive secondary- or tertiary-level care. Common mental disorders place a large burden on primary health care services, however, but most of the patients suffering from mental disorders seek care for physical disorders that mask proper diagnosis and treatment. Thus, the World Health Organization advocates the introduction of mental health components in primary health care services in developing countries. In order to reach those who remain outside of the health care system, community-based interventions such as self-help groups or efforts to promote wider social changes or address poverty should be undertaken. Mental health in developing countries is gaining attention as the attendant loss in economic productivity of human capital has become apparent.^ieng