Adherence to PKU guidelines among patients with phenylketonuria: A cross-sectional national multicenter survey-based study in Argentina, Brazil, and Mexico.

Objective: To characterize adherence to Phenylketonuria (PKU) management practices among PKU patients treated at reference sites around Argentina, Brazil, and Mexico. Methods: This is a retrospective, observational, multicenter, and multinational survey-based study using aggregate data. From an initial list of 40 sites, 22 clinicians expressed interest in completing the survey, with 20 clinicians from 20 unique sites fulfilling all the study criteria. The Survey contained 28 questions, including respondent's clinic characteristics, clinic PKU treatment recommendations, and patient adherence to clinic recommendations. Survey was available in local languages, and the respondents were asked to consult their clinic records to complete their responses. Adherence was assessed by target blood phenylalanine (Phe), target blood testing frequency, and clinic visits. Results: A total of 1077 (out of 1377) actively managed PKU patients (seen in the clinic in the last 3 years) from 13 clinics in Brazil, six in Argentina, and one in Mexico were analyzed. Upper blood Phe target was set over 360 µMol/L in 70% of the clinics for adult patients. Around 40% of the patients >30 years old had Phe blood tests done twice a year or less, with 60% of the clinics recommending semestral visits for adults <30 years old. Twice a month was the most common frequency of visits for <1 year old. The COVID-19 pandemic was a disruptor for frequency of visits and exams. Conclusions: These results show that there is still room for improvement in terms of adherence, namely in adults and older children. More efforts must be made to educate patients and healthcare professionals about the importance of treatment adherence, accompanied by public policies that expand access to pharmacological and dietary treatment with diversity and quality to improve adherence to adequate blood Phe levels.

Missed opportunities to vaccinate in Peru.

PIP: In October 1995, in Peru, the Ministry of Health (MOH) conducted a follow-up survey of missed opportunities to vaccinate children aged less than 2 years to evaluate the impact of recommendations made following the 1990 survey of missed opportunities. The follow-up survey also examined missed opportunities to vaccinate women of reproductive age with tetanus toxoid. 1784 persons accompanying children aged less than 2 years to a health facility and 4299 women of reproductive age were interviewed at 13 hospitals and 14 health centers in six departmental health units. Vaccination data for the children were collected from vaccination cards (21%) and verbally by the accompanying person (79%). Those for the women were collected from vaccination cards (11%) and verbal histories (89%). Between 1990 and 1995, missed opportunities decreased from 52% to 13%. The reduction was 75% for children aged less than 2 years and 84% for infants. The key causes of missed opportunities were different in 1995 than those in 1990. Between 1990 and 1995 false contraindications increased 60%. Negative attitudes of health workers were responsible for 32% of missed opportunities in 1990, while they were responsible for only 4% in 1995. Other important causes of missed opportunities were policy/logistics (19%) and family attitudes (17%). Missed opportunities were common in 47% of women of childbearing age. The first dose of tetanus toxoid was the most commonly missed dose (40%). Reasons for missed opportunities to vaccinate for tetanus toxoid were policy (31%), personal attitudes (30%), logistics (15%), false contraindications (20%), and health workers' attitude (4%). Based on these findings, MOH developed recommendations to further reduce missed opportunities to vaccinate children and women of childbearing age. For example, training of health workers needs to be improved to reduce the number of false contraindications. MOH must implement strategies to improve accessibility to vaccinations in hospitals.^ieng

Wanted: better care for pregnant women.

In three prenatal clinics in Latin America the average attendance time by pregnant women was 129 minutes but the average time spent with a doctor was only 8-10 minutes. In order to improve prenatal care, providers should analyse what happens during visits. Assessments should be made of the usefulness of the services offered and some thought should be given as to who might best provide them.

PIP: An evaluation of 3 prenatal care clinics in Mexico City, Panama City, and Caracas was conducted to examine the effect of long waiting times before appointments on a woman's decision to continue attending clinics. The clinic in Mexico City had more patients per day than did those in Panama City and Caracas (136 vs. 64 and 102). The average daily hours of operation were more or less equal (5 hours, 35 minutes to 6 hours, 31 minutes). There was a wide range in the average waiting time in the clinics (71-190 minutes), but the average time with clinic personnel was about the same (17-21 minutes). The average time patients had with physicians was short (8-10 minutes). Women with high-risk pregnancies were in the clinics for 81-147 minutes, with clinic personnel for 23-25 minutes, and with physicians for 11-15 minutes. The only slightly improved times for high-risk pregnancies suggested inadequate prenatal care. 34% and 47% of the time physicians spent at the clinics in Panama City and Caracas, respectively, consisted of 2-7 minute long interviews. Physical examinations generally lasted on average about 1 minute. They included measurement of uterine height, blood pressure, fetal heart rate, and vaginal and ankle edema examinations. These findings can help clinic staff identify major administrative and management problems and find ways to resolve them. The length of time with clinic personnel and physicians is not conducive to a sympathetic and considerate attitude. Health providers should encourage women to ask questions and express their views. All clinic staff should work to make the clinic atmosphere welcoming. These program managers should use evaluations to analyze what happens during prenatal care visits and to assess the value of the services provided. They can also use evaluations to determine who can best provide prenatal care services.

The impact of service delivery frequency on family planning program output and efficiency.

Operations research is the study of factors that can be controlled by program administrators. Among such factors is the frequency of performing program activities. The present experiment, conducted in Lima, Peru during 1985-86, tested the impact of holding family planning post sessions once per month, twice per month, and weekly. Frequency was shown to have a major impact on program outputs, costs, and cost-effectiveness. Depending on the indicator, sessions held twice per month produced between 1.5 and 2.1 times the output of those conducted once per month. Weekly sessions produced between 1.3 and 1.6 times the output of those held twice per month. At an output level of nearly 11,200 visits per year, twice-per-month sessions were estimated to be 7-38 percent more cost-effective, depending on the indicator, than once-per-month sessions, and 6-28 percent more cost-effective than weekly sessions.

PIP: Operations research is the study of factors that can be controlled by program administrators. One of these factors is the frequency of performing program activities. The operational variable is the frequency of having clinical sessions in medical back-up posts in a community-based distribution (CBD) program in Lima, Peru. The study covered 42 posts in urban marginal areas of Lima. 3 performing frequencies were compared: 1) once a month; 2) twice a month; and 3) weekly. A randomized block design was used. The study lasted 12 months--from August, 1985-July, 1986. 3 output indicators were chosen: 1) effectiveness; 2) efficiency; and 3) cost-effectiveness. Outputs include program acceptors, total visits, IUD insertions, sessions and family planning (FP) visits. The once-per-month posts finished 98% of scheduled sessions while the twice-a-month and weekly sessions finished 97% and 96%, respectively. Mean duration of the clinic sessions held by the monthly and twice-monthly posts was 2.9 hours (s.d.=.84 and .73, respectively). Mean duration for the weekly group was 2.8 hours (s.d.=.67). About 73% of the FP talks scheduled for the monthly post were really accomplished compared to 66% for the twice-monthly and weekly groups. The 42 posts held 1136 clinic sessions during the year and had 11,196 visits, including 5371 FP visits. 1705 women accepted a FP method at the posts. 77% were IUD takers; 15% chose pills; and 8% accepted barrier methods. There were 4768 IUD visits. There were 414 pill visits and 18% barrier method visits. About 89% of all FP visits were IUD-related. 87% of all IUD insertions were referred by CBD workers and 5% by supervisors. There were 2954 total visits in monthly posts; 3501 in twice-monthly; and 5641 in weekly posts. Output went up linearly with session frequency, but in lesser proportion than the rise in the number of sessions held. Differences are statistically significant for all outputs. Twice-a-month posts had 1.5-2.1 times the output of once-a-month posts; weekly posts had about 1.3-1.6 times the output as twice-a-month posts, depending on the variable chosen. With output level of nearly 11,200 visits per year, twice-a-month sessions were estimated to be 7-38% more cost-effective than once-a-month sessions; 6-28% more cost-effective than weekly sessions.

An assessment of contraceptive need in the inner city.

A survey of low-income areas of Los Angeles County indicates that 41 percent of nonsterile women in their childbearing years who had not made a family planning visit in three years were using some means of birth control, 21 percent were not, 25 percent were not sexually active and 13 percent were pregnant or trying to become pregnant. Given that approximately 10 percent of the respondents were using unreliable means of contraception, at least one-third of respondents were in need of effective contraception. This proportion corresponds roughly to the percentage of respondents who expressed a desire to receive family planning care from a doctor or clinic (34 percent). The percentage of women who were at risk of unwanted pregnancy but not using any method of contraception was greatest among those with incomes below poverty level and among black and Hispanic women. A comparison of survey respondents to a parallel sample of low-income women who had made a family planning visit shows that those who utilized formal family planning services were substantially more likely than those who did not to be married (40 percent vs. 32 percent) and to belong to a health maintenance organization (24 percent vs. 14 percent), whereas nonusers of formal family planning services were slightly older, on average (29.6 years vs. 28.0 years), and more likely to have other types of private health insurance (47 percent vs. 25 percent).(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: A survey of low-income areas of Los Angeles County indicates that 41% of nonsterile women in their childbearing years who had not made a family planning (FP) visit in 3 years were using some means of births control, 21% were not, 25% were not sexually active and 13% were pregnant or trying to become pregnant. Given than approximately 10% of the respondents were using unreliable means of contraception, at least 1/3 of respondents were in need of effective contraception. This proportion corresponds to the % of respondents who expressed a desire to receive FP care from a doctor or clinic (34%). The % of women who were at risk of unwanted pregnancy, but not using any method of contraception was greatest among those with incomes below poverty level and among black and hispanic women. A comparison of survey respondents to a parallel sample of low-income women who had made a FP visit shows that those who utilized formal FP services were more likely than those who did not to be married (40% vs. 32%) and to belong to a health maintenance organization (24% bs. 14%), whereas, nonusers of formal FP services were slightly older, on average (29.6 vs. 28 years) and more likely to have other types of private health insurance (47% vs. 25%). In addition, 95% of those who were at risk of unintended pregnancy and who had made a FP visit were practicing contraception compared with 67% of women at risk of unintended pregnancy who had not made a visit. (Author's modified).

[Community education in perinatal health]. / Educacion comunitaria en salud perinatal

PIP: The National Institute of Perinatology develops educational programs for the population using its services in order to promote positive behavior related to reproduction. One of the most frequently observed problems during prenatal control is patient abandonment of the services offered by health institutions. We present an investigation of the relationship between the educational program for pregnant women offered by the Institute and compliance with prenatal care. A group of 215 patients elected to participate in the educational program. The program consisted of themes on the evolution and culmination of the pregnancy, preparation for nursing, nutrition, developmental milestones, and dental health. Another group was selected at the same time, equal in size to the first but without participation in the course, as a control group. Both groups contained patients categorized in the 3 perinatal risk groups accepted by the Institute.^ieng

The use of oral hydration in the treatment of children with acute diarrhea in primary care.

The use of oral rehydration solutions (ORSs) for treating children with diarrhea is spreading in hospitals in Chile, but it has not yet been incorporated into routine primary care programs. We sequentially compared the effectiveness of an ORS, with 60 mmol/L of Na+, with the standard treatment for diarrhea used in primary care centers, in a study with 285 diarrheal children under 2 years of age who consulted a health center in a low-income periurban neighborhood of Santiago. When compared with the control group, the patients treated with ORS showed a significantly higher percentage weight gain in the first few days after treatment was begun, required fewer medical visits for follow-up treatment at other facilities (8.4 vs. 15.5%; p less than 0.05), and experienced fewer episodes of subsequent clinical dehydration that needed rehydration (oral or intravenous) in emergency services (2.8 vs. 10.6%; p less than 0.01). In addition, there were no metabolic complications in either group. Our results reinforce the feasibility, efficaciousness, and safety of programs that use ORS at the primary care level and indicate that this is an effective method of preventing metabolic complications and reducing hospitalizations of children with acute diarrhea.

PIP: The use of oral rehydration solution (ORS) for treating children with diarrhea is spreading in hospitals in Chile, but it has not yet been incorporated into routine primary care programs. The authors sequentially compared the effectiveness of an ORS with 60 mmol/L of Na+ with the standard treatment for diarrhea used in primary care centers. This was done with 285 diarrheal children under age 2 who consulted a health center in a low-income periurban neighborhood of Santiago. When compared with the control group, the patients treated with ORS showed a significantly higher % of weight gain in the 1st few days after treatment was begun, required fewer medical visits for follow-up treatment at other facilities (8.4 vs 15.5%; p0.05), and experienced fewer episodes of subsequent clinical dehydration that required rehydration (oral or intravenous) in emergency services (2.8 vs 10.6%; p0.01). In addition, there were no metabolic complications in either group. These results reinforce the feasibility, efficaciousness, and safety of programs that use ORS at the primary care level and indicate that this is an effective method of preventing metabolic complications and reducing hospitalizations of children with acute diarrhea.

Help-seeking behavior, use, and satisfaction among frequent primary care users in Santiago de Chile.

PIP: A survey of 140 low-income, urban consumers of primary health care services provided by the public sector at Santiago, Chile's Villa O'Higgins Clinic suggested that organizational factors are more significant predictors of frequency of clinic use and patient satisfaction than demographic characteristics of the clinic population. 73% of respondents interviewed were female; the mean family size was 5, most were from families that fell well below the official poverty level, and 76% of household income went toward food. 29% of the households represented lacked adult men or had unemployed male workers. 66% were acute care patients; the remainder were receiving treatment for chronic conditions such as diabetes, high blood pressure, and alcoholism. 70% had been attending the clinic for the past few years; the mean number of visits per year was 6.4. 53% indicated a preference for a public rather than a private doctor, even if the latter were affordable. Only 51% expressed a dislike of any aspect of the clinic (long waits, 24%; discourteous staff, 19%; and lack of cleanliness, 5%). 84% perceived the quality of the care they received as good; this perception was strongly associated with satisfaction with the physician and receipt of prescription drugs. Multiple regression analysis indicated that 4 organizational variables (travel time to clinic, distance from home to clinic, waiting time at clinic, and travel time-travel distance) and 3 demographic factors (mother bringing child for care, presence of children under 5 years of age, and acute rather than chronic illness) were the best predictors of the frequency of clinic visits. Changes in clinic management by Chile's military government may jeopardize this pattern of high satisfaction with public health services by the poor.^ieng

[Gyneco-obstetrical morbidity in the population of Santiago]. / Estudio de morbilidad ginecoobstétrica en la población de Santiago.

PIP: 1607 women were interviewed about their gyneco-obstetrical health in a survey of 469 randomly selected households in the province of Santiago, Chile. The dependent variables correspond to the frequency of gynecologic or obstetrical morbidity and demand for medical attention in 2 weeks of April, 1987. Independent variables were age, educational status, and health insurance coverage. 125 of the households were headed by uninsured persons. The average woman was 34.4 years old. 43.1% had 8 years or less of education, 42.6% had 9.12 years, and 14.2% had 13 or more years. 21 new cases of acute obstetrical or gynecological disorders were reported, including 15 of vulvovaginitis, 3 abortions, 1 bartholinitis, 1 intrahepatic cholestasis of pregnancy, and 1 urinary tract infection. There were 55 cases of chronic disorders, including 12 benign ovarian lesions, 8 dysmenorrheas, 8 uterine dystropias, 10 cases of menstrual disturbances, 1 of infertility, 4 benign cervical lesions, 5 benign uterine lesions, 2 pelvic inflammations, 2 cervical cancers, 2 breast cancers, and 1 ovarian cancer. Among the 1607 women, 11 had consulted for family planning in the 2 weeks, 25 for pregnancy, 22 for gynecological conditions, and 9 for postpartum care. 58.3% of the women aged 15-49 used a contraceptive method. The proportions of users of oral contraceptives and IUDs respectively were 62.5% and 37.5% for women under 20, 60% and 40% for women 20-29, 27% and 61% for women 30-39, and 15.1% and 60.6% for women 40-49. 28.2% of women over 15 had had a Pap test in the past year. The proportions of different age groups having Pap tests ranged from 2.0% for women under 20 to 46.7% for women aged 30-39. 3 women in the sample households had died in the past year of gyneco-obstetric causes, 1 of complications of childbirth and 2 of cervical cancer.^ieng

The well baby lottery: motivational procedures for increasing attendance at maternal and child health clinics.

A lottery system was used to improve attendance at four well baby clinics in four colonias in Tijuana, Mexico. Mothers earned one lottery ticket for each visit to each clinic during the intervention period. At the end of each month, ticket receipts were entered into drawings for one of three bags of groceries. The lottery system was evaluated within a "multiple baseline design" whereby the intervention was staggered across the four clinics on a month-by-month basis. Although attendance was not enhanced uniformly, an overall improvement of 25 percent was realized. The lottery system was at times hampered by administrative problems, such as the breakdown of a public address system used to announce the open hours of a clinic in one of the colonias.

PIP: A lottery system was used to improve attendance at 4 well baby clinics in 4 colonias in Tijuana, Mexico. Mothers earned 1 lottery ticket for each visit to each clinic during the intervention period. At the end of each month, ticket receipts were entered into drawings for 1 of 3 bags of groceries. The lottery system was evaluated within a multiple baseline design whereby the intervention was staggered across the 4 clinics on a month-by-month basis. Although attendance was not enhanced uniformly, an overall improvement of 25% was realized. The lottery system was hampered by administrative problems, such as the breakdown of a public address system used to announce the open hours of a clinic in 1 of the colonias. The present study shows that behavior modification can serve as an important constituent technique to an overall child survival strategy. However, behavior modification should never be considered in isolation but only with respect to other central requisite components of overall interventions that may be designed for enhancing the health, well-being, or at least survival of children under the age 5 in the world's developing countries.

Improvement in coverage of primary health care in a developing country through use of food incentives.

To improve attendance at mobile clinics for children food incentives were offered to attenders in a rural municipality in northern Nicaragua. Clinic attendance in villages where food incentives were offered was higher than that in control villages (96.5% vs 63.3% of child population, p less than 0.005). When food was later offered in control villages, attendance rose by 60.2% to full attendance (p less than 0.001). Some of the large amounts of non-emergency food aid available could be offered as incentives to increase the use of basic health services in developing countries.

[Vaginitis due to Gardnerella vaginalis in a university medical service]. / Vaginitis por Gardnerella vaginalis en un servicio medico universitario.

PIP: Between August 1983 and June 1984, a total of 363 women were studied who had been referred to the medical service of the School of Bacteriology and Laboratory Clinic of the University of Antioquia, Medellin, Colombia, for obtaining vaginal cytology. They either had or did not have vaginal discharge. The smears were tested for Gardnerella vaginalis and Trichomonas vaginalis. The majority of the patients were in the third, fourth, and fifth decades of their lives: 51%, 24.5%, and 14%, respectively. 104 (28.7%) patients had discharge as ascertained both subjectively and objectively. 74 (20.4%) complained of discharge, but it could not be confirmed objectively; 38 (10.5%) did not have discharge by objective findings; and 147 (40.5%) neither complained of, nor were found to have, discharge. 223 (61.4%) women did not use contraceptives. 56 (15.4%) women used hormonal contraceptives and 45 (12.4%) used IUDs; 20 (5.5%) had undergone tubal ligation; 8 (2.2%) used spermicides and 10 (2.8%) had undergone hysterectomy; and 1 woman used various combinations of methods. 70 (21.8%) had vaginitis caused by Gardnerella, 28 (7.7%) had candidiasis, and 10 (2.8%) had trichomoniasis; 4 cases were associated with Gardnerella and Candida and 2 cases had mixed infection (both Candida and Trichomonas); and 240 (66.1%) patients did not show any kind of bacteria. The following variables were associated with Gardnerella vaginitis (p 0.0001) as opposed to other forms of vaginitis: Gram compatibility with Gardnerella; the pH of the vaginal secretion was 4.51 or higher; the homogeneous aspect of the discharge; the presence of cells and odor; the absence of lactobacilli and Corynebacteria; the positivity of Gardnerella culture; and the absence or low count of leukocytes (p 0.02). 20 (25.3%) of the 79 patients with Gardnerella vaginitis, 3 (10.7%) of the 28 patients with candidiasis, and 2 (20%) of 10 patients with trichomoniasis neither had discharge nor could that be confirmed by speculum examination. On the other hand, 62 (25.8%) of the 240 patients without the etiologic agents of vaginitis did have discharge as ascertained objectively. Of these, 22 (35.5%) displayed congestion and erosion of the cervix.^ieng

Introduction of a home- and clinic-based growth chart in Dominica.

PIP: A description of the Dominican Child Health Passport (CHP) and its clinic-based counterpart are presented. These are adaptions of the World Health Organization (WHO) growth chart. A prototype of the chart was introduced in June, 1980 for a pilot project in the town of Portsmouth. At 7 consequtive child welfare clinics all parents who received a CHP at an earlier visit were interviewed. Questions were asked about some aspects of clinic attendance, the use of and attitude towards the CHP; and understanding of it. The children ranged in age from 1-21 months with a mean of 7 months. 31 parents (61%) had visited the clinic 4 weeks ago (the usual period between visits) and the average was 5 weeks. Weighing was the reason that 49% of the mothers brought their children to the clinic. This could mean that there is already an awareness of the importance of weighing for monitoring child health. Of the 51 parents, only 1 had forgotten the CHP. 10 children possessing a CHP were taken to a doctor. 6 mothers took the CHP along, and on 5 occasions the doctor showed an interest. Opinions on various aspects of the CHP are given. The price--60 cents Eastern Caribbean Currency (=US $0.22) was considered acceptable. Almost all mothers liked to have the CHP at home. However, a substantial % did not like the idea of having child spacing methods entered on the card. 4 CHPs with different weight curves were shown to mothers, who were asked if they would worry about a child who showed the growth pattern indicated. Severe underweight with loss of weight was recognized by 51% of the interviewees. Obesity was not usually considered something to worry about; this is understandable in a place where undernourishment is common in infants. About 1/3 of the respondents recognized the danger if an infant was still in the normal range of weight-for-age but was losing weight.^ieng

The significance of ritual in a church-based healing model.

Four major ritual patterns are exhibited in a church-based clinic in Jamaica that represents a model of collaborative clinical care catering to spiritual, psychological, and orthodox medical needs. Three of the ritual patterns correspond to the three sectors of care, with their different beliefs and values, and this creates tension. The fourth pattern has the potential to be a superordinate ritual that could bring the clinic together in a cohesive approach to the task of health care, but this does not occur, as staff and patients remain bound in their unique sociocultural traditions and heritage.

PIP: The ritual patterns of a church based healing clinic in Kingston, Jamaica were examined. This West Indian clinic is a model of tripartite collaborative clinical care catering to spiritual, psychological, and orthodox medical needs. Due to the fact that these 3 subsystems are founded on different beliefs, values, and traditions, their rituals are naturally dissimilar and have at least some opposing functions. It was hypothesized that the juxtaposition of the subsystems creates tension in the clinic, which negatively affects its functioning. The church that sponsors this clinic is a full and active member of the Jamaica Baptist Union and is located in an urban area of Kingston. The minister and deacons of the church gave their permission for observation of the workings of the healing ministry and to interview the clinic's patients and staff and church members. Each of the 82 patients who attended the clinic during 12 consecutive sessions was invited to an hour long interview, which 39 of them completed. Owing to the incompleteness of clinic records and the nature of the research interviews, assessing how this group compared with other clinic patients was a problem. No patient in the sample was observed in different treatment modalities for the same problem. 4 principal patterns of ritual took place in the clinic. The 1st pattern took the form of a short devotional service, which was held at the beginning of each clinic session and was led by a group of women who were called prayer partners. Most of these women had no special technical skills and little formal education. The 2nd principal ritual occurred within the medical subsystem of the clinic and was conventional and orthodox. Patients were screened by a nurse who took their temperature, blood pressure, and pulse. The 3rd pattern of ritual, performed by the psychological counselors, was geared to helping patients solve their problems in living within a Christian framework. Emphasis was on the development of a practical, problem solving approach. The prayer room was the center of the spiritual activity led by the prayer partners and was the location for the 4th ritual pattern. The ritual was clearly religious. These multiple healing modes are characterized by their distinctively different rituals. Since rituals reflect definite beliefs, values, and traditions, founders of any holistic system need to work hard to devise patterns of activity that reflect a melange of different philosophies. Fostering the success of the opening devotional services as an overarching ritual in the Jamaican clinic would at least helped to faciltate the interaction and assimilation of the 3 healing systems.

Diarrheal diseases, nutritional status and health care: analysis of their interrelationships.

PIP: The relationship between diarrheal disease, nutritional status, and health care was studied prospectively in Guatemalan Indian children 0-24 months of age. Subjects were drawn from the Patulul Project, a nutrition intervention study conducted by the Institute of Nutrition of Central America and Panama. The total population includes 7000 Indians who live on 12 coffee plantations in Guatemala. Data were collected from October 1977 to September 1978 and analyzed by quarter: October-December (dry season), April-June (rainy season), and January-March and July-September (transitional). Most diarrhea was found to occur during the rainy season, yet visits to a simplified health care clinic set up as part of the Patulul Project steadily declined from October to September. The conditional probability of visiting the clinic was calculated at less than 50% for children with either simple diarrhea or diarrhea with blood and mucus. Although there were no sex differences in the rate of diarrhea, boys with gastrointestinal disorders were more likely to be taken to the clinic than girls. When children were grouped by nutritional status (weight-for-age, length-for-age, weight-for-length), the cumulative incidence of and percent time ill with diarrhea with blood and mucus were consistently higher in malnourished children. The magnitude of the differences between nutritional groups was highest during the rainy season. The effects of diarrhea episodes and visits to the clinic on weight-for-age changes were also examined. Children with initially low weight-for-age (or=75%) and with diarrhea during the trimester gained significantly less weight-for-age during that period than children without diarrhea. In addition, children with diarrhea who visited the health clinic gained more weight-for-age than those with diarrhea who did not receive care. Diarrhea and health service utilization had less of an effect on well-nourished children. These results support the hypothesis that the negative nutritional consequences of diarrhea are more significant among malnourished children and demonstrate the positive effect of a simplified health care program on the nutritional status of children suffering from gastrointestinal disorders.^ieng

Contraception and pregnancy after dropping out of family planning clinics: a national interview survey in Jamaica.

PIP: Interviews were conducted among a random national sample of 299 clinic dropouts from the Jamaica National Family Planning Program at least 5 months after their 1st missed clinic appointment. The Health Belief Model is used as a framework for discussion of the findings; this model has been recently modified to allow for "compliance" behavior which considers factors associated with continuing medical treatment. The objective is to determine continued contraceptive practice after dropping out, a measure of "compliance," and the pregnancy experience since visiting the clinic. Of the 299 women, 52.5% had stopped visiting the clinics after 1 or 2 visits; 47.5% had stopped after 3 or more visits; and 35.1% stopped after 4 or more visits. Approximately 90% of the women who subsequently dropped out of the clinic started using contraception after their 1st visit. About 40% of the respondents had used some form of family planning since dropping out of the clinic, and longer contact with the clinic prior to dropping out was strongly associ ated with continued contraceptive practice. It was found that women who continued contraception tended to be older, of higher parity, to have had more education, to have been older at 1st pregnancy, to be married, and to have stopped visiting the clinic because the time was inconvenient. On pregnancy experience since dropping out, only 6 women stopped visiting the family planning clinic because they wanted to become pregnant. Of the great majority of women who did not drop out because they wanted to conceive, over 1/4 were pregnant at the time of the interview. The number of visits to the clinic before dropping out did not correlate with pregnancy. In using the Health Belief Model as it applies to continued clinic attendance, length of attendance at the clinic before dropping out, and contraception after dropping out, a strong relationship was observed between period of clinic attendance prior to dropping out and continued contraception since visiting the cli nic - the more visits before dropping out the better the chance of continued contraception.^ieng