Evaluation of triple touch. An assessment of program delivery.

Triple Touch is a breast health education program developed by the Florida Division of the American Cancer Society in 1994. The program reaches more Florida women each year, and has a larger group of volunteers, than any other breast cancer program sponsored by this American Cancer Society division. The purpose of the evaluation of Triple Touch was to assess and evaluate the program delivery methods of the program. The specific objectives were to identify and describe instructor characteristics, program delivery patterns, and satisfaction with the program. Results will be used for the following purposes: 1) for the future development and implementation of the Triple Touch program; and 2) for building greatly needed research-based knowledge on program implementation and delivery methods. Last, important lessons were learned from using the Collaborative Evaluation Fellows Project model to conduct evaluation research from all perspectives, including those of the evaluation fellow, the evaluation faculty, and the evaluation facilitator.

Man to Man prostate cancer support groups.

PURPOSE: In this report, the authors describe Man to Man prostate cancer support group characteristics and functioning to identify ways to strengthen the program as it expands nationally and internationally. DESCRIPTION OF STUDY: A mail survey of 38 groups in Florida collected data on group meeting practices, facilitator background, training, and perceived needs, and on participant characteristics and satisfaction with the group. Descriptive statistics and bivariate analyses of survey data were performed. RESULTS: Typical groups included both survivors and significant others, met on a monthly basis, and followed a format that combined educational content with sharing of personal experiences. Facilitators and participants alike were typically retired white men in their 60s and 70s from well-educated professional backgrounds, who joined the groups after undergoing treatment for prostate cancer. High levels of satisfaction with the program's organization and functioning were reported. Perceived needs were in the areas of increasing access to support services, achieving a more diverse membership, and better outreach to newly diagnosed patients. CLINICAL IMPLICATIONS: Healthcare professionals can play a key role in informing newly diagnosed prostate cancer patients about the availability of support groups in their communities. Earlier referral to support groups would enhance patients' access to shared experiences and resources for guidance in treatment decisions. Greater attention to psychosocial issues in Man to Man support groups might better meet the emotional needs of patients and families.

Filarial elephantiasis among Haitian women: social context and behavioural factors in treatment.

Few studies have addressed the social and behavioural aspects of lymphatic filariasis. The research reported here investigated the ethnographic context of filarial elephantiasis among women in Léogane, Haiti, and focused on explanatory models of the illness, the impact of the disease on women's lives, and the difficulties patients experienced in following a therapeutic regimen provided at a local hospital. Qualitative data were collected through focus group and individual interviews and direct observation of patients enrolled in the treatment programme. Results indicate that traditional understanding and treatment for the disease are prevalent in the community, although biomedical explanations are gaining credence as a consequence of long-term filariasis control activities in this area. Women's lives are substantially burdened both socially and economically by the physical impairment of elephantiasis, most notably in the loss of income due to restrictions on mobility. The degree of social discrimination encountered varies by the timing of onset of symptoms in the life course. Difficulties encountered with the physical therapy regimen included maintenance of the compressive bandage and availability of suitable foot wear. Similarities between these findings and those reported for other parts of the world are noted. Recommendations from the study cite the need for community education and peer support activities to provide a knowledge base and support structure for current and future intervention programmes.

Maternal employment and preventive child health practices.

BACKGROUND: The impact of maternal employment on preventive child health practices has not been studied empirically. Using a household production model, we investigated the relationship between level of maternal employment and child immunization status, use of automobile seat belts, and use of bicycle helmets. METHODS: Data from a longitudinal study of public school children in Pinellas County, Florida, were used to draw an analytic sample of 4,153 African American and white non-Hispanic children whose mothers responded to school surveys in 1989, 1991, and 1993. Analyses of the relationship between maternal hours worked per week and preventive child health practices were performed using multiple logistic regression procedures, controlling for maternal age and education, household income, ethnicity and gender of child, and number of siblings living at home. RESULTS: No significant statistical relationships were found between maternal employment and child immunization status or use of automobile seat belts. However, maternal employment was significantly associated with bicycle helmet use, after controlling for confounders. Children of mothers who worked less than 21 h per week were 37% more likely to wear helmets compared with children of mothers who worked 21 h or more per week. CONCLUSIONS: Findings suggest that children of full-time working mothers are not at greater risk for under-immunization or failure to use seat belts regularly, but they may be less likely to use bicycle helmets. These results support the hypothesis that employment does not affect episodic child health practices but may have some negative impact on preventive practices involving daily, repetitive activities. It also suggests that the effects of maternal employment may be greater on preventive practices that are nonnormative and occur in the absence of adult supervision.

Cultural feasibility studies in preparation for clinical trials to reduce maternal-infant HIV transmission in Haiti.

A cultural feasibility study is defined as one that investigates scientific as well as ethical, behavioral, and social issues in the design of clinical trials. The value of such a broadly defined assessment is illustrated through the presentation of two case studies conducted to prepare for clinical trials to reduce maternal-infant HIV transmission on Cité Soleil, Haiti. The first study addressed issues surrounding a trial of breast-feeding and exclusive bottle-feeding among HIV seropositive mothers. The second study focused on the implementation of a double-blind trial of HIV immune globulin and standard immune globulin to be administered to infants of seropositive mothers shortly after birth. Both cases used focus group interviews with mothers and in-depth interviews with key informants to investigate AIDS-related beliefs, acceptability of trial participation, risks to subjects, and community reactions and repercussions to the trial. Findings point to the difficulties posed by attempts to conduct trial involving complex research designs in socially disadvantaged populations. Recommendations highlight the need to consider the community-wide impact of a trial, and the need to undertake extensive educational preparation of participants to ensure informed consent and adherence to protocols.

PIP: Cultural feasibility studies use ethnographic methods to explore ethical, behavioral, and social issues inherent in the design of proposed clinical trials. This approach was applied in advance of clinical trials aimed at reducing maternal-infant HIV transmission in Cite Soleil, Haiti. The first focused on conditions that would be necessary to conduct a trial of breast feeding versus exclusive bottle feeding by HIV-positive mothers; the second investigated the feasibility of a double-blind trial of administration of a high- titer antibody preparation--HIV immune globulin (HIVIG)--to infants of seropositive mothers shortly after birth. Study methods included focus group discussions with mothers and in-depth interviews with key informants about AIDS-related beliefs, acceptability of trial participation, risks to subjects, and community repercussions. Concerns identified included the potential negative effect on breast feeding promotion efforts in Haiti, the scarcity of economic means to sustain safe bottle feeding, the risk of being labeled HIV-positive by virtue of study participation, the potential for the HIVIG trial to reinforce the misconception that a vaccine effective against AIDS exists, and problems explaining the concept of a double-blind study and accepting random assignment to treatment and control groups. As a result of these studies, it was decided to conduct the infant feeding study in a community with higher rates of exclusive bottle feeding and lower infant mortality than exist in Cite Soleil. The HIVIG trial could be conducted, but only after extensive community education to ensure informed consent. An objective assessment of subject comprehension was developed for this purpose.

Arrested pregnancy syndrome in Haiti: findings from a national survey.

This report describes findings from a national survey of pregnant women in Haiti regarding the social epidemiology of pedisyon (perdition), or "arrested pregnancy syndrome," a condition believed to be associated with infertility. Data collected on mortality of respondents' sisters were used to indirectly measure the prevalence of this culture-bound syndrome in the adult female population and to compare its distribution in urban and rural areas. Perdition appears to be a fairly common event that affects a large proportion of Haitian women. Reported cases of pedisyon were significantly higher in urban areas, which also differed from rural areas on respondent education, economic status, use of prenatal care, and fertility. No differences were found on sociodemographic, health, or fertility variables when women reporting perdition deaths were compared with women who reported other sister deaths. The utility and limitations of the proxy respondent method are discussed. Possible explanations for the higher rate of pedisyon among urban Haitian women are discussed, and suggestions are made for future research on arrested pregnancy syndrome.

Health professionals and breastfeeding counseling: client and provider views.

Health care providers are the most influential and trusted source of information about breastfeeding, yet many are neither prepared nor able to provide good breastfeeding counseling to their clients. This paper reports findings on low-income mothers' and on providers' perceptions of professional breastfeeding counseling. Data collection included focus group discussions with mothers recruited from public health department clinics in the Southeast USA and who were stratified by age, parity, rural/urban residence and feeding method, and focus groups and individual interviews were conducted with health care providers from the same geographic area. The results of the study indicate a gap between the promotion and support processes for breastfeeding, and point to areas where breastfeeding counseling can be strengthened.

Recognition and management of teething diarrhea among Florida pediatricians.

According to current medical opinion, teething diarrhea (TD) is a myth; yet cross-cultural data document a worldwide distribution of popular belief in the association of frequent, loose stools with tooth eruption. A mail survey in 1990 of 215 pediatricians practicing in Florida investigated beliefs and practices related to TD. Thirty-five percent of respondents believed there is a real association between diarrhea and tooth eruption. When compared with pediatricians who do not believe in TD, these respondents were more likely to be more recent graduates of medical school, to be in general pediatric practice, to be female, to see more patients per week, and to practice in metropolitan areas. The most common explanations for the link between dentition and diarrhea were changes in eating habits, increased salivation, and stress. Respondents reported that both they and the parents of their patients tended to view TD as less serious than other types of diarrhea, and both managed it accordingly. When compared with earlier studies, our findings indicate that belief in TD among pediatricians may have increased since the 1970s. The results suggest a need for more empirical research on the effects of tooth eruption on bowel function.

Group interview methods in community health research.

Scholarly development of group interview techniques within the social sciences has lagged behind the rapid popularization of this method. This article offers conceptual clarification regarding different types of group interviews and analyzes case examples to highlight important methodologic issues in the application of group interviews to community health research. Selected problem areas and desirable future directions in the refinement of group interview methods are discussed. An appendix traces the historical development of focus group interviews in social science research.

Social and psychological costs of preventive child health services in Haiti.

Much of the research on determinants of health service utilization has focused on economic and cognitive variables which influence preventative health behavior. Our ethnographic study of maternal perceptions of the barriers and incentives to immunization use in Haiti underscores the importance of 'hidden' social and psychological costs of utilization, such as embarrassment, fear, child care difficulties, and competing demands on maternal time. Findings from focus group interviews with mothers, individual interviews with health care providers, and observation at health posts identified five categories of maternal factors (competing priorities, low motivation, socioeconomic constraints, fears about health or social consequences, knowledge and folk beliefs) and five categories of system factors (accessibility, acceptability, availability, accommodation, affordability) which can deter immunization completion. The discussion focuses on how these factors influence maternal decision-making regarding use of preventive child health services. More attention is needed on the psychosocial costs of health behavior in developing country settings.

Sexual behavior, smoking, and HIV-1 infection in Haitian Women.

OBJECTIVE: To determine whether a previously observed association between human immunodeficiency virus type 1 (HIV-1) infection and smoking in Haitian women could be explained by confounding high-risk behaviors. DESIGN AND SETTING: A nested case-control study at a primary care health clinic in Cité Soleil, Haiti. PARTICIPANTS: Women who reported having smoked (n = 89) and randomly selected nonsmokers (n = 329) who had participated in a survey 1 to 12 months earlier evaluating risk factors for HIV-1 infection. MAIN OUTCOME MEASURES: Lifetime sexual practices, smoking, health beliefs and practices, and other factors potentially confounding the relationship between smoking and HIV-1 infection. RESULTS: Compared with nonsmokers, smokers reported higher rates of high-risk behaviors, including more lifetime sex partners (P less than .001), being less likely to be married (P less than .01), and being more likely to have visited folk healers (P less than .01). No intravenous drug use was reported, and no significant differences were noted between smokers and nonsmokers in numbers of past surgical or dental procedures or injections. Adjustment for all factors associated with HIV-1 infection and smoking in regression analyses revealed an independent association between smoking and HIV-1 infection (odds ratio [OR], 3.4; 95% confidence interval [Cl], 1.6 to 7.5). Other factors associated with HIV-1 infection included having more than two life-time sex partners (OR, 3.4; 95% Cl, 1.7 to 6.8) and lower socioeconomic status as reflected by a dirt floor in the home (OR, 8.6; 95% Cl, 3.3 to 22.0). CONCLUSIONS: Smoking is a marker for high-risk sexual behavior and is associated with an increased risk of HIV-1 infection in this population. The persistent association between smoking and HIV-1 infection after adjustment for all known risk factors suggests the possibility of a biologic effect of smoking that warrants further evaluation in other populations.

A strategy for promoting breastfeeding among economically disadvantaged women and adolescents.

Best Start is an innovative social marketing approach to promote breastfeeding among low-income women. Focus group interviews were used to identify the determinants of infant-feeding decisions and the most effective strategies for encouraging women to breastfeed. Motivations and perceived barriers related to breastfeeding and social network influences on feeding choice are discussed. The findings were used to design a multifaceted breastfeeding promotion campaign aimed at new mothers, family members, health professionals, and the community at large.

Predictors of smoking among Mexican-Americans: findings from the Hispanic HANES.

BACKGROUND: This report presents findings from the Hispanic HANES on patterns and predictors of smoking in the Mexican-American subsample. Data are drawn from men and women ages 20-74 years who were administered the Adult Sample Person Questionnaire (N = 3,464). METHODS: Four smoking variables (current, ever, former, and daily consumption) are analyzed in relation to sociodemographic measures, including gender, age, marital status, employment status, occupational prestige, income, acculturation, co-workers' smoking, and presence of others in the home who smoke. All analyses were conducted separately for young, middle-age, and older age groups and for males and females. Multiple logistic and multiple regression analyses were performed, controlling for sociodemographic factors, to identify predictors of smoking. RESULTS: The most important factors found to be associated with smoking were the presence of other smokers in the immediate social environment (home and workplace) and the degree of acculturation (particularly among women). Associations with age, income, and marital status were inconsistent across age and gender groups. With minor exceptions, education, employment, and occupational prestige were unrelated to smoking. CONCLUSIONS: These findings support interventions on the basis of age categories, differential acculturation, and social influence, but overall the findings are more striking for their similarity to predictors of smoking in the general population than for their differences.

Use of ethnographic research for instrument development in a case-control study of immunization use in Haiti.

A rapid ethnographic assessment of barriers to health service utilization was conducted to identify maternal factors predicting use of child immunizations in Haiti. Methods included four focus group interviews, four natural group interviews, individual interviews with 14 health care providers and participant observation at vaccination posts. Analysis of qualitative data identified five categories of maternal factors associated with immunization use: competing priorities, low motivation, socioeconomic constraints, perceived accessibility of services, fears about health or social consequences and knowledge and folk beliefs related to vaccines. Selected variables among these factors were incorporated into a survey instrument designed to compare mothers of completely vaccinated children (cases) with mothers of incompletely vaccinated children (controls). The questionnaire was administered to 299 randomly selected mothers (217 cases, 82 controls). Bivariate and multivariate analyses found that of the factors identified through ethnographic research, only vaccine-related knowledge was significantly associated with immunization status. The utility and constraints of using ethnographic research for instrument development in epidemiological studies are discussed.

PIP: A rapid ethnographic assessment consisting of 4 focus groups, 4 natural group interviews, 14 provider interviews and participant observation rally posts was combined into a questionnaire which was tested by chi square for use in predicting which Haitian mothers utilize immunization services. The study population were mothers of 1800 children 12-23 months old in the Mirebalais Area Community Health program in the central highlands of Haiti. The program uses the rally post system, with teams visiting villages at 6-week intervals. Audio tapes and written notes were reduced to lists of all possible barriers to maternal utilization, and then regrouped into 16 categories, under 5 topics: competing priorities, lack of motivation, socioeconomic constraints, perceived accessibility of posts, fears of health consequences and knowledge of folk beliefs about vaccines. 22 questionnaire items were then developed, which were edited by the overall project director without input from the ethnographer. The questions were administered to 299 mothers, 82 with incompletely immunized, and 217 with completely immunized children. The questions which significantly predicted complete vaccination by bivariate analysis were knowledge of the name of 1 or more vaccines or illnesses, the recommended number of doses, and the correct age to begin vaccinations. It was likely that time demands from subsistence farming and income generating activities also affected service utilization, but the women probably interpreted the question on employment incorrectly.

Adoption of oral rehydration therapy among Haitian mothers.

The paper reports findings from a study of mothers' knowledge and use of oral rehydration therapy (ORT) for childhood diarrhea in a mixed urban and rural population in Haiti. From the perspectives of the adoption of a medical innovation and the decision to use it in various situations, we assessed the differential exposure to information about the treatment and identified sociocultural factors which predict ORT knowledge, utilization, and choice between alternative methods of preparation (packaged mix versus home recipe). Three hundred and twenty mothers and caretakers of preschool children were given a questionnaire to compare respondent characteristics and attributes of recent episodes of child diarrhea in relation to knowledge and use of ORT. The data were analyzed with multiple regression techniques to determine which factors had independent effects on 6 outcome variables. Significant effects were found for urban/rural residence; literacy; economic position; use of medical services; conjugal status; and the explanatory model of the effect of ORT. No characteristics of diarrheal episodes had predictive effects in the multivariate analyses.

Smoking among Mexican Americans: a three-generation study.

Smoking behavior was investigated with data from a three-generation study of Mexican Americans in San Antonio, Texas. Rates of smoking among the men were found to be higher than rates for other White men obtained in previous studies, while rates for women were slightly lower than those reported for other White women. However, the percentage of light smokers was considerably higher among Mexican Americans than among other groups. There was no evidence that acculturation was a consistent predictor of greater likelihood of smoking. However, there was evidence that the smoking behavior of younger Mexican Americans, particularly the women, was associated with the smoking behavior of their parents.