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.

Allocation of family resources for health care in rural Haiti.

A household survey of 230 episodes of infant and child illness in rural Haiti was analyzed to identify sociocultural and environmental factors that determine allocation of family resources for health care. The analysis tested the hypothesis that expenditures of time and money would vary according to expectations about the prognosis for the disease in question, the age and sex of the child, the household composition and family structure, and seasonal fluctuations in weather and financial resources. The results show that these factors are significant predictors of resource allocation, although they do not always produce the kind of influence that was hypothesized. The findings emphasize the importance of cultural and ecological variables, as well as of purely medical and economic factors, in understanding family response to illness. The importance of nonmonetary resources (such as the free time available to adult family members) in that response is also indicated. The study has methodological and practical implications for Haiti and other areas.

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.

'New age' healing in the U.S.

This paper provides a conceptual overview of the 'New Age' phenomenon and of 'New age healing,' concepts which have gone virtually unaddressed in social science research, health-related or otherwise. First, drawing upon diverse sources, the authors attempt to define 'New age,' after which they discuss those medical, spiritual, and sociocultural developments which help account for the rise of new age healing in the U.S. Next, a comprehensive review of over a dozen schemata of healing, healers, and medical systems fails to provide a satisfactory classification of new age healing. Finally, by analyzing data derived from primary and secondary source materials on 81 healing systems or techniques identifying themselves with the new age, a typology of new age healing itself is inductively generated. Three general modes are found: mental or physical self-betterment, esoteric teachings, and contemplative practice. These types of new age healing place primary emphasis, respectively, on body, mind and soul.

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.

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.

The health of Hispanics in the southwestern United States: an epidemiologic paradox.

Recent reports in the literature on the health status of southwestern Hispanics, most of whom are Mexican Americans, are reviewed critically. The review is organized into the following sections: infant mortality, mortality at other ages, cardiovascular diseases, cancer, diabetes, other diseases, interview data on physical health, and mental health. Despite methodological limitations of much of the research, it can be concluded with some certainty that the health status of Hispanics in the Southwest is much more similar to the health status of other whites than that of blacks although socioeconomically, the status of Hispanics is closer to that of blacks. This observation is supported by evidence on such key health indicators as infant mortality, life-expectancy, mortality from cardiovascular diseases, mortality from major types of cancer, and measures of functional health. On other health indicators, such as diabetes and infectious and parasitic diseases, Hispanics appear to be clearly disadvantaged relative to other whites. Factors explaining the relative advantages or disadvantages of Hispanics include cultural practices, family supports, selective migration, diet, and genetic heritage. The recently completed Hispanic Health and Nutrition Examination Survey will go a long way to provide answers to many questions regarding the health of Hispanics in the Southwest or elsewhere.

A survey of pediatricians' attitudes and practices about maternal employment.

A survey of 281 members (31 percent) of the Texas Pediatric Society was performed in 1981 to assess members' knowledge of, attitudes toward, and practices regarding mothers who work outside the home. Only 15 percent correctly answered two of three knowledge questions about maternal employment. Thirty-five percent of the pediatricians failed to inquire about maternal employment. Although only 1 percent advised all mothers not to work, 22 percent said that mothers with children at home should not work. Most pediatricians had traditional conservative attitudes and opinions (exemplified by the statement "a woman's place is in the home") in regard to two factors, "acceptability of maternal employment" and "effects of maternal employment on children." More liberal views were associated with more recent graduation from medical school, being a woman, having a working wife, being in favor of wife's working status, and knowledge of statistics concerning maternal employment. These results suggest that if the practices of those Texas pediatricians who responded correspond with other pediatricians' practices in the United States, a large proportion of pediatricians may not be providing adequate support for the 17 million working mothers and their children.

Ethnicity and cancer prevention in a tri-ethnic urban community.

A pilot study of knowledge and behavior regarding primary cancer prevention was conducted in a tri-ethnic urban community. Knowledge of smoking and dietary risk factors was substantial, but awareness of cancer safeguards involving reduced sun exposure and mouth and proctological examinations was low. One of five respondents had taken measures to prevent cancer, and these persons tended to rate their own risk higher than respondents who made no life-style changes. Self-motivated behavior change focused on avoidance of cancer-promoting food. Blacks differed from whites and Mexican-Americans in awareness of cancer cause and prevention, particularly regarding dietary factors and behavior modification. The findings have implications for the design of cancer control measures in multiethnic communities.

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.

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.

Parental evaluations of a sex education course for young adolescents.

Parental evaluations of their children's participation in a school-based sex education program for young adolescents were conducted by interview using a structured questionnaire. Parents were asked questions concerning: course objectives, course content, instructional materials, expectations, perceived effectiveness, and important outcomes of the instruction. The sex education course was six weeks in length, meeting for 50 minutes daily. The program was comprehensive and did not avoid areas typically thought of as controversial. The results indicated parental support for the sex education program and the evaluation provided useful information for program revision. An examination of the findings suggest a paradox in that parents want their children to be informed about sexuality and to be able to make decisions that would avoid problems, but they are uneasy about dealing directly with sexual behavior.

PIP: Parents evaluated their adolescent children's participation in a school-based sex education in Galveston, Texas. Parents rated the frequency of their own sex education activities, the effect of the course on their communication about sexuality with their children, their expectations for course content, and the importance of course objectives. Parents generally agreed with course objectives, thought the course was valuable for their children, reported that it had become easier to communicate about sex with their children, and tended to support course content and materials. Most think that other children should be given a chance to take the course. Although these parents were a self-selected group because they had given permission for their children to take the course, the very positive response has demonstrated support for the program and its expansion to other grades. The controversial nature of some of the materials used in the class shows that, given the chance, parents are likely to support a realistic approach to controversial subjects. Parents often view the biological aspects as the most important area of sexuality for their child to learn, although they also viewed relationships, contraception, emotional aspects, health aspects, and decision making as important. This may indicate a paradox: that parents want their children to be informed about sexuality and to be able to make decisions about sex but may be uncomfortable dealing directly with sexual behavior.

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.

Locus of illness control: a cross-cultural study.

A comparative study of rural Haitian and southern Appalachian health beliefs revealed significant differences both within and between groups regarding perceived control over illness. Data consisted of scores (N = 293) on the Locus of Illness Control Scale, a 15-item forced-choice instrument designed to include two subscales, one focused on illness prevention, the other on cure. Both cultural groups scored more externally on the cure dimension than they did on prevention. Group differences, however, were reversed for the subscales. While Appalachians apparently expect greater success in preventing illness, interestingly, Haitians show greater perceived ability to cure illness. The findings have implications for traditional views of "fatalistic" cultures, for the refinement of concepts related to health locus of control, and for the practical utility of standardized instruments among populations that vary in health problems and therapeutic resources.

Parallel structures in professional and folk health care: a model applied to rural Hati.

The paper argues that professional and folk sectors of pluralistic health care systems share certain structural features that in some respects have equal or greater importance than obvious differences. A model based on the concepts of primary, secondary and tertiary care is adapted to an analysis of both folk and professional domains of the rural Haitian health care system. Ethnographic and survey data are presented to support the position that underlying similarities are evident in patterns of cost, accessibility, specialization, recruitment and training of practitioners in both health sectors. The level of care model provides an analytic framework which gives proper attention to diversity in traditional healing, which is applicable to other health care systems, and which has relevance for the development of primary care resources in developing areas.

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.