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Folate knowledge, intake from fortified grain products, and periconceptional supplementation patterns of a sample of low-income pregnant women according to the Health Belief Model.

OBJECTIVE: This study assessed folate-related knowledge and behaviors and folate intake from grain products, assuming 1998 fortification requirements, of socioeconomically disadvantaged pregnant women. DESIGN: Interviews (based on the Health Belief Model) concerning folate and neural tube defects were conducted in a prenatal care clinic. SUBJECTS/SETTING: The convenience sample of 251 low-income, predominantly minority, pregnant women received services in an Atlanta, Georgia, public hospital. All subjects were eligible for or enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children. STATISTICAL ANALYSES: Frequency counts, means, and standard multiple linear regression. RESULTS: More than 80% of subjects did not take supplements preconceptionally. Many subjects (57%) had heard of folate, but fewer could correctly define folate (26%) or list any food sources of folate (30%). Most subjects (77%) will be able to achieve the goal of 400 micrograms folate per day exclusively through intake of fortified grain products. Approximately 20% of subjects will consume in excess of 1,000 micrograms folate per day solely through intake of fortified grains. Preconceptional use of supplements and several indicators of subjects' knowledge about folate were correlated with Health Belief Model constructs in manners consistent with the model framework. APPLICATIONS/CONCLUSIONS: This population of low-income women is likely to benefit substantially from folate fortification of grain products. However, health education remains essential for those women who are still unable to meet their folate requirements. The Health Belief Model may serve as an effective framework for tailoring folate educational interventions to high-risk populations. Research must be conducted into the risks of long-term high intakes of folate.

Adolescent↗

Income taxes and the timing of marital decisions.

"In this paper we estimate the impact of the [U.S.] federal individual income tax on the timing of marital decisions.... Using household data from the Panel Study on Income Dynamics, we estimate various models of the probability of delaying marriage as a function of the change in tax burden caused by marriage (as well as several other variables). We find that there is a significant positive relationship between the marriage penalty in a year and the probability of delaying marriage until the following year. The magnitude of the effect, however, is small."

Americas↗

Income poverty, poverty co-factors, and the adjustment of children in elementary school.

Since 1990, there have been great advances in how developmental researchers construct poverty. These advances are important because they may help inform social policy at many levels and help frame how American culture constructs poverty for children, both symbolically and in the opportunities children and families get to escape from poverty. Historically, developmental perspectives have embodied social address and main effects models, snapshot views of poverty effects at single points in time, and a rather narrow focus on income as the symbolic marker of the ecology of disadvantage. More recent views, in contrast, emphasize the diverse circumstances of disadvantaged families and diverse outcomes of disadvantaged children, the multiple sources of risk and the multiple determinants of poor outcomes for these children, dynamic aspects of that ecology, and change as well as continuity in outcome trajectories. The advances also consist of more powerful frames for understanding the ecology of disadvantage and the risk it poses for child outcomes. Most developmental researchers still tend to frame causal variables ultimately in terms of the dichotomy between social causation and social selection views, with a primary emphasis on the former. In part, this framing has reflected limitations of sample size and design, because the theoretical and empirical power of reciprocal selection models is clear (Kim et al., 2003). The conceptual advances that prompt such models include widespread acknowledgement of third variable problems in interpreting effects, of the clear need for multivariate approaches, and the need to pursue mechanisms and moderators of the relations between causal candidates and child outcomes. In the context of these advances, one of the core goals of our research program has been to construct robust representations of environmental adversity for disadvantaged families. Most of our research focuses on contextual co-factors at a family level (e.g., maternal relationship instability), which either have not been described by many researchers or have been described in a way that does not fit the ecology of disadvantage (e.g., marital status). We found that income poverty, key contextual co-factors, and endogenous child attributes tend to show independent and selective associations with child academic competence and externalizing behavior, and that co-factor effects tend to be direct rather than mediated by harsh parenting, tend to have effects that are episodic and concurrent, and are easily- and well-represented by multiple risk indexes that bear powerful relations to child problem behaviors. A second core goal has been to better understand the developmental construction of poor outcomes for disadvantaged children, which requires consideration of dynamic aspects of the ecology and the potential importance of the timing of risk experiences. We found that family instability and change in environmental circumstances predict increases in problem behaviors, and that dose of adversity seems to matter for some variables if it is recent, and not for other variables. Through person-centered research, we also are beginning to understand some factors that seem to underlie the convergence of adjustment problems over grade in school. Many of our co-factor findings and many of our developmental findings seem both complex and double-edged. One edge is that they encourage a certain pessimism in showing how environmental adversity progressively constructs poor outcomes for disadvantaged children in school. Overall, for instance, we saw more problems and more multi-dimensional problems in fifth grade than in first grade, and the impact of environmental change was mostly negative. The other edge, however, is more positive in reflecting the possibility of discontinuity in child adjustment problems associated with positive changes in family circumstances. Findings for minimal persistence and for the strength of recent and concurrent effects argue that the possibility of self-righting and emergent competence in school is robust through the fifth grade even for the most problematic disadvantaged children.

Achievement↗

Breast cancer screening among ethnically diverse low-income women in a general hospital psychiatry clinic.

Most low-income minority women do not obtain screening mammography on a regular basis. Compliance with recommended breast cancer screening guidelines may be even lower in women with psychiatric illnesses. We investigated compliance with breast cancer screening guidelines among 121 ethnically diverse low-income women recruited from a general hospital psychiatry clinic. Mammography and clinical breast examination (CBE) had been obtained in the previous year by 59% and 70% of the patients 40 years of age and older, respectively. Among patients 20 years of age and older, 42% reported monthly breast self-examination (BSE). Physician recommendation of mammography was the strongest predictor of having obtained both a mammogram and a CBE within the previous year. There was an inverse relationship between breast cancer knowledge and screening mammography. Patients who were Hispanic, more educated, more confident in performing BSE, and whose physicians recommended monthly BSE were more likely to perform BSE monthly. These results highlight the importance of physician recommendation of compliance with screening guidelines for early detection of breast cancer. Because psychiatric patients typically are treated by psychiatrists on a regular and frequent basis, psychiatrists are in a unique position not only to encourage cancer screening but also to monitor patient compliance with their recommendations.

Adult↗

Development of a 'communication disability model' and its implication on service delivery in low-income countries.

This paper argues that higher priority should be given to the development of services which support people with communication disabilities in low income countries and that these services should be different from those in other countries. Present services for this population group have poor coverage levels, tend to be centrally located and are orientated to specialist services. WHO (Health Programme Evaluation, Geneva, WHO, 1981) argue that health services should be based on meeting people's needs. This paper describes an analysis of 'needs related' qualitative data concerning people with communication disabilities and their families in two low income countries and examines the results in relation to service development. The data was collected as part of five different studies concerning people with communication disabilities carried out in Uganda and Nigeria. Using the principles of established theory, these data helped develop, a theoretical model. This model is compared with WHO's classification of Impairment Disability and Handicap ICIDH-2 WHO (International Classification of Impairments Disabilities and Handicaps (ICIDH-2), A manual of classification relating to the consequences of diseases, Geneva, WHO. 1997a; 1999). Suggestions are made as to how this model might inform planning and practice from the perspective of the five major stakeholder groups; government and non-government organizations, people with communication disabilities, their families and professionals. Consideration is also given as to how this theory can be used to strengthen existing services, or encourage a complete paradigm shift, with the creation of different services in new and innovative ways.

Adult↗

Improving antibiotic use in low-income countries: an overview of evidence on determinants.

The inappropriate use of antibiotics has often been identified as a problem in effective health care delivery. High levels of antibiotics use, often clinically unnecessary, have led to a steady increase in drug resistance. Low-income countries, home to the majority of the world's population, are believed to have an important role in this phenomena. Effective intervention in these practices is often constrained by the paucity of information on determinants of antibiotic use. This review provides information from studies on the factors that influence the use of antibiotics by health providers, dispensers and community members in low-income countries. A proper understanding of these factors should be seen as a precondition for the development of more effective policies and programmes to address inappropriate antibiotic use. The review encompasses physicians' practices, the role of drug dispensers, and the influences on patterns of drug use across community members. Although a set of papers with useful research data was identified, probably the most important finding of the review was the scarcity of research. If interventions into antibiotic use are to be effective, future research must explore in more depth the socio-cultural rationality of antibiotic usage. The most productive approach would be to combine quantitative studies of the patterns of antibiotic use with the rich variety of qualitative methods like case simulations, focus group discussions, in-depth interviews, informal interviews, or illness diaries to explore determinants.Research programmes alone are unlikely to improve antibiotic use. Priority programme activities would include a carefully designed mix of activities by governments, health delivery systems, health training institutions, professional societies, pharmaceutical companies, consumer organisations, and international organisations. Strategies that lean too heavily on professional education are unlikely to result in large-scale or long-lasting improvement.

Anti-Bacterial Agents↗

Low-income mothers' views on breastfeeding.

Nourishing infants presents women today with choices, desires, obligations and constraints. Despite mounting evidence about the health, psychosocial and societal benefits of breastfeeding both for women and infants, current breastfeeding rates worldwide are far from optimal, particularly among low-income women. Many mothers choose to use infant formula. Drawing from structured interviews with 154 mothers from an urban low-income multiethnic population in the United States, a typology of mothers' feelings about their infant feeding method is developed. Findings indicate that regardless of their feeding method, mothers tended to attribute higher health benefits to breastfeeding and perceived community norms as probreastfeeding. They differed in their rating and perceptions of logistics and the extent to which benefits mattered in their infant-feeding decision. Contradictions associated with the practice of breastfeeding even among mothers who breastfed, were reflected in their perceptions of social disapproval of breastfeeding in public, reports of ridicule by friends, lack of support from some health providers, and difficulties associated with working. A typology of mothers' emotional states resulting from such contradictions summarizes the findings and underscores how some mothers who did not, but would have liked to breastfeed, may be subjected to feelings of guilt and deprivation. Implications for educational interventions are to amplify prenatal infant feeding consultations and address ways to overcome logistical and apprehension barriers.

Bottle Feeding↗

Surviving physical and sexual abuse: what helps low-income women?

OBJECTIVES: This paper contributes to the growing literature on help-seeking among women who experience violence. METHODS: We interviewed 390 low-income women who reported experiencing physical or sexual violence during adulthood, half of whom were infected with HIV. We obtained information on actions taken in response to episodes of violence and for leaving abusive relationships. RESULTS: A substantial proportion of women could predict an oncoming episode of violence; although the majority took some action either before or during the violent episode, almost 20% took no action at that time to protect themselves. Although family and friends were the greatest source of help for leaving violent relationships, the majority of women who left their abusers, 70%, did not receive assistance. Jobs and education were identified services that would help women leave abusive relationships. CONCLUSIONS: There is need for more services for low-income women experiencing violence that focus on safety and on supporting and promoting financial independence.

Adolescent↗

Quality of diabetes care among low-income patients in North Carolina.

BACKGROUND: Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina. METHODS: Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics. RESULTS: Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease. CONCLUSIONS: This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.

Aged↗

Depression, anxiety, and associated health status in low-income Chinese patients.

BACKGROUND: Little is known about the prevalence of mental disorders and the associated impact on health status in low-income immigrant Chinese Americans. METHODS: This cross-sectional study surveyed low-income Chinese patients attending a community health center in Chinatown (New York City) from July through November 2001 to determine the prevalence of depressive and anxiety disorders. Selected modules translated into Chinese from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ), a self-administered measure designed to diagnose mental health disorders in primary care, were used. To assess the relationship between mental disorders and health status and to examine convergent validity, mean scores on the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were examined according to PHQ diagnoses and calculated severity of depression. RESULTS: A total of 856 patients were approached and data were obtained from 523 (61%) eligible participants. Thirty-two (6.1%) patients met the established criteria for major depressive disorder; 26 (5.0%) patients met the criteria for other depressive disorder; and 24 (4.6%) patients met the criteria for other anxiety disorder. Compared to patients without depression or anxiety, patients with major depressive and other anxiety disorder had significantly lower mean scores on all eight SF-36 subscales, while patients with other depressive disorder had lower mean scores on all subscales except for physical functioning. SF-36 subscale scores tended to decrease with increasing depression severity. CONCLUSIONS: Depression and anxiety were prevalent and demonstrated an adverse impact on health status, as measured by the SF-36. Strategies for screening for mental disorders may vary depending on the needs of the primary care setting and may be accomplished using a general health status measure or a disease-specific approach.

Adult↗

Impact of the Advisory Committee on Immunization Practices' 4-day grace period in a low-income community.

BACKGROUND: In 2002, the Advisory Committee on Immunization Practices (ACIP) recommended vaccine doses administered < or = 4 days before the minimum age or interval be counted as valid. The study objective was to assess the impact of the 4-day grace period on the need for revaccination and associated costs in a low-income community, compared to standard practice (i.e., repeating all doses that fall outside current ACIP guidelines). METHODS: From 1999 to 2001, semi-annual immunization assessments of 8293 randomly selected children, aged 19-35 months, were conducted at a 16-practice network serving an underserved community in New York City. Outcome measures were rates of antigen-specific invalid doses and number of children needing revaccination, with and without the 4-day grace period. Revaccination costs were based on the Vaccines for Children (VFC) price list. RESULTS: The 4-day grace period reduced the number of children needing revaccination from 17.1% to 12.0%, a drop of 30%. The rates of invalid doses decreased from 1.9% to 1.3%, a drop of 33%. Invalid doses for hepatitis B (HepB)-2 decreased by two thirds (69.7%); for diphtheria-tetanus-acellular pertussis (DTaP)-1, Haemophilus influenzae type b (Hib)-1 and Hib-3 by half (44.9%-50.0%); for Polio-1, Polio-2, Polio-3, and measles-mumps-rubella (MMR) by one third (31.6%-33.3%); and for DTaP-2, DTaP-3, HepB-3, and varicella by nearly one quarter (20.0%-24.0%). At these rates, revaccinating 100,000 children younger than age 3 years would cost 213,588 dollars per year, compared to 152,539 dollars with the 4-day grace period, in vaccine costs alone. CONCLUSIONS: In a low-income community, ACIP's 4-day grace period made a significant impact on the number of children requiring revaccination and on revaccination costs. However, the number of children needing revaccination remains high.

Child, Preschool↗

Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents.

CONTEXT: Rapid repeat pregnancy (RRP) among adolescents, usually defined as pregnancy onset within 12-24 months of the previous pregnancy outcome, has frequently been the target of public health interventions, due to the exacerbation of negative consequences associated with recurrent adolescent pregnancy (and more specifically with childbearing). OBJECTIVE: To examine what, if any, relationship exists between RRP and the experience of interpersonal violence and abuse among low-income adolescents at one semi-urban health center. DESIGN: Case-control study using retrospective chart review. PARTICIPANTS AND SETTING: 100 women aged 13-21 who received prenatal care at one independent nonprofit health center that serves adolescents and their children from June 1994 through June 1996. MAIN OUTCOME MEASURES: Number and timing of pregnancies, occurrence of physical or sexual abuse; other psychosocial risk factors were evaluated. RESULTS: In this population, the experience of any form of physical or sexual violence during the study interval was associated with RRP within 12 months (p = 0.01, OR = 3.46) and 18 months (p = 0.013, OR = 4.29). Other previously reported predictors of RRP, including family stress, financial stress, and other environmental stressors did not reach statistical significance at either 12 months or 18 months in this sample. Of additional note, young women who experienced any form of abuse during the 12-month study interval were substantially more likely to miscarry than were their nonabused peers, and spontaneous abortion was also very strongly associated with RRP (p < 0.00001; OR = 22.6). CONCLUSIONS: The experience of interpersonal violence is correlated with rapid repeat pregnancy among low-income adolescents. This study strongly suggests a need for both extensive screening for partner and family violence among pregnant and postpartum adolescents, and follow-up safety planning support in combination with family planning interventions.

Adolescent↗

Addiction recovery for low-income pregnant and parenting women: a process of becoming.

A naturalistic field study of low-income women (N = 17) in an intensive outpatient addiction recovery program addressed the question: What is the nature of addiction recovery for pregnant and parenting-women in an addiction treatment program? Grounded theory methodology was used to determine the nature of the interpersonal and social processes that define addiction recovery for women in this study. Over 2 years, audiotaped semi-structured interviews, document reviews of medical records, treatment progress and group therapy notes, and participant observation notes were collected and analyzed. The constant comparison method of analysis involved an ongoing process of theoretical sampling, memoing, and open and then axial coding to identify, group, link, and reduce the categories produced. A developmental model of addiction recovery in pregnant and parenting women emerged that consisted of the dimensions of becoming drug and alcohol free, a partner in a relationship, a person, and a parent. These four dimensions parallel and transform each other, yielding different outcomes but similar patterns over time. This model of addiction recovery provides a beginning framework for understanding the transactional nature of addiction recovery for low-income women who are adapting to a drug and alcohol-free lifestyle and the task and role of parenting a newborn.

Female↗

Prevalence and correlates of early smoking among elementary schoolchildren in multiethnic, low-income inner-city neighborhoods.

PURPOSE: The prevalence and correlates of early smoking were investigated among schoolchildren in grades 4-6 living in multiethnic, low-income neighborhoods in Montreal. METHODS: As part of the evaluation of a school-based heart health promotion program, baseline data on the prevalence of early smoking were collected from 2285 students aged 9-13 years in 24 inner-city elementary schools during May-June 1993. RESULTS: Overall, 28.7% of boys and 20.3% of girls had smoked. Girls began trying later than boys, but by age 13 the prevalence of experimental or regular smoking by girls overtook that of boys. Univariately, ever smoking varied considerably by family origin, from 2.1% among Vietnamese girls, to 35.8% among Portuguese boys. In multivariate analysis, age, perceived smoking habits of friends, and smoking by family members, were strong correlates of smoking. Being of Asian family origin was negatively associated with smoking. None of the indicators of social class were significantly associated with ever smoking. CONCLUSIONS: Smoking prevention should begin with children even younger than age 9 in multiethnic, low-income, inner-city neighborhoods. With the exception of a lower prevalence of smoking among Asian children, ethnicity and social class were not strong influences on early smoking behavior in this population.

Adolescent↗

Prevalence and correlates of overweight among elementary schoolchildren in multiethnic, low income, inner-city neighbourhoods in Montreal, Canada.

PURPOSE: Increased understanding of the early determinants of obesity is essential because of the increasing prevalence of obesity in many industrialized countries. METHOD: As part of the evaluation of a school-based heart health promotion intervention, we measured height, weight, and triceps skinfold thickness at baseline in 2108 students aged 9-12 years (80.5% of eligible students) in 24 inner-city elementary schools located in multiethnic, low income neighbourhoods in Montreal, Canada. Data on student's socio-demographic and lifestyle characteristics were collected in classroom-administered questionnaires, and parents completed an at-home self-administered questionnaire. RESULTS: Overall, 35.2% of boys and 33.0% of girls were overweight (> or = 85th age and gender-specific percentiles from NHANES 11, for body mass index and triceps skinfold thickness); 15.1% of boys and 13.3% of girls were obese (> or = 95th age and gender-specific percentiles for body mass index and triceps skinfold thickness). Younger age, having lived all one's life in Canada, and being of European or Central American/Caribbean family origin were independent correlates of obesity in boys. Younger age, ever smoked, mother obese and father obese were independent correlates of obesity in girls. Girls of Asian family origin were protected. CONCLUSIONS: The very high prevalence of overweight students in this low income, multiethnic population suggests an important need for preventive intervention.

Anthropometry↗

Perceived parental monitoring and health risk behaviors among urban low-income African-American children and adolescents.

PURPOSE: To examine gender and age differences among urban, low-income, African-American children and adolescents in perceived monitoring by their parents, and the association of perceived parental monitoring with family characteristics, health risk behaviors, and risk perceptions. METHODS: Three cross-sectional surveys were conducted in 1992 (n = 455), 1994 (n = 355), and 1996 (n = 349). Respondents aged 9-17 years were recruited from low-income urban areas including public housing communities and associated recreation centers. Both multivariate analysis of variance and correlation analysis were performed. RESULTS: Low levels of perceived parental monitoring were associated with participation in several health risk behaviors, including sexual behavior, substance/drug use, drug trafficking, school truancy, and violent behaviors. Females perceived themselves to be more monitored than did males. In general, the perceived parental monitoring tended to decrease with advancing age of the youth. CONCLUSIONS: The strong inverse correlation between perceived parental monitoring and adolescent risk behavior suggests that parental monitoring initiatives may be an effective intervention tool. Longitudinal studies are needed to determine the long-term relationship between perceived parental monitoring and adolescent risk involvements.

Adolescent↗

Clinical diagnosis of smear-negative pulmonary tuberculosis in low-income countries: the current evidence.

Sputum smear examination for acid-fast bacilli (AFB) can diagnose up to 50-60% of cases of pulmonary tuberculosis in well-equipped laboratories. In low-income countries, poor access to high-quality microscopy services contributes to even lower rates of AFB detection. Furthermore, in countries with high prevalence of both pulmonary tuberculosis and HIV infection, the detection rate is even lower owing to the paucibacillary nature of pulmonary tuberculosis in patients with HIV infection. In the absence of positive sputum smears for AFB, at primary care level, most cases of pulmonary tuberculosis are diagnosed on the basis of clinical and radiological indicators. This review aims to evaluate various criteria, algorithms, scoring systems, and clinical indicators used in low-income countries in the diagnosis of pulmonary tuberculosis in people with suspected tuberculosis but repeated negative sputum smears. Several algorithms and clinical scoring systems based on local epidemiology have been developed to predict smear-negative tuberculosis. Few of these have been validated within the local context. However, in areas where smear-negative tuberculosis poses a major public-health problem, these algorithms may be useful to national tuberculosis programmes by providing a starting point for development their own context-specific diagnostic guidelines.

AIDS-Related Opportunistic Infections↗

Food shopping practices are associated with dietary quality in low-income households.

ABSTRACT Nutrition education for low-income audiences often focuses on building skills in food shopping and food resource management to help families receive the best nutrition from the resources they have available. However, empirical evidence for the effect of food shopping practice on dietary quality has been limited. This article presents new analyses from two studies that found an association between food shopping practices and diet quality. Logistic regression of data from 957 respondents from the 1996 National Food Stamp Program Survey found that food shopping practices were significantly (p </= .05) associated with the availability of nutrients in the food the households used during a week. Similarly, analysis of baseline data from 5159 women from selected counties of states who participated in the Expanded Food and Nutrition Education Program found that food shopping practices were significantly (p </= .05) associated with increased consumption of nutrients as measured through a single 24-hour recall. These findings suggest that food shopping practices are an important area for nutrition education with low-income audiences.

Diet↗