A focused ethnographic study of community social capital

Social capital, a relatively new public health concept, represents the intangible resources embedded in social relationships that facilitate collective action. Current interest in the concept stems from empirical studies linking social capital with health outcomes. However, in order for social capital to function as a meaningful research variable, conceptual development aimed at refining the domains, attributes, and boundaries of the concept are needed. An existing framework of social capital (Uphoff, 2000), developed from studies in India, was selected for congruence with the inductive analysis of pilot data from a community that was unsuccessful at mobilizing collective action. This framework provided the underpinnings for a formal ethnographic research study designed to examine the components of social capital in a community that had successfully mobilized collective action. The specific aim of the ethnographic study was to examine the fittingness of Uphoff's framework in the contrasting American community. A contrasting context was purposefully selected to distinguish essential attributes of social capital from those that were specific to one community. Ethnographic data collection methods included participant observation, formal interviews, and public documents. Data was originally analyzed according to codes developed from Uphoff's theoretical framework. The results from this analysis were only partially satisfactory, indicating that the theoretical framework required refinement. The refinement of the coding system resulted in the emergence of an explanatory theory of social capital that was tested with the data collected from formal fieldwork. Although Uphoff's framework was useful, the refinement of the framework revealed, (1) trust as the dominant attribute of social capital, (2) efficacy of mutually beneficial collective action as the outcome indicator, (3) cognitive and structural domains more appropriately defined as the cultural norms of the community and group, and (4) a definition of social capital as the combination of the cognitive norms of the community and the structural norms of the group that are either constructive or destructive to the development of trust and the efficacy of mutually beneficial collective action. This explanatory framework holds increased pragmatic utility for public health practice and research. ^

The meaning of informal BMT caregiving

Objectives. The aims of this qualitative descriptive exploratory study were to (1) describe informal caregiver commitment in informal caregiving; (2) describe caregiver expectations in informal caregiving; (3) describe caregiver role negotiation in informal caregiving, (4) identify other important caregiver energy sources; and (5) refine the conceptual model of Informal Caregiving Dynamics based on the study results. ^ Methods. Participants were 40 informal caregivers of blood and marrow transplant patients being treated at a comprehensive cancer center who told their caregiving stories in an audiotaped dialogue. Patients consented to have their caregivers contacted about the study and to have information collected from their medical records. To address the specific aims, the dialogues were analyzed for major elements and themes with an adaptation of the descriptive exploratory method. ^ Findings. Commitment was redefined as enduring caregiver responsibility that inspires life changes to make the patient a priority. Commitment calls caregivers to supportive presence and self-affirming loving connection with the patient. Expectation management was defined as envisioning the future and yearning to return to normal. Expectation management includes taking one day at a time, gauging behavior from past experiences with the patient, and reconciling anticipated to actual treatment twists and turns. Role negotiation was defined as appropriate pushing by the caregiver toward patient recovery and independence after getting a handle on complex care that demands shared responsibilities. Role negotiation happens as caregivers determine action with attention to patient voice and vigilantly bridge communication between patients and the health care system. Three additional energy sources of caring for self, gaining insight, and connecting with others, were identified and added to the model as underpinnings for commitment, expectation, and role negotiation respectively. ^ Discussion and implications. Methods of supporting informal caregivers that deserve investigation include consistent acknowledgment of caregiver contribution to patient care; provision of clear, present-focused information; opportunities to reconcile expectations with outcomes by developing a coherent caregiving story; and encouragement to maintain good health habits while caregiving. Patient contribution to the dynamics of caregiving warrants future research attention as does change in energy sources over time as a caregiver. ^

A focused ethnographic study of women in recovery from alcohol abuse

Alcohol abuse and its related problems are among the most pervasive health and social concerns in the United States (U.S.) today. Women are especially vulnerable to the physical and social devastation of alcohol abuse. Yet, although there is extensive research about alcohol drinking patterns, treatment strategies, and early recovery, there is little information about the factors that facilitate successfully sustained abstinence in women. The purpose of this study was to examine and describe the common factors to successful recovery from alcohol abuse among women and to place these factors within both the context of their social networks and the larger social environment. This study draws from the population of New Mexico, where alcohol-related deaths are the highest of any state in the U.S. and the leading cause of death for individuals under the age of 65 years. The study was a focused ethnography of women who had successfully maintained long-term recovery from alcohol abuse. As an ethnographic study, data collection included participant observation, in-depth interviews with 21 women, and the collection of historical and current culturally relevant data. A purposive sampling plan was used to maximize the selection of participants who had used traditional and non-traditional approaches to recovery. As such, the analysis of the success narratives revealed two distinct findings: the first that women used several different trajectories to achieve long-term recovery. Three trajectory typologies were identified from the success narratives and labeled, A.A. as ceremony, A.A. as grounding, and Recovery as self-management. ^ However, within each of these trajectories, variations in successful recovery were seen. The second major finding was that all women articulated an overarching theme of connections as an indispensable aspect of sustained recovery. The success narratives demonstrated the powerful role that connections played in their long-term recovery and the analysis distinguished two unifying concepts of connections—those that focused beyond self (spirituality, social support, and pets) and those that focused toward self (self-nurturance, agency, and identity). This discussion will focus on the implications for clinical practice related to both women who are still actively abusing alcohol and for those who are successfully maintaining long-term recovery. ^

Factors affecting the symptom burden in chronic heart failure

Background. Heart failure (HF) is a health problem of epidemic proportions and a clinical syndrome that leads to progressively severe symptoms, which contribute significantly to the burden of the disease. Several factors may affect the symptom burden of patients with HF, including physiological, psychological, and spiritual factors. This study was designed to examine the inter-relationship of physiological, psychological, and spiritual factors affecting symptoms for patients with HF. ^ Objectives. The aims of this study were to examine symptom burden of heart failure patients related to: (1) the physiological factor of brain natriuretic peptide (BNP); (2) the psychological factor of depression; (3) the spiritual factors of self transcendence and purpose in life; and (4) combined effects of physiological, psychological and spiritual factors. One additional aim was to describe symptom intensity related to symptom burden. ^ Methods. A cross-sectional non-experimental correlational design was used to examine factors affecting symptom burden in 105 patients with HF from a southwestern medical center outpatient heart failure clinic. Both men and women were included; average age was 56.6 (SD = 16.86). All measures except BNP were obtained by patient self-report. ^ Results. The mean number of symptoms present was 8.17 (SD = 3.34) with the three most common symptoms being shortness of breath on exertion, fatigue, and weakness. The mean symptom intensity was 365.66 (SD = 199.50) on a summative scale of visual analogue reports for 13 symptoms. The mean BNP level was 292.64 pg/ml (SD = 57 1.11). The prevalence rate for depression was 43.6% with a mean score of 3.48 (SD = 2.75) on the Center for Epidemiological Studies - Depression scale (CES-D 10) scale. In a multivariate analysis, depression was the only significant predictor of symptom burden (r = .474; P < .001), accounting for 18% of the variance. Spirituality had an interaction effect with depression (P ≤ .001), serving as a moderator between depression and symptom burden. ^ Conclusion. HF is a chronic and progressive syndrome characterized by severe symptoms, hospitalizations and disability. Depression is significantly related to symptom burden and this relationship is moderated by spirituality. ^

The impact of a brief foot care intervention for persons with diabetes

Purpose of the study. The purpose of this randomized controlled clinical trial was to determine if a brief intervention would improve foot self-care behaviors in adult patients with Type 2 diabetes who presented to the emergency department for non-emergent care in a predominantly Hispanic southwestern border community. ^ Methods. A pre-post-test, three-group design was used to compare the foot self-care behaviors of patients who received usual care to those who received lower extremity amputation (LEA) risk assessment and to those who received LEA risk assessment plus a brief foot self-care intervention. After being randomized into 3 groups (N = 167), baseline assessments of demographics, diabetes history, acculturation, and the Summary of Diabetes Self Care Activities (SDSCA) questionnaire and Modified Insulin Management Diabetes Self Efficacy Scale (MIMDSES) were completed in English or Spanish. At one-month, 144 (84%) participants were available for follow-up by the research assistant masked to group assignment. ^ Results. At baseline, significant differences in foot self-care behaviors and self monitoring blood glucose were noted based on ethnicity and gender. Men had significantly lower confidence in their ability to manage their diabetes overall. There was a significant difference between baseline and follow up self reported foot self-care behaviors within the intervention group (t (47) = −4.32, p < .01) and the control group (t (46) = −2.06, p < .05). There were no significant differences between groups for self-reported foot self-care behaviors. There was a significant difference in observed foot self-care behaviors between groups (F(2,135) = 2.99, p < .05). Self-efficacy scores were positively correlated with self-reported self-care behaviors. ^ Conclusions. This predominantly Hispanic population with type 2 diabetes reported performing diabetes self-care behaviors less than five days a week. There were within group changes, but no significant between group changes in reported self-care behaviors. However, at the one month follow up, there were significant differences between groups in observed foot self-care behaviors with the intervention group demonstrating the most accurate behaviors. Differences based on gender and ethnicity emphasize the need to individualize diabetes education. Priorities for culturally competent diabetes education, approaches to increasing self-efficacy and future research directions are suggested. ^

Sociodemographic characteristics as predictors of successful smoking cessation among a group of Hispanic Spanish speaking smokers

Few studies have examined predictors of smoking abstinence among Hispanic groups. The purpose of this dissertation was to examine the relations of sociodemographic characteristics and smoking related factors with smoking abstinence among a group of Hispanic Spanish speaking smokers. This study utilized previously collected data from Hispanic Spanish-speaking smokers (N = 246) who participated in a study entitled Smoking Cessation Services for Hispanic Smokers in Texas. ^ The first study examined sociodemographic characteristics and smoking related mechanisms that predicted smoking abstinence among this group. Two of the characteristics were related to smoking abstinence, marital status and acculturation level. Being unmarried increased the likelihood of being abstinent at the 12 week assessment (OR = 1.80). Those in the high acculturation group were twice as likely to be abstinent (OR = 2.24). Of the smoking related mechanisms, those with higher positive reinforcement expectancies were less likely to be abstinent (OR = .86), as were those with a higher level of affiliative attachment (OR = .86), a higher level of craving (OR = .78) and a higher tolerance to the effect of smoking (OR = .74). The second study was to examine the relationship of objective measures of socioeconomic status (SES) (income, education, or employment) with smoking abstinence among this group. This study also compared the relationship of a subjective measure of SES (Social Status Ladder) to smoking abstinence. None of the objective measures of SES were related to smoking abstinence at the 12 week assessment. The subjective measure of SES did predict smoking abstinence (OR = 1.9) indicting that those that rated themselves ≤4 on the SES scale were more likely to be abstinent. ^ Although this group was recruited using various methods across the state of Texas, the fact that they preferred to interact with the counselor in Spanish may limit the study findings. The results of this study highlight the need for research to examine specific subgroups of people and understand the special circumstances that influence their health behaviors. Furthering our knowledge of the relations between sociodemographic characteristics and smoking cessation could lead to interventions that reduce disparities in smoking cessation. ^

The biologic and signaling effects of Tiam1 overexpression in colorectal carcinoma

Cellular migration is essential to many normal cellular processes. In tumor cells, aberrant activation of the normal pathways regulating migration is one of the critical steps in the development of metastasis. Previously, I demonstrated for the first time that overexpression of Tiam1, a guanine nucleotide exchange factor (GNEF) for small G proteins in the Rho family, could alter migration in colorectal tumor cells. ^ This dissertation focuses on the roles of Tiam1 in promoting cell migration, survival, and metastasis of colorectal carcinoma cells, utilizing the model system I developed. To determine the in vivo phenotype of the migratory cell lines, athymic nude mice were injected with cells into the orthotopic site. Several of the mice injected with cells of increased migratory potential had metastases. Thus, the in vitro selection for increased migration resulted in increased metastatic potential in vivo, and therefore, the Tiam1-overexpressing cells provide a model to examine signal transduction pathways important to this process. ^ To examine effects of Tiam1 signaling on small G proteins critical to cellular functions associated with migration, I examined the activation status of the small G proteins Rac, Rho, and Cdc42. The cells of increased migratory potential have increased GTP-bound Rac and Rho, compared to control SW480 cells. Cells that overexpress Tiam1 are more migratory and are resistant to detachment-induced death, or anoikis. To determine which effects and phenotypes were Tiam1-specific, we utilized siRNA to downregulate Tiam1 expression. These results demonstrate that Tiam1 is sufficient but not required for the migration of colorectal carcinoma cells in our model system, and that the biologically selected cells have additional changes that promote migration besides the increase in Tiam1. I also show that Tiam1 protects colorectal carcinoma cells from detachment-induced death, but is not required for anoikis resistance in the biologically selected migratory cells. ^ In summary, my studies demonstrate a heretofore-unknown regulator of phenotypes critical to the development of colorectal carcinoma metastases, overexpression of Tiam1. Understanding the mechanism by which Tiam1 contributes to cellular migration and metastasis is crucial to developing desperately needed new therapies for colorectal carcinoma. ^

Factors influencing time to HIV disease progression in Romanian children

The purpose of this research was two-fold; to investigate the effect of institutionalization on death and CD4 decline in a cohort of 325 HIV-infected Romanian children, and to investigate the effect of disclosure of the child's own HIV status in this cohort. All children were treated with Kaletra-based highly active antiretroviral therapy, and were followed from November, 2001 through October, 2004. The mean age of the children included in the cohort is 13. The study found that children in biological families were more likely to experience disease progression through either death or CD4 decline than children in institutions (p=0.04). The family home-style institution may prove to be a replicable model for the safe and appropriate care of HIV-infected orphaned and abandoned children and teens. The study also found that children who do not know their own HIV infection status were more likely to experience disease progression through either death or CD4 decline than children who know their HIV diagnosis (p=0.03). This evidence suggests that, in the context of highly active anti retroviral therapy, knowledge of one's own HIV infection status is associated with delayed HIV disease progression. ^

Clinical decisions related to CBC screening of asymptomatic full-term infants at risk for group B streptococcus disease

Objective. Although complete blood count (CBC) changes occur with the development of clinical sepsis in newborns, the CBC has not been reported to be a sensitive predictor of sepsis in asymptomatic full-term newborn infants, nor has it been reported to be related to risk factors for sepsis or clinical decisions. The objective of this study was to evaluate the relationship between the WBC/I:T (immature:total neutrophil) ratio and maternal group B streptococcal (GBS) risk factors (rupture of membranes ≥18 hours, maternal temperature ≥100.4°F, maternal age ≤20 years, previous infant with invasive GBS disease, maternal GBS bacteriuria, and black ethnicity); and to evaluate the relationship between the WBC/I:T ratios and providers' clinical decisions (observe versus repeat the CBC or complete sepsis evaluation) in the asymptomatic full-term newborn at risk for early-onset GBS sepsis. ^ Methods. Medical records of infants admitted to the well baby nursery at a tertiary care teaching hospital in Houston, TX between 1/1/99 and 12/31/00 whose gestational ages were ≥35 weeks; who had mothers with GBS positive or unknown culture status and inadequate intrapartum antibiotic prophylaxis; and who had screening CBCs performed in the first 30 hours of life because of GBS risk were reviewed (n = 412). Demographic information, maternal GBS risk factors, CBC results, clinical decisions, and rationales for clinical decisions were collected. ^ Results. With the exception of black ethnicity (p = .0000, odds ratio = 0.213), no statistically significant differences in risk factors between infants with normal and abnormal WBC counts or normal and abnormal I:T ratios were found. Infants with abnormal WBCs had a significantly higher likelihood of having a CBC repeated (p = 0.002 for WBC). Providers documented the CBC result in the rationale for clinical decisions in 62% of the cases. ^ Conclusion. The CBC results were not related to maternal risk factors for GBS except for ethnicity. Black infants had significantly lower WBC levels than infants of other ethnicities, although this difference was clinically insignificant. Infants with abnormal WBCs had a significantly higher likelihood of undergoing repeat CBCs but not sepsis evaluations. Provider rationale was difficult to evaluate due to insufficient documentation. The screening CBC result did not impact the clinicians' decisions to initiate sepsis evaluations in this population. ^

The effectiveness of a promotora-led intervention for Mexican Americans with type 2 diabetes

Purpose. The purpose of this randomized control repeated measures trial was to determine the effectiveness of a self-management intervention led by community lay workers called promotoras on the health outcomes of Mexican Americans with type 2 diabetes living in a major city on the Texas - Mexico border. The specific aims of this study, in relation to the intervention group participants, were to: (1) decrease the glycosylated hemoglobin (A1c) blood levels at the six-month assessment, (2) increase diabetes knowledge at the three and six-month assessments, and (3) strengthen the participants' beliefs in their ability to manage diabetes at the three and six-month assessments.^ Methods. One hundred and fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into an intervention group and a usual-care control group. Personal characteristics, acculturation and baseline A1c, diabetes knowledge and diabetes health beliefs were measured. The six-month, two-phase intervention was culturally specific and it was delivered entirely by promotoras. Phase One of the intervention consisted of sixteen hours of participative group education and bi-weekly telephone contact follow-up. Phase Two consisted of bi-weekly follow-up using inspirational faith-based health behavior change postcards. The A1c levels, diabetes knowledge and diabetes health beliefs were measured at baseline, and three and six months post-baseline. The mean changes between the groups were analyzed using analysis of covariance. ^ Results. The 80% female sample, with a mean age of 58 years, demonstrated very low: acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the three-month assessment, but the mean change of the A1c levels (F (1, 148 = 10.28, p < .001) and the diabetes knowledge scores (F (1, 148 = 9.0, p < .002) of the intervention group improved significantly at six months, adjusting for health insurance coverage. The diabetes health belief scores decreased in both groups.^ Conclusions. This study demonstrated that an intervention led by promotoras could result in decreased A1c levels and increased diabetes knowledge in spite of the very low acculturation, educational level and insurance coverage of the intervention group participants. Clinical implications and recommendations for future research are suggested. ^

Border intervention by Promotores for type 2 diabetes

Purpose of the study. This study had two components. The first component of the study was the development and implementation of an infrastructure that integrated Promotores who teach diabetes self-management into a community clinic. The second component was a six-month randomized clinical trial (RCT) designed to test the effectiveness of the Promotores in changing knowledge, beliefs, and HbA1c levels among Mexican American patients with type 2 diabetes. ^ Methods. Starfield's adaptation of the Donbedian structure, process, and outcome methodology was used to develop a clinic infrastructure that allowed the integration of Promotores as diabetes educators. The RCT of the culturally sensitive Promotores-led 10-week diabetes self-management program compared the outcomes of 63 patients in the intervention group with 68 patients in a wait-list, usual care control group. Participants were Mexican Americans, at least 18 years of age, with type 2 diabetes, who were patients at a Federally Qualified Health Center on the Texas-Mexico border. At baseline, three months, and six months, data were collected using the Diabetes Knowledge Questionnaire (DKQ, the Health Beliefs Questionnaire (HBQ, and HbA1c levels were drawn by the clinic laboratory. A mixed model methodology was used to analyze the data. ^ Results. The infrastructure to support a Promotores-led diabetes self-management course designed in concert with administration, the physicians, and the CDE, resulted in (1) employment of Promotores to teach diabetes self-management courses; (2) integration of provider and nurse oversight of course design and implementation; (3) management of Promotora training, and the development of teaching competencies and skills; (4) coordination of care through communication and documentation policies and procedures; (5) utilization of quality control mechanisms to maintain patient safety; and (6) promotion of a culturally competent approach to the educational process. The RCT resulted in a significant improvement in the intervention group's DKQ scores over time (F [1, 129] = 4.77, p = 0.0308), and in treatment by time (F [2, 168] = 5.85, p = 0.0035). Neither the HBQ scores nor the HbA1c changed over time. However, the baseline HbA1c was 7.49, almost at the therapeutic level. The DKQ, HBQ, and HbA1c results were significantly affected by age; the DKQ and HbA1c by years with diabetes. ^ Conclusions. The clinic model provides a systematic approach to safely address the educational needs of large numbers of patients with type 2 diabetes who live in communities that suffer from a lack of health care professionals. The Promotores-led diabetes self-management course improved the knowledge of patients with diabetes and may be a culturally sensitive strategy for meeting patient educational needs. The low baseline HbA1c levels in this border community suggested that patients in this Federally Qualified Health Center on the Texas-Mexico border were experiencing good medical management of their diabetes. ^

Modifier genes and susceptibility to colorectal cancer in individuals with Lynch syndrome

Lynch syndrome, is caused by inherited germ-line mutations in the DNA mismatch repair genes resulting in cancers at an early age, predominantly colorectal (CRC) and endometrial cancers. Though the median age at onset for CRC is about 45 years, disease penetrance varies suggesting that cancer susceptibility may be modified by environmental or other low-penetrance genes. Genetic variation due to polymorphisms in genes encoding metabolic enzymes can influence carcinogenesis by alterations in the expression and activity level of the enzymes. Variation in MTHFR, an important folate metabolizing enzyme can affect DNA methylation and DNA synthesis and variation in xenobiotic-metabolizing enzymes can affect the metabolism and clearance of carcinogens, thus modifying cancer risk. ^ This study examined a retrospective cohort of 257 individuals with Lynch syndrome, for polymorphisms in genes encoding xenobiotic-metabolizing enzymes-- CYP1A1 (I462V and MspI), EPHX1 (H139R and Y113H), GSTP1 (I105V and A114V), GSTM1 and GSTT1 (deletions) and folate metabolizing enzyme--MTHFR (C677T and A1298C). In addition, a series of 786 cases of sporadic CRC were genotyped for CYP1A1 I462V and EPHX1 Y113H to assess gene-gene interaction and gene-environment interaction with smoking in a case-only analysis. ^ Prominent findings of this study were that the presence of an MTHFR C677T variant allele was associated with a 4 year later age at onset for CRC on average and a reduced age-associated risk for developing CRC (Hazard ratio: 0.55; 95% confidence interval: 0.36–0.85) compared to the absence of any variant allele in individuals with Lynch syndrome. Similarly, Lynch syndrome individuals heterozygous for CYP1A1 I462V A>G polymorphism developed CRC an average of 4 years earlier and were at a 78% increased age-associated risk (Hazard ratio for AG relative to AA: 1.78; 95% confidence interval: 1.16-2.74) than those with the homozygous wild-type genotype. Therefore these two polymorphisms may be additional susceptibility factors for CRC in Lynch syndrome. In the case-only analysis, evidence of gene-gene interaction was seen between CYP1A1 I462V and EPHX1 Y113H and between EPHX1 Y113H and smoking suggesting that genetic and environmental factors may interact to increase sporadic CRC risk. Implications of these findings are the ability to identify subsets of high-risk individuals for targeted prevention and intervention. ^

Influenza vaccination and peoples' knowledge and attitudes towards it: Factors that influenced influenza vaccination during the 2004--2005 influenza vaccine shortage

Influenza and pneumonia together comprise the seventh leading cause of death among adults in the U.S and were responsible for 65,163 deaths in 2003 and an average of 36,000 deaths per year in the United States from 1990 to 1999. Vaccination is efficacious and cost-effective in terms of preventing the infection and reducing both health care costs and productivity losses associated with influenza illness. The vaccine shortage of 2004–2005 resulted in a 39% decrease in the influenza vaccine supplies. During the fall of 2004, we conducted a nationwide, random-digit dialing, telephonic-interview survey of 1,202 adults aged 18 years and older to ascertain influenza vaccine knowledge, attitude and behavior. Of the 1,202 total interviewed subjects, 44.7% had received or intended to receive vaccine at the time of the survey (2004–05) and 39.6% had received the influenza vaccine the previous year (2003–04). Receipt of vaccine increased with previous receipt of the influenza vaccine (OR 13.17, 95% CI 8.65–20.08), increased motivation status (OR 7.58, 95% CI 4.03–14.25), subjective risk status (OR 3.33, 95% CI 2.23–4.97), age (OR 1.83, 95% CI 1.22–2.75) and previous receipt of the pneumococcal vaccine (OR 1.75, 95% CI 1.02–3.0). The influenza vaccine shortage of 2004–05 did not have a negative impact on the vaccination rates of study population. In addition to the increased rates, a large majority of respondents were also aware of the shortage of influenza vaccine during the 2004–05 season, about the indications for receiving the influenza vaccine, about alternative methods to prevent contracting the influenza and increased motivation to receive the vaccine. ^

The global initiative to eradicate polio- A review of Nigeria's situation

Poliomyelitis is one of the worlds remaining vaccine preventable infectious diseases. In 1988 the World Health Assembly in its general assembly resolved to eradicate polio in the year 2000 and the Global Initiative to Eradicate Polio was launched. ^ This initiative sprang from the successful eradication of smallpox from the world in the year 1979, and the World Health Organization sought to eradicate polio from the world's populations by the year 2000. ^ Several years have passed since this objective was launched, and while some advances have been made, the goal of global eradication remains elusive. At this present time (2007), only four countries are considered polio endemic regions (areas in which the transmission of wild poliovirus has never been truncated). These countries are Nigeria, India, Pakistan and Afghanistan. ^ This descriptive study seeks to examine the process and progress of polio eradication worldwide, with particular emphasis on the polio eradication efforts in Nigeria, problems encountered and progress that has been made towards attaining this goal. ^ The methodology of this study is an extensive examination of documentation and data from the Global Initiative to Eradicate Poliomyelitis (GPEI), the World Health Organization through the World Health Organization Library Information Service (WHOLIS), UNICEF, the Centers for Disease Control and related peer reviewed journals. ^

Breastfeeding the very preterm hospitalized infant: An ethnographic study

Purpose. To develop a greater understanding of the experience—including the thoughts, feelings, and actions—of mothers' initiation and maintenance of lactation within the context of the NICU following the birth of a very preterm infant. ^ Design. Mixed method with dominant focused ethnographic approach. Setting: A 76-bed neonatal intensive care unit in the largest children's hospital located in a large metropolitan city in southeast Texas. ^ Sample. Purposeful sampling resulted in 23 interviews with 14 subjects. ^ Methods. Mixed method design with a dominant qualitative approach combined with a quantitative component to further identify and expand upon the investigation of the population in question. Open-ended semi-structured interviews and fieldwork were used to explore the experience of breastfeeding in the context of the NICU for mothers of very preterm infants. Longitudinal data obtained from each subject included in-depth interviews, demographic and clinical information, milk expression patterns (including pumping frequency, duration, and milk volumes obtained), and scores obtained from the Edinburgh Postpartum Depression Scale (EPDS). ^ Findings. Thematic analysis revealed that mothers of very preterm infants experienced an interruption in the process of becoming a mother, a paradoxical experience related to aspects of their milk expression routines and patterns, and negotiating the NICU environment. Sub-themes of becoming a mother-interrupted included: attribution, separation, connection, and navigation. Additional sub-themes related to the paradoxical experience included: the pump sometimes acting as a wedge or link to the infant; diversionary thoughts/activities during pumping; and perceptions of milk flow/volume. The process of negotiation included the environment, adaptive/maladaptive strategies related to milk expression, motivating factors related to the provision of breast milk, and learning their infant's feeding cues/abilities. EPDS scores did not reveal congruent differences in those mothers scoring high compared to those scoring low. ^ Conclusions. Understanding the experiences of the mothers in this study allows for a better perspective of breastfeeding the very preterm infant in the context of the NICU. Findings from this study validate the difficult and incremental process of attaining maternal identity and the significant burden placed on these women with regards to the provision of breast milk and breastfeeding during their infant's hospitalization. ^