Better together: Addressing maternal and child health outcomes through community health worker continuing education curricula

Background. The incidence of birth defects is a significant public health issue in the United States, adversely affecting the quality of life for parents as well as children born with these defects. Minority populations face a greater burden of birth defects and associated health problems. Prenatal practices can have a large impact on infant health outcomes. Several behaviors during pregnancy, including the intake of folic acid, can greatly influence the likelihood of a child being born with a birth defect. Community Health Workers have been shown to be effective agents at improving prenatal practices, especially when they facilitate support groups that feature pregnant women. ^ Methods. A continuing education curriculum has been created for Community Health Workers that provides content in the area of Maternal and Child Health. Content was selected after conducting a review of relevant literature and theory. Materials for conducting a training for Community Health Workers have been created in addition to materials that were designed for the population with whom the CHWs work. ^ Results. A description of each "key point" of the curriculum and a justification how it relates to the literature of the prevention of birth defects is given here. Additionally, the process of creating the curriculum using the platform delineated in the methods is described. ^ Discussion. Insights for future curriculum development are discussed along with next steps in the process of certifying the curriculum at the state level. A framework for future evaluation of the curriculum is given.^

Strengthening Families: Parents' Voices on Discipline and Child Rearing

This qualitative study conducted semi-structured, multi-session focus groups and interviews with twenty-seven participants to explore in-depth, participant constructs of child discipline and punishment methods and reasons for the continuing support for corporal punishment of U.S. children. The research assumed that parents want to parent well and utilized the strengths perspective as the instrument to listen to participants' voices. Narratives revealed that participants were thoughtful about discipline and parenting strategies and viewed their parent role as a serious commitment. Non-violent discipline strategies, particularly communication, were often used. However, parents generally framed use of physical punishment as “when children need spanking” versus articulating the view that corporal punishment is a choice. Parents were unfamiliar with risks associated with physical punishment and only three parents, as a result of their foster parent training, had ever heard, “Do not spank.” Participants enumerated services and recommendations that would support and inform their own parenting, as well as, benefit children and the eighty percent of women and men in the United States who become mothers and fathers. Recommendations included: creation of a national campaign to build on parent strengths and the intentionality of effective parenting; child development education and increased public awareness of positive discipline methods; parenting supports, including respite and venues for dialogue and discourse about parenting. Recommendations are intended to inform child welfare practice and policy, particularly child abuse prevention. Creating, funding, and implementing a national campaign as described would challenge the dominant child welfare paradigm from one currently perceived as punitive and focused on parents' deficits to a strengths-based paradigm that provides supports and assistance to parents and children.

A summative evaluation of a HIV/AIDS Early Childhood Care, Education and Development Teacher Training Workshop in Mongu, Zambia

Objective. To conduct a summative evaluation of an Early Childhood Care, Education and Development (ECCED) Teacher Training Workshop in Mongu, Zambia by assessing changes in knowledge, attitudes and intent to use the information. ^ Study design. A matched cohort survey design was used with additional qualitative data collected by structured observation of workshop sessions, daily facilitator and participant debriefs and participant interviews. ^ Results. Matching pre and post tests were completed by 27 individuals in addition to daily debriefs, structured workshop observation and participant interviews with 22% of the group. The participant population was predominantly female individuals aged 15-44 years old that had completed high school and additional post-secondary training, been teaching children aged 0 – 8 years for 2-5 years in the Western Province and received other HIV/AIDS and ECCED education. Pre-tests indicated a strong understanding of ECCED principles and misconceptions regarding HIV transmission, prevention and the disease's impact on early childhood development. The workshop was found to significantly increase the participants' knowledge of topics covered by the curriculum (paired t-test, N=27, p = 0.004, 95% CI 1.8, 8.6). Participants began with a more limited understanding of HIV/AIDS than ECCED, but the mean gain was much greater at 7.4 +/- 12.3 points. Significantly more participants believed at post-test that HIV/AIDS education should increase for future educators. The 77.8% of participants that increased their knowledge scores at post-test expressed significantly less fear of having a child with HIV/AIDS in the classroom (Independent Samples t-test, N= 27, p = 0.011). Overall participant fear decreased 15.5%. 92.6% and 88.9% of participants planned at post-test to respectively use and share the taught information in their daily professional lives and reported on innovative strategies to communicate with the community. ^ Conclusions. Teacher training workshops can significantly increase HIV/AIDS awareness and promote positive attitudes in educators working with children affected by HIV/AIDS. Using participant suggested teaching techniques such as poems and songs and translating the materials to the local language could assist future facilitators to both culturally and professionally relate to the workshop audience as well as increase participant capacity to share the information with the local community. ^

Human Trafficking, Sex Tourism, and Child Exploitation on the Southern Border

Human trafficking and various other forms of child sexual exploitation on the United States-Mexico border are described from social science and law enforcement perspectives, including current laws and definitions, case examples, and descriptions of victims and traffickers. The Southern Border Initiative of the AMBER Alert Project is outlined as one effort to combat trafficking through collaboration between law enforcement agencies and programs in the United States and Mexico. Policy recommendations include increasing knowledge and collaboration between law enforcement, social service agencies, and judicial systems across the border region and between the United States and Mexico.

Commentary on "Strengthening Families: Parents' Voices on Discipline and Child Rearing"

There is a growing consensus among professionals working with parents and children, and advocates for child rights, that a ban on the use of corporal punishment (CP) in raising children is justified in accordance with the United Nations Convention on the Rights of the Child (CRC, 1989). However, this is an issue which seems to polarize people and opponents of banning CP have attacked the scientific literature and made dire predictions of adverse consequences if parents are not allowed to use CP. The problem is that so much attention has been focused on the “to spank or not to spank” issue, the developmental benefits for children and parents stemming from positive parenting have been largely ignored. There is increasing evidence that public health approaches to increasing parenting support reduces coercive parenting practices. Breshears' study represents an effort to gain a clearer understanding of the reasons many parents continue to support CP and draws on innovative qualitative methods to argue that parents’ views about CP are important and must be taken into account in planning intervention programs.

Toxic Stress and Child Hunger Over the Life Course: Three Case Studies

The causes and contexts of food insecurity among children in the U.S. are poorly understood because the prevalence of food insecurity at the child level is low compared to the prevalence of household food insecurity. In addition, caregivers may be reluctant to admit their children may not be getting enough food due to shame or fear they might lose custody of their children. Based on our ongoing qualitative research with mothers of young children, we suggest that food security among children is related to adverse childhood experiences of caregivers. This translates into poor mental and physical health in adolescence and adulthood, which can lead to inability to secure and maintain meaningful employment that pays a living wage. In this paper we propose that researchers shift the framework for understanding food insecurity in the United States to adopt a life course approach. This demands we pay greater attention to the lifelong consequences of exposure to trauma or toxic stress—exposure to violence, rape, abuse and neglect, and housing, food, and other forms of deprivation—during childhood. We then describe three case studies of women from our ongoing study to describe a variety of toxic stress exposures and how they have an impact on a woman’s earning potential, her mental health, and attitudes toward raising children. Each woman describes her exposure to violence and deprivation as a child and adolescent, describes experiences with child hunger, and explains how her experiences have shaped her ability to nourish her children. We describe ways in which we can shift the nature of research investigations on food insecurity, and provide recommendations for policy-oriented solutions regarding income support programs, early intervention programs, child and adult mental health services, and violence prevention programs.

Analyses of maternal and child mortality rates of five West African countries: Cote d'Ivoire, Guinea, Liberia, Senegal, Sierra Leone

After traveling to a small country in West Africa last summer, I became interested in learning more about the maternal, infant, and child death rates of that particular region of the continent. For the purposes of this paper I limited the number of countries that would be included in this research to five: Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. There are three hypotheses that were considered when conducting the research for this paper. The first was that there is no difference in the under five mortality rates for Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. The second hypothesis was that there is no difference in the female literacy rates for Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. The final hypothesis was that there is no difference in the male literacy rates for Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. The data used were collected from publicly available sources that include the CIA World Factbook, the WHO website, the UNICEF website, the Penn World Data table, and the World Bank website. The p-values that were calculated for all three hypotheses were found to be very significant, and all three of the null hypotheses were rejected. ^

Pediatric antiretroviral adherence and child disclosure in Botswana

The scale-up of antiretrovirals (ARVs) to treat HIV/AIDS in Africa has been rapid over the last five years. Botswana was the first African nation to roll out a comprehensive ARV program, where ARVs are available to all citizens who qualify. Excellent adherence to these ARVs is necessary to maintain HIV suppression and on-going health of all individuals taking them. Children rely almost entirely on their caregivers for the administration of these medications, and very little research has been done to examine the factors which affect both adherence and disclosure to the child of their HIV status. ^ Methods. This cross-sectional study used multiple methods to examine adherence, disclosure, and stigma across various dimensions of the child and caregiver's lives, including 30 caregiver questionnaires, interviewer-administered 3-day adherence recalls, pharmacy pill counts, and chart reviews. Fifty in-depth interviews were conducted with caregivers, male caregivers, teenagers, and health care providers. ^ Results. Perceived family stigma was found to be a predictor of excellent adherence. After controlling for age, children who live with their mothers were significantly less likely to know their HIV status than children living with any other relative (OR=0.403, p=0.014). Children who have a grandmother living in the household or taking care of them each day are significantly more likely to have optimal adherence than children who don't have grandmother involvement in their daily lives. ^ Discussion. Visible illness plays an intermediary role between adherence and perceived family stigma: Caregivers know that ARVs suppress physical manifestations of HIV, and in an effort to avoid unnecessary disclosure of the child's status to family members, therefore have children with excellent adherence. Grandmothers play a vital role in supporting the care and treatment of children in Botswana. ^

Health, education and community: Assets and needs of a small urban community in north east Tamaulipas, Mexico: A community based participatory research assessment

This study explored the health, education, social assets, needs, attitudes, and behaviors of residents of Ferrocarril #4, a small urban community in Tamaulipas, Mexico. A collaborative Participatory Action Research approach was used to emphasize community involvement. Using Triangulation to ensure validity, qualitative methods included key informant in depth interviews, participant observation and participatory discussion groups with women and men. A personal interview with a probability sample of women was done. The median age of interviewees was 37 years. The majority was married or had a partner. Over half of respondents completed grades 6-9. Employed women (25%) earned a median weekly salary equivalent to ∼56 USD. Women with health insurance (67.7%) were covered mainly through Social Security and Seguro Popular. One in 5 reported bad health. Barriers to care were primarily money and transportation. To improve health care, women wanted a full service clinic in or close to the community and affordable health care. Socially, 28% of respondents had no close friends in the community and most did not participate in beneficial community activities. Many women did not socialize with others and help from neighbors was situational. Primary school teachers lacked parental support and it interfered with classroom efforts. Healthy community discussion groups focused on personal and environmental hygiene and safety. Valuable assets exist in the community. To date, collaborative efforts resulted in a school First Aid station, a school nurse visit weekly, posting of emergency contact phone numbers in the school and community center, and development of a student health information form. ^

AN ANALYSIS OF THE RELATIVE INFLUENCE OF RACE, INCOME, EDUCATION, AND FOOD STAMP PROGRAM PARTICIPATION/NONPARTICIPATION ON THE FOOD AND NUTRIENT CONSUMPTION OF A NORTH FLORIDA URBAN CLINIC POPULATION IN CONJUNCTION WITH A SURVEY OF NUTRITION RELATED HABITS AND ATTITUDES

The relative influence of race, income, education, and Food Stamp Program participation/nonparticipation on the food and nutrient intake of 102 fecund women ages 18-45 years in a Florida urban clinic population was assessed using the technique of multiple regression analysis. Study subgroups were defined by race and Food Stamp Program participation status. Education was found to have the greatest influence on food and nutrient intake. Race was the next most influential factor followed in order by Food Stamp Program participation and income. The combined effect of the four independent variables explained no more than 19 percent of the variance for any of the food and nutrient intake variables. This would indicate that a more complex model of influences is needed if variations in food and nutrient intake are to be fully explained.^ A socioeconomic questionnaire was administered to investigate other factors of influence. The influence of the mother, frequency and type of restaurant dining, and perceptions of food intake and weight were found to be factors deserving further study.^ Dietary data were collected using the 24-hour recall and food frequency checklist. Descriptive dietary findings indicated that iron and calcium were nutrients where adequacy was of concern for all study subgroups. White Food Stamp Program participants had the greatest number of mean nutrient intake values falling below the 1980 Recommended Dietary Allowances (RDAs). When Food Stamp Program participants were contrasted to nonparticipants, mean intakes of six nutrients (kilocalories, calcium, iron, vitamin A, thiamin, and riboflavin) were below the 1980 RDA compared to five mean nutrient intakes (kilocalories, calcium, iron, thiamin and riboflavin) for the nonparticipants. Use of the Index of Nutritional Quality (INQ), however, revealed that the quality of the diet of Food Stamp Program participants per 1000 kilocalories was adequate with exception of calcium and iron. Intakes of these nutrients were also not adequate on a 1000 kilocalorie basis for the nonparticipant group. When mean nutrient intakes of the groups were compared using Student's t-test oleicacid intake was the only significant difference found. Being a nonparticipant in the Food Stamp Program was found to be associated with more frequent consumption of cookies, sweet rolls, doughnuts, and honey. The findings of this study contradict the negative image of the Food Stamp Program participant and emphasize the importance of education. ^

Possible selves of inner city fourth graders: What do they believe about their future education and occupation?

Possible selves, a component of self-concept, are the thoughts people have about their future. The overall purpose of this study was to examine the educational and occupational possible selves of inner city children. Specific aims of the study were to: 1) Assess the similarities and differences between the level of schooling inner city children hope to complete and expect to complete, and 2) Assess the similarities and differences between the jobs inner city children hope to have in the future and expect to have. As part of a larger study designed to pilot test a health promotion intervention, fourth grade students (n = 19) completed two measures: the Level of Schooling Questionnaire and the Jobs Questionnaire. No significant differences were found between students' hoped-for and expected educational possible selves or their hoped-for and expected occupational possible selves. Future studies can explore methods and strategies to support, encourage, and cultivate inner city children's possible selves.^

Sudden Infant Death disparities: A systematic review on health education and policy recommendations for decreasing Sudden Infant Death in the African-American community

Objective: To perform a systematic review of the literature on SIDS and SUID deaths concentrated in the African-American community, describe health education and policy recommendations and recommend a new approach that may aid in decreasing the disparity of infant mortality in the African-American community. ^ Methods: The PubMed database was systematically searched to identify relevant articles for final review and analysis. Using the CASP 2006 system to critique literature, twelve articles were found that met inclusion and exclusion criteria. ^ Results: Evidence in the literature confirmed there was a current disparity among African Americans' infant mortality rates in comparison to other US ethnic groups. The underlying reasons for these disparities included the following maternal and infant characteristics: mothers younger than eighteen, having more than one live infant, having a high school education or less, never been married, and have infants born preterm or with low birth weight. Maternal smoking, substance abuse, and breastfeeding did not have a significant impact on infant sleep environments among African Americans. ^ Conclusion: Tailored health education programs at the community level, better access to pre-pregnancy and prenatal care, and increased maternal perception of risk that is relevant to the infants sleeping environment are all possible solutions that may decrease African American infant mortality rates.^

The Relationship of Provincial Economic Level and Child Injury Mortality in Thailand: A Cross-Sectional Analysis in a Middle Income Country

The objective of this cross-sectional study was to examine the relationship of provincial economic development indices with incidences of child injury mortality in Thailand from 1999 - 2001. All injury deaths among children age 1-14 years were included. The independent variables included gross provincial product per capita (GPP/c), poverty and inequality indices, material and social deprivation indices, population in rural/ urban areas, and migration. Due to multicollinearity of such variables, the 76 provinces were categorized by GPP/c quartile, and means of overall injury, drowning, and transport-related mortality rates were compared among quartile groups. Spearman’s rho correlation between GPP/c and injury mortality rates was also performed. Finally, factor analysis was employed to create a set of factors to be treated as uncorrelated variables and stepwise multiple regression was carried out for the effects of the factors on injury mortality rates. A significant direct relationship was observed between GPP/c and overall injury mortality among children age 1-4 years, and 10-14 year-olds of both genders. Drowning was the main cause of this relationship among children age 1-4 years, and transport-related injury was the principle cause among children age 10-14 years. Conversely, provinces with lower GPP/c experienced higher injury mortality rates among school-age children 5-9 years old for both genders, mostly due to drowning. Factor analysis, and multiple regression results confirmed the relationships between economic development and injury mortality rates. These findings revealed that economic development had an adverse impact on injury-related mortality among children 1 to 4 and 10 to14 in Thailand.

The impact of parent acculturation on parental fruit and vegetable intake, child fruit and vegetable intake, and child perceived access and availability to fruits and vegetables in the home environment

The purpose of this thesis was to investigate the association between parent acculturation and parental fruit and vegetable intake, child fruit and vegetable intake, and child access and availability to fruits and vegetables. Secondary data analysis was performed on a convenience sample of low-income Hispanic-identifying parents (n = 177) and children from a baseline survey from the Sprouting Healthy Kids intervention. T tests were used to examine the association between parent acculturation status (acculturated or non-acculturated) and fruit intake, vegetable intake and combined fruit and vegetable intake of both the parent and the child. T tests were also used to determine the relationship between parent acculturation and child access and availability to fruits, vegetables, and combined fruits and vegetables. Statistical significance was set at a p level of 0.05. The mean FVI for the parents and children were 3.41 servings and 2.96 servings, respectively. Statistical significance was found for the relationships between parent acculturation and parent fruit intake and parent acculturation and child fruit access. Lower acculturation of the parent was significantly related to higher fruit intake. Counter to the hypothesis, higher acculturation was found to be associated with greater access to fruits for the child. These findings suggest the necessity for not only culturally specific nutrition interventions, but the need for interventions to target behaviors for specific levels of acculturation within a culture. ^

Parent modeling and child food consumption

Obesity, among both children and adults, is a growing public health epidemic. One area of interest relates to how and why obesity is developing at such a rapid pace among children. Despite a broad consensus about how controlling feeding practices relate to child food consumption and obesity prevalence, much less is known about how non-controlling feeding practices, including modeling, relate to child food consumption. This study investigates how different forms of parent modeling (no modeling, simple modeling, and enthusiastic modeling) and parent adiposity relate to child food consumption, food preferences, and behaviors towards foods. Participants in this experimental study were 65 children (25 boys and 40 girls) aged 3-9 and their parents. Each parent was trained on how to perform their assigned modeling behavior towards a food identified as neutral (not liked, nor disliked) by their child during a pre-session food-rating task. Parents performed their assigned modeling behavior when cued during a ten-minute observation period with their child. Child food consumption (pieces eaten, grams eaten, and calories consumed) was measured and food behaviors (positive comments toward food and food requests) were recorded by event-based coding. After the session, parents self-reported on their height and weight, and children completed a post-session food-rating task. Results indicate that parent modeling (both simple and enthusiastic forms) did not significantly relate to child food consumption, food preferences, or food requests. However, enthusiastic modeling significantly increased the number of positive food comments made by children. Children's food consumption in response to parent modeling did not differ based on parent obesity status. The practical implications of this study are discussed, along with its strengths and limitations, and directions for future research.^