Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.     

Fever and its treatment among the more and less poor in sub-Saharan Africa

This paper uses individual and household level data to explore empirically the associations between household wealth and the incidence and treatment of fever, as an indicator of malaria, among children in sub-Saharan Africa. The data used are from Demographic and Health Surveys collected in the 1990s from 22 countries where malaria is prevalent. The results suggest that the incidence of fever and its treatment are related to poverty in sub-Saharan Africa. Incidence is typically lower at the very top of the wealth distribution. The relationship, however, is not strong, especially after controlling for potentially confounding factors. Treatment patterns are strongly related to poverty as wealthier households are more likely to seek care or advice. While it is perhaps unsurprising that treatment from private sources increases with household wealth, government services--despite their public nature--are typically also used more by wealthier households. While general results hold for many of the countries, there is sufficient variation across countries that any policy seeking to reform the health sector in order to better cater to the poor needs to be informed by country-specific work.     

Parent Recruitment and Retention in a Universal Prevention Program for Child Behavior and Emotional Problems: Barriers to Research and Program Participation

Despite the potential of parent training as a prevention and behavioral family intervention strategy, there are a number of important issues related to implementation (e.g., recruitment and retention of families). This paper presents recruitment and retention data from families enrolling in a randomized controlled universal prevention trial for child behavior problems conducted in Germany. The recruitment rate averaged 31% (general project participation), with families of lower socioeconomic status (SES) participating at a lower rate. Project-declining families most often reported intrusion of privacy as their primary concern. In contrast, once parents were enrolled in the project, participation among those randomized to the parent training group averaged 77% (program/intervention participation); non-participation was mostly due to logistical issues. Parents accepting the offer of parent training were more likely to report child behavior problems than did declining parents. Although parents from more disadvantaged areas had a lower overall level of participation in the project once recruited, parents with children having higher levels of behavior problems indeed were more likely to participate in the intervention. Different recruitment methods may be required to engage high-risk families from socioeconomically disadvantaged areas to further improve community-level impact on child mental health.     

Secular Trends and Individual Differences in Toilet-Training Progress

Longitudinal data were obtained for a group of 71 children between18 and 33 months old for the age of onset and completion ofmature toileting behavior, physiological maturity, and maternalpressure for toilet training. The first appearance of toiletingskills and the acquisition of mature toilet-training behavioroccurred later in 1975 than in a comparable 1947 cohort: Onsetoccurred between 18 and 26 months and completion was between26 and 33 months, with girls finishing sooner than boys. Motherswho press for training have children whose skills emerge sooner.Girls who start sooner finish sooner. Mature boys (as measuredby sleep patterns) finish sooner. Partial support was foundfor the hypothesis that onset of toileting skills depends moreon socialization, while completion depends more on maturation.The unexpected sex difference may be due to differences in therelationship of sleep maturity to overall maturation for boysand girls.     

RETINOBLASTOMA IN THE ANTERIOR CHAMBER OF THE EYE

An uncommon presentation of retinoblastoma in an eleven-year-old boy is discussed. There was no family history of retinoblastoma and the child had never complained of a sore eye. He was not aware that he could not see out of his right eye.     

BLACK CHILDREN''S RACE AWARENESS, RACIAL ATTITUDES AND SELF-CONCEPT: A REINTERPRETATION

Results of a study of 130 black preschool children support the previous research finding that black preschoolers show majority group racial attitudes. Eighty percent of the sample obtained positive self-concept scores, while demonstrating pro-white biased cultural values on a racial attitude and preference measure. This significant finding is contrary to previous theorizing and consistent with recent data for a Southern sample (Spencer, 1982a). Few studies have empirically questioned this relationship, assuming less positive self-concepts of black children who have consistently shown pro-white cultural values. Race awareness affected majority group-preferenced racial attitudes. Results suggest that black preschool children effectively compartmentalize personal identity (i.e. self-concept) from knowledge of racial evaluations.     

Medical decision making: a selective review for child psychiatrists and psychologists

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice-expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry.     

Risk factors of parents abused as children: a mediational analysis of the intergenerational continuity of child maltreatment (Part I)

BACKGROUND: This study provides an exploration of factors implicated in the intergenerational cycle of child maltreatment. Families with newborns where at least one of the parents was physically and/or sexually abused as a child (AP families) were compared in terms of risk factors to families where the parents had no childhood history of victimization (NAP families). The mediational properties of risk factors in the intergenerational cycle of maltreatment were then explored. METHODS: Information was collected by community nurses as a part of the 'health visiting' service. Data was collated across 4351 families, of which 135 (3.1%) had a parent who self-reported a history of abuse in childhood. The health visitor visited each family at home when the child was 4 to 6 weeks of age to assess the presence of risk factors. RESULTS: Within 13 months after birth, 9 (6.7%) AP families were referred for maltreating their own child in comparison to 18 (.4%) NAP families. Assessments found a significantly higher number of risk factors for AP families. Mediational analysis demonstrated that the presence of three significant risk factors (parenting under 21 years, history of mental illness or depression, residing with a violent adult) provided partial mediation of the intergenerational continuity of child maltreatment, explaining 53% of the total effect. CONCLUSION: Prevention may be possible, once a history of parental childhood abuse has been identified, by offering services in priority to those families where a parent is under 21 years, has a history of mental illness/depression and/or there is a violent adult residing in the household. However, it must also be acknowledged that these factors do not provide a full causal account of the intergenerational transmission and consideration should be given to additional factors, such as parenting styles (see Part II of this mediational model, Dixon, Hamilton-Giachritsis, and Browne, 2004).     

The importance of parenting in the development of disorganized attachment: evidence from a preventive intervention study in adoptive families

Background:  As infant disorganized attachment is a serious risk factor for later child psychopathology, it is important to examine whether attachment disorganization can be prevented or reduced.
Method:  In a randomized intervention study involving 130 families with 6-month-old adopted infants, two attachment-based intervention programs were tested. In the first program, mothers were provided a personal book, and in the second program mothers received the same personal book and three home-based sessions of video feedback. The third group did not receive intervention (control group).
Results:  The intervention with video feedback and the personal book resulted in enhanced maternal sensitive responsiveness ( d  = .65). Children of mothers who received this intervention were less likely to be classified as disorganized attached at the age of 12 months ( d  = .46), and received lower scores on the rating scale for disorganization than children in the control group ( d  = .62). In the book-only intervention group children showed lower disorganization ratings compared to the control group, but no effect on the number of infants with disorganized attachment classifications was found.
Conclusion:  Our short-term preventive intervention program with video feedback and a book lowered the rate of disorganized attachment. The effectiveness of our intervention documents the importance of parenting in the development of infant attachment disorganization.     

Assessing children's appraisals of security in the family system: the development of the Security in the Family System (SIFS) scales

BACKGROUND: Although delineating the processes by which children appraise the family as a source of security from their collective experiences in the family subsystem has assumed center stage in many conceptualizations of child development, the dearth of measures of child adaptation in the family system has hindered empirical advances. Therefore, this study introduced and tested the psychometric properties of the Security in the Family System (SIFS) scales, a new measure designed to assess children's appraisals of security in their family as a whole. METHODS: The SIFS was administered to 853 10-15-year-old schoolchildren and readministered to a smaller subsample two weeks later. Additional data was gathered from children, caregivers and teachers using a variety of instruments tapping family instability, cohesion, and conflict; parenting warmth and psychological control; child externalizing and internalizing symptoms; parent-child and interparental insecurity; and children's reactions to conflict simulations. RESULTS: Consistent with models of emotional security in the family, exploratory and confirmatory factor analyses yielded three reliable (i.e., good internal consistency, test-retest reliability) dimensions of family security: Preoccupation, Security, and Disengagement. Concurrent and prospective associations between the SIFS scales and measures of family functioning, children's psychological problems, and insecurity in specific family relationships supported the validity of the SIFS. Support for the discriminant validity of the SIFS was evidenced by its specific patterns of relations with children's psychological problems and ability to predict psychological problems after controlling for insecurity in specific family subsystems. CONCLUSIONS: Results indicate that the SIFS is a psychometrically sound tool capable of advancing family process models, and that family security is a viable construct whose factors parallel already-identified patterns of children's security in other family relationships.