Peter Sandiford

Why do child mortality rates fall? An analysis of the Nicaraguan experience.

A comprehensive review of available sources of mortality data was undertaken to document the changes that have occurred in infant mortality in Nicaragua over the last three decades. It was found that a rapid fall in infant mortality commenced in the early 1970s and has continued steadily since. Trends in several different factors which might have led to this breakthrough were examined including: income, nutrition, breastfeeding practices, maternal education, immunizations, access to health services, provision of water supplies and sanitation, and anti-malarial programs. Of these, improved access to health services appears to have been the most important factor. At a time when the number of hospital beds per capita was dropping, increasing numbers of health care professionals, particularly nurses, were becoming available to staff primary health care facilities built in the 1960s. These were provided at least partly in response to the growing political turmoil enveloping the nation at that time. Certain Nicaraguan cultural attributes may have added to the impact of the reforms. Efforts in the field of public health made since the 1979 insurrection appear to have maintained the decline in child mortality.

The cultural construction of childhood diarrhoea in rural Nicaragua: Relevance for epidemiology and health promotion

As a component of a series of studies of childhood diarrhoea in rural Nicaragua, lay knowledge regarding the condition and its appropriate management has been investigated through semistructured interviews with 70 mothers. These data have been combined with information from focus group discussions and observations from investigators who have been resident in the study area for many years. For any episode of childhood diarrhoea, the lay nosology influences the treatment path followed. Thus for some types of diarrhoea, treatment at a health centre or health post and the use of rehydration fluids is seen to be appropriate, while for other types the use of traditional healers or home-based treatment, often explicitly without the use of rehydration fluids, is applicable. The implications of lay nosological systems for the interpretation of epidemiological studies and for the implementation of health promotion programmes are discussed.

Aids in Nicaragua: Epidemiological, Political, and Sociocultural Perspectives

The AIDS epidemic in Nicaragua is several years behind that in the United States and neighboring countries of Central and South America. A combination of events, including the isolation caused by the war of the U.S.-backed Contra army against the Sandinista government, the complete economic embargo imposed on Nicaragua by the United States in 1985, self-sufficiency for blood products, and a low rate of recreational injectable-drug use, have contributed to this situation. Since the Sandinistas were defeated in the general election of 1990, people have returned to Nicaragua from areas where HIV is more prevalent, such as Honduras and the United States. It is probable that many HIV-infected persons have now entered the country. Because of the high rates of sexually transmitted diseases and cultural factors such as “machismo,” HIV is likely to spread rapidly by heterosexual transmission, unless effective, culturally appropriate education and sexually transmitted disease prevention programs are implemented now.

Determinants of drinking water quality in rural Nicaragua.

One hundred and fifty-three water samples from rural Nicaragua were examined for the presence of faecal coliforms during both wet and dry periods. A linear model was fitted by analysis of covariance with the logarithm of the faecal coliform count as the dependent variable. As expected, traditional water sources were grossly contaminated at all times whereas piped water sources were much cleaner. Hand-dug protected wells had significantly higher levels of faecal contamination than unprotected riverside wells and springs during the dry season. The possible reasons for this unexpected finding are discussed. A close association between rainfall and faecal contamination was demonstrated but the effect of rainfall depended on the type of water source. An association between water quality and the size of the community served by the source was also detected. The finding that stored water was usually more contaminated than fresh water samples is consistent with the results from other studies. Since it is unusual for water quality to be inversely correlated with accessibility, this study site would be suitable for investigating the relative importance of water-borne versus water-washed transmission mechanisms in childhood diarrhoea.

Does Health Information Alone Help in Equitable Distribution of Essential Drug Kits between Health Units at District Level

In Tanzania, the essential drugs programme (EDP) faces acute shortage of drugs brought about by a deteriorating economy and an expanding primary health care system. Many health units complain of shortages of drugs but no increase in the district allocation of EDP kits is foreseen. In the light of the aforementioned problem, a study was carried out in the Kisarawe district of Tanzania to discover, on behalf of the District Health Management Team (DHMT), the extent of the maldistribution with a view to reallocate the EDP kits among the health units on the basis of workload and catchment population. The relative workload of each health unit was estimated from the number of outpatient attendants and the catchment population estimates are based on a 1988 national census. An equitable distribution of EDP kits for each indicator was then developed by ranking the health units in order of workload and catchment population and dividing up the available number of EDP kits proportionately. Health units were categorised as either ‘over-allocated’, ‘appropriately-allocated’ or ‘under-allocated’ with EDP kits by comparing their actual drug supply with the equitable supply. The findings were presented to a meeting of the DHMT attended by the Regional Medical Officer and Ministry of Health officials. Despite being presented evidence of astounding inequity in drug distribution, there was a marked reluctance on the part of the DHMT to decide upon actions to redress some of the imbalance. In this study, we demonstrate that although data from the routine information system on essential drugs at peripheral health units provided sufficient information for managerial purposes, decision-making was delayed and limited. Several possible reasons for this are discussed.

Why do Child Mortality Rates Fall? An Analysis of the Nicaraguan Experience.

A comprehensive review of available sources of mortality data was undertaken to document the changes that have occurred in infant mortality in Nicaragua over the last three decades. It was found that a rapid fall in infant mortality commenced in the early 1970s and has continued steadily since. Trends in several different factors which might have led to this breakthrough were examined including: income, nutrition, breastfeeding practices, maternal education, immunizations, access to health services, provision of water supplies and sanitation, and anti-malarial programs. Of these, improved access to health services appears to have been the most important factor. At a time when the number of hospital beds per capita was dropping, increasing numbers of health care professionals, particularly nurses, were becoming available to staff primary health care facilities built in the 1960s. These were provided at least partly in response to the growing political turmoil enveloping the nation at that time. Certain Nicaraguan cultural attributes may have added to the impact of the reforms. Efforts in the field of public health made since the 1979 insurrection appear to have maintained the decline in child mortality.