Sally E. Findley

Does drought increase migration? A study of migration from rural Mali during the 1983-1985 drought.

Using data from a longitudinal panel study conducted in 1982 and 1989 in the first region of Mali, this article demonstrates that the level of migration did not rise during the drought of 1983–1985. However, there was a dramatic increase in the migration of women and children during the severe 1983–1985 drought. Along with this increase in migration by women and children, there was a shift to short-cycle circulation, with 64 percent of the migrants adopting circular patterns. The study describes the characteristics of these migrants and recommends changes to development and migration policies that will facilitate such migrations in subsequent droughts.

Elevated Asthma and Indoor Environmental Exposures Among Puerto Rican Children of East Harlem

Objective. East Harlem in New York City, a community with a large Puerto Rican population, has among the highest rates of asthma hospitalizations and mortality in the United States, but it is not known if the high rates are related to the ethnic composition, environmental or community factors, or if the higher rates reflect differentials in access to appropriate asthma care. A survey was conducted to: (a) estimate the prevalence of current asthma by ethnicity among school-age children, (b) assess indoor environmental risk factors for childhood asthma, and (c) assess health care utilization and school absences associated with childhood asthma. Design. A cross-sectional survey of parents of elementary school children, using a self-administered questionnaire with a 12-month recall on asthma symptoms based on the International Study of Asthma and Allergies in Childhood. Setting. Two public elementary schools in East Harlem (n = 1615 students 5–12 years of age). Results. Among the 1319 respondents (response rate 82%), the prevalence for current asthma (doctor or nurse diagnosis at any time plus wheezing in the past 12 months) was 23%. Puerto Rican children had a prevalence of 35%. Puerto Rican children reported both higher symptomatic frequencies and higher rates of physician diagnosis. Living in a home where cockroaches, rats, or mice had been seen in the past month and with a dust-enhancing heating system also was associated with having asthma, regardless of ethnicity. Compared with other children with asthma, Puerto Rican children with asthma were more likely to live in homes where rats or mice had been seen in the past month. Regardless of ethnicity, children with more frequent, more severe asthma symptoms and incomplete asthma action plans were more likely to have visited the emergency department in the past year. Puerto Rican children were more likely to have missed school because of their asthma in the past year. Conclusion. The prevalence of current asthma was significantly higher among Puerto Ricans, who had higher symptomatic frequency and greater diagnosis rates. Although all children with asthma in the East Harlem study appear to be sensitive to selected indoor environmental risk factors, only Puerto Rican children with asthma appear to be sensitive to the presence of rodents in their buildings. However, their higher school absence rate suggests problems with routine asthma management that could be addressed by improved medical management, programs to help parents manage their childrens asthma, or school staff assistance with medications.

Changing WIC changes what children eat

This study assessed the impact of revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages on nutritional behavior and obesity in children 0‐ to 4‐years‐old participating in the New York State (NYS) WIC program. In January 2009, NYS was the first to implement these revisions, which added fruits, vegetables, and whole grains and replaced whole milk with low(1%)‐/nonfat milk for children 2‐ to 4‐year‐old.

Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative

In 2005, local leaders in New York City developed the Washington Heights/Inwood Network for Asthma Program to address the burden of asthma in their community. Bilingual community health workers based in community organizations and the local hospital provided culturally appropriate education and support to families who needed help managing asthma. Families participating in the yearlong care coordination program received comprehensive asthma education, home environmental assessments, trigger reduction strategies, and clinical and social referrals. Since 2006, 472 families have enrolled in the yearlong program. After 12 months, hospitalizations and emergency department visits decreased by more than 50%, and caregiver confidence in controlling the childs asthma increased to nearly 100%. Key to the programs success was the commitment and involvement of community partners from program inception to date.

Forecasting non-stationary diarrhea, acute respiratory infection, and malaria time-series in Niono, Mali.

Background Much of the developing world, particularly sub-Saharan Africa, exhibits high levels of morbidity and mortality associated with diarrhea, acute respiratory infection, and malaria. With the increasing awareness that the aforementioned infectious diseases impose an enormous burden on developing countries, public health programs therein could benefit from parsimonious general-purpose forecasting methods to enhance infectious disease intervention. Unfortunately, these disease time-series often i) suffer from non-stationarity; ii) exhibit large inter-annual plus seasonal fluctuations; and, iii) require disease-specific tailoring of forecasting methods. Methodology/Principal Findings In this longitudinal retrospective (01/1996–06/2004) investigation, diarrhea, acute respiratory infection of the lower tract, and malaria consultation time-series are fitted with a general-purpose econometric method, namely the multiplicative Holt-Winters, to produce contemporaneous on-line forecasts for the district of Niono, Mali. This method accommodates seasonal, as well as inter-annual, fluctuations and produces reasonably accurate median 2- and 3-month horizon forecasts for these non-stationary time-series, i.e., 92% of the 24 time-series forecasts generated (2 forecast horizons, 3 diseases, and 4 age categories = 24 time-series forecasts) have mean absolute percentage errors circa 25%. Conclusions/Significance The multiplicative Holt-Winters forecasting method: i) performs well across diseases with dramatically distinct transmission modes and hence it is a strong general-purpose forecasting method candidate for non-stationary epidemiological time-series; ii) obliquely captures prior non-linear interactions between climate and the aforementioned disease dynamics thus, obviating the need for more complex disease-specific climate-based parametric forecasting methods in the district of Niono; furthermore, iii) readily decomposes time-series into seasonal components thereby potentially assisting with programming of public health interventions, as well as monitoring of disease dynamics modification. Therefore, these forecasts could improve infectious diseases management in the district of Niono, Mali, and elsewhere in the Sahel.

Northern Nigeria Maternal, Newborn and Child Health Programme: Selected Analyses from Population-Based Baseline Survey

Maternal mortality in Northern Nigeria is among the highest in the world. To guide programme planning we in- terviewed 7,442 women in April and May 2009 in three northern states (Katsina, Yobe, and Zamfara) to understand pat- terns of antenatal care and delivery. Here, we present findings from a population-based survey conducted under the PRRINN-MNCH Programme to provide evidence-base programmatic interventions aimed at improving maternal and child health indicators. In the paper, we outline the health challenges facing northern Nigeria, describe the PRRINN- MNCH Programme, describe the baseline survey design, implementation, and subsequent data. We provide a series of maternal and child health indicators in order to address two key important policy issues: (1) the importance of visits to health care facilities to enable women get proper maternal care, and (2) the importance of having access to skilled person- nel at birth. We further describe how these data can be used to develop appropriate strategies for integrated programmes to increase awareness of pregnancy and delivery complications and to reduce the barriers to assessing risk and accessing the facilities in a timely manner. Appropriate strategies and interventions are necessary to address the existing health chal- lenges. To a large extent, these data also provide an opportunity to measure the impact of the programme in assisting Ni- geria attain the health Millennium Development Goals of maternal and child health.

Change in parental reasons for use of an urban pediatric emergency department in the past decade.

Objective: To assess changes over the past decade in parental reasons associated with nonurgent visits to pediatric emergency departments (PEDs) during regular primary care office hours. Methods: Secondary analysis of cross-sectional surveys of families of children younger than 3 years visiting a PED in a low-socioeconomic area in New York City conducted in 1997 and 2006. We performed multivariable analyses to assess differences in parental reported reasons for PED use over the period, controlling for sociodemographic factors. Results: Most children (95.6%) had a usual source of care across both periods. Compared with those seen in 1997, children seen in 2006 were far less likely to be brought to the PED during regular primary care office hours for parental perceived urgency (adjusted odds ratio [AOR], 0.076; 95% confidence interval [CI], 0.024-0.24; P < 0.001). At the same time, these children were more likely to be brought to the PED for limited access to their usual source of care (AOR, 3.35; 95% CI, 1.24-9.02; P < 0.05) and greater trust in the medical expertise of the PED (AOR, 5.95 95% CI, 1.20-29.45; P < 0.05). Conclusions: Over the last decade, despite the presence of a usual source of care, a greater number of parents report visiting this urban PED during regular office hours for reasons unrelated to parental perceived urgency. Limited access to care and greater trust in the medical expertise available in PEDs have played important roles. Approaches to decreasing nonurgent visits must take into account all of these factors.

Balancing “Fidelity” and Community Context in the Adaptation of Asthma Evidence-Based Interventions in the “Real World”

The Merck Childhood Asthma Network (MCAN) initiative selected five sites (New York City, Puerto Rico, Chicago, Los Angeles, and Philadelphia) to engage in translational research to adapt evidence-based interventions (EBIs) to improve childhood asthma outcomes. The authors summarize the sites’ experience by describing criteria defining the fidelity of translation, community contextual factors serving as barriers or enablers to fidelity, types of adaptation conducted, and strategies used to balance contextual factors and fidelity in developing a “best fit” for EBIs in the community. A conceptual model captures important structural and process-related factors and helps frame lessons learned. Site implementers and intervention developers reached consensus on qualitative rankings of the levels of fidelity of implementation for each of the EBI core components: low fidelity, adaptation (major vs. minor), or high fidelity. MCAN sites were successful in adapting core EBI components based on their understanding of structural and other contextual barriers and enhancers in their communities. Although the sites varied regarding both the EBI components they implemented and their respective levels of fidelity, all sites observed improvement in asthma outcomes. Our collective experiences of adapting and implementing asthma EBIs highlight many of the factors affecting translation of evidenced-based approaches to chronic disease management in real community settings.

Community Health Worker Insights on Their Training and Certification

Background: In recent years, the community health worker (CHW) field has grown significantly in the United States, with increasing numbers, roles, and visibility of CHWs. State health department regulators, health program administrators, and community health advocates have observed this growth with uncertainty about the definition of a CHW, how CHW roles differ from those of other health professionals, CHW training needs, and the potential impact of the growing certification and accreditation regulations. Objective: Despite the proliferation of regulatory policies, few studies have examined how regulation can most effectively support CHWs in the field. Our objective is to define CHW, identify training needs, and examine possibilities for credentialing from the perspective of CHWs in New York City. Methods: Community-based participatory research (CBPR) was used to engage CHW leadership and gather input from CHWs in the design and conduct of the study. The academic–community–state partnership designed focus group topic guides, and conducted fifteen focus groups with CHWs in New York City. The focus group responses were analyzed using HyperResearch and formed the basis for policy recommendations to the participating partners. Results: We developed a consensus definition of CHW and its fundamental qualities. We identified unmet training needs in the area of core competencies. We outlined the characteristics of a credentialing process that would support and advance the work of CHWs. Conclusions: CBPR enabled CHWs to have a direct voice in defining their description, roles, training, and certification preferences. This informed policy recommendations to the state, university, and CHWs through a collaborative process.

A Community-Based Strategy for Improving Asthma Management and Outcomes for Preschoolers

Although almost one in ten (8.6%) preschool children has been diagnosed with asthma, few asthma management programs are designed for parents of preschool children. The Asthma Basics for Children program addressed this need in 2003–2008 by implementing a multi-layered approach that offered educational activities to center staff, parents, and children and PACE training to physicians in 31 Northern Manhattan daycare centers. Following program participation, 85% of parents reported reducing their childs triggers, 89% said it was easier to talk to their childs physician, and 80% were confident in their ability to manage their childs asthma. Childrens any daytime symptoms dropped from 78% to 42%, any nighttime symptoms from 81% to 49%, any daycare absences from 56% to 38%, any asthma-related emergency department (ED) visits from 74% to 47%, and any asthma-related hospitalizations from 24% to 11% (p < .001 for all differences). Outcomes varied by level of exposure. In the Center-Only group (no parent participation), the only reduction was from 19% to 10% (McNemar = 3.77, p = .052) in hospitalizations. Children whose parents participated in the program had significant reductions in daycare absences (62% to 38%, McNemar = 11.1, p < .001), ED visits (72% to 43%, McNemar = 19.2, p < .001), and hospitalizations (24% to 11%, McNemar = 5.54, p = .018). Children whose parents and healthcare provider participated had the greatest improvements with asthma-related daycare absences dropping from 62% to 32% (McNemar = 9.8, p = .001), ED visits from 72% to 37% (McNemar = 14.4, p < .001), and hospitalizations from 35% to 15% (McNemar = 8.33, p = .003). This study demonstrates that a multi-layered approach can improve asthma outcomes among preschoolers with a combination of parent and provider education having the greatest impact.