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Objectives: The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program. Methods: 1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted χ2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics. Results: Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to “know-how”—that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes. Conclusions: This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency.

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995-May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care: and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants' chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.

Background Infant mortality rates vary substantially among municipalities in the State of Ceara, from 14 to 193 per 1000 live births. Identification of the determinants of these differences can be of particular importance to infant health policy and programmes in Brazil where local governments play a pivotal role in providing primary health care. Methods Ecological study across 140 municipalities in the State of Ceara, Brazil. Results To determine the interrelationships between potential predictors of infant mortality, we classified 11 variables into proximate determinants (adequate weight gain and exclusively breastfeeding), health services variables (prenatal care up-to-date, participation in growth monitoring, immunization up-to-date, and decentralization of health services), and socioeconomic factors (female literacy rate, household income, adequate water supply, adequate sanitation, and per capita gross municipality product), and included the variables in each group simultaneously in linear regression models. In these analyses, only one of the proximate determinants (exclusively breastfeeding (inversely), R 2 = 9.3) and one of the health services variables (prenatal care up-to-date (inversely), R 2 = 22.8) remained significantly associated with infant mortality. In contrast, female literacy rate (inversely), household income (directly) and per capita GMP (inversely) were independently associated with the infant mortality rate (for the model including the three variables R 2 = 25.2). Finally, we considered simultaneously the variables from each group, and selected a model that explained 41% of the variation in infant mortality rates between municipalities. The paradoxical direct association between household income and infant mortality was present only in models including female illiteracy rate, and suggests that among these municipalities, increases in income unaccompanied by improvements in female education may not substantially reduce infant mortality. The lack of independent associations between inadequate sanitation and infant mortality rates may be due to the uniformly poor level of this indicator across municipalities and provides no evidence against its critical role in child survival. Conclusions These results suggest that promotion of exclusive breastfeeding and increased prenatal care utilization, as well as investments in female education would have substantial positive effects in further reducing infant mortality rates in the State of Ceara.

Objective: In 1989, a validation study of eight nutrients was performed on a modified food frequency questionnaire (FFQ) specifically designed for low-income pregnant women. The purpose of this study was to broaden the scope of the previous study by assessing the validity of the FFQ for 17 additional nutrients. Methods: The Pregnancy Food Frequency Questionnaire (PFFQ) was administered to a sample of 295 low-income, pregnant women aged 14–43 years living in Massachusetts. A randomly selected subsample of 101 women who provided at least one diet recall and reported intake of less than 4,500 calories were included in this analysis. Results: Mean intake of 25 nutrients as assessed by one administration of the PFFQ and up to three diet recalls collected over 1 month were similar. Unadjusted correlation coefficients between nutrient intake measured by diet recalls and the questionnaire ranged from .28 (carotene) to .61 (folate). After adjusting for energy intake the correlations ranged from .03 (B12) to .46 (folate). The correlations corrected for day-to-day variation were higher, ranging from .07 (B12) to .90 (zinc). The mean correlation was .47 and there were 54% over .40. Conclusions: A food frequency questionnaire for English-speaking, low-income, pregnant women can provide maternal and child health practitioners and researchers a valid estimate of diet across a wide range of nutrients.

Objective: To assess the validity of the Harvard Service Food Frequency Questionnaire (HFFQ) in the diet assessment of Native American and Caucasian children 1 to 5 years of age participating in the North Dakota WIC program. Methods: The 84-item HFFQ was administered twice to the parent or guardian of 131 Native American and 102 Caucasian children ages 1 to 5 years (total n = 233), first at the child's routine WIC visit and then following the completion of three 24-hr dietary recalls taken over approximately 1 month. Average nutrient intakes from the three 24-hr dietary recalls were compared to average nutrient intakes from the HFFQs by calculating Pearson correlation coefficients and adjusting for energy intake and within person variation. Results: Correlation coefficients ranged from 0.26 for dietary fiber to 0.63 for magnesium. The average correlation was 0.52, similar to that found in validation studies among adolescents and adults. The following nutrients had correlations of 0.50 or greater: carbohydrate, sucrose, total fat, vitamin C, vitamin E, vitamin Bl, vitamin B2, niacin, folate, vitamin B6, calcium, magnesium, and iron. Conclusions: The HFFQ is a simple self-administered questionnaire completed by the child's parent or guardian and is useful in assessing the diets of Native American and Caucasian children. It may also provide important nutritional information about this age group for future program planning, research, education, and intervention purposes.

Among a culturally diverse group of 344 low-income pregnant women, self-reported rates of supplement use prior to confirmation of pregnancy were much lower than those reported for young women in national surveys (16% vs. up to 40%, respectively). Prenatal vitamins, prescribed routinely for all patients, were reportedly taken at least four times a week by 86% of the subjects and two to three times a day by 5%. About 5% of the sample reported consuming highly fortified cereal at least once daily. There is a possibility of higher than recommended use of supplemental vitamins among these women resulting from misunderstanding of the number of pills to be taken and/or high consumption of highly fortified cereals.

Background Food frequency questionnaires (FFQs) have been validated in pregnant women, but few studies have focused specifically on low-income women and minorities. The purpose of this study was to examine the validity of the Harvard Service FFQ (HSFFQ) among low-income American Indian and Caucasian pregnant women. Methods The 100-item HSFFQ was administered three times to a sample of pregnant women, and two sets of 24-hour recalls (six total) were collected at approximately 12 and 28 weeks of gestation. The sample included a total of 283 pregnant women who completed Phase 1 of the study and 246 women who completed Phase 2 of the study. Deattenuated Pearson correlation coefficients were used to compare intakes of 24 nutrients estimated from the second and third FFQ to average intakes estimated from the week-12 and week-28 sets of diet recalls. Results Deattenuated correlations ranged from 0.09 (polyunsaturated fat) to 0.67 (calcium) for Phase 1 and from 0.27 (sucrose) to 0.63 (total fat) for Phase 2. Average deattenuated correlations for the two phases were 0.48 and 0.47, similar to those reported among other groups of pregnant women. Conclusion The HSFFQ is a simple self-administered questionnaire that is useful in classifying low-income American Indian and Caucasian women according to relative dietary intake during pregnancy. Its use as a research tool in this population may provide important information about associations of nutrient intakes with pregnancy outcomes and may help to identify groups of women who would benefit most from nutritional interventions.

This ecological study examines the variations in diarrhoea-specific infant mortality rates among municipalities in the State of Ceará, north-east Brazil, using data from a community health workers’ programme. Diarrhoea is the main cause of postneonatal deaths in Ceará, and diarrhoea mortality rates vary substantially among municipalities, from 7 to 50 per thousand live births. To determine the inter-relationships between potential predictors of diarrhoea-specific infant mortality, eleven variables were classified into proximate determinants (i.e. adequate weight gain and exclusive breast-feeding in first 4 months) and underlying determinants (i.e. health services and socioeconomic variables). The health services variables included percentage with prenatal care up-to-date, participation in growth monitoring and immunization up-to-date, while the socioeconomic factors included female illiteracy rate, per capita gross municipality product and percentage of households with low income, percentage of households with inadequate water supply and inadequate sanitation, and urbanization. Using linear regression analysis variables were included from each group to build regression models. The significant determinants of variability in diarrhoea-specific infant mortality between municipalities were prevalence of infants exclusively breast-feeding, percentage of infants with adequate weight gain, percentage of pregnant women with prenatal care up-to-date, female illiteracy rate and inadequate water supply. These findings suggest that community-based promotion of exclusive breast-feeding in the first 4 months and care-giving behaviours that prevent weight faltering, including weaning practices and feeding during and following diarrhoea episodes, may further reduce municipality-level diarrhoea-specific mortality. Primary heath care strategies addressing these two proximate determinants provide only a partial solution to reducing diarrhoeal disease mortality. Improvements in municipal health services (prenatal care) and socioeconomic status variables, including water supply and maternal education, can also contribute to reduction of infant mortality due to diarrhoea. These results may be used by government health officials to set priorities by considering not only the strength of the association between selected risk factors and diarrhoea mortality rates, but also the prevalence of the risk factors being considered at the municipality level. Finally, the methods used are applicable to other settings with community-based primary health care decentralized to the state or municipal level.

Concern is growing about the adequacy and safety of health services provided for medically complex children in public schools. A national survey of state health and education agencies was conducted to learn if guidelines existed governing the practice of eight selected nursing procedures in schools. Thirteen states (26%) had no written guidelines, 13 states (26%) had guidelines only for medication administration, and only six states (12%) had guidelines for the eight selected nursing procedures.

Long term recalls of dietary intake are frequently used in case-control studies, but their validity and reliability have not been established. In this study, 91 middle-aged adults (median age, 50 years) who were participants in the Longitudinal Study of Child Health and Development at the Harvard School of Public Health in Boston, Massachusetts, starting in the early 1930s, were asked in 1984-1985 to report present food intake and to recall food intakes at ages 5-7 years. 18 years, and 30 years using food frequency questionnaires. Their recalled intakes were validated by comparison with historical records of intake collected during the earlier time periods. Recall of food intake in the distant past was a better predictor of historical intake than was current diet. However, correlations between recalled and historical consumption for individual foods and food groups were generally low, rarely exceeding 0.3. Current intakes exerted a powerful influence on accuracy of recall. The consideration of participant characteristics did not prove to be consistently useful in explaining variations in food item and food group-related recall. The authors conclude that recall of food intake in the distant past may be a sufficiently valid estimate of past intake to justify its collection.