Category 1 Continuing Medical Education credit for physicians is available to Wilderness Medical Society members for this article. Go to http://wms.org/cme/cme.asp?whatarticle=1812 to access the ...instructions and test questions. Objective.—Cuzco, Peru, is host to a dangerous mix of high altitude and rapid access from low elevation, which results in a high prevalence of acute mountain sickness (AMS). Thus, it is important that travelers entering Cuzco understand the basics of AMS. To this end, we assessed travelers' awareness of AMS, especially the resources used to obtain this knowledge. With this information we make recommendations with regard to better avenues for distribution of AMS information. Methods.—One hundred foreign travelers, representing an international population, completed a 45-item written questionnaire that was subsequently analyzed. Results.—Over half of the respondents (51%) rated their knowledge of AMS as “low” or “none.” Furthermore, very few respondents knew about acetazolamide (Diamox) as prophylaxis for (9%) or treatment of AMS (5%). People who consulted physicians for AMS information were more likely to know about the utility of acetazolamide than those who depended on a guidebook (P = .0266) but were less likely to correctly identify the symptomatology of AMS (P = .047). While AMS knowledge was poor, the majority of travelers (90%) indicated compliance with recommended pretravel vaccinations. Conclusions.—This survey adds to the body of knowledge that indicates a lack of AMS knowledge among travelers. In addition, this survey identifies 2 potential avenues for improved dispersal of information: 1) guidebooks for countries of concern and 2) national health agency Web sites linked to information on pretravel vaccinations. Recommendations are made to utilize these commonly accessed resources to increase AMS information distribution to the general populous.
Fifty mothers of children attending a hospital outpatient clinic with non-severe pneumonia (fast breathing but no chest indrawing) were interviewed in depth. Maternal perceptions and practices with ...clinical significance were documented. Results showed that most mothers initially tried "heat-producing" home remedies designed to counter the "coldness" of the disease, allowed only 2 days for any particular allopathic medicine to work, and did not go to the same practitioner twice. When mothers were asked what had alarmed them enough to come to the hospital, the symptoms named most frequently were persistent severe cough and high fever, inability to sleep and excessive crying. Fast breathing was spontaneously mentioned by only a few, although when questioned, 32/50 said that they had noticed it. The mothers who had prior experience with child pneumonia were more likely to notice fast breathing and also came to the hospital earlier than those who were inexperienced. Relatively higher levels of maternal education and income were suggestively associated with bringing a female child rather than a male child for pneumonia treatment. Fewer than half of the mothers knew where air goes when a person breathes in and where the lungs are located. Most held treatment preferences at odds with the protocols proposed for the national ARI program currently being initiated in Pakistan, e.g. they said that a doctor should use a stethoscope, should prescribe suspensions rather than tablets and should give injections. This study provides baseline data on attitudes and behaviors that can either be built on in that program or addressed through public education campaigns.
In mountain villages of Chitral District in northwestern Pakistan, dried cow dung is used as Westerners would use talcum powder when babies are swaddled and rock salt is consumed in tea and other ...foods. Both substances are esteemed as conveying beneficial 'heat' and 'strength'. Unfortunately, however, cow dung sometimes contains a bacterium that causes neonatal tetanus, and the resulting toxin may enter through the baby's unhealed umbilical cord and cause death. Further, rock salt contains no iodine, and Chitral's soil is so iodine-deficient that goiter is very common. Thus local health workers advocate use of talcum powder rather than cow dung, immunization against tetanus, and replacement of rock salt by powdered iodized salt. The present report documents widespread community acceptance of these innovations despite the fact that the biomedical model of tetanus and goiter was not well understood and indigenous concepts of the causes of the diseases remained virtually undisturbed. Most of the villagers were Ismaili Muslim followers of the Aga Khan; their receptivity to such health messages was influenced by the high value that their religion places on advancement through 'education' and was correlated with their proximity to Ismaili health workers whom they trusted. A major implication of this research for primary health care programs is that when one is attempting to change existing health practices, explication of biomedical models should not be the only focus of concern. Attentiveness to the context in which behavior changes are introduced and interpreted is at least equally important. Further, the fact that new knowledge was added to the old without replacing it illustrates the complexity of human cognition and points to limitations in the KAP (knowledge-attitude-practice) model of health belief and behavior. This report adds to a small but important body of literature documenting the dynamic nature of medical pluralism in the developing world.
Objective To describe pica behavior (ingestion of nonfood items) in pregnant low-income Mexicon-born women in Mexico and the United States.Design A convenience sample of informants was interviewed ...with a questionnaire containing open-ended and closed-ended questions. SettingA low-income community on the outskirts of Ensenada, Mexico, and clinics serving low-income people in southern California (Santa Ana, Bakersfield, andLos Angeles). Participants Of a total of 225 Mexican-born women, 75(33%) were interviewed in Ensenada, and 150 (67%) were interviewed in southernCalifornia. Results The prevalence of pica during pregnancy was 44% (n= 33) in the Ensenada group and 31% (n = 46) in the southern California group.Those who reported pica behavior more commonly had a relative who also practiced pica. Conclusion The high reported rate of pica in this sample indicates that pregnant Mexican-born women should be screened for pica and educated about the potentially serious effects on the fetus and mother.
Although previous research has demonstrated frequent complementary and alternative medicine (CAM) use by Hispanic patients, it remains unclear whether the status of immigration plays a role in the ...frequency and reasons for use.
A survey of 164 patients from a federally qualified health center in South Central Los Angeles was used; the health center serves a predominantly Latino immigrant patient population. The study included the following variables: patient age; sex; place of birth; number of years living in the United States; CAM use within the last year; and, if positive CAM use, what type(s) and for what condition(s).
Sixty-six percent of patients had used a CAM substance within the past year. Ninety-seven percent of the patients were immigrants (primarily from Mexico, El Salvador, and Guatemala). Differences in CAM use between recently arrived (< or =9 years) and long-term immigrants (> or =10 years) were not significant. Ninety-four percent of patients using CAM reported using herbal/tea/plant-based substances, with the most frequent reason for CAM use being digestive problems. Although most CAM substances were obtained from a market (64%), a not insignificant number of CAM substances were grown at home (23%).
Time since immigration does not seem to impact the frequency of CAM use by Hispanic immigrant patients. Herbal/tea/plant-based substances are frequently used in the Hispanic patient population, often for digestive complaints.
In 1992, 320 mothers were interviewed in a Rawalpindi hospital to identify which of the signs and symptoms they saw in their own children were most consistently linked with a clinical diagnosis of ...pneumonia as opposed to common cold. A related goal was to determine whether mothers could correctly judge the actual presence or absence of two major pneumonia signs--fast breathing and chest indrawing. The mothers were predominantly poor and 43% were illiterate. The study sample was composed of four matched groups: (1) mothers of 80 children with pneumonia, most with severe disease, interviewed after the child was referred to the ward; (2) mothers of 80 such children interviewed in the outpatient clinic prior to any discussion of the pneumonia diagnosis; (3) mothers of 80 children with common cold; and (4) mothers of 80 'well' children. Results showed that when mothers were interviewed in the clinic, their perception that a child had fast breathing and/or chest indrawing was highly correlated with pneumonia (sensitivity 64%, specificity 90%). Mothers were even more likely to say that a child had these signs after the pneumonia diagnosis had been conveyed, suggesting that interaction with doctors influenced their views. Fast breathing was better recognized than chest indrawing, and accurate diagnosis of both signs was better among mothers having prior experience with childhood pneumonia. The data suggest that even in the absence of formal ARI education, a majority of Pakistani mothers attending hospitals in indigent areas can recognize these two signs in their own children. However, the seriousness of the signs and their connection with pneumonia should be stressed in education campaigns since a high percentage of children had chest indrawing (a late sign of severe disease) by the time they were brought to the hospital.
In Pakistan approx. 30% of the 18,000 known leprosy patients have dropped out of their treatment programs. To investigate reasons for such widespread noncompliance, 128 diagnosed leprosy patients--59 ...outpatients and 69 inpatients--were interviewed in Karachi. More than half of the 'noncompliant' outpatients denied having the disease. Denial was found to be an understandable coping mechanism in view of the severe stigma associated with leprosy. The presence of close-knit extended families, in which joint decision-making was the norm and in which such a dread diagnosis could spell the end of job and marriage prospects for even distant relatives, contributed to the likelihood of denial. In such a setting, the very term 'noncompliant' appeared to be an oversimplification since it covered so many different types of culturally-constrained behavior. In addition, many of the patients who initially seemed most 'compliant' by virtue of being long-term hospital inpatients in fact owed their hospitalization to the fact that they had been markedly noncompliant in the past. Thus the usual view that adherence to a biomedical treatment regimen constitutes 'compliance' and that nonadherence to such a regimen constitutes 'noncompliance' proved inadequate for understanding the health behavior of these Third World leprosy victims. The study also showed that many patients had initially consulted traditional healers, inadequately-trained physicians, and/or untrained medical practitioners for treatment of their symptoms, which resulted in lengthy delays before they were correctly diagnosed. Further, even after the diagnosis was made and appropriate medications were prescribed by trained personnel, most patients were not told what had caused their leprosy and how the drug regimen worked to combat it: when questioned, only 4% of the 128 respondents attributed the disease to infectious organisms. In addition, patients were usually not warned in advance of the possibility of undesirable side effects from their leprosy medications, which led to further 'compliance' problems. The findings of this study emphasize the need for better training of physicians and other health care providers in early diagnosis of leprosy and better health education of diagnosed patients. To be truly effective, the treatment of leprosy must include counseling of extended families and education of the public at large as well as enhanced communication with the patients themselves.
To describe the cultural context of type 2 diabetes mellitus among Vietnamese immigrants in the United States, including people's ideas about cause and proper treatment; and to suggest ways in which ...better control of the disease can be achieved in this population.
The method was ethnographic. A native speaker used a structured interview guide to talk with 38 Vietnamese patients, and family members of 2 other patients, being treated for type 2 diabetes. In addition, 8 Vietnamese health providers--5 physicians, 2 nurses, and an herbalist--were interviewed.
A low-income area of southern California populated by a large number of Vietnamese.
Forty patients being treated for type 2 diabetes and 8 health practitioners.
Three quarters of the patients had not achieved good control of their diabetes. Ideas about the cause and proper treatment of the disease were culturally shaped. Many patients used eastern (herbal) medicine and described a strong aversion to insulin injections. Patients stopped taking their oral medications when using eastern medicine, and a quarter lowered their dose whenever they felt "out of balance." Almost two thirds had used traditional home remedies for diabetes. Two had received nonstandard medical care from neighborhood physicians trained in Viet Nam; 1 of these patients died during the study.
The Vietnamese community and physicians serving that community need culturally appropriate education about type 2 diabetes and modern therapy for the disease.
Family physicians are generalists trained at the postgraduate level to address the majority of primary care needs of patients of all ages in communities they serve. Throughout the world there is a ...need for family physicians to serve as cornerstones of comprehensive health care systems that provide high-quality, cost-effective medical and public health services to the entire population. To meet this need, each country must value and adequately finance essential medical and public health services and must provide family physicians with a thorough education focused on the relevant health care problems of the population being served. The authors present an overview of the status of this training throughout the world, outline challenges to the development of such training, and suggest strategies for successful development accompanied by illustrative case studies from South Korea, Venezuela, and Pakistan.
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