Addressing Social Determinants of Health by Integrating Assessment of Caregiver-Child Attachment into Community Based Primary Health Care in Urban Kenya

Orphans and Vulnerable Children's Project in Africa, and Department of International Health, Johns Hopkins Bloomberg School of Public Health, and Department Public Health Sciences, University of Virginia Faculty of Medicine, 250 Pantops Mountain Road, Apt 5223 Charlottesville, VA 22911, USA. .
International Journal of Environmental Research and Public Health (Impact Factor: 1.99). 12/2012; 9(10):3588-98. DOI: 10.3390/ijerph9103588
Source: PubMed

ABSTRACT A principle strategic insight of the Final Report for WHO's Commission on Social Determinants of Health (SDOH) is that the nurturant qualities of the environments where children grow up, live, and learn matter the most for their development. A key determinant of early childhood development is the establishment of a secure attachment between a caregiver and child. We report initial field-tests of the integration of caregiver-child attachment assessment by community health workers (CHWs) as a routine component of Primary Health Care (PHC), focusing on households with children under 5 years of age in three slum communities near Nairobi, Kenya. Of the 2,560 children assessed from July-December 2010, 2,391 (90.2%) were assessed as having a secure attachment with a parent or other caregiver, while 259 (9.8%) were assessed as being at risk for having an insecure attachment. Parent workshops were provided as a primary intervention, with re-enforcement of teachings by CHWs on subsequent home visits. Reassessment of attachment by CHWs showed positive changes. Assessment of caregiver-child attachment in the setting of routine home visits by CHWs in a community-based PHC context is feasible and may yield valuable insights into household-level risks, a critical step for understanding and addressing the SDOH.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Mothers (N = 125) and their firstborn sons were studied over an 11-month period to examine relations between mothers' representations of their relationships with their children (measured at 15 months by using the Parent Development Interview [PDI]), adult representations of attachment (measured at 12 months by using the Adult Attachment Interview [AAI]), and observed mothering (measured at 15 and 21 months). Results indicate (a) that mothers classified as autonomous on the AAI scored highest on the joy-pleasure/coherence dimension of the PDI and mothers classified as dismissing on the AAI scored highest on the anger dimension of the PDI and (b) that mothers scoring higher on the joy-pleasure/coherence dimension of the PDI engaged in less negative and more positive mothering.
    Developmental Psychology 06/1999; 35(3):611-9. DOI:10.1037/0012-1649.35.3.611 · 3.21 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: In the absence of a feasible, noninvasive gold standard, iron deficiency (ID) is best measured by the use of multiple indicators. However, the choice of an appropriate single iron biomarker to replace the multiple-criteria model for screening for ID at the population level continues to be debated. We compared ID defined as ≥ 2 of 3 abnormal ferritin (< 12 μg/L), soluble transferrin receptor (TfR; > 8.3 mg/L), or zinc protoporphyrin (ZP; > 80 μmol/mol) concentrations (ie, multiple-criteria model) with ID defined by abnormal concentrations of any of the independent candidate iron biomarkers (ferritin alone, TfR alone, or ZP alone) and TfR/ferritin index (ID, > 500). Values either were adjusted for inflammation [as measured by C-reactive protein (> 5 mg/L) and α(1)-acid glycoprotein (> 1 g/L) before applying cutoffs for ID] or were unadjusted. In this community-based cluster survey, capillary blood was obtained from 680 children (aged 6-35 mo) for measurement of iron status by using ferritin, TfR, and ZP. On the basis of the multiple-criteria model, the mean (±SE) prevalence of ID was 61.9 ± 2.2%, whereas the prevalences based on abnormal ferritin, TfR, or ZP concentrations or an abnormal TfR/ferritin index were 26.9 ± 1.7%, 60.9 ± 2.2%, 82.8 ± 1.6%, and 43.1 ± 2.3%, respectively, for unadjusted values. The prevalences of ID were higher for adjusted values only for low ferritin and an elevated TfR/ferritin index compared with the unadjusted values. The κ statistics for agreement between the multiple-criteria model and the other iron indicators ranged from 0.35 to 0.88; TfR had the best agreement (κ = 0.88) with the multiple-criteria model. Positive predictive values of ID based on the other iron indicators in predicting ID based on the multiple-criteria model were highest for ferritin and TfR. Receiver operating characteristic curve analysis indicated that TfR (AUC = 0.94) was superior to the other indicators in diagnosing ID based on the multiple-criteria model (P < 0.001). The inflammation effect did not appear to alter these observations appreciably. TfR better estimates the prevalence of ID in preschoolers than do ferritin, ZP, and the TfR/ferritin index on the basis of multiple indexes in a high inflammation, resource-poor setting. This trial was registered at as NCT101088958.
    American Journal of Clinical Nutrition 03/2012; 95(5):1231-7. DOI:10.3945/ajcn.111.029900 · 6.50 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study was designed to examine the relationship of maternal and child human immunodeficiency virus (HIV) infection to the security of attachment of Ugandan infants. The attachment patterns of two groups of Ugandan mother-infant pairs: 35 HIV-positive mothers and their infants and 25 HIV-negative mothers and their infants were compared. We tested the hypothesis that infants of HIV-positive mothers would demonstrate less secure attachment as measured by the Waters Attachment Q-set than infants of HIV-negative mothers. No differences were found in the security of attachment of infants of HIV-positive versus HIV-negative mothers. Infants of HIV-positive mothers with Acquired Immunodeficiency Syndrome (AIDS) were less securely attached than infants of mothers without AIDS. These findings underscore the relationship of infant security of attachment to maternal HIV infection in the presence of AIDS-related symptoms but not to asymptomatic maternal HIV infection.
    Child Psychiatry and Human Development 08/2001; 32(1):3-17. DOI:10.1023/A:1017581412328 · 1.93 Impact Factor


Available from