Browsing by Author "Ibraheem, Rasheedat"
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Item Acceptability of reminders for immunization appointments via mobile devices by mothers in Ilorin, Nigeria: a cross-sectional study.(Oman Medical Specialty Board, 2017-11) Ibraheem, Rasheedat; Akintola, MoshoodOBJECTIVES: Immunization coverage in Nigeria remains low despite the protection it confers. Reminders via mobile phones may be deployed as a means of improving vaccination coverage but requires the participation and cooperation of the caregiver. Therefore, we evaluated the acceptability of reminders for immunization appointment by mothers in Ilorin, Nigeria. METHODS: This descriptive cross-sectional study recruited 526 mothers from two public hospitals in Ilorin. Semi-structured questionnaires were used to collect information on ownership and access to phones, willingness to receive reminders, household, antenatal, and delivery characteristics. RESULTS: The majority (92.7%) of mothers had a personal phone, and all willingly provided contact details. Over half (69.0%) of mothers were willing to receive reminders. Postsecondary education (odds ratio (OR) = 1.958; 95% confidence interval (CI): 1.232-3.111) and antenatal care attendance by mothers (OR = 8.381; 95% CI: 2.495-28.170) were significant determinants of mothers willingness to receive reminders. Mothers with less than or equal to four children had a three-fold increased odds of wanting reminders. Artisan mothers were less likely to want reminders compared with unemployed mothers (OR = 0.506; 95% CI: 0.291-0.847). CONCLUSIONS: Most mothers are willing to receive reminders on immunization appointments via their mobile phone. Determinants of maternal willingness to receive reminders include mothers with less than four children, postsecondary education, and antenatal care attendance. Program planners should consider utilizing reminders as a strategy to increase the immunization uptake with access to contact details making this feasible.Item Challenges in the management of mucopolysaccharidosis Type II (Hunter’s Syndrome) in a developing country: a case report.(College of Health Sciences, Jimma University, Ethiopia, 2015-07) Ibraheem, Rasheedat; Oladele, Patrick; Abdulazeez, A; Abdulkadir, M; Katibi, S; Ibraheem, GBACKGROUND: Mucopolysaccharidosis type II (Hunter's syndrome) is an X-linked chromosomal storage disorder due to deficiency of the lysosomal enzyme iduronate-2-sulfatase with patients rarely living till adulthood. Failure to identify patients early could contribute to an increased morbidity as identified in this case report. CASE DETAILS: An eight year old patient with Hunter's syndrome identified five years after disease onset with severe cardiovascular complications exemplifies the challenges faced in resource-limited countries towards making diagnosis and treatment of rare conditions. Elevated urinary glycosaminoglycans levels or a strong clinical suspicion of Hunter's syndrome, as identified in the index case, is a prerequisite for enzyme activity testing. Urinary mucopolysaccharide(MPS) level was 69.6 mg/mmol(normal range is 0.0 - 11.6 mg/mmol), and the confirming MPS electrophoresis analysis showed elevated heparan sulphate in the urine sample. Enzyme activity testing, with absent or very low iduronate-2-sulfatase activity, is diagnostic. However, the scarce availability and high cost of these tests is another constraint in making a diagnosis. CONCLUSION: Identification and management of mucopolysaccharidosis type II pose a problem in resource-constrained countries due to late presentation, lack of facility for diagnosis and treatment, cost and expertise required for the management.Item Childhood pneumonia seen at University of Ilorin Teaching Hospital, Nigeria(Peadiatric Association of Nigeria, 2013) Abdulkarim, Aishatu; Ibraheem, Rasheedat; Adegboye, Abdulrasheed; Johnson, 'Wahab; Adeboye, MuhammedBackground/Objectives:Pneumonia is a leading cause of morbidity and mortality in children and thus this study was designed to document the sociodemographic, clinical features as well as the bacterial agents responsible for pneumonia in children seen at University of IlorinTeaching Hospital. Methodology: A descriptive cross-sectional study of children aged one month to 14 years with features of pneumonia admitted between July 1st 2010 and June 31st,2011 was carried out. Sociodemograpic data, clinical features, complications and outcome were obtained. Chest radiographs and blood samples for culture of bacterial organism and full blood counts were obtained in all children. Results: Pneumonia accounted for 13.3% (167 out of 1254) of the all admissions during this period. The male: female ratio was 1.5:1, and 101(60.5%) of the children were infants. Bronchopneumonia was identified in 147(88%) children, lobar pneumonia in 15 (9%) while 5(3%) had a combination of both. Cough, fever, difficulty in breathing, tachypnoea and chest wall recessions were recognized as clinical features in the study population. Bacteraemia was present in 46(27%)children and Staphylococcus aureus was the most common organism cultured from the blood of children with pneumonia present in 11 (23.9%) out of the 46 (100.0%) isolates. Heart failure was associated complication present in 52 of the 60 children with one or more complications accounting for over 30% of all patients. Eleven out of the 15 children with lobar pneumonia had pneumonia-related complications which was significantly higher compared to 46 of 157 children with bronchopneumonia, p=0.003. The case fatality was 6.6%. Eight (72.7%) of the children that died were infants while the remaining three (27.3%) were aged between 12 and 60 months. The mean duration of hospitalization among those who survived of 6.5 ±5.0 days was significantly lower than the corresponding value of 10.2 ±12.3 days in those that died, p= 0.042. Conclusion: Pneumonia-related mortality and morbidity is high in under-five children, with the infant age group most affected. Bronchopneumonia is the most prevalent ALRI diagnosis but lobar pneumonia is associated with a higher mortality.Item Clinical presentation of childhood tuberculosis in a Nigerian hospital: what are the implications?(The College of Health Sciences, University of Ilorin., 2017-04) Gobir, Aishatu; Ibraheem, Rasheedat; Johnson, Wahab; Muhammed, Sheni; Oladele, Damilola; Ojuola, OItem A comparative analysis of mothers’ preference for specific type of phone-derived reminders for routine immunization appointments in Ilorin, Nigeria.(College of Medicine, University of Jos, 2018) Ibraheem, Rasheedat; Akintola, Moshood; Abdulkadir, Mohammed Baba; Adeboye, M.A.N; Muhammed, M.JBackground: Forgotten immunization appointment is a factor associated with low immunization uptake in Nigeria which could be addressed by a reminder-based intervention. Thus, there is a need to identify the type of reminder which would be preferred by the recipients which was the aim of this study conducted in Ilorin, Nigeria. Materials and Methods: A descriptive, cross-sectional study involving 363 mothers was conducted at two public-based immunization centers. Responses on willingness to receive text message or call reminders, preferred timing of appointment, and language of communication, willingness to pay, antenatal, and delivery characteristics were obtained via questionnaires. Data were analyzed with the Statistical Package for the Social Sciences version 20.0 software (IBM Corporation, Virginia, USA). Results: Text messages were preferred by 189 (52.1%) mothers and call by 174 (47.9%) mothers. A day prior to the scheduled appointment was the preferred timing by 322 (88.7%) mothers. The local language was preferred by 133 (76.4%) mothers who wanted calls, and 154 (81.5%) mothers who preferred text messages wanted English language. Logistic regression identified the odds of mothers preference for text message compared with calls was eightfold to fivefold among those aged 21–25 and 31–35 years, respectively compared with those aged <21 years, with each P < 0.005. Willingness to pay at most 50 naira for the reminders increased by eightfold among those who preferred text messages compared with calls (odds ratio 8.4; 95% confidence interval 2.8–25.1). Conclusion: Phone-derived reminders are a possible deployable tool for increasing immunization coverage in Nigeria. The optimal timing for sending reminders is the day preceding the appointment. Call reminders are preferred delivered in the local language, whereas English is preferred for text messages.Item A comparative study of the ownership and utilization of insecticide treated nets in households of children with uncomplicated malaria in Nigeria.(The College of Health Sciences, University of Ilorin., 2016-07) Abdulkadir, Mohammed; Ibraheem, Rasheedat; Ahmed, Ahmed; Oyebamiji, JamesItem Cross-sectional survey of school teachers knowledge of Ebola virus diseases in Ilorin.(The College of Health Sciences, University of Ilorin., 2016-01) Abdulkadir, Mohammed; Abdulkadir, Zainab; Ibraheem, Rasheedat; Afolabi, JosephThe current outbreak of Ebola virus disease (EVD) is the largest ever. It had led to major disruptions in academic calendars due to closing of schools. However, recent successes in curtailing the epidemic had led to the reopening of schools. School teachers who are in close contact with children should have the necessary knowledge regarding the disease to carry out appropriate actions for ill children. We sought to determine the knowledge of primary and secondary school teachers in privately owned schools regarding EVD. The study is a descriptive questionnaire based survey on knowledge of teachers regarding EVD. Study participants were primary and secondary school teachers working in privately owned transmission within the school population. A purposive sampling technique was used in selecting participants. One hundred questionnaires were distributed with an 89% response rate. The mean age of the teachers was 34.18 years ± 8.49. Majority (87.6%) of the teachers recognized close contact with an infected person as a method of transmission. Most (68.5%) of the teachers were able to correctly six or more common symptoms of EVD. Over 70% of the teachers recognized the need to isolate suspected confirmed cases, frequent hand washing and the use of hand sanitizers as effective strategies for the prevention of EVD. School teachers in the current study have a good knowledge of EVD and strategies for its prevention.Item Hepatotoxicity Due to Antituberculosis Therapy among Paediatric Patients Seen at the University of Ilorin Teaching Hospital, North Central Nigeria.(College of Health Sciences, Jimma University, Ethiopia, 2017-03) Gobir, Aishatu; Ibraheem, Rasheedat; Johnson, 'Wahab; Mohammed, Sheni; Oladele, Damilola; Ojuola, AdeniyiBACKGROUND: The liver is vulnerable to injury from the first line anti-tuberculosis drugs. This may result in mortality, long term morbidity and reduced compliance to therapy. Nigeria recently introduced fixed drug combinations in the treatment of children amid concerns of hepatotoxicity. A 6-year-old boy was treated in our unit had fulminant hepatic failure two weeks after completing his anti-tuberculosis therapy. This prompted the unit to investigate hepatotoxicity due to anti-tuberculosis therapy among children. There is no data on the incidence of hepatotoxicity due to antituberculosis therapy among Nigerian children, and no uniform guide to monitoring of patients exists. The objective of this study was to investigate the incidence of hepatotoxicity among children receiving anti-tuberculosis therapy. METHODS: A cross-sectional study was conducted among all 62 cases that completed treatment over a two year period. Liver Function Tests was done at baseline and 2 and 5 months of therapy. Elevation of Alanine aminotransferase and/or Aspartate aminotransferase above 3 times the reference values was considered an indication of hepatotoxicity. RESULTS: A total of 62 patients aged 3 months -17 years were treated at our unit during the study period. Twenty-two (35.5%) had elevated liver enzymes at baseline. Four (6.5%) had elevation of alanine aminotransferase of 3 times the upper limit at 2 months, but at 5 months, tests were within normal limits in all patients. Hepatotoxicity defined as liver enzymes above 3 times upper limit was not documented among the 62 cases treated over the period. CONCLUSION: Hepatotoxicity due to antituberculosis therapy is uncommon in children, hence repeated routine evaluation of liver function may not be necessary in all patients receiving anti-TB therapy.Item Hypoxaemia as a measure of disease severity in young hospitalized Nigerian children with pneumonia: A cross-sectional study.(South African Medical Association., 2015-01) Abdulkadir, Mohammed Baba; Ibraheem, Rasheedat; Johnson, 'WBR; Abdulkarim, A.ABackground. Pneumonia remains a common cause of mortality among children in developing countries. Hypoxaemia is a common consequence of pneumonia in children. Objectives. To define the relationship between Hb oxygen saturation (SpO2) and parameters of outcome, duration of supplemental oxygen and duration of hospitalisation among children with pneumonia. Methods. A cross-sectional study was carried out at the paediatric wards of a tertiary hospital in North-Central Nigeria. Two hundred children aged between 2 and 59 months with pneumonia seen at the University of Ilorin Teaching Hospital were recruited consecutively. Sociodemographic and clinical information regarding the illness was obtained. Hb SpO2 of subjects was recorded with a pulse oximeter at presentation. The primary outcome was the SpO2 of the children with pneumonia. Secondary outcome measures were disease outcome, duration of supplemental oxygen and duration of hospitalisation among children with pneumonia. Results. The prevalence of hypoxaemia among the children was 41.5% and their mean SpO2 was 90.4% (standard deviation (SD) 8.9%). Surviving children with hypoxaemia had a longer mean (SD) duration of hospitalisation of 6.9 (6.4) days compared with those without hypoxaemia (4.9 (2.7) days; p=0.001). Children with hypoxaemia spent a longer duration receiving supplemental oxygen compared with those without hypoxaemia (p=0.001). The case fatality rate from pneumonia was 8.5% (17 deaths). The risk of death among children with hypoxaemia was 48 times higher than among the non-hypoxaemic children. Conclusion. Hypoxaemia with increasing severity significantly predicts a longer duration of hospitalisation, duration on supplemental oxygen and poorer outcome in children with pneumonia.Item Hypoxaemia in hospitalized under-five Nigerian children with pneumonia(West African College of Physicians and West African College of Surgeons., 2014) Ibraheem, Rasheedat; Johnson, 'WB; Abdulkarim, A.ABACKGROUND: Hypoxaemia constitutes a possible complication of severe respiratory illness which is often under-reported in developing countries. Therefore, the current study was carried out to determine the prevalence and clinical predictors of hypoxaemia in hospitalized under-five children with pneumonia in Ilorin, Nigeria. METHODS: This is a descriptive cross-sectional study of 200 children aged between two months and five years with pneumonia recruited consecutively. Socio-demographic, clinical and laboratory data were obtained. The pulse oximetry measurement was recorded after a stable reading for at least one minute while the child was breathing room air. Hypoxaemia was defined as an arterial oxygen saturation of less than 90%. Data was analyzed using the SPSS 20.0 software. RESULTS: The male/female ratio was 1.5:1.The prevalence of hypoxaemia in the children with pneumonia was 41.5%.Using a linear regression analysis, the clinical features that were significantly associated with hypoxaemia were restlessness, lower chest wall indrawing, bronchial breath sounds and tender hepatomegaly (p<0.05 each). Restlessness had a sensitivity of 22.9%, specificity of 91.5%, while chest wall indrawing had a sensitivity of 86.7% and specificity of 53.3%. Bronchial breath sound had a sensitivity of 16.9%, a specificity of 95.7% whereas tender hepatomegaly had a sensitivity of 48.2% and specificity of 82.9%. CONCLUSION: There is a high local burden of pneumonia-associated hypoxaemia. Restlessness, chest wall indrawing, bronchial breath sounds and tender hepatomegaly could be useful in detecting pneumonia-related hypoxemia in poorly equipped health facilities.Item Is this eosinophilic meningitis in a Nigerian child?.(The College of Health Sciences, University of Ilorin., 2016) Ibraheem, Rasheedat; Oladele, Damilola; Mohammed, S.S; Gobir, A.AMeningitis is a dreaded disease entity with a clinical course and prognosis that is dependent on its etiology, which is an important source of concern in ensuring proper management. The frequently implicated etiologic agents are bacterial and less often viral; however, rare causes requiring a different management approach may also masquerade as these common causes as is seen in eosinophilic meningitis (EoM). Against this background, the case of a Nigerian male child with suspected helminth‑induced EoM, management approach, and outcome is described.Item Missed vaccination opportunities at a secondary health facility in Ilorin, Nigeria.(The Association of Public Health Physicians of Nigeria, 2016) Ibraheem, Rasheedat; Bello, Abdulafeez; Adeboye, Muhammed; Adeyeba, James; Muhammed, MuhammedBackground: Immunization remains a key strategy in the control of childhood diseases, with a child expected to have five visits according to the current National Programme on Immunization. The study aimed to identify missed vaccination visits and the associated factors in children presenting at the general out-patient clinic of a secondary health facility in Ilorin, Nigeria. Method: Through a descriptive cross-sectional study, the vaccination data of all children seen at the out-patient clinic were critically reviewed over a period of one month. Socio-demographic and immunization details were obtained and reasons for missed vaccination documented. Those that had missed vaccination were commenced on the needed vaccine(s) after counselling of their parent(s), and adequate follow-up was instituted. Results: Eighty-two (5.1%) children out of 1603 seen had missed at least one vaccine visit. The mean (SD) age of the children was 20.1(14.9) months. The male to female ratio was 1.1:1. Thirty-nine (47.2%) children had missed one visit while 43(52.7%) had missed two or more visits; 16(19.5%) had missed all five visits. Major reasons for missed visits were ill child(26.8%), ignorance about routine vaccine but received vaccine during the National Immunization Days(NID) (19.5%), mother travelled (14.6%), forgot(9.8%), and reaction to previous vaccine(6.1%). Conclusion: The missed opportunity for immunization is high therefore health care providers should enquire about the vaccination status of children at all contact. There is a need to increase awareness on illnesses that are not contra-indications to vaccination, and routine vaccine status should be checked during NID.Item Relationship between some risk factors of pneumonia and hypoxaemia in hospitalized Nigerian children.(Pan African Thoracic Society (PATS), 2014-09) Ibraheem, Rasheedat; Johnson, 'WBR; Abdulkarim, A.AThere is a current body of knowledge linking various risk factors with the frequency of pneumonia and a fatal outcome. Despite this, there is a dearth of published data assessing the association between these risk factors of pneumonia and the occurrence of hypoxaemia. Thus, the current study was carried out to determine the relationship between the risk factors of pneumonia and hypoxaemia in hospitalised under-5 children at the University of Ilorin Teaching Hospital, Nigeria. This is a descriptive study involving 200 children aged between 2 months and 5 years with pneumonia. Sociodemographic, anthropometric, clinical, and laboratory data were obtained. The pulse oximetry measurement was recorded after a stable reading for at least 1 minute while the child was breathing room air. Hypoxaemia was defined as an arterial oxygen saturation of less than 90%. Data were analysed using the SPSS 20.0 software package. There were 119 males and 81 females. Bronchopneumonia was identified in 168 (84.0%) of the children while lobar pneumonia was diagnosed in 32 (16.0%) children. After a multivariate logistic regression, low social status of the child was significantly associated with hypoxaemia, p=0.023. There was a negative correlation between the socio-economic status of the child, maternal age (years), maternal literacy level, birth order of the child, and of immunisation status with the presence of hypoxaemia (r= -0.191, -0.151, -0.162, -0.154, -0.148; p=0.007, 0.032, 0.022, 0.030, and 0.036, respectively). The study concluded that socio-economic class of the child was a risk factor of pneumonia associated with the presence of hypoxaemia.Item Serum zinc levels as a predictor of clinical features and outcome of paediatric acute lower respiratory infections in Nigeria.(Peadiatric Association of Nigeria, 2013) Ibraheem, Rasheedat; Johnson, 'Wahab; Abdulkarim, Aishatu; Abdulkadir, Mohammed; Oladele, Damilola; Biliaminu, SikiruBackground: Malnutrition, especially macronutrient deficiency, has been shown to be interrelated with ALRI-related morbidity and mortality. However the import of zinc deficiency has only recently become the focus of research attention. Objective: The current study was carried out in Ilorin, Kwara State, Nigeria to determine the relationship between serum zinc levels, clinical features and outcome in hospitalized children with acute lower respiratory infections (ALRI). Method: A descriptive cross-sectional hospital-based study involving 120 children aged two months to five years with ALRI. Socio-demographic, clinical and laboratory data were obtained. The serum zinc was analyzed with a Jenway™ spectrophotometer after initial preparation with the QuantiChrom™ zinc assay kit. Results: Children with tachypnoea and crepitations had significantly lower mean serum zinc levels compared to the corresponding values in those without these features (each p<0.05). Significantly higher mean serum zinc level was recorded in children with grunting respiration compared with those without grunting (p=0.028). Age-related tachypnoea, grunting, and crepitations remained significant (each p<0.05) following a linear regression analysis. The mean serum zinc level in children with multiple complications was significantly lower than the corresponding level recorded in children who had one complication, p=0.020. No significant difference was found between the mean serum zinc level of the children who were discharged compared with the corresponding level recorded in those that died, p=0.589. Conclusion: The presence of crepitations had the strongest clinical association with a low serum zinc level. Children managed for ALRI would benefit from post-treatment zinc supplements and appropriate zinc-rich sources of food at discharge.Item Serum zinc levels in hospitalized children with acute lower respiratory infections in the North-Western region of Nigeria.(College of Medicine, University of Makerere, Uganda, 2014-03) Ibraheem, Rasheedat; Johnson, W B R; Abdulkarim, Aishatu; Biliaminu, S.A.Background: Macronutrient deficiency has continued to attract significant research interest, where as the import of micronutrients like zinc has only recently become the focus of interest. Thus against the background of a dearth of data on zinc levels in Nigerian children with Acute Lower Respiratory Infection (ALRI), this study was carried out in Ilorin, Nigeria to determine the serum zinc levels in hospitalized children with ALRI. Methodology: A comparative cross-sectional hospital based study involving 120 children aged two months to five years with ALRI recruited as subjects, and 120 age- appropriate controls without ALRI was carried out. Socio-demographic, clinical and laboratory data were obtained. The serum zinc was analyzed with a Jenway™ spectrophotometer after an initial preparation with the QuantiChrom™ zinc assay kit. Results: The male/ female ratio was 1.6:1. The mean (SD) serum zinc level in subjects with ALRI of 18.7(11.8)µg/dl was significantly lower than the corresponding value of 53.1(18.5)µg/dl recorded in the controls, p=0.001. The prevalence of 98.3% for low serum zinc levels recorded in children with ALRI was significantly higher than that recorded in controls of 64.2%, p=0.001. Conclusion: Low serum zinc levels are significantly associated with ALRI. There is a need to determine whether hospitalized children managed for ALRI might benefit from post discharge zinc supplementation.Item Socio-demographic and clinical factors predicting time to presentation for children with pneumonia in Ilorin, Nigeria.(Faculty of Medicine, Alexandria University, Egypt, 2017) Ibraheem, Rasheedat; Abdulkadir, M. B; Gobir, A; Johnson, 'WBackground: Pneumonia is a major contributor to morbidity and mortality in children, and the time to presentation is a recognized contributor towards disease severity and outcome. Objectives: The current study aimed to explore the influence of some socio-demographic and clinical factors in children with pneumonia on the time to presentation at a health facility in Ilorin, North Central Nigeria. Materials and method: A prospective cross-sectional study of 167 children with pneumonia was done. The duration of the various symptoms and first presentation to a health facility was obtained. Time to presentation was categorized as 0–2 days (early), 3–5 days (intermediate) and greater than five days (late). Multinomial logistic regression analysis was used to identify significant predictors of either early or intermediate presentation compared with late presentation. A p-value of less than 0.05 was considered significant. Results: Fifty-one (30.5%) children with pneumonia had an early presentation, 73 (43.7%) had intermediate presentation and 43 (25.7%) were late in presentation. Predictors of early presentation were younger age (OR 0.96, 95%CI 0.93–0.99), higher respiratory rates (OR 1.03, 95%CI 1.01–1.06) and bronchopneumonia (OR 6.93, 95%CI 1.52–31.63). Predictors of intermediate presentation were families with few number of children (OR 0.73, 95%CI 0.57–0.92) and bronchopneumonia (OR 3.41, 95%C.I. 1.02–11.38). Conclusion: Infancy and families with few children are socio-demographic features that are likely to determine early-to-intermediate presentation of children with pneumonia while high respiratory rates and bronchopneumonia are disease related factors that predict early presentation.Item Sociodemographic and clinical determinants of time to care-seeking among febrile children under-five in North-Central Nigeria.(Oman Medical Specialty Board, 2015-09) Abdulkadir, Mohammed Baba; Ibraheem, Rasheedat; Johnson, 'W.B.Objectives: Our study sought to determine the time parents of febrile children under the age of five took to seek competent medical care. We also looked at the possible sociodemographic/clinical factors that influenced this presentation. Methods: Four hundred and nine under-fives presenting at the emergency unit with a history of fever in the last 48 hours along with their mothers were recruited over four months. Relevant sociodemographic information as well as symptoms and duration of illness were obtained. Multinomial regression analysis was performed to determine the predictors of early and late presentation. Results: Over half (57%) of patients presented within 24 hours of onset of fever. The mean age of the children and mothers were 22±15 months and 30±5 years, respectively. High social class (odds ratio (OR) 6.5, 95% CI 1.6–26.4), Hausa ethnic group (OR 19.3, 95% CI 5.7–65.6), convulsions (OR 3.2, 95% CI 1.6–6.5) and appearance of other symptoms (OR 6.0, 95% CI 3.0–12.0) were significant predictors of early presentation. Secondary school education, belonging to another ethnic group, and non-resolution of fever were significant predictors of late presentation. Conclusion: The majority of febrile under-fives came to the hospital to seek competent medical care within the first 24 hours of illness. However, there is a need for more parental education on early hospital presentation for parents of low socioeconomic status and educational background.