Determinants of breastfeeding in Salisbury and Durham.

BACKGROUND: The practice of breastfeeding is related to socio-demographic characteristics: both show marked variation by place within the United Kingdom. This study set out to test the commonly held assumption that geographical variations in breastfeeding practices are explained by socio-demographic differences. METHODS: The mothers of 326 six-week-old babies living in Salisbury or Durham Health Districts were interviewed to determine attitudes to breastfeeding practice. RESULTS: More mothers in Salisbury breastfed than mothers in Durham, both immediately after birth (Salisbury 79 per cent, Durham 54 per cent) and at six weeks (50 per cent and 26 per cent). Higher rates of breastfeeding after birth were associated with higher level of qualification, encouragement to breastfeed antenatally and the mother having been breastfed herself. Higher rates at six weeks were associated with higher level of qualification, higher parity and willingness to breastfeed away from home. The differences between districts persisted after adjustment for these variables, but were diminished when willingness to breastfeed away from home was taken into account. CONCLUSION: Differences between the two districts in breastfeeding practice cannot be wholly explained by traditional socio-demographic characteristics, and may be related to local culture. Health education is unlikely to change breastfeeding practices unless prevailing cultural attitudes also change.

Standardized mortality from cervical cancer: a measure of performance?

A retrospective cohort analysis, using data extracted from clinical notes, examined the validity of standardized mortality ratios (SMRs) for cervical cancer as an indicator of the quality of health services by exploring the mortality at five years of patients presenting with cervical cancer, identifying factors associated with survival, and studying the relationship of those factors to SMRs for the disease. The subjects were 1038 women aged 15-64 registered at the Yorkshire Cancer Registry as having invasive cervical cancer between 1979 and 1983. It was found that independent risk factors for mortality within five years of presentation were stage at diagnosis and smoking habit. Method of treatment had an effect that failed to reach statistical significance. Independent risk factors for late stage at presentation were absence of a history of cervical smear and increasing age. Considerable variation remained unexplained in both models. District SMRs were not related to five-year survival, stage at presentation or screening history. SMRs were related to proportions of smokers. It is concluded that SMRs are subject to considerable influence from a range of unidentified factors, as well as identified risk factors. They are too broad an indicator to be a valid measure of health service performance. The health service's ability to reduce case fatality does not outweigh the effects of incidence and severity. Better indicators would be survival to five years of those presenting at stage II or less and distribution of stage at presentation.

Audit: what's in the name?

Medical audit is based on a cyclical model which is ideally suited to operational work that is (1) regularly repeated in similar situations; (2) clearly and directly linked to outcomes; (3) amenable to criteria of quality. The work of public health physicians is both operational (e.g. investigation of outbreaks of communicable disease) and strategic (e.g. health needs assessment). A cyclical model is not appropriate to strategic activity. Evaluation of that activity is essential--but should not be constrained/limited by inappropriate adherence to the audit cycle.

Maternal and fetal influences on blood pressure.

To study maternal and fetal influences on blood pressure in childhood 405 children aged 4 years who were born and still resident in the Salisbury health district were visited at home for blood pressure and growth measurements. Information on the pregnancy, delivery, and baby was abstracted from the routine obstetric notes. Similar to recent findings in adults, the child's systolic pressure was inversely related to birth weight and positively related to placental weight. Systolic pressure at 4 years increased by 1.2 mm Hg for every SD decrease in the ratio of head circumference to length at birth, and by 1.1 mm Hg for every SD decrease in ponderal index at birth. Mothers whose haemoglobin concentrations fell below 100g/l during pregnancy had children whose systolic pressures were on average 2.9 mm Hg higher than the children of mothers with higher haemoglobin concentrations. Patterns of placental weight, birth weight, head circumference, and length that are associated with high blood pressure in adults are also associated with higher blood pressure in 4 year old children. Identification of the intrauterine influences that lead to these patterns of fetal growth could lead to the primary prevention of hypertension.

Assessment of the psychological impact of a breast screening programme.

In order to assess the psychological effect of mammographic screening, questionnaires (which included psychometric tests) were sent to 750 women at invitation and, 6 weeks after screening, to 420 women normal after the first mammograph, to 240 women normal after special assessment, and to 68 women normal after open biopsy. Increasing degree of the investigation was associated both with increasing frequency of breast self examination (10% were practising breast self-examination at least once a week before screening compared with 24% for women after special assessment and 35% of women who had had an open biopsy (p less than 0.001)), and with greater confidence that any malignancy in the breast would have been found. Psychometric scores showed no increase of general levels of anxiety or depression in the screened groups. For anxiety, percentages abnormal were 5, 4, 2 and 6 for the four groups, respectively, and for depression the percentages abnormal were 5, 4, 4 and 6, respectively; 10% of screened women were more anxious about having breast cancer as a result of the screening. At least 10% of women proceeding to open biopsy of benign lesions require professional counselling and support. Psychological ill effects were not detected by the psychometric test among women who did not proceed to this final investigation. Behavioural changes did suggest a raised awareness or fear of potential cancer among the screened population.

Fetal and placental size and risk of hypertension in adult life.

OBJECTIVE: To study the effect of intrauterine growth and maternal physique on blood pressure in adult life. DESIGN: A follow up study of infants born 50 years previously whose measurements at birth were recorded in detail. SETTING: Preston, Lancashire. SUBJECTS: 449 Men and women born in hospital in Preston during 1935-43 and still living in Lancashire. MAIN OUTCOME MEASURES: Placental weight, birth weight, and blood pressure at age 46 to 54 years. RESULTS: In both sexes systolic and diastolic pressures were strongly related to placental weight and birth weight. Mean systolic pressure rose by 15 mm Hg as placental weight increased from less than or equal to 1 lb (0.45 kg) to greater than 1.5 lb and fell by 11 mm Hg as birth weight increased from less than or equal to 5.5 lb to greater than 7.5 lb. These relations were independent so that the highest blood pressures occurred in people who had been small babies with large placentas. Higher body mass index and alcohol consumption were also associated with higher blood pressure, but the relations of placental weight and birth weight to blood pressure and hypertension were independent of these influences. CONCLUSIONS: These findings show for the first time that the intrauterine environment has an important effect on blood pressure and hypertension in adults. The highest blood pressures occurred in men and women who had been small babies with large placentas. Such discordance between placental and fetal size may lead to circulatory adaptation in the fetus, altered arterial structure in the child, and hypertension in the adult. Prevention of hypertension may depend on improving the nutrition and health of mothers.

Perspectives on the assessment of need.

The new arrangements for the NHS require that health services are procured which meet the identified needs of the population. To reach an agreed understanding of those needs a number of different perspectives must be reconciled--the nature of disease at a population level versus the individual's perception of illness, the general manager's desire to estimate what level of a particular service to provide versus the medical concept of packaging different services to meet a need, the clinical and epidemiological tendency to consider disease processes rather than unclassified symptomatology, and the balance of need and demand. These conflicts are described in relation to ischaemic heart disease. The task is one of complexity, challenge and opportunity.

Investigation of an outbreak of hepatitis A simplified by salivary antibody testing.

In March 1988 a general practitioner notified two cases of hepatitis A in a private boarding school. Epidemiological investigation, including testing for salivary antibodies revealed a further five cases and established immunity to, and recent infection with, hepatitis A virus (HAV). The pattern of the outbreak was described. A number of practices which would encourage cross-infection were corrected. Normal human immunoglobulin was given to contacts. Repeat salivary testing 10 weeks later revealed that two more boys had become reactive for anti-HAV, though at a low titre. These may have been serological responses to HAV infection modified by the passive immunization.

Items of care--an approach to the staffing of community services.

Adrian Bull describes a method of setting out a strategy for community services in terms that allow a more rational approach to resource allocation, the debate on funding of the service to be held in terms of process rather than structure, and a wider and more systematic approach to evaluation of health care in the community.