Drivers of international variation in prevalence of disabling low back pain: Findings from the Cultural and Psychosocial Influences on Disability study.

BACKGROUND: Wide international variation in the prevalence of disabling low back pain (LBP) among working populations is not explained by known risk factors. It would be useful to know whether the drivers of this variation are specific to the spine or factors that predispose to musculoskeletal pain more generally. METHODS: Baseline information about musculoskeletal pain and risk factors was elicited from 11 710 participants aged 20-59 years, who were sampled from 45 occupational groups in 18 countries. Wider propensity to pain was characterized by the number of anatomical sites outside the low back that had been painful in the 12 months before baseline ('pain propensity index'). After a mean interval of 14 months, 9055 participants (77.3%) provided follow-up data on disabling LBP in the past month. Baseline risk factors for disabling LBP at follow-up were assessed by random intercept Poisson regression. RESULTS: After allowance for other known and suspected risk factors, pain propensity showed the strongest association with disabling LBP (prevalence rate ratios up to 2.6, 95% CI: 2.2-3.1; population attributable fraction 39.8%). Across the 45 occupational groups, the prevalence of disabling LBP varied sevenfold (much more than within-country differences between nurses and office workers), and correlated with mean pain propensity index (r = 0.58). CONCLUSIONS: Within our study, major international variation in the prevalence of disabling LBP appeared to be driven largely by factors predisposing to musculoskeletal pain at multiple anatomical sites rather than by risk factors specific to the spine. SIGNIFICANCE: Our findings indicate that differences in general propensity to musculoskeletal pain are a major driver of large international variation in the prevalence of disabling low back pain among people of working age.

Solid fuel use is a major risk factor for acute coronary syndromes among rural women: a matched case control study.

OBJECTIVES: Almost half of the world's population uses solid fuel for cooking, exposing women to high levels of particulate pollution in indoor air. The risk of acute coronary syndrome (ACS) was assessed among rural women, according to their use of solid fuel. STUDY DESIGN: Matched case control study. METHODS: Data were collected at a public tertiary care hospital in a rural district of Pakistan. Seventy-three women with ACS were compared with controls, individually matched for sex and age (± 5 years), who were admitted to hospital for other reasons. Fuels used for cooking and exposures to potentially confounding variables were ascertained through a questionnaire administered at interview and measurement of height and weight. Conditional logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: After adjustment for potential confounding factors, current use of solid fuel was strongly associated with ACS (OR 4.8, 95% CI: 1.5-14.8), and risk was lowest in women who had last used solid fuel more than 15 years earlier. The population attributable fraction for ACS in relation to current use of solid fuel was 49.0% (95% CI: 41.3%-57.4%). CONCLUSIONS: These findings support the hypothesis that indoor air pollution from use of solid fuel is an important cause of ACS. Our study demonstrates the feasibility of case-control studies in rural populations of women to address this question, and is an encouragement to larger and statistically more powerful investigations.

Incidence of typical and atypical hanging among 66 hanging cases.

Present Study conducted prospectively to find out the position of knot in the neck in all hanging cases coming for post mortem examination at Mymensingh Medical College Mortuary in the year 2005. Hanging is a process in which the body is suspended with a ligature around the neck, which causes constriction of air passage preventing exchange of air between atmosphere & alveoli of lungs, leading to asphyxia & death. The constriction force is either the weight of the whole body or the weight of the head alone. A weight of 2Kg is sufficient for death in hanging. According to position of knot hanging is of two types-Typical hanging and Atypical hanging. In typical hanging the knot of the ligature should be at the nape of the neck and the knot of the ligature at any site other than the nape of the neck is Atypical hanging. A total of 557 postmortems were conducted in the year 2005 out of which 66 cases were of hanging. Among these, 66 cases (100%) position of knot on neck were on center of occiput (Typical hanging) in 14 cases (21.21%), on right side in 17 cases (25.75%), on left side in 21 cases (31.81%) and on front of neck in 14 cases (21.21%). Total of 52 cases are of Atypical hanging. This study suggests that Atypical hanging is more common (78.78%) than Typical hanging (21.21%) and more on left side of the neck (31.81%). Study at S.P. Medical College and A.G Hospitals, Bikaner in 2004 shows that out of 390 cases 35 (8.97%) were of hanging. Amongst those 35 cases in 33 cases position of knot on nape of the neck in 5 cases (15.15%), right side of neck 15 cases (45.45%), left side of neck in 11 cases (33.33%) and front of the neck 2 cases (6%). In their study, Typical hanging was found in 15.15% and Atypical hanging was in 84.85%; and Maximum on right side of the neck i.e. 45.45%. In both the studies Atypical hanging was more common but Maximum was on right side in their study and We found maximum on left side.

Survey and surveillance development in settings with low human immunodeficiency virus prevalence.

In most countries, during the early phases of a human immunodeficiency virus epidemic, independently initiated surveys of perceived high-risk groups tend to precede the development of formal surveillance systems. Unfortunately, in low-prevalence settings, small sample sizes produce unreliable estimates of prevalence and trends, with an inevitable tendency towards positive results. In our study, we present sample size calculations and typical samples used in actual surveys, with Pakistan as our example. More useful data on risk behaviour and potential for spread can be derived from the study of commoner sexually transmitted diseases and associated risk behaviours, including assessments of knowledge, attitudes, beliefs and practices.

Community knowledge, attitude and practices regarding sexually transmitted infections in a rural district of Pakistan.

OBJECTIVE: To determine knowledge, attitude and practices regarding sexually transmitted infections in district Khairpur, Sindh, Pakistan. DESIGN AND METHODOLOGY: A needs assessment study employing a community based survey, key informant interviews and focus group discussions was conducted in all seven sub-districts of the district. This paper is based on the results of the key informant interviews and the focus group discussions. Thirty interviews and six group discussions were held with members of the community and with the health care providers. RESULTS: There was little awareness regarding causes and prevention of sexually transmitted infections in the community. The situation was slightly better among health care providers. While health care providers believed that the prevalence of sexually transmitted infections is high, the community did not consider themselves at risk. The community believed that these diseases are a problem among a sub-population of male adolescents, especially those who have homosexual relations. However, due to social norms, they rarely discussed such health problems with other family members or elders. Adolescents with any sexual health problems visit hakims and quacks. The community was aware about aetiology and some of the risk factors associated with AIDS and hepatitis, most probably due to the recent public health campaigns against both diseases. CONCLUSION: Considering the suspected high prevalence of sexually transmitted infections and the relative lack of knowledge, it is imperative that a public health intervention be initiated. This must include educating not only the community but also the health workers. The governments' initiative to train community workers in reproductive health is a step in the right direction (JPMA 52:21, 2002).

Health and social impacts of improved stoves on rural women: a pilot intervention in Sindh, Pakistan.

UNLABELLED: To assess the acceptability, social and health impacts of improved stoves among women. A cross-sectional study was conducted from April to May 2002 among households using improved stoves in the two villages of District Thatta and Hyderabad, Sindh, Pakistan. A questionnaire was administered to 45 women using improved stoves named Smoke Free Stoves (SFS). The same questionnaire was administered to a sample of 114 women, using Traditional Stoves (TS). Carbon monoxide (CO) levels were measured in a sample of both groups. Multivariate analysis was carried out to adjust for confounders. In addition, focus group discussions (FGDs) were conducted to evaluate the perception of women regarding acceptability and impact of SFS on women. A majority of women reported that SFS produce less smoke and have a beneficial impact on their health. In the multivariate analysis, symptoms of dry cough (AOR=0.61; 95% CI 0.26-1.41), sneezing (AOR=0.54; 95% CI 0.22-1.30) and tears while cooking (TWC) (AOR=0.51; 95% CI 0.21-1.21) are less likely to occur in women using SFS compared to TS. However, the results were not statistically significant possibly due to the small sample. The mean (+/-s.e.) CO levels were 15.4+/-3.4 ppm in SFS and 28.5+/-5.7 ppm in TS kitchens with a mean difference of -13.1 (95% CI -29.5 and 3.2). The results indicate a trend favorable for SFS and suggest that a larger scale project should be undertaken to reach to a definitive conclusion, ideally using a longitudinal design. PRACTICAL IMPLICATIONS: In order to enhance IAQ in kitchens in developing regions of the world stoves for burning of biomass should be constructed in a way that the emission of fuel gases are low. In this way the risk of negative health effects will be reduced.

Health needs of clients as reported by medical practitioners from two districts of Sindh.

OBJECTIVE: To identify the major health and reproductive health problems for which people consult local medical practitioners. METHODOLOGY: Forty-one practitioners completed a self-administered questionnaire. A startified purposive sample of practitioners was selected by asking the community members from various towns and rural areas to identify practitioners who have most busy practices and are perceived as providing quality care. RESULTS: Nine of the forty-one practitioners were females. Twenty-two were consulted mainly by women and another seventeen by an equal number of women and men. Practitioners pointed to malnutrition, malaria, gastrointestinal and respiratory tract problems as being the most common ailments. They identified menstrual problems, malnutrition among pregnant women, burning micturition and vaginal discharge as the most common reproductive health problems of their clients. Only 16 medical practitioners said that they diagnosed someone in the last one-month as suffering from sexually transmitted infections. CONCLUSION: The survey helped in developing an understanding of health issues from provider perspective. Findings indicate a concordance between what has been revealed by previous population based studies in similar situations and to what health problems practitioners pointed as common. While a comprehensive needs-assessment requires surveys and qualitative interviews with communities, consultations with relatively fewer medical practitioners could also provide a quick and fair approximation of priority health problems in the area.

Utility of participatory rural appraisal for health needs assessment and planning.

BACKGROUND: While poverty and lack of life opportunities are root causes of a high burden of disease and infant and maternal mortality, inadequate health care contributes heavily. Often those who are left without care are those who need it most. Existing health services are managed without taking into account acceptance and need perspectives. This further reduces the effectiveness of and equity in health care. In order to guide the planning of reproductive health services by a national NGO, health needs were assessed in a district in Sindh using a combination of participatory rural appraisal (PRA) and qualitative and quantitative research methods. PRA is considered as a better framework to assess, analyse and develop programs with communities. OBJECTIVE: The objective of PRA was to initiate community involvement and to understand the needs of health care from a community perspective. METHODOLOGY: PRA was conducted with groups of men and women from three rural areas in a district of Sindh, Pakistan using a life cycle framework. The community members identified various stages of their life with the associated health issues. RESULTS: This research was empowering to community members as it facilitated community involvement. The respondents took charge of the process of identification of health needs at PRA sessions. PRA helped identify health problems considered prevalent and important by the community. More importantly, it helped potential service providers and the community to initiate community involvement in planning. CONCLUSION: PRA is not only an effective tool for assessment and analysis of health issues but also a vehicle to promote community involvement. Additionally, participatory methods contribute to understand the context of quantitative data generated for planning purposes.

Community knowledge, attitude and practices regarding sexually transmitted infections in a rural district of Pakistan.

OBJECTIVE: To determine knowledge, attitude and practices regarding sexually transmitted infections in district Khairpur, Sindh, Pakistan. DESIGN AND METHODOLOGY: A needs assessment study employing a community based survey, key informant interviews and focus group discussions was conducted in all seven sub-districts of the district. This paper is based on the results of the key informant interviews and the focus group discussions. Thirty interviews and six group discussions were held with members of the community and with the health care providers. RESULTS: There was little awareness regarding causes and prevention of sexually transmitted infections in the community. The situation was slightly better among health care providers. While health care providers believed that the prevalence of sexually transmitted infections is high, the community did not consider themselves at risk. The community believed that these diseases are a problem among a sub-population of male adolescents, especially those who have homosexual relations. However, due to social norms, they rarely discussed such health problems with other family members or elders. Adolescents with any sexual health problems visit hakims and quacks. The community was aware about aetiology and some of the risk factors associated with AIDS and hepatitis, most probably due to the recent public health campaigns against both diseases. CONCLUSION: Considering the suspected high prevalence of sexually transmitted infections and the relative lack of knowledge, it is imperative that a public health intervention be initiated. This must include educating not only the community but also the health workers. The governments' initiative to train community workers in reproductive health is a step in the right direction.

Adult mortality in slums of Karachi, Pakistan.

OBJECTIVE: Cause-specific death rates are rarely available to guide health interventions for adults in South Asia. We report mortality patterns among Karachi's urban poor. METHODS: We conducted verbal autopsies for adult deaths under active surveillance during 1990-1993 in five urban slums of Karachi. Two physicians assigned underlying cause of death by consensus. Analysis included cause- and category-specific rates, 45Q15s and comparison with 1991 Japanese national statistics. RESULTS: All 345 adult deaths (15-59 years) in the 5 slums (total population 45,389) were included. Male mortality exceeded female (4.4 vs 3.3/1000, p = .02). Noncommunicable diseases claimed 59% of deaths, communicable and reproductive 27% and injuries, 15%. The leading identified death rates (/100,000) among women were: circulatory disorders (66), maternal causes (33), tuberculosis (30), and burns (23); and among men they were: circulatory disorders (124) tuberculosis (30) and road traffic accidents (30). Overall Karachi adult mortality was 3.7 times Japanese rate. Compared to Japan, adults in Karachi had one to two orders of magnitude excess mortality due to maternal causes, tuberculosis and burns. Circulatory disorders and tuberculosis accounted for 47% of excess male mortality; these plus maternal causes and burns accounted for 55% of excess female mortality. CONCLUSION: These mortality levels and patterns compel interventions and research for poor urban adults beyond maternal health. Women's health would equally benefit from tuberculosis control or burn prevention. Men need safer travel. Both need improved cardiovascular health.

Survey and surveillance development in settings with low human immunodeficiency virus prevalence.

In most countries, during the early phases of a human immunodeficiency virus epidemic, independently initiated surveys of perceived high-risk groups tend to precede the development of formal surveillance systems. Unfortunately, in low-prevalence settings, small sample sizes produce unreliable estimates of prevalence and trends, with an inevitable tendency towards positive results. In our study, we present sample size calculations and typical samples used in actual surveys, with Pakistan as our example. More useful data on risk behaviour and potential for spread can be derived from the study of commoner sexually transmitted diseases and associated risk behaviours, including assessments of knowledge, attitudes, beliefs and practices.

Out-of-pocket expenses borne by the users of obstetric services at government hospitals in Karachi, Pakistan.

OBJECTIVE: Financing health services is a challenge for health policy makers world over, especially in developing countries. Alternate mechanisms such as user fees are being proposed. However, there is a feeling that in developing countries, users of government hospitals spend appreciable personal income to obtain "free services" at these facilities. METHODS: This study aimed to measure the extent and the factors associated with of out-of-pocket expenses borne by the users of obstetric care at government hospitals. It also aimed to determine willingness of consumers to bear out of pocket expenses. It was conducted in three government hospitals in Karachi. RESULTS: Seven hundred cases were registered in the study. Sixty-five percent of them had a monthly household income of less than Rupees (Rs.) 3000. Overall, users spent mean of Rs. 590 as out-of-pocket expenses for obstetric services. Of this Rs. 330 was spent on drugs and Rs. 24 on user fees. Thirty-nine percent of the patients were willing to spend out of pocket for services provided at government hospital and 39% declined to do so. Of the patients indicating willingness to spend, 98% agreed to do so for drugs. CONCLUSION: The results suggest that considerable expenses are borne out of pocket by the users of government hospitals for supposedly "free services". If user fees are to be increased the government needs to provide services for which the people will pay, such as drugs, otherwise increase in this fees will simply add to financial burden on the users.

Survey and surveillance development in settings with low human immunodeficiency virus prevalence

In most countries, during the early phases of a human immunodeficiency virus epidemic, independently initiated surveys of perceived high-risk groups tend to precede the development of formal surveillance systems. Unfortunately, in low-prevalence settings, small sample sizes produce unreliable estimates of prevalence and trends, with an inevitable tendency towards positive results. In our study, we present sample size calculations and typical samples used in actual surveys, with Pakistan as our example. More useful data on risk behaviour and potential for spread can be derived from the study of commoner sexually transmitted diseases and associated risk behaviours, including assessments of knowledge, attitudes, beliefs and practices

Risk factors for lower urinary tract cancer: the role of total fluid consumption, nitrites and nitrosamines, and selected foods.

Many cases of lower urinary tract cancer cannot be attributed to the known risk factors of cigarette smoking and certain occupational chemical exposures. Data from a case-control study conducted on Oahu, Hawaii, from 1979 to 1986 were used to determine the role of several additional exposures in the etiology of lower urinary tract cancer, such as total fluid intake and dietary nitrites and nitrosamines, as well as intake of selected foods. A total of 195 male and 66 female lower urinary tract cancer cases of Caucasian and Japanese ancestry were matched to two population-based controls on age, sex, and race. Total fluid intake, and tap water in particular, showed a strong inverse dose-response relationship to cancer risk among women (odds ratio (OR) for highest to lowest quartile of total fluid intake = 0.3; trend P < 0.01).. This association was stronger in smokers than nonsmokers. Although fluid intake showed no overall association among men, the findings among smokers were suggestive of an effect similar to that found in women. Intake of dietary nitrites and nitrosamines was positively associated with risk in Japanese men (for nitrites, OR for highest to lowest tertile = 2.0; trend P = 0.05; for nitrosamines, OR for highest to lowest tertile = 3.0; trend P = 0.01). Consumption of processed meats, in particular bacon, sausage, and ham, was also significantly associated with increased risk in Japanese men. No other ethnic sex group exhibited this association with processed meats, although an effect was suggested for sausage in Japanese females and for bacon in Caucasian females. Unfortunately, it was not possible to determine whether these elevated risks were due to the fat, nitrite, or sodium content of the processed meats, or to the fact that they may have been fried.