Comparison of Pulmonary TB DOTS clinic medication before and after the introduction of daily DOTS treatment and attitudes of treatment defaulters in the Western Division of the Gambia.

BACKGROUND: Over a third of the world's population is infected with the tuberculin bacteria. In 1993 WHO launched the DOTS-strategy to enhance treatment compliance. Despite Gambia's adaption in 1985 it falls below WHO target of 85% cure rate. The defaulter rate was 14% in 2001, which reached 16% in the urban areas of the Western Division in 2003. OBJECTIVES: This study aimed to compare TB treatment and outcomes before and after the introduction of daily directly observed therapy (DOTS) medication and the perceptions/attitudes of defaulters in the Western Division of the Gambia. METHODS: The study employed a mixed study design; a quantitative cross sectional study that reviewed the clinic records of pulmonary TB patients before and after the introduction of daily TB-DOTS medication and an in-depth interview of defaulters on the daily medication. The study was conducted at the Brikama TB-clinic in Gambia, located at the main hospital of Brikama serving all satellite villages. It registers on average 110/100 000 new smear-positive pulmonary TB-cases per annum. The quantitative arm compared clinic-based records of TB-DOTS medication before and after the introduction of daily medication. The qualitative arm explored the perceptions of daily medication defaulters. RESULTS: There was no statistically significant difference between the treatment outcomes of the two medication policies. However patients were less likely to have had three sputum tests reviewed in the daily medication period (22% v 72% Odds Ratio 6.2 (p <0.001). However, they reported that daily medication with its fixed-dose combination was more convenient. CONCLUSION: Patients' full compliance with daily medication was hindered by socio-economic factors. The daily medication with its increased workload undermines the proper implementation of fundamental DOTS-elements, particularly follow up and sputum review.

Comparison of Pulmonary TB DOTS Clinic Medication before and after the Introduction of Daily DOTS Treatment and Attitudes of Treatment Defaulters in the Western Division of the Gambia

Background: Over a third of the world's population is infected with the tuberculin bacteria. In 1993 WHO launched the DOTS-strategy to enhance treatment compliance. Despite Gambia's adaption in 1985 it falls below WHO target of 85cure rate. The defaulter rate was 14in 2001; which reached 16in the urban areas of the Western Division in 2003. Objectives: This study aimed to compare TB treatment and outcomes before and after the introduction of daily directly observed therapy (DOTS) medication and the perceptions/attitudes of defaulters in the Western Division of the Gambia. Methods: The study employed a mixed study design; a quantitative cross sectional study that reviewed the clinic records of pulmonary TB patients before and after the introduction of daily TB-DOTS medication and an in-depth interview of defaulters on the daily medication. The study was conducted at the Brikama TB-clinic in Gambia; located at the main hospital of Brikama serving all satellite villages. It registers on average 110/100 000 new smear-positive pulmonary TB-cases per annum. The quantitative arm compared clinic-based records of TB-DOTS medication before and after the introduction of daily medication. The qualitative arm explored the perceptions of daily medication defaulters. Results: There was no statistically significant difference between the treatment outcomes of the two medication policies. However patients were less likely to have had three sputum tests reviewed in the daily medication period (22v 72Odds Ratio 6.2 (p 0.001). However; they reported that daily medication with its fixed-dose combination was more convenient. Conclusion: Patients' full compliance with daily medication was hindered by socio-economic factors. The daily medication with its increased workload undermines the proper implementation of fundamental DOTS-elements; particularly follow up and sputum review

Depression in Mongolian women over the first 2 months after childbirth: prevalence and risk factors.

BACKGROUND: Social, political and economic changes in Mongolia have followed post-Soviet style government policies and contributed to both increased liberalisation and reduced security in employment and family finances. This is the first study to attempt to assess the prevalence of depression in a population of Mongolian women in the post-partum period and assess risk factors, including financial position, associated with the condition. METHODS: A total of 1044 women who had delivered healthy babies in Ulaanbaatar between October and December 2002 were screened for depression using the WHO Self Reporting Questionnaire between 5 and 9 weeks post-partum. Further details on the mother, her family and social and economic circumstances were simultaneously collected. Analysis of risk factors for probable depression was undertaken using multiple logistic regression techniques. RESULTS: The prevalence of depression was 9.1% (95% CLs 7.5%-11.1%). Variables significantly and independently associated with risk of probable maternal depression included economic factors, mother being subject to physical abuse, dissatisfied with the pregnancy, concerned about her baby's behaviour, and her own health problems. LIMITATIONS: The sample was drawn from a population of mothers all of whom had healthy, full-term babies of normal birth weight. Clinical confirmation of diagnosis was not established. CONCLUSIONS: Mongolian women with young infants in Ulaanbaatar probably experience depression at rates comparable with other cultures. Factors associated with probable depression were dominated by health, relationships and financial position.

Detection of depression in women of child-bearing age in non-Western cultures: a comparison of the Edinburgh Postnatal Depression Scale and the Self-Reporting Questionnaire-20 in Mongolia.

BACKGROUND: This study assesses, for the first time, the validity and internal reliability of the Edinburgh Post Natal Depression Scale (EPDS) and the WHO Self-Reporting Questionnaire 20-item version (SRQ-20) in detecting depression in Mongolian women of reproductive age. METHODS: 100 women age recruited from two psychiatric units specialising in depression (n = 55) and three community-based child immunisation clinics (n = 45) in Ulaanbataar, Mongolia, were formally psychiatrically assessed by a clinician and by administering the revised Clinical Interview Schedule (CIS-R). Each woman also completed the EPDS and SRQ-20. RESULTS: Ninety four women provided complete data and identical optimal cut-off points for both the EPDS (11.5) and SRQ-20 (8.5) were determined against both the psychiatrist's and CIS-R based diagnosis using standard validation parameters. On all parameters the SRQ-20 performed better than the EPDS. The sensitivity of the SRQ-20 in detecting depression was 93% and the specificity 97% against the psychiatrist's diagnosis. Internal reliability was satisfactory. LIMITATIONS: The use of a mixed clinical and community sample for validation, and a single psychiatrist may limit the generalisability of these results. CONCLUSIONS: The SRQ-20 performed well and better than the EPDS in detecting depression in this group of Mongolian women.

Health and social factors for health visitor caseload weighting: reliability, accuracy and current and potential use.

The reliability and validity of data collection and recording for a health visitor caseload weighting system operating in a large combined acute and community trust in Bristol was examined. Client families were recruited from all participating (service) health visitors and were interviewed by a research health visitor attached to the project. The presence or absence of 28 health needs factors, selected for their known impact on health in the longer term, was subsequently compared with the service health visitor's own caseload records and with the computer record derived from them. Substantial differences were determined in the records obtained between the service and research health visitors and between the written and computerised records. Whilst the mean total score recorded for each family by the service health visitor was 2.0, the average of the differences in the total number of health factors recorded by the service and research health visitors was 1.9. Discrepancies were mostly associated with differences in interpretation of definitions, knowledge of recent events, changing circumstances and issues of confidentiality. Health factors at particular risk of being misinterpreted and those associated with other health factors were identified in order to propose a reduced factor set with greater inherent reliability and validity. At the level of the ward, the caseload weighting score, as currently defined, is highly correlated with standard deprivation indices in widespread common use. The results of this study indicate the need for users of the caseload weighting data to decide on the primary function of this data set - area-based community profiling or identification of at-risk client families in the community. This decision will inform further efforts to identify the most useful factors, tighten definitions, streamline data collection and train health visitors in their use. Interpretation of data will be facilitated by a scientifically developed scoring system. This work will assist trusts, both locally and nationally, in rationalising their allocation of health visiting activities to areas of greatest need.

Retinopathy of prematurity in the UK II: audit of national guidelines for screening and treatment.

AIMS: To ascertain how closely in 1995, neonatologists and ophthalmologists were adhering to the national guidelines for the screening of retinopathy of prematurity (ROP, 1990) and those for screening and treatment (1995). METHODS: Questionnaires about the local arrangements for the screening and treatment of retinopathy of prematurity were sent to the entire consultant membership (n = 648) of the Royal College of Ophthalmologists (RCOphth) and to the clinical directors (n= 259) of neonatal units in the UK in 1995. RESULTS: One hundered and eighty-three ophthalmologists in the UK were identified as undertaking ROP screening and/or treatment, and ROP screening took place in 207 neonatal units. Seventy-seven per cent of the ophthalmologists either complied with or exceeded recommendations for determining which babies required screening, while 7% used criteria that would have resulted in substantially fewer babies being screened. Only 17% units and 12% ophthalmologists provided written information for parents, although 66% ophthalmologists talked to the parents of babies they screened. There was a lack of clarity about responsibilities for ensuring the continuation of screening on transfer to another hospital or on discharge to home. There was a wide range of views on the ophthalmic criteria that determined when screening examinations could cease and on the indications for treatment. CONCLUSIONS: While ROP screening is almost universally adopted in the UK, there is a need for the process to be more efficient and effective. Despite the delay in reporting this survey several issues remain extant and future guidelines should clarify and refine the criteria for screening and treatment. There is a need for improved communication with parents, and particularly for written information.

Project Pró-natal: population-based study of perinatal and infant mortality in natal, Northeast Brazil.

The Pró-Natal project is a collaborative initiative that aims to improve maternal and infant health in a deprived community in Natal, Northeast Brazil. To assess the perinatal and infant mortality in this population of 40,000, we have collected over a 2-year period a consecutive series of 39 autopsy examinations on deaths under 1 year of age. During this period there were 2212 live births in the study population. The 14 perinatal deaths are described using the Wrigglesworth classification, and the 25 infant deaths, using a clinicopathological system. The contribution of normally formed stillbirths was small (14%), which probably reflects the underreporting of stillbirths in this community. The most common cause of death in the live births was complications of prematurity (43%). Specific causes (22%) of perinatal deaths were predominantly infections, including one case of congenital syphilis. Perinatal asphyxia was diagnosed in 14%, and there was one case (7%) of a chromosome abnormality. Infant deaths were predominantly due to respiratory (45%) and gastrointestinal infections (28%), with chronic malnutrition as an underlying cause in 80% of cases. Prenatal care could theoretically have prevented three of the perinatal deaths, and a further six deaths could have been avoided by improved management of labor and the immediate neonatal period. Prevention of malnutrition and improved treatment of acute infections would contribute to a reduction in infant mortality in this population. The Pró-Natal project will use these data to design preventative interventions to reduce perinatal and infant mortality in this community.

Extreme attitudes to body shape, social and psychological factors and a reluctance to breast feed. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood.

Despite widespread advocacy of breast feeding, many babies are breast fed only briefly, if at all. Mothers' decisions on how to feed are often made before the birth; so we have sought demographic, social and psychological factors that might be amenable to intervention during pregnancy. In the Avon Longitudinal Study of Pregnancy and Childhood about 12,000 women completed questionnaires in pregnancy. Univariate analyses were carried out to establish which factors were related to breast feeding intentions. All significant factors in univariate analyses were entered into logistic regression analyses. Demographic characteristics independently related to intentions to breast feed included older maternal age, more maternal education, primiparity and not smoking; in previous work all these had been associated with actual feeding behaviour. Social relationship variables had a small influence. Of the psychological variables, a notable finding was that women who were preoccupied with their body shape and those who expressed controlling, less child-centred, responses to managing an infant in the postnatal months were less likely to express intentions to breast feed. Depression did not predict breast feeding intentions once the other factors had been taken into account. Health care professionals may be able to intervene to increase breast feeding by making routine enquiries during antenatal care and targeting appropriate subgroups.

Mature maternity: long term associations in first children born to older mothers in 1970 in the UK.

STUDY OBJECTIVES: To identify the physical, behavioural, medical, and educational outcomes in first children born to women aged 30 or more compared with those born to younger women. DESIGN: Longitudinal cohort study design employing logistic regression analysis of data obtained from the British births survey of 1970 and the child health and education study follow ups to this cohort at ages 5 and 10. SETTING: One week birth cohort covering the whole of the United Kingdom. PARTICIPANTS: The carers of 4315 first children born to women during the week of April 5th-11th 1970 inclusive in the whole of the United Kingdom except Northern Ireland, and followed up at both 5 and 10 years of age. In addition, information was obtained from health visitors, the child's teacher at 10, and the medical officer who completed an examination. At 10 the child also completed a questionnaire. MEASUREMENTS: Data were obtained from questionnaires administered to the carers of the child at each time point, from their teacher at age 10, and from the results of a medical examination at age 10. Educational tests were also conducted at this age. MAIN RESULTS: Having adjusted for the effects of confounding factors, late primiparity was significantly associated with a number of events in labour and delivery involving obstetric interventions ranging from induction to operative deliveries and general anaesthesia. At 5 years of age, controlling additionally for family size at that time, associations were found between late primiparity and fewer adverse measures of behaviour in the child. Both the child's head circumference and the score on a picture based vocabulary test at this age were slightly greater in the index group. At 10 years of age, adjusting for background factors and present family size, late primiparity was associated with few outcome measures. Children born to older mothers, however, scored slightly higher on a broad range of educational tests administered at school. CONCLUSIONS: No clearly demonstrable adverse outcomes could be linked to later primiparity in the 1970 child health and education study national cohort study. Modest behavioural and educational advantages were detected in the group with older first-time mothers. A woman's later primiparity may be associated with their child having a slightly larger head circumference compared with whole of the rest of the study cohort.

Night-waking at five years of age: predictors and prognosis.

A statistical study was made of reported night-waking in a national cohort of British 5-year-olds in order to explore long-term associations with physical, behavioural and mental development. After adjusting for the most likely confounders, reported night-waking at five was found to be linked at 10 years of age to certain chronic medical conditions and some symptoms of emotional distress. No convincing relationships existed between night-waking at five and selected measures of later physical development or intellectual ability.

Long-term associations with infant feeding in a clinically advantaged population of babies.

Information on infant feeding and child development was obtained from the 1970 British Births Survey and subsequent follow-ups at five and 10 years of age. A clinically advantaged subsample of infants who were either exclusively bottle-fed or exclusively breast-fed for at least three months were selected in order to minimise biases against a disadvantaged bottle-fed group. Only in the area of educational ability and attainment were differences observed as a function of the child's feeding patterns as an infant. Higher vocabulary test scores at five years and higher British Ability Scales test scores at 10 years were significantly associated with exclusive breast-feeding for more than three months. These data support and extend results obtained in previous studies on long-term developmental differences between breast-fed and bottle-fed children.

Social epidemiology of chickenpox in two British national cohorts.

STUDY OBJECTIVE: To provide a quantitative description of factors independently predictive of reported chickenpox infections in two national cohorts of British children. DESIGN: Longitudinal cohort study design employing logistic regression analysis of data obtained in the 1970 British Births Survey (later to become the Child Health and Education Study, CHES), and the 1958 British Perinatal Mortality Survey (later to become the National Child Development Survey, NCDS). SETTINGS: One-week birth cohorts covering the whole of the United Kingdom. PARTICIPANTS: Data were obtained from questionnaires administered to the carers of 10,196 children born in the UK between 5 and 11 April 1970 (CHES) and 10,927 children born in the UK between 3 and 9 March 1958 (NCDS). These numbers consist of the whole of the surviving cohorts excluding those for whom data were incomplete. MEASUREMENTS: Biological, social, and medical factors in the parents and children, as recorded by the child's principle carer or from clinical notes. MAIN RESULTS: Chickenpox by the age of 10 years was reported to be more common in the children of advantaged families (higher social class, higher parental education levels), with a higher prevalence in those parts of the United Kingdom normally associated with affluence, such as the South East and South West of England, and lower rates in Wales and Scotland. Chickenpox by 10 years was also associated with more crowding in the home. A similar but less marked pattern occurred for chickenpox by the age of 11 years in the 1958 NCDS cohort. This social distribution apparently reflected overall rather than age-specific susceptibility. CONCLUSIONS: The national and international pattern of chickenpox epidemiology indicate that both social and climatological factors may be important in defining groups at risk. Further research is indicated if a vaccination service is to be implemented in this country.

Vitamin C biosynthesis in prosimians: evidence for the anthropoid affinity of Tarsius.

This report examines the taxonomic distribution of the in vitro biosynthesis of ascorbic acid in the Prosimii (Order: Primates). Liver and kidney samples of 15 prosimian taxa, including Tarsius bancanus, were quantitatively tested for the enzyme L-gulono-1,4-lactone oxidase. Liver samples from all taxa except Tarsius had substantial levels of the enzyme. Furthermore, unlike other eutherian mammals, kidney tissue from members of the family Lemuridae showed low but consistent levels of enzyme activity. The result for Tarsius, by fitting with the pattern exhibited by the monkeys, apes, and man, adds significant independent evidence for this animal's relatively close genetic relationship with the Anthropoidea.

Female dominance in Indri indri.

A total of 15 months were spent on field research in eastern Madagascar studying the largest extant lemur Indri indri. Social relationships were analysed according to the frequency and direction of affiliative and agonistic behaviours, and with respect to the relative tree positions and behavioural synchrony of group members. The relationship between the adult male and adult female in each group was distinguished by the subordinance of the former. Between group variation in adults' relationships are examined with respect to the function of this behaviour.