Is it feasible to implement a community-based participatory group programme to address issues of access to healthcare for people with disabilities in Luuka district Uganda? A study protocol for a mixed-methods pilot study

INTRODUCTION

On average, people with disabilities face many difficulties in accessing healthcare and experience worse health outcomes. Yet, evidence on how to overcome these barriers is lacking. Participatory approaches are gaining prominence as they can generate low-cost, appropriate and scalable solutions. This study protocol is for the pilot testing of the co-created Participatory Learning and Action for Disability (PLA-D) groups to assess feasibility.

METHODS AND ANALYSIS

We will pilot test PLA-D in five groups in Luuka district, Uganda during 2023. Each group will include approximately 20 members (people with disabilities, family members, carers) who will meet every 2-3 weeks over a 9-11 month period. The groups, guided by a trained facilitator, will identify issues about health and healthcare access and plan and implement locally generated solutions (eg, raising awareness of rights, advocacy and lobbying, establishing health savings and financing schemes). We will collect diverse sources of data to assess feasibility: (1) in-depth interviews and focus group discussions with group participants, non-participants and group facilitators; (2) monitoring of group activities; (3) direct observation of groups and (4) quantitative survey of group participants at baseline and endline. Data analyses will be undertaken to assess feasibility in terms of: acceptability, demand, implementation and practicality. We will develop and refine evaluation tools in preparation for a future trial.

ETHICS AND DISSEMINATION

Ethical approval for the study has been received by the London School of Hygiene & Tropical Medicine and the Uganda Virus Research Institute ethics committees. Informed consent will be obtained from all study participants, making adaptations for people with disabilities as necessary. We will reach different groups for our dissemination activities, including (1) people with disabilities (eg, community meetings); (2) policy and programme stakeholders in Uganda and international (eg, individual meetings, evidence briefs) and (3) academics (journal articles, conference/seminar presentations).

Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability

WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.

Risk factors associated with experienced stigma among people diagnosed with mental ill-health: a cross-sectional study

PURPOSE

to examine the relationship between religiosity, social support, trauma, quality of life and experienced stigma of mental illness amongst a population diagnosed with mental ill-health.

METHODS

A cross-sectional survey of day service users in Northern Ireland (n = 295) covering a range of issues including religiosity, social support, quality of life and prior experience of trauma. Stigma was measured using a recognised stigma scale. We used multinomial logistic regression to examine risk factors associated with experienced stigma.

RESULTS

Univariate analysis showed significant associations between stigma and age, number of friends, social support, quality of life and prior experience of trauma. Age, quality of life, and trauma remained independently associated with stigma in a multivariate logistic regression model (x2(12) = 98.40, p < 0.001).

CONCLUSION

Younger people, those with less social support, prior experience of trauma and with poorer quality of life are at increased risk of experiencing stigma related to their diagnosis of mental illness. The findings provide further understanding of stigma and are useful for those overseeing programmes to improve access to mental health treatment.

Unmet need for chronic mental ill health: A population-based record linkage study

Introduction

Many people with chronic mental ill health do not receive the treatment they require, though the true extent of the associated socio-demographic and socio-economic factors is unknown.

Objectives

This unique record linkage study quantifies the characteristics of those reporting chronic poor mental health and the likelihood of being in receipt of pharmacological treatment for those who report chronic mental ill health.

Methods

The Northern Ireland Longitudinal Study (NILS), a random 28% of the 2011 Census returns (aged 25-74), was linked to a population-wide electronic database of prescribed medications. All cohort attributes, including presence of chronic poor mental health were derived from the Census. Logistic regression was used to test the likelihood of people with poor mental health being prescribed psychotropic medication. These findings were compared against similarly derived characteristics of those with respiratory illness on treatment.

Results

Overall, 23,803 (8.3%) of the enumerated 286,717 reported poor mental health and, while 81.5% received pharmacological treatment, those of non-white background (OR=0.38: 95%CI=0.26-0.54), never married (OR=0.67: 95%CI=061-0.73), unemployed (OR=0.65: 95%CI=0.53-0.81) or living in a rural area (OR=0.88: 95%CI=0.79-0.98) were less likely than their respective peers to receive medication for poor mental health. Non-treatment of respiratory illness was less socially patterned.

Conclusions

Some but not all of the observed variation in receipt of psychotropic medicines may represent unmet need. Further studies are required to clarify the patterning of and possible reasons for underuse, including understanding of and attitudes towards healthcare services of groups who are identified as being less likely to receive treatment (for example ethnic minorities and unemployed).

Highlights

Dissimilar molecular and morphological patterns in an introgressed peripheral population of a sand dune species (Armeria pungens, Plumbaginaceae)

Introgression is a poorly understood evolutionary outcome of hybridisation because it may remain largely undetected whenever it involves the transfer of small parts of the genome from one species to another. Aiming to understand the early stages of this process, a putative case from the southernmost border of the Armeria pungens range from its congener A. macrophylla is revisited following the discovery of a subpopulation that does not show phenotypic signs of introgression and resembles typical A. pungens. We analysed morphometrics, nuclear ribosomal DNA ITS and plastid DNA (trnL-trnF) sequences, genome size, 45S and 5S rDNA loci-FISH data and nrDNA IGS sequences. Within the study site, most individuals match morphologies of either of the two hybridising species, particularly the new subpopulation, with intermediate phenotypes being scarce. This pattern does not fully fit molecular evidence revealing two ITS ribotypes co-occurring intragenomically in most plants from the study site and one single plastid haplotype. Genome size and structural features of the IGS sequences both indicate that A. pungens from the study site is genetically more similar to its sympatric congener than to the remainder of its conspecifics. Introgression of A. macrophylla into A. pungens and plastid capture explain all the evidence analysed. However, important features to understand the origin and fate of the introgressed population, such as the degree and direction of introgression, which are important for understanding early stages of hybridisation in plants with low reproductive barriers, should be addressed with new data.

The equity impact of community women's groups to reduce neonatal mortality: a meta-analysis of four cluster randomized trials

BACKGROUND

Socioeconomic inequalities in neonatal mortality are substantial in many developing countries. Little is known about how to address this problem. Trials in Asia and Africa have shown strong impacts on neonatal mortality of a participatory learning and action intervention with women's groups. Whether this intervention also reduces mortality inequalities remains unknown. We describe the equity impact of this women's groups intervention on the neonatal mortality rate (NMR) across socioeconomic strata.

METHODS

We conducted a meta-analysis of all four participatory women's group interventions that were shown to be highly effective in cluster randomized trials in India, Nepal, Bangladesh and Malawi. We estimated intervention effects on NMR and health behaviours for lower and higher socioeconomic strata using random effects logistic regression analysis. Differences in effect between strata were tested.

RESULTS

Analysis of 69120 live births and 2505 neonatal deaths shows that the intervention strongly reduced the NMR in lower (50-63% reduction depending on the measure of socioeconomic position used) and higher (35-44%) socioeconomic strata. The intervention did not show evidence of 'elite-capture': among the most marginalized populations, the NMR in intervention areas was 63% lower [95% confidence interval (CI) 48-74%] than in control areas, compared with 35% (95% CI: 15-50%) lower among the less marginalized in the last trial year (P-value for difference between most/less marginalized: 0.009). The intervention strongly improved home care practices, with no systematic socioeconomic differences in effect.

CONCLUSIONS

Participatory women's groups with high population coverage benefit the survival chances of newborns from all socioeconomic strata, and perhaps especially those born into the most deprived households.

Are Volunteering and Caregiving Associated with Suicide Risk? A Census-based Longitudinal Study

Background

This record linkage study explores the suicide risk of people engaged in caregiving and volunteering. Theory suggests opposing risks as volunteering is associated with better mental health and caregiving with a higher prevalence and incidence of depression.

Methods

A 2011 census-based study of 1,018,000 people aged 25–74 years (130,816 caregivers and 110,467 volunteers; 42,099 engaged in both). All attributes were based on census records. Caregiving was categorised as either light (1–19 hours/week) or more intense (20+ hours/week). Suicide risk was based on 45 months of death records and assessed using Cox proportional hazards models with adjustment for and stratification by mental health status at census.

Results

More intense caregiving was associated with worse mental health (ORadj = 1.15: 95%CI = 1.12, 1.18); volunteering with better mental health (OR 0.87; 95%CIs 0.84, 0.89). The cohort experienced 528 suicides during follow-up. Both volunteering and caregiving were associated with a lower risk of suicide though this was modified by baseline mental ill-health (P = 0.003), HR 0.66; 95%CIs 0.49, 0.88 for those engaged in either activity and with good mental health at baseline and HR 1.02; 95%CIs 0.69, 1.51 for their peers with poor mental health. There was some indication that those engaged in both activities had the lowest suicide risk (HR 0.34; 95%CIs 0.14, 0.84).

Conclusions

Despite the poorer mental health amongst caregivers they are not at increased risk of suicide. The significant overlap between caregiving and volunteering and the lower risk of suicide for those engaged in both activities may indicate a synergism of action.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

BACKGROUND

In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system. We assessed the value of community involvement to improve capture and response to community maternal deaths.

METHODS

We designed and piloted a community-linked maternal death review (CLMDR) process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths. The CLMDR process involved five stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews involving both community and facility representatives.

RESULTS

The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District (population 456,500 in 2008). 52 maternal deaths were identified between July 2011 and June 2012, 27 (52%) of which would not have been identified without community involvement. Based on district estimates of population (500,000) and crude birth rate (35 births per 1000 population), the maternal mortality ratio was around 300 maternal deaths per 100,000 live births. Of the 41 cases that started the CLMDR process, 28 (68%) completed all five stages. We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review (MDR). The process resulted in high rates of completion of community-planned actions (82%), and district hospital (67%) and health centre (65%) actions to prevent maternal deaths.

CONCLUSIONS

CLMDR is an important addition to the established forms of MDR. It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.

Do women who intermittently attend breast screening differ from those who attend every invitation and those who never attend?

Objectives

Analysis of screening uptake usually dichotomizes women into attenders and non-attenders, though many women respond positively to some but not all invitations. This paper studies these intermittent attenders.

Methods

A cohort of 8,571 women invited for consecutive breast screens in the Northern Ireland Breast Screening Programme were followed in a study linking screening and census records. Multivariate logistic analysis was used to analyze the characteristics of those who attended both times (consistent), once (intermittent or ‘one-time only’), or not at all (non-attenders).

Results

Overall, 15.5% of women attended once and 13.4% were non-attenders. Non-attenders were characteristically disadvantaged (as measured by social renting, car access, and employment status), less likely to be married, and more likely to be healthy. One-time attenders were younger, and suffering poor health, though there was no association with either social renting or employment status. Privately rented accommodation and city living was associated with both one-time attendance and non-attendance.

Conclusions

One-time attenders are an important and distinct subgroup of screening invitees in this analysis. Their distinct characteristics suggest that transitory factors, such as change in marital status, ill-health, or addressing difficulties through change of residence are important. These distinct characteristics suggest the need for different approaches to increase attendance, among both intermittent attenders and those not attending at all.

Strategies developed and implemented by women's groups to improve mother and infant health and reduce mortality in rural Malawi

We evaluated the strategies to tackle maternal and infant health problems developed by women's groups in rural Malawi. Quantitative data were analyzed on strategies developed by 184 groups at two of the meetings in the community action cycle (attended by 3365 and 3047 women). Data on strategies implemented was collected through a survey of the 197 groups active in January 2010. Qualitative data on the identification and implementation of strategies was collected through 17 focus group discussions and 12 interviews with men and women. To address the maternal and child health problems identified the five most common strategies identified were: health education sessions, bicycle ambulances, training of traditional birth attendants, wetland vegetable garden (dimba garden) cultivation and distribution of insecticide treated bednets (ITNs). The five most common strategies actually implemented were: dimba garden cultivation, health education sessions, ITN distribution, health programme radio listening clubs and clearing house surroundings. The rationale behind the strategies and the factors facilitating and hindering implementation are presented. The potential impact of the strategies on health is discussed. Women's groups help communities to take control of their health issues and have the potential to reduce neonatal, infant and maternal mortality and morbidity in the longer term.

Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial

BACKGROUND

Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi.

METHODS

We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods.

RESULTS

For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality.

CONCLUSIONS

Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries

BACKGROUND

Most maternal deaths are preventable with emergency obstetric care; therefore, ensuring access is essential. There is little focused information on emergency transport of pregnant women.

OBJECTIVES

The literature on emergency transport of pregnant women in low- and middle-income countries (LMICs) was systematically reviewed and synthesized to explore current practices, barriers, and facilitators for transport utilization.

SEARCH STRATEGY

MEDLINE, EMBASE, BNI, Cochrane Library, CINAHL, African Index Medicus, ASSIA, QUALIDATA, RHL, and Science Citation Index (inception to April 2012) were searched without language restriction.

SELECTION CRITERIA

Studies using qualitative methodology and reporting on emergency transportation in LMICs were included.

DATA COLLECTION AND ANALYSIS

Thematic framework and synthesis through examination and translation of common elements were used to analyze and synthesize the data.

MAIN RESULTS

Twenty-nine articles were included. Eight major themes were identified: time for transport; transport options; geography; local support; autonomy; culture; finance; and ergonomics. Key issues were transport availability; transport speed; terrain; meteorology; support; dependence for decision making; cultural issues; cost; and lack of safe, comfortable positioning during transport.

CONCLUSION

Themes should be appreciated within local contexts to illuminate barriers and facilitators. Potential solutions include motorcycle ambulance programs, collaboration with taxi services, community education, subsidies, and vehicle maintenance.

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

BACKGROUND

Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings.

METHODS

We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries.

FINDINGS

Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries.

INTERPRETATION

With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.

FUNDING

Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial

BACKGROUND

Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi.

METHODS

We did a 2×2 factorial, cluster-randomised trial in 185,888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126.

FINDINGS

We monitored outcomes of 26,262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0.93, 0.64-1.35) and MMR (0.54, 0.28-1.04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0.85, 0.59-1.22) and MMR (0.48, 0.26-0.91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0.26, 0.10-0.70), and NMR by 41% (0.59, 0.40-0.86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1.09, 0.40-2.98, and 1.38, 0.75-2.54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0.82, 0.67-1.00) and an improvement in EBF rates (2.42, 1.48-3.96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0.64, 0.48-0.85) but no effect on EBF (1.18, 0.63-2.25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1.05, 0.82-1.36) and an increase in EBF (5.02, 2.67-9.44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons.

INTERPRETATION

Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.

FUNDING

Saving Newborn Lives, UK Department for International Development, and Wellcome Trust.

Development and formative evaluation of a visual e-tool to help decision makers navigate the evidence around health financing

Background

There are calls for low and middle income countries to develop robust health financing policies to increase service coverage. However, existing evidence around financing options is complex and often difficult for policy makers to access.

Objective

To summarize the evidence on the impact of financing health systems and develop an e-tool to help decision makers navigate the findings.

Methods

After reviewing the literature, we used thematic analysis to summarize the impact of 7 common health financing mechanisms on 5 common health system goals. Information on the relevance of each study to a user’s context was provided by 11 country indicators. A Web-based e-tool was then developed to assist users in navigating the literature review. This tool was evaluated using feedback from early users, collected using an online survey and in-depth interviews with key informants.

Results

The e-tool provides graphical summaries that allow a user to assess the following parameters with a single snapshot: the number of relevant studies available in the literature, the heterogeneity of evidence, where key evidence is lacking, and how closely the evidence matches their own context. Users particularly liked the visual display and found navigating the tool intuitive. However there was concern that a lack of evidence on positive impact might be construed as evidence against a financing option and that the tool might over-simplify the available financing options.

Conclusions

Complex evidence can be made more easily accessible and potentially more understandable using basic Web-based technology and innovative graphical representations that match findings to the users’ goals and context.

Research report--Volunteer infant feeding and care counselors: a health education intervention to improve mother and child health and reduce mortality in rural Malawi

The aim of this report is to describe a health education intervention involving volunteer infant feeding and care counselors being implemented in Mchinji district, Malawi. The intervention was established in January 2004 and involves 72 volunteer infant feeding and care counselors, supervised by 24 government Health Surveillance Assistants, covering 355 villages in Mchinji district. It aims to change the knowledge, attitudes and behaviour of women to promote exclusive breastfeeding and other infant care practices. The main target population are women of child bearing age who are visited at five key points during pregnancy and after birth. Where possible, their partners are also involved. The visits cover exclusive breastfeeding and other important neonatal and infant care practices. Volunteers are provided with an intervention manual and picture book. Resource inputs are low and include training allowances and equipment for counselors and supervisors, and a salary, equipment and materials for a coordinator. It is hypothesized that the counselors will encourage informational and attitudinal change to enhance motivation and risk reduction skills and self-efficacy to promote exclusive breastfeeding and other infant care practices and reduce infant mortality. The impact is being evaluated through a cluster randomised controlled trial and results will be reported in 2012.

MaiMwana women's groups: a community mobilisation intervention to improve mother and child health and reduce mortality in rural Malawi

This article presents a detailed description of a community mobilization intervention involving women's groups in Mchinji District, Malawi. The intervention was implemented between 2005 and 2010. The intervention aims to build the capacities of communities to take control of the mother and child health issues that affect them. To achieve this it comprises trained local female facilitators establishing groups and using a manual, participatory rural appraisal tools and picture cards to guide them through a community action cycle to identify and implement solutions to mother and child health problems. Significant resource inputs include salaries for facilitators and supervisors, and training, equipment and materials to support their work with groups. It is hypothesized that the groups will catalyse community collective action to address mother and child health issues and improve the health and reduce the mortality of mothers and children. Their impact, implementation and cost-effectiveness have been rigorously evaluated through a randomized controlled trial design. The results of these evaluations will be reported in 2011.

The low uptake of breast screening in cities is a major public health issue and may be due to organisational factors: a Census-based record linkage study

BACKGROUND

Cancer screening uptake is generally lower in UK cities but quantifying city-level effects from causes due to population composition that comprise cities is hampered by data limitations.

METHODS

A unique data linkage project combining a 2001 Census-based longitudinal study in Northern Ireland with the NHS Breast Screening Program. Validated uptake in the three years following the Census for Belfast Metropolitan Urban Area was compared against the rest of the country with adjustment for cohort attributes defined at Census.

RESULTS

Belfast Metropolitan Urban Area contained 34.8% of invited women but a greater proportion who rented their accommodation (40.3%) or who did not have a car (47.1%). After full adjustment for demographic and socio-economic factors, Belfast Metropolitan Urban Area uptake was lower for first and subsequent screen (Odds ratio (OR) 0.72; 95% CIs 0.66, 0.78 and OR 0.58; 95% CIs 0.55, 0.62 respectively). There were no significant interactions between patient characteristics and area of residence indicating that all residents in Belfast Metropolitan Urban Area are equally affected.

CONCLUSION

The reduced uptake of screening in cities is a major public health issue; the effects are large and a large proportion of the population are affected, organisational factors appear to be the primary cause. Strategies to correct this imbalance might help reduce inequalities in health.

Women's groups' perceptions of neonatal and infant health problems in rural Malawi

AIMS

To present the perceptions of women in rural Malawi regarding the health problems affecting neonates and infants and to explore the relevance of these perceptions for child health policy and strategy in Malawi.

METHODS

Women's groups in Mchinji district identified newborn and infant health problems (204 groups, 3484 women), prioritised problems they considered most important (204 groups, 3338 women) and recorded these problems on monitoring forms. Qualitative data was obtained through 6 focus-group discussions with the women's groups and 22 interviews with individuals living in women's group communities but not attending groups.

RESULTS

Women in Malawi do not define the neonatal period according to any epidemiological definition. In order of importance they identified and prioritised the following problems for newborns and infants: diarrhoea, infection, preterm birth, tetanus, malaria, asphyxia, respiratory tract infection, hypothermia, jaundice, convulsions and malnutrition.

CONCLUSION

This study suggests that women in rural Malawi collectively have a developed understanding of neonatal and infant health problems. This makes a strong argument for the involvement of lay people in policy and strategy development and also suggests that this capacity, harnessed and strengthened through community mobilisation approaches, has the potential to improve neonatal and infant health and reduce mortality.

A cluster randomised controlled trial of the community effectiveness of two interventions in rural Malawi to improve health care and to reduce maternal, newborn and infant mortality

BACKGROUND

The UN Millennium Development Goals call for substantial reductions in maternal and child mortality, to be achieved through reductions in morbidity and mortality during pregnancy, delivery, postpartum and early childhood. The MaiMwana Project aims to test community-based interventions that tackle maternal and child health problems through increasing awareness and local action.

METHODS/DESIGN

This study uses a two-by-two factorial cluster-randomised controlled trial design to test the impact of two interventions. The impact of a community mobilisation intervention run through women's groups, on home care, health care-seeking behaviours and maternal and infant mortality, will be tested. The impact of a volunteer-led infant feeding and care support intervention, on rates of exclusive breastfeeding, uptake of HIV-prevention services and infant mortality, will also be tested. The women's group intervention will employ local female facilitators to guide women's groups through a four-phase cycle of problem identification and prioritisation, strategy identification, implementation and evaluation. Meetings will be held monthly at village level. The infant feeding intervention will select local volunteers to provide advice and support for breastfeeding, birth preparedness, newborn care and immunisation. They will visit pregnant and new mothers in their homes five times during and after pregnancy.The unit of intervention allocation will be clusters of rural villages of 2500-4000 population. 48 clusters have been defined and randomly allocated to either women's groups only, infant feeding support only, both interventions, or no intervention. Study villages are surrounded by 'buffer areas' of non-study villages to reduce contamination between intervention and control areas. Outcome indicators will be measured through a demographic surveillance system. Primary outcomes will be maternal, infant, neonatal and perinatal mortality for the women's group intervention, and exclusive breastfeeding rates and infant mortality for the infant feeding intervention.Structured interviews will be conducted with mothers one-month and six-months after birth to collect detailed quantitative data on care practices and health-care-seeking. Further qualitative, quantitative and economic data will be collected for process and economic evaluations.

TRIAL REGISTRATION

ISRCTN06477126.

Evidence-based policy-making: the implications of globally-applicable research for context-specific problem-solving in developing countries

In the past 15 or so years, the "evidence-based medicine" (EBM) framework has become increasingly institutionalized, facilitating its transfer across the globe. In the late 1990s, the basic principles of EBM began to have a marked influence in a number of non-clinical public policy arenas. Policy-makers working in these areas are now being urged to move away from developing policies according to political ideologies to a more legitimate approach based on "scientific fact," a process termed "evidence-based policy-making" (EBPM). The conceptual diffusion of EBM to non-clinical arenas has exposed epistemologically destabilizing views regarding the definition of "science," particularly as it relates to the demands of global versus national/sub-national policy-making. Using the maternal and neonatal subfield as an ethnographic case-study, this paper explores the effects of these divergences on EBPM in 5 developing countries (Bangladesh, Burkina Faso, Ghana, Malawi and Nepal). In doing so, our analysis aims to explain why EBPM has thus far had a limited impact in the area of context-specific programmatic policy-development and implementation at the national and sub-national levels. Results highlight that the political contexts in which EBPM is played out promote uniformity of methodological and policy approaches, despite the fact that disciplinary diversity is being called for repeatedly in the public health literature. Even in situations where national EBPM diverges from international priorities, national evidence-based policies are found to hold little weight in countering global policy interests, which some informants claim are themselves legitimated, rather than informed, by evidence. Informants also highlight the way interpretations of research findings are shaped by the broader political context within which donors set priorities and distribute limited resources - contexts that are driven by the need to provide generalisable research recommendations based on scientifically replicable methods. Added to this are clear rifts between senior and junior-level experts within countries that constrain national and sub-national research agendas from serving as tools for empowered knowledge production and problem-solving. We conclude by arguing for diverse forms of research that can more effectively address context-specific problems. While such diversity may render EBPM more conflict-ridden, debate is by no means an undesirable characteristic in any evolving system of knowledge, for it has the potential to foster critical insight and localized change.

AIDS mortality in African migrants living in Portugal: evidence of large social inequalities

OBJECTIVE

To examine infectious disease and AIDS mortality among African migrants in Portugal, gender and socio-economic differences in AIDS mortality risk, and differences between African migrants to Portugal and to England and Wales.

METHODS

Data from death registrations, 1998-2002, and the 2001 Census were used to derive standardised death rates by country of birth, occupational class (men only), and marital status.

RESULTS

Compared with people born in Portugal, African migrants had higher mortality for infectious diseases including AIDS. There was considerable heterogeneity among Africans, with those from Cape Verde having the highest mortality. Death rates were more than five times higher among those who were unmarried than those who were. A larger proportion of Africans were unmarried accounting for some excess mortality. Death rates were also higher among men from manual occupational classes than among men from non-manual. A comparison with England and Wales shows that death rates for infectious disease and AIDS in Portugal are much higher and Africans in Portugal also fare worse than Africans in England and Wales.

CONCLUSION

AIDS mortality rates were higher among Africans than those born in Portugal and were associated with socio-environmental factors. Further research is required to interpret the excess mortality among Africans and there is a need to ensure the inclusion of relevant data items on ethnicity in national monitoring and surveillance systems.

Community participation: lessons for maternal, newborn, and child health

Primary health care was ratified as the health policy of WHO member states in 1978.(1) Participation in health care was a key principle in the Alma-Ata Declaration. In developing countries, antenatal, delivery, and postnatal experiences for women usually take place in communities rather than health facilities. Strategies to improve maternal and child health should therefore involve the community as a complement to any facility-based component. The fourth article of the Declaration stated that, "people have the right and duty to participate individually and collectively in the planning and implementation of their health care", and the seventh article stated that primary health care "requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care". But is community participation an essential prerequisite for better health outcomes or simply a useful but non-essential companion to the delivery of treatments and preventive health education? Might it be essential only as a transitional strategy: crucial for the poorest and most deprived populations but largely irrelevant once health care systems are established? Or is the failure to incorporate community participation into large-scale primary health care programmes a major reason for why we are failing to achieve Millennium Development Goals (MDGs) 4 and 5 for reduction of maternal and child mortality?

Meiotic behavior and DNA content in alloplasmic lines of maize

The cytoplasm of Zea mays ssp. mexicana (teosinte) affects several inherited traits when combined with genotypes of maize (Zea mays ssp. mays). The meiotic behavior and the total DNA content of four lines of maize with teosinte cytoplasm were compared with those of the parental lines. The results obtained suggest that the cytoplasm of teosinte promotes an increase in total nuclear DNA content, perhaps through an increase of highly repetitive DNA in the knob zones. The analysis of meiotic behavior indicates that the cytoplasm of teosinte can alter the spatial distribution of the genomes, since two groups of five bivalents each were observed at a high frequency. During prophase I - anaphase I, each group of five bivalents behaves in a slightly asynchronous way with respect to the other group and, moreover, two nucleoli were observed in 10% of the cells. These results suggest that the cytoplasm of teosinte could induce changes affecting genomic structure and function in some maize genotypes. These changes are of potential importance for breeding programs and evolutionary studies.

Meiotic loss of the B chromosomes of maize is influenced by the B univalent co-orientation and the TR-1 knob constitution of the A chromosomes

The suppression of meiotic loss when the maize B chromosomes are unpaired is genetically determined. Two genotypes were selected in 1B x 0B crosses: the H line where the B transmission rate is Mendelian (50%) and the L line where the B is present in only about 40% of the progeny. Using the ZmBs probe located at the centromere and at the distal portion of the B chromosome in FISH, we found that the centromeric and telomeric ends of the B univalent co-orient at metaphase I. This feature seems to promote proper centromere orientation causing the lack of meiotic loss of the unpaired B. The co-orientation was observed in both lines, however in the L line the B univalents were not always properly oriented, showing amphitelic orientation in about 25% of the metaphase I cells. We also studied plants of the H and L lines with FISH to test the possible relation between the knob constitution and B loss. It has been found that the plants of both lines are similarly variable for the 180-bp knob repeat, but they differ in the TR-1 350-bp repeat, the L line having more TR-1 knobs. The use of a 45S rDNA probe which labels chromosome 6, allowed us to determine that this chromosome shows the main variability between the two lines: the L line has TR-1 in both arms, showing a large TR-1 knob on the long arm. The H line has only one, generally located on the short arm besides the NOR.

Trends for coronary heart disease and stroke mortality among migrants in England and Wales, 1979-2003: slow declines notable for some groups

Objective:

To examine trends in coronary heart disease and stroke mortality in migrants to England and Wales.

Design:

Cross-sectional.

Outcome measures:

Age-standardised and sex-specific death rates and rate ratios 1979–83, 1989–93 and 1999–2003.

Results:

Coronary mortality fell among migrants, more so in the second decade than the first. Rate ratios for coronary mortality remained higher for men and women from Scotland, Northern Ireland, Republic of Ireland and South Asia, and lower for men from Jamaica, other Caribbean countries, West Africa, Italy and Spain. Rate ratios increased for men from Jamaica (1979–83: 0.45, 0.40 to 0.50; 1999–2003: 0.81, 0.73 to 0.90), Pakistan (1979–83: 1.14, 1.04 to 1.25; 1999–2003: 1.93, 1.81 to 2.06), Bangladesh (1979–83: 1.36, 1.15 to 1.60; 1999–2003: 2.11, 1.90 to 2.34), Republic of Ireland (1979–1983: 1.18, 1.15 to 1.21; 1999–2003: 1.45, 1.39 to 1.52) and Poland (1979–83: 1.17, 1.09 to 1.25; 1999–2003: 1.97, 1.57 to 2.47), and for women from Jamaica (1979–83: 0.63, 0.52 to 0.77; 1999–2003: 1.23, 1.06 to 1.42) and Pakistan (1979–83: 1.14, 0.88 to 1.47; 1999–2003: 2.45, 2.19 to 2.74), owing to smaller declines in death rates than those born in England and Wales. Rate ratios for stroke mortality remained higher for migrants. As a result of smaller declines, rate ratios increased for men from Pakistan (1979–1983: 0.99, 0.76 to 1.29; 1999–2003: 1.58, 1.35 to 1.85), Scotland (1979–1983: 1.11, 1.04 to 1.19; 1999–2003: 1.30, 1.19 to 1.42) and Republic of Ireland (1979–1983: 1.27, 1.19 to 1.36; 1999–2003: 1.67, 1.52 to 1.84).

Conclusion:

For groups with higher mortality than people born in England and Wales, mortality remained higher. Smaller declines led to increasing disparities for some groups and to excess coronary mortality for women from Jamaica. Maximising the coverage of prevention and treatment programmes is critical.

Women's groups' perceptions of maternal health issues in rural Malawi

BACKGROUND

Improvements in preventive and care-seeking behaviours to reduce maternal mortality in rural Africa depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of maternal health problems by individual women. We report the perceptions of women's groups to such issues in the rural Mchinji district of Malawi.

METHODS

Participatory women's groups in the Mchinji district identified maternal health problems (172 groups, 3171 women) and prioritised problems they considered most important (171 groups, 2833 women). In-depth qualitative data was obtained through six focus-group discussions with the women's groups, three with women's group facilitators, and four interviews with facilitator supervisors.

FINDINGS

The maternal health problems most commonly identified by more than half the groups were anaemia (87%), malaria (80%), retained placenta (77%), obstructed labour (76%), malpresentation (71%), antepartum and postpartum haemorrhage (70% each), and pre-eclampsia (56%). The five problems prioritised as most important were anaemia (sum of rank score 304), malpresentation (295), retained placenta (277), obstructed labour (276). and postpartum haemorrhage (275). HIV/AIDS and sepsis were identified or prioritised much less because complexity and contextual factors hindered their consideration.

INTERPRETATION

Rural Malawian women meeting in participatory groups showed a developed awareness of maternal health problems and the concern and motivation to address them. Community mobilisation strategies, such as women's groups, might be effective at reducing maternal mortality because they can draw on the collective capacity in communities to solve problems and make women's voices heard by decision-makers.

FISH detection of ribosomal cistrons and assortment-distortion for X and B chromosomes in Dichroplus pratensis (Acrididae)

Assortment-distortion with respect to the X and NOR activity of a rare mitotically stable B chromosome (B(N)), was examined in 16 males of Dichroplus pratensis (Acrididae: Melanoplinae) from Argentine populations. In 1B individuals, the X and B associate preferentially during prophase I reaching a maximum level of association at zygotene. Frequency of X/B association remains relatively high up to diplotene-diakinesis and decreases steeply towards metaphase I. The percent X/B association at each stage is positively influenced by association at the previous stage, and interindividual variability in X/B association decreases as the frequency of association increases. Both chromosomes tended to preferentially orientate toward the same pole at MI (mean ratio of 16 individuals, 1.50:1) which determined an excess of XB and 00 second spermatocytes over X0 and 0B ones (1.39:1). No significant differences occurred between the MI, AI and MII assortment ratios. Fluorescent in situ hybridisation (FISH) confirmed that the B chromosome carries ribosomal genes and helped to establish that, during spermiogenesis, both the B and the normal NOR-bearing chromosome (S8) are clustered near the centriole adjunct region of spermatids. However, FISH failed to reveal the existence of inactive ribosomal cistrons in the X chromosome, as previously suggested, thus providing no support to a simple origin of the B from the X.

The parasitic effects of rye B chromosomes might be beneficial in the long term

Rye B chromosomes (Bs) have strong parasitic effects on fertility. B carrying plants are less fertile than 0B ones, whereas the Bs have no significant effects on plant vigour. On the other hand, it has been reported that B transmission is under genetic control in such a way that H line plants transmit the Bs at high frequency, whereas the Bs in the low B transmission rate line (L) fail to pair at metaphase I and are frequently lost. In the present work we analyse variables affecting vigour and fertility considering not only the number of Bs of each plant, but also its H or L status and the B number of its maternal parent. Our results show that the Bs not only decrease female fertility of the B carrier, but the fertility of its progeny, with the exception of 0B plants coming from a 4B mother, which are the most fertile. In this way B chromosomes can be considered as a selective factor. Pollen abortion was higher in B carriers, in the progeny of B carriers and in H plants, but 4B plants coming from B carrying mothers produce less aborted pollen, indicating that a high B number is more deleterious if it is transmitted in the pollen grains. A similar result was obtained for endosperm quality estimated as grain weight, because it is negatively influenced by the Bs in 4B plants coming from a 0B mother. H plants were always less fertile than L ones, indicating that alleles increasing the loss of Bs in the L line will be probably selected as a defence of the A genome against the invasive Bs of the H line. Flower number is not affected by the Bs.

Mycobacterium tuberculosis isolates belonging to katG gyrA group 2 are associated with clustered cases of tuberculosis in Italian patients

Fifty-one consecutive isolates of Mycobacterium tuberculosis, collected during a 2-year period in the north-east of Italy, were subjected to IS6110-RFLP analysis to detect the presence of clusters and assigned to one of the three genotypic groups delineated by single nucleotide polymorphisms in the genes katG and gyrA. All the isolates collected from the local population belonged to group 2 or 3, while group 1 isolates were found only in specimens collected from African immigrants. Clustered cases of tuberculosis, which are likely to be related to recently transmitted infection, were found to be significantly associated with katG gyrA group 2. In the local situation, strains belonging to this group may therefore present a higher risk of transmission.

One gene determines maize B chromosome accumulation by preferential fertilisation; another gene(s) determines their meiotic loss

Genotypes of high (H(m)) and low (L(m)) male B transmission rate (B-TR) were obtained. B-TR segregation in the F2 is reported, showing that the H(m) and L(m) lines differ in a single locus we call mBt (male B transmission), controlling B preferential fertilisation in maize. The egg cells control which one of the sperm nuclei is going to fertilise them, mBt(h) egg cells being preferentially fertilised by the sperm nucleus carrying the supernumerary B chromosomes (Bs). It is hypothesised that the mBt gene is involved in the normal fertilisation of maize but the parasitic Bs take advantage of the mBt(h) allele to increase their own transmission. Selection was also carried out when the Bs were transmitted on the female side (H(f) and L(f) lines). The F1 hybrids show that the gene(s) that we call fBt (female B transmission), controlling female B-TR, is located on the A chromosomes acting at diploid level, the fBt(l) allele(s) for low transmission being dominant. This allele causes the loss of Bs at meiosis, which is shown using a specific B molecular probe to determine B presence/absence in microspores of both lines and hybrids. Maize Bs are a nice example of intragenome conflict, because the mBt and fBt loci are a polymorphic system of attack and defence between A and B chromosomes.

Is maize B chromosome preferential fertilization controlled by a single gene?

In previous work, genotypes for high and low B chromosome transmission rate were selected from a native race of maize. It was demonstrated that the B transmission is genetically controlled. The present work reports the fourth and fifth generations of selection and the F1 hybrids between the lines. The native B is characterized by a constant behaviour, with normal meiosis and nondisjunction in 100% of postmeiotic mitosis. It is concluded that genetic variation for B transmission between the selected lines is due to the preferential fertilization process. The F1 hybrids show intermediate B transmission rate between the lines. They are uniform, the variance of the selected character being one order of magnitude lower than that of the native population. In addition, 0B x 2B and 2B x 2B crosses were made to study the effect of the presence of B chromosomes in the female parent, resulting in non-significant differences. Several crosses were made both in Buenos Aires and in Madrid to compare the possible environmental effect, but significant differences were not found. Our results are consistent with the hypothesis of a single major gene controlling B transmission rate in maize, which acts in the egg cell at the haploid level during fertilization. It is also hypothesized that maize Bs use the normal maize fertilization process to promote their own transmission.

Chromosome nondisjunction and instabilities in tapetal cells are affected by B chromosomes in maize

Abnormal mitosis occurs in maize tapetum, producing binucleate cells that later disintegrate, following a pattern of programmed cell death. FISH allowed us to observe chromosome nondisjunction and micronucleus formation in binucleate cells, using DNA probes specific to B chromosomes (B's), knobbed chromosomes, and the chromosome 6 (NOR) of maize. All chromosome types seem to be involved in micronucleus formation, but the B's form more micronuclei than do knobbed chromosomes and knobbed chromosomes form more than do chromosomes without knobs. Micronuclei were more frequent in 1B plants and in a genotype selected for low B transmission rate. Nondisjunction was observed in all types of FISH-labeled chromosomes. In addition, unlabeled bridges and delayed chromatids were observed in the last telophase before binucleate cell formation, suggesting that nondisjunction might occur in all chromosomes of the maize complement. B nondisjunction is known to occur in the second pollen mitosis and in the endosperm, but it was not previously reported in other tissues. This is also a new report of nondisjunction of chromosomes of the normal set (A's) in tapetal cells. Our results support the conclusion that nondisjunction and micronucleus formation are regular events in the process of the tapetal cell death program, but B's strongly increase A chromosome instability.

Risk of mortality, cancer incidence, and stroke in a population potentially exposed to cadmium

OBJECTIVES

To follow up mortality and cancer incidence in a cohort potentially exposed to cadmium and to perform a geographical (ecological) analysis to further assess the health effects of potential exposure to cadmium.

METHODS

The English village of Shipham has very high concentrations of cadmium in the soil. A previous cohort study of residents of Shipham in 1939 showed overall mortality below that expected, but a 40% excess of mortality from stroke. This study extends the follow up of the cohort for mortality to 1997, and includes an analysis of cancer incidence from 1971 to 1992, and a geographical study of mortality and cancer incidence. Standardised mortality and incidence ratios (SMRs and SIRs) were estimated with regional reference rates. Comparisons were made with the nearby village of Hutton.

RESULTS

All cause cohort mortality was lower than expected in both villages, although there was excess cancer incidence in both Shipham (SIR 167, 95% confidence interval (95% CI) 106 to 250) and Hutton (SIR 167, 95% CI 105 to 253). There was an excess of mortality from hypertension, cerebrovascular disease, and nephritis and nephrosis, of borderline significance, in Shipham (SMR 128, 95% CI 99 to 162). In the geographical study, all cause mortality in Shipham was also lower than expected (SMR 84, 95% CI 71 to 100). There was an excess in genitourinary cancers in both Shipham (SIR 160, 95% CI 107 to 239) and Hutton (SIR 153, 95% CI 122 to 192).

CONCLUSION

No clear evidence of health effects from possible exposure to cadmium in Shipham was found despite the extremely high concentrations of cadmium in the soil.

Intimal-medial thickness of the common carotid arteries and lower limbs atherosclerosis in the elderly

BACKGROUND

In the present study, the authors consider the possible association between intimal-media thickness of the common carotid arteries and lower limb atherosclerosis, in a group of elderly patients; the authors also consider the presence of cardiovascular risk factors.

METHODS

B-mode ultrasound measurement of the intimal-media thickness of the common carotid arteries was performed on 80 subjects. Lower limbs atherosclerosis was defined as the presence of intermittens claudicatio and/or ankle-arm index < 0.9. Baseline clinic examination and blood tests were performed in all subjects to consider the presence of cardiovascular risk factors. Linear regression analysis was used to assess the linear relationship between intimal-media thickness of the common carotid arteries and lower limb atherosclerosis.

RESULTS

Linear regression analysis showed a statistical association between increased values of intimal-media thickness of the common carotid arteries and lower limb atherosclerosis. Sixty-four (80%) subjects presented one or more associated cardiovascular risk factors.

CONCLUSIONS

The results of the the present study confirm that intimal-media thickness of the common carotid arteries is a marker for the identification of generalized atherosclerosis and may be useful for the identification of subjects, even at early stages, at risk of cardiovascular diseases.

Cancer incidence among first generation Scottish, Irish, West Indian and South Asian migrants living in England and Wales

OBJECTIVES

To examine the incidence of cancers among persons born in Scotland, Northern Ireland, the Irish Republic, Caribbean Commonwealth and Indian subcontinent and living in England and Wales.

METHODS

Longitudinal Study of 1% of population of England and Wales followed from 1971 to 1989. Standardised incidence ratios (SIRs) were derived for commonly occurring cancers and all cancers using the age-sex-specific rates for all females and all males in the Longitudinal Study.

RESULTS

The incidence of all malignant neoplasms among West Indians (females SIR = 67, male SIR = 70) and Indians (female SIR = 32, male SIR = 52) was low. Among South Asians, this pattern was consistent for Hindus, Sikhs and Moslems. Scottish females showed raised incidence of lung cancer (SIR = 149) and those from the Irish Republic of oral cavity and pharynx (SIR = 321), oesophageal (SIR = 219) and liver (SIR = 373) cancers. Among Northern Irish females, incidence of lung cancer (SIR = 193) was raised. West Indian and South Asian females showed low incidence of breast cancer (SIR = 55 and 45, respectively). High incidence of laryngeal (SIR = 229) and renal (SIR = 203) cancers was observed for Scottish males and of oral cancer (SIR = 259) for males from the Irish Republic. At ages 15-64, raised incidence of prostate cancer (SIR = 129) and of leukaemia (SIR = 252) was also observed for men from the Irish Republic. Northern Irish males showed raised incidence of stomach cancer (SIR = 200).

CONCLUSION

This study describes patterns of cancer incidence among migrant groups, most of which reflect environmental influences. This has challenging implications for sensitive targeting of primary interventions. It is important not to be complacent about lower risks of main cancers among West Indians and South Asians. In all Longitudinal Study members, breast cancer was the most common malignancy among females and lung cancer among males. This was also true for all migrant groups with the exception of Northern Irish women for whom lung cancer was the most common.

Longitudinal study of socio-economic differences in the incidence of stomach, colorectal and pancreatic cancers

Using the ONS Longitudinal Study, the incidence of stomach, colorectal and pancreatic cancers from 1976-90 was examined for men and women aged 30 years and over by their housing tenure and occupational social class. Large socio-economic differences in the incidence of stomach cancer for both men and women were found. The pattern of colorectal cancer was less clear, with women in more advantaged social groups experiencing higher incidence while for men there was no significant association. Pancreatic cancer showed no association with socio-economic status. Consistent findings with each indicator strengthen the interpretation of the results. Risk factors for these cancers are known to vary by socio-economic status, and this study demonstrates the importance of continued monitoring of the distribution of cancer incidence.

Does social mobility affect the size of the socioeconomic mortality differential?: evidence from the Office for National Statistics Longitudinal Study

"The effect of social mobility on the socioeconomic differential in mortality is examined with data from the Office for National Statistics Longitudinal Study. The analyses involve 46,980 men aged 45-64 years in 1981. The mortality risk of the socially mobile is compared with the mortality risk of the socially stable after adjustment for their class of origin (their social class in 1971) and class of destination (their social class in 1981) separately. Among those in employment there is some evidence that movement out of their class of origin is in the direction predicted by the idea of health-related social mobility. This evidence, however, seems strongest for causes of death which are least likely to have been preceded by prolonged incapacity. Movement into the class of destination, however, shows the opposite relationship with mortality."

Localization of the genes controlling B chromosome transmission rate in maize (Zea mays ssp. mays, Poaceae)

In previous papers we found that the frequency of B chromosomes in native races of maize varies considerably in different populations. Moreover, we found genotypes that control high and low transmission rates (TR) of B chromosomes in the Pisingallo race. In the present work crosses were made to determine whether the genes controlling B-TR are located on the normal chromosome set (As) or on the B chromosomes (Bs). We made female f.0B × male m.2B crosses between and within high (H) and low (L) B-TR groups. The Bs were transmitted on the male side in all cases. The mean B-TR from the progeny of f.0B (H) × m.2B (H) and f.0B (H) × m.2B (L) crosses was significantly higher than that from f.0B (L) × m.2B (L) and f.0B (L) × m.2B (H) crosses. The results show that the B-TR of the crosses corresponds to the H or L B-TR of the 0B female parents irrespective of the Bs of the male parent. This indicates that B-TR is genetically controlled by the 0B female parent and that these genes are located on the A chromosomes.