Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China.

OBJECTIVE: To estimate the national costs relating to diarrhoea and acute respiratory infections from not handwashing with soap after contact with excreta and the costs and benefits of handwashing behaviour change programmes in India and China. METHODS: Data on the reduction in risk of diarrhoea and acute respiratory infection attributable to handwashing with soap were used, together with World Health Organization (WHO) estimates of disability-adjusted life years (DALYs) due to diarrhoea and acute respiratory infection, to estimate DALYs due to not handwashing in India and China. Costs and benefits of behaviour change handwashing programmes and the potential returns to investment are estimated valuing DALYs at per capita GDP for each country. RESULTS: Annual net costs to India from not handwashing are estimated at US$ 23 billion (16-35) and to China at US$ 12 billion (7-23). Expected net returns to national behaviour change handwashing programmes would be US$ 5.6 billion (3.4-8.6) for India at US$ 23 (16-35) per DALY avoided, which represents a 92-fold return to investment, and US$ 2.64 billion (2.08-5.57) for China at US$ 22 (14-31) per DALY avoided - a 35-fold return on investment. CONCLUSION: Our results suggest large economic gains relating to decreases in diarrhoea and acute respiratory infection for both India and China from behaviour change programmes to increase handwashing with soap in households.

Did the tobacco industry inflate estimates of illicit cigarette consumption in Asia? An empirical analysis.

OBJECTIVE: Estimates of illicit cigarette consumption are limited and the data obtained from studies funded by the tobacco industry have a tendency to inflate them. This study aimed to validate an industry-funded estimate of 35.9% for Hong Kong using a framework taken from an industry-funded report, but with more transparent data sources. METHODS: Illicit cigarette consumption was estimated as the difference between total cigarette consumption and the sum of legal domestic sales and legal personal imports (duty-free consumption). Reliable data from government reports and scientifically valid routine sources were used to estimate the total cigarette consumption by Hong Kong smokers and legal domestic sales in Hong Kong. Consumption by visitors and legal duty-free consumption by Hong Kong passengers were estimated under three scenarios for the assumptions to examine the uncertainty around the estimate. A two-way sensitivity analysis was conducted using different levels of possible undeclared smoking and under-reporting of self-reported daily consumption. RESULTS: Illicit cigarette consumption was estimated to be about 8.2-15.4% of the total cigarette consumption in Hong Kong in 2012 with a midpoint estimate of 11.9%, as compared with the industry-funded estimate of 35.9% of cigarette consumption. The industry-funded estimate was inflated by 133-337% of the probable true value. Only with significant levels of under-reporting of daily cigarette consumption and undeclared smoking could we approximate the value reported in the industry-funded study. CONCLUSIONS: The industry-funded estimate inflates the likely levels of illicit cigarette consumption.

Transnational tobacco company influence on tax policy during privatization of a state monopoly: British American Tobacco and Uzbekistan.

OBJECTIVES: The International Monetary Fund encourages privatization of state-owned tobacco industries. Privatization tends to lower cigarette prices, which encourages consumption. This could be countered with effective tax policies. We explored how investment by British American Tobacco (BAT) influenced tax policy in Uzbekistan during privatization there. METHODS: We obtained internal documents from BAT and analyzed them using a hermeneutic process to create a chronology of events. RESULTS: BAT thoroughly redesigned the tobacco taxation system in Uzbekistan. It secured (1) a reduction of approximately 50% in the excise tax on cigarettes, (2) an excise system to benefit its brands and disadvantage those of its competitors (particularly Philip Morris), and (3) a tax stamp system from which it hoped to be exempted, because this would likely facilitate its established practice of cigarette smuggling and further its competitive advantage.. CONCLUSIONS: Privatization can endanger effective tobacco excise policies. The International Monetary Fund should review its approach to privatization and differentiate the privatization of an industry whose product kills from privatization of other industries.

A Systematic Review and Meta-analysis of the Acceptability and Effectiveness of University Smoke-Free Policies.

OBJECTIVE: Systematically review studies of support for, and effectiveness of, university campuses' smoke-free policies. PARTICIPANTS/METHODS: A search was carried out for studies in English related to campus smoking bans through June 2013. Eligible studies had outcomes for student or faculty attitudes, or measures of smoking prevalence or secondhand smoke (SHS) exposure. RESULTS: Nineteen eligible studies were identified, 18 from the United States and 1 from the United Kingdom. A meta-analysis found 58.94% (95% confidence interval [CI] [52.35%, 65.53%]) of students (12 studies) and 68.39% (95% CI [65.12%, 71.67%]) of faculty (7 studies) supported smoke-free policies. Both studies measuring student smoking prevalence indicated a postban reduction (16.5% to 12.8% after 1 year [p < .001] and 9.5% to 7.0% [p = .036] after 3 years). Only 5% of UK universities were smoke-free compared with 25% of US universities. CONCLUSIONS: A majority of students and faculty support smoke-free campus policies, which may reduce smoking and SHS exposure.

A clinical and cost evaluation of hemodialysis in renal satellite units in England and Wales.

BACKGROUND: The prevalence rate of renal replacement therapy in the United Kingdom has increased significantly, particularly by long-term hemodialysis (HD) therapy in renal satellite units (RSUs). These are largely nurse-run units linked to main renal units (MRUs). We compared outcomes, processes of care, and costs in RSUs with those in MRUs. METHODS: A cross-sectional comparison was performed of HD patients from a representative sample of 12 RSUs in England and Wales and HD patients in the linked MRUs deemed suitable by the senior nurse for RSU care. Data for patient characteristics, clinical process and outcome measures, health-related quality of life (HRQoL), and patient satisfaction were collected. A partial analysis of National Health Service and social care costs was undertaken. Geographic access was assessed by road time and distance traveled to dialysis sessions. RESULTS: Seven hundred thirty-six of 895 eligible patients (82%) participated. RSU patients were older (mean age, 63 versus 57 years), but had comorbidity similar to that of MRU patients. There were no significant differences in most processes of care or clinical outcomes; achievement of standards for adequacy of dialysis (urea reduction ratio) was significantly greater in RSU patients and hospitalization in the last year was less frequent. Patient HRQoL was similar, but patient satisfaction was greater in RSU patients. RSU patients potentially saved 19 minutes traveling for each dialysis session. Costs for routine dialysis and health/social care were similar. CONCLUSION: RSUs appear to be as effective as main HD units for a wide spectrum of patients, improve geographic access, and are more acceptable to patients. There is evidence that they are as cost-effective as main units.

A qualitative study exploring junior paediatricians', midwives', GPs' and mothers' experiences and views of the examination of the newborn baby.

OBJECTIVE: to explore the experiences and attitudes of midwives, junior paediatricians (SHOs), GPs, and mothers to the examination of the newborn baby. To provide an appreciation of their views on several issues, in particular the purpose and value of the examination, who is thought to be appropriate to carry it out and when and where it should take place. DESIGN: qualitative using semi-structured interviews, which were exploratory and interactive, in order to examine the range and diversity of experiences and attitudes to the neonatal examination. SETTING: South-east England. PARTICIPANTS: four samples were purposefully selected to include ten each of midwives, SHOs, GPs and recently delivered mothers. SHOs were currently working in paediatric departments of a district general hospital or teaching hospital and their experience of conducting examinations of the newborn baby ranged from several months to several years. Midwives included both those trained in the examination and currently conducting examinations, and those not so trained and not carrying out the examination. Most of the midwives had been qualified for over ten years and had a wide range of clinical experience in hospital and community settings. The GPs were from ten practices in two Health Authorities and all had some experience of conducting neonatal examinations. Of the mothers, a few had had their babies examined at home by midwives, others in hospital by an SHO. Mothers included those with a family history of problems relevant to the examination, those with previous pregnancy complications and others with no problems or complications. Some were first-time mothers. FINDINGS: all groups perceived the examination to be a useful screening tool providing reassurance to parents. They considered both midwives and SHOs to be appropriate professionals to carry out the examination, if adequately trained. Most thought that midwives have a better rapport with mothers, are able to provide continuity of care and more often discuss health-care issues than do SHOs. Few SHOs reported receiving any formal training in the examination of the newborn baby. IMPLICATIONS FOR PRACTICE: the extension of the practice of midwives examining the newborn baby following relevant training would be acceptable to all stakeholders. The implications of increased demands on the midwives' workload may need to be considered.

A qualitative study exploring midwives' perceptions and views of extending their role to the examination of the newborn baby.

OBJECTIVES: to explore midwives' attitudes and perceptions about extending their role to the examination of the newborn baby, as well as their general perceptions and attitudes to new role developments. DESIGN: qualitative, data collected using semi-structured interviews, which were exploratory and interactive in form. SETTING: six maternity hospitals in South-east England. PARTICIPANTS: ten midwives were purposefully selected, including five trained in the examination of the newborn baby and currently conducting examinations and five who had not. Most of the midwives had been qualified for over ten years and had a wide range of clinical experience in hospital and community settings. FINDINGS: midwives identified many benefits to themselves, to their profession and to the mothers as a result of developing their role into the examination of the newborn baby. The major benefit cited was improved job satisfaction, which was directly related to their ability to give continuity and total care to mothers and babies. Midwives also perceived that undertaking the examination strengthened their position as autonomous practitioners, by enabling them to provide total care to mothers and babies who fitted their criteria of normality. Moreover, midwives thought that improvements in the overall quality of care to mothers would result from them performing the examination, including improved communication, greater continuity of care and a more holistic examination. Although midwives were concerned about possible increase in workloads and pressure to take on new roles, the examination was generally perceived as being easily incorporated into their current practice without compromising overall standards in midwifery care. Midwives expressed concern about 'extending' practice into areas that did not fit their perceptions of normality and about being 'pressurised' into taking on new roles. IMPLICATIONS FOR PRACTICE: it would appear from this study that an important consideration for midwives in their acceptance of new roles, is the relationship of that role to their position as experts in normality. Midwives in this study viewed the examination of the newborn baby as 'fitting in' with their perceptions of the core values of midwifery.

A national survey in England of the routine examination of the newborn baby.

OBJECTIVE: To identify current practices for the initial routine examination of healthy newborn babies, and determine the extent to which midwives are carrying out this examination. DESIGN AND PARTICIPANTS: Postal questionnaires were sent to consultant paediatricians and midwifery managers in all maternity units in England. Questionnaires were also sent to the 12 universities in England which run the N96 post-registration course in the examination of the newborn baby. FINDINGS: Questionnaires were returned from 197 (86%) maternity units. Senior house officers examined in 83% (160/193) a median of 92% of babies; 44% (74/167) had at least one midwife (median of two) with qualifications to carry out the examination and in 31% (51/167) some examinations were conducted by a midwife. However, a third of midwives with this qualification carried out no examinations, and nationally only about 2% of babies were examined by a midwife. Rates of referral by midwives and senior house officers were similar. Examinations were carried out between four and 48 hours from birth; most units considered six hours an acceptable minimum. An estimated 1% of babies were transferred home without routine examination; the GP was responsible for most (83-93%) of these babies' examinations; midwives for 10-23%; and senior house officers in hospital for 4-7%. Twelve per cent (23/194) of units carried out a second examination prior to discharge. Most respondents were in favour of midwives carrying out the examinations provided they were adequately trained. CONCLUSIONS: Many of the consultant paediatricians and midwifery managers stated that suitably trained midwives could routinely examine the healthy newborn baby; however, many currently N96 trained midwives were examining few or no babies. An extension of training would be needed were midwife examination to become general policy.

A randomised controlled trial of maternal satisfaction with the routine examination of the newborn baby at three months post birth.

OBJECTIVE: to determine whether any differences in maternal satisfaction with the examination of a newborn baby between midwives and junior paediatricians are maintained over a three-month period. DESIGN, SETTING AND PARTICIPANTS: randomised controlled trial. Eight hundred and twenty-six mother and baby pairs in a district general hospital in South East England were randomised to a junior paediatrician or a midwife for the routine examination. Four hundred and eighty-six mothers completed a maternal satisfaction questionnaire on day-one and again three-months later. Maternal satisfaction with the examination was analysed in relation to randomised group, process and background variables. FINDINGS: high satisfaction with the examination was reported by most mothers (day-one: 82%; three-months: 79%). At day-one, mothers whose babies were examined by a midwife were more satisfied with the examination (crude odds ratio (OR) for the lowest tertile of satisfaction 0.49, 95% CI 0.32-0.73). However, after controlling for provision of health education during the examination (e.g. discussing feeding, sleeping and skin care) and continuity of care provided, maternal satisfaction was no longer related to status of examiner (adjusted OR 0.83, 95% CI 0.52-1.33). Three months later, there was no significant difference in maternal satisfaction with midwife and junior paediatrician examinations of the newborn baby (crude OR 0.89, 95% CI 0.58-1.37). Discussion of health-care issues by the examiner during the examination was significantly related to increased satisfaction even at three-months. Three month ratings of low satisfaction with the examination were most strongly predicted by current maternal depressive mood, even when other factors were adjusted for (adjusted OR 2.58, 95% CI 1.19-5.59). KEY CONCLUSIONS: from the mother's perspective, the quality of midwife examination is at least as satisfactory as that of junior paediatricians and this perception is maintained over a three-month period. Satisfaction can be significantly enhanced if the examiner provides information on behavioural and health-care issues. The examination of the newborn baby provides an important window of opportunity for sharing information on newborn behaviour and care issues.

Pricing Policies And Control of Tobacco in Europe (PPACTE) project: cross-national comparison of smoking prevalence in 18 European countries.

Limited data on smoking prevalence allowing valid between-country comparison are available in Europe. The aim of this study is to provide data on smoking prevalence and its determinants in 18 European countries. In 2010, within the Pricing Policies And Control of Tobacco in Europe (PPACTE) project, we conducted a face-to-face survey on smoking in 18 European countries (Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden) on a total of 18 056 participants, representative for each country of the population aged 15 years or older. Overall, 27.2% of the participants were current smokers (30.6% of men and 24.1% of women). Smoking prevalence was highest in Bulgaria (40.9%) and Greece (38.9%) and lowest in Italy (22.0%) and Sweden (16.3%). Smoking prevalence ranged between 15.7% (Sweden) and 44.3% (Bulgaria) for men and between 11.6% (Albania) and 38.1% (Ireland) for women. Multivariate analysis showed a significant inverse trend between smoking prevalence and the level of education in both sexes. Male-to-female smoking prevalence ratios ranged from 0.85 in Spain to 3.47 in Albania and current-to-ex prevalence ratios ranged from 0.68 in Sweden to 4.28 in Albania. There are considerable differences across Europe in smoking prevalence, and male-to-female and current-to-ex smoking prevalence ratios. Eastern European countries, lower income countries and those with less advanced tobacco control policies have less favourable smoking patterns and are at an earlier stage of the tobacco epidemic.

A pragmatic randomised controlled trial in primary care of the Camden Weight Loss (CAMWEL) programme.

OBJECTIVES: To evaluate effectiveness of a structured one-to-one behaviour change programme on weight loss in obese and overweight individuals. DESIGN: Randomised controlled trial. SETTING: 23 general practices in Camden, London. PARTICIPANTS: 381 adults with body mass index ≥25 kg/m(2) randomly assigned to intervention (n=191) or control (n=190) group. INTERVENTIONS: A structured one-to-one programme, delivered over 14 visits during 12 months by trained advisors in three primary care centres compared with usual care in general practice. OUTCOME MEASURES: Changes in weight, per cent body fat, waist circumference, blood pressure and heart rate between baseline and 12 months. RESULTS: 217/381 (57.0%) participants were assessed at 12 months: missing values were imputed. The difference in mean weight change between the intervention and control groups was not statistically significant (0.70 kg (0.67 to 2.17, p=0.35)), although a higher proportion of the intervention group (32.7%) than the control group (20.4%) lost 5% or more of their baseline weight (OR: 1.80 (1.02 to 3.18, p=0.04)). The intervention group achieved a lower mean heart rate (mean difference 3.68 beats per minute (0.31 to 7.04, p=0.03)) than the control group. Participants in the intervention group reported higher satisfaction and more positive experiences of their care compared with the control group. CONCLUSIONS: Although there is no significant difference in mean weight loss between the intervention and control groups, trained non-specialist advisors can deliver a structured programme and achieve clinically beneficial weight loss in some patients in primary care. The intervention group also reported a higher level of satisfaction with the support received. Primary care interventions are unlikely to be sufficient to tackle the obesity epidemic and effective population-wide measures are also necessary. CLINICAL TRIAL REGISTRATION NUMBER: Trial registrationClincaltrials.gov NCT00891943.

Reproductive health and quality of life of young Burmese refugees in Thailand.

BACKGROUND: Of the 140,000 Burmese* refugees living in camps in Thailand, 30% are youths aged 15-24. Health services in these camps do not specifically target young people and their problems and needs are poorly understood. This study aimed to assess their reproductive health issues and quality of life, and identifies appropriate service needs. METHODS: We used a stratified two-stage random sample questionnaire survey of 397 young people 15-24 years from 5,183 households, and 19 semi-structured qualitative interviews to assess and explore health and quality of life issues. RESULTS: The young people in the camps had very limited knowledge of reproductive health issues; only about one in five correctly answered at least one question on reproductive health. They were clear that they wanted more reproductive health education and services, to be provided by health workers rather than parents or teachers who were not able to give them the information they needed. Marital status was associated with sexual health knowledge; having relevant knowledge of reproductive health was up to six times higher in married compared to unmarried youth, after adjusting for socio-economic and demographic factors. Although condom use was considered important, in practice a large proportion of respondents felt too embarrassed to use them. There was a contradiction between moral views and actual behaviour; more than half believed they should remain virgins until marriage, while over half of the youth experienced sex before marriage. Two thirds of women were married before the age of 18, but two third felt they did not marry at the right age. Forced sex was considered acceptable by one in three youth. The youth considered their quality of life to be poor and limited due to confinement in the camps, the limited work opportunities, the aid dependency, the unclear future and the boredom and unhappiness they face. CONCLUSIONS: The long conflict in Myanmar and the resultant long stay in refugee camps over decades affect the wellbeing of these young people. Lack of sexual health education and relevant services, and their concerns for their future are particular problems, which need to be addressed. Issues of education, vocational training and job possibilities also need to be considered.*Burmese is used for all ethnic groups.

Weight-management interventions in primary care: a pilot randomised controlled trial.

BACKGROUND: There is a paucity of randomised controlled trials of weight management in primary care. AIM: To ascertain the feasibility of a full trial of a nurse-led weight-management programme in general practice. DESIGN OF STUDY: Factorial randomised control trial. SETTING: Primary care, UK. METHOD: A total of 123 adults (80.3% women, mean age 47.2 years) with body mass index > or =27 kg/m(2), recruited from eight practices, were randomised to receive structured lifestyle support (n = 30), structured lifestyle support plus pedometer (n = 31), usual care (n = 31), or usual care plus pedometer (n = 31) for a 12-week period. RESULTS: A total of 103 participants were successfully followed up. The adjusted mean difference in weight in structured support compared to usual care groups was -2.63 kg (95% confidence interval [CI] = -4.06 to -1.20 kg), and for pedometer compared to no pedometer groups it was -0.11 kg (95% CI = -1.52 to 1.30 kg). One in three participants in the structured-support groups (17/50, 34.0%) lost 5% or more of their initial weight, compared to less than one in five (10/53, 18.9%) in usual-care groups; provision of a pedometer made little difference (14/48, 29.2% pedometer; 13/55, 23.6% no pedometer). Difference in waist circumference change between structured-support and usual-care groups was -1.80 cm (95% CI = -3.39 to -0.20 cm), and between the pedometer and no pedometer groups it was -0.84 cm (95% CI = -2.42 to 0.73 cm). When asked about their experience of study participation, most participants found structured support helpful. CONCLUSION: The structured lifestyle support package could make substantial contributions to improving weight-management services. A trial of the intervention in general practice is feasible and practicable.

Health promotion for adolescents in primary care: randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of inviting teenagers to general practice consultations to discuss health behaviour concerns and appropriate follow up care. DESIGN: Randomised controlled trial, with participants randomised to a consultation (intervention) or usual care (control). Questionnaires completed at baseline, 3 months, and 12 months. SETTING: Eight general practices in Hertfordshire, England. PARTICIPANTS: 1516 teenagers aged 14-15 years. INTERVENTION: Consultations with practice nurses to discuss health concerns and develop plans for healthier lifestyles. MAIN OUTCOME MEASURES: Mental and physical health, "stage of change" for health related behaviour, and use of health services. RESULTS: At baseline 970 teenagers completed questionnaires; 23% smoked, 35% had been drunk in the previous three months, 64% considered they ate unhealthily, 39% took little exercise, and 36% had possible depression. 41% (304) of teenagers invited attended for a consultation; over one third (112) were offered follow up care. More intervention group teenagers reported positive movement in stage of change for diet and exercise and in at least one of four behaviours (diet, exercise, smoking, drinking alcohol) at 3 months (41% v 31%, P<0.01), but this did not persist at 12 months. There was marginally more positive change in actual behaviour by intervention teenagers at 3 months (16% v 12%, P=0.06). Recognition of possible depression resulted in improved mental health outcomes at 3 and 12 months. 97% of attenders said they would recommend the intervention to a friend. CONCLUSIONS: Change in behaviour was slight but encouraging, and the intervention was well received and relatively cheap.