Rojiroti microfinance and child nutrition: a cluster randomised trial.

OBJECTIVE: To determine whether Rojiroti microfinance, for poor Indian women, improves child nutrition. DESIGN: Cluster randomised trial. SETTING: Tolas (village communities) in Bihar State. PARTICIPANTS: Women and children under 5 years. INTERVENTIONS: With Rojiroti microfinance, women form self-help groups and save their money to provide loans to group members. After 6 months, they receive larger external loans. Tolas were randomised to receive Rojiroti immediately or after 18 months. OUTCOME MEASURES: The primary analysis compared the mean weight for height Z score (WHZ) of children under 5 years in the intervention versus control tolas who attended for weight and height measurement 18 months after randomisation. Secondary outcomes were weight for age Z score (WAZ), height for age Z score, mid-upper arm circumference (MUAC), wasting, underweight and stunting. RESULTS: We randomised 28 tolas to each arm and collected data from 2469 children (1560 mothers) at baseline and 2064 children (1326 mothers) at follow-up. WHZ was calculated for 1718 children at baseline and 1377 (674 intervention and 703 control) at follow-up. At 18 months, mean WHZ was significantly higher for intervention (-1.02) versus controls (-1.37; regression coefficient adjusted for clustering ß=0.38, 95% CI 0.16 to 0.61, p=0.001). Significantly fewer children were wasted in the intervention group (122, 18%) versus control (200, 29%; OR=0.46, 95% CI 0.28 to 0.74, p=0.002). Mean WAZ was better in the intervention group (-2.13 vs -2.37; ß=0.27, 95% CI 0.11 to 0.43, p=0.001) as was MUAC (13.6 cm vs 13.4 cm; ß=0.22, 95% CI 0.03 to 0.40, p=0.02). In an analysis adjusting for baseline nutritional measures (259 intervention children and 300 control), only WAZ and % underweight showed significant differences in favour of the intervention. CONCLUSION: In marginalised communities in rural India, child nutrition was better in those who received Rojiroti microfinance, compared with controls. TRIAL REGISTRATION NUMBER: NCT01845545.

Is microfinance associated with changes in women's well-being and children's nutrition? A systematic review and meta-analysis.

BACKGROUND: Microfinance is the provision of savings and small loans services, with no physical collateral. Most recipients are disadvantaged women. The social and health impacts of microfinance have not been comprehensively evaluated. OBJECTIVE: To explore the impact of microfinance on contraceptive use, female empowerment and children's nutrition in South Asia, Sub-Saharan Africa and Latin America and the Caribbean. DESIGN: We conducted a systematic search of published and grey literature (1990-2018), with no language restrictions. We conducted meta-analysis, where possible, to calculate pooled ORs. Where studies could not be combined, we described these qualitatively. DATA SOURCES: EMBASE, MEDLINE, LILACS, CENTRAL and ECONLIT were searched (1990-June 2018). ELIGIBILITY CRITERIA: We included controlled trials, observational studies and panel data analyses investigating microfinance involving women and children. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed risk of bias. The methodological quality of included studies was assessed using the Cochrane risk-of-bias tool for controlled trials and quasi-experimental studies and a modified Newcastle Ottawa Scale for cross-sectional surveys and analyses of panel data. Meta-analyses were conducted using STATA V.15 (StataCorp). RESULTS: We included 27 studies. Microfinance was associated with a 64% increase in the number of women using contraceptives (OR 1.64, 95% CI 1.45 to 1.86). We found mixed results for the association between microfinance and intimate partner violence. Some positive changes were noted in female empowerment. Improvements in children's nutrition were noted in three studies. CONCLUSION: Microfinance has the potential to generate changes in contraceptive use, female empowerment and children's nutrition. It was not possible to compare microfinance models due to the small numbers of studies. More rigorous evidence is needed to evaluate the association between microfinance and social and health outcomes. PROSPERO REGISTRATION NUMBER: CRD42015026018.

Estimating the health-care costs of children born to pregnant smokers in England: cohort study using primary and secondary health-care data.

BACKGROUND AND AIMS: Little is known about the long-term economic consequences of smoking during pregnancy. We estimated the association between smoking in pregnancy and the costs of delivering health-care to infants and children in England, and investigated which aspects of care are the key drivers of these costs. METHODS: We used Hospital Episode Statistics (HES) linked with Clinical Practice Research Datalink (CPRD) data in England from January 2003 to January 2015 in children with longitudinal data for at least 1, 5 and 10 years after birth. Poisson regression provided rate ratios (RR) and 95% confidence intervals (CIs) comparing health-care episode rates between those exposed and not exposed to smoking during pregnancy. Linear regression was used to compare estimated costs between groups (£ sterling, 2015 prices) and generalized linear multivariable (GLM) models adjusted for potentially moderating factors. RESULTS: A total of 93 152 singleton pregnancies with the required data were identified. Maternal smoking in pregnancy was associated with higher primary care, prescription and hospital in-patient episode rates, but lower out-patient visit and diagnostic test rates. Adjusting for year of birth, socio-economic deprivation, parity, sex of child and delivery method showed that maternal smoking in pregnancy was associated with increased child health-care costs at 1 year [average cost difference for children of smokers, ß = £91.18, 95% confidence interval (CI) = £47.52-134.83 and 5 years of age (ß = £221.80, 95% CI = £17.78-425.83], but not at 10 years of age (ß = £365.94, 95% CI = -£192.72 to £924.60). CONCLUSION: In England, maternal smoking in pregnancy is associated with increased child health-care costs over the first 5 years of life; these costs are driven primarily by greater hospital in-patient care.

Rapidly Increasing Trend of Recorded Alcohol Consumption Since the End of the Armed Conflict in Sri Lanka.

AIM: To evaluate temporal changes in recorded alcohol consumption in Sri Lanka during and after the armed conflict 1998-2013. METHODS: District level alcohol sales, and mid-year population data for the whole study period (1998-2013) were consistently available from the Department of Excise and the Department of Census and Statistics for 18 of 25 districts. These data were used to estimate the recorded per capita consumption for the areas that were not directly exposed to the armed conflict. An interrupted time series design was employed to estimate the impact of the end of the armed conflict on recorded adult per capita alcohol consumption of population lived in the 18 districts. RESULTS: Adult per capita recorded alcohol consumption among Sri Lankans living in the 18 districts was 1.59 l of pure alcohol in 1998. This increased up to 2.07 l in 2009 and 2.55 l in 2013. Prior to the end of the conflict in 2009 adult per capita recorded consumption increased by 0.051 l of pure alcohol per year (95% CI: 0.029-0.074, P < 0.001); after 2009 this was 0.166 l per year (95% CI: 0.095-0.236, P < 0.001). Beer consumption showed the highest per capita growth compared with other beverages. CONCLUSIONS: Adult per capita recorded alcohol consumption among Sri Lankans living in areas that were not directly exposed to the conflict increased markedly after the end of the conflict. Rapid socio-economic development, alcohol industry penetration and lack of alcohol control strategies during the post-conflict period may have driven this increase. SHORT SUMMARY: Adult per capita recorded alcohol consumption among Sri Lankans living in 18 districts that were not directly exposed to the armed conflict increased markedly after the end of the conflict in 2009, with a dramatic acceleration in the trend of per capita beer consumption.

Effect of implementation of a smoke-free policy on physical violence in a psychiatric inpatient setting: an interrupted time series analysis.

BACKGROUND: Smoke-free policies are important to protect health and reduce health inequalities. A major barrier to policy implementation in psychiatric hospitals is staff concern that physical violence will increase. We aimed to assess the effect of implementing a comprehensive smoke-free policy on rates of physical assaults in a large UK mental health organisation. METHODS: We did an interrupted time series analysis of incident reports of physical assault 30 months before and 12 months after the implementation of the policy in the inpatient wards of South London and Maudsley National Health Service Foundation Trust, London, UK. We used a quasi-Poisson generalised additive mixed model to model the monthly incidence of physical assaults as a function of several explanatory variables. FINDINGS: 4550 physical assaults took place between April 1, 2012, and Sept 30, 2015; 225 (4·9%) of which were smoking-related. After adjustment for temporal and seasonal trends and key confounders (sex, age, schizophrenia or related disorders, or having been sectioned under the Mental Health Act), there was a 39% reduction in the number of physical assaults per month after the policy introduction compared with beforehand (incidence rate ratio 0·61, 95% CI 0·53-0·70; p<0·0001). INTERPRETATION: Introduction of a comprehensive smoke-free policy appeared to reduce the incidence of physical assaults. Adequately resourced smoke-free policies could be part of broader violence reduction strategies in psychiatric settings. FUNDING: National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South London (King's College Hospital NHS Foundation Trust).

Economic cost of smoking in people with mental disorders in the UK.

BACKGROUND: Smoking is the largest preventable cause of death in the UK and imposes a huge economic burden on society. Both the prevalence and extent of smoking are significantly higher among people with mental disorders than among the general population. AIMS: To estimate the economic costs of the health effects of cigarette smoking among people with mental disorders in the UK from a societal perspective. METHODS: This study uses the WHO's economics of tobacco toolkit to assess the costs of the health effects of cigarette smoking among people with mental disorders in 2009/10 in the UK. Based on the cost of illness approach, direct healthcare costs, indirect morbidity costs and indirect mortality costs due to smoking-related diseases were calculated to estimate the avoidable economic burden of smoking in people with mental disorders. RESULTS: The estimated economic cost of smoking in people with mental disorders was £2.34 billion in 2009/10 in the UK, of which, about £719 million (31% of the total cost) was spent on treating diseases caused by smoking. Productivity losses due to smoking-related diseases were about £823 million (35%) for work-related absenteeism and £797 million (34%) was associated with premature mortality. CONCLUSIONS: Smoking in people with mental disorders in the UK imposes significant economic costs. The development and implementation of smoking cessation interventions in this group should therefore be a high economic and clinical priority.

Feasibility and pilot study of the effects of microfinance on mortality and nutrition in children under five amongst the very poor in India: study protocol for a cluster randomized controlled trial.

BACKGROUND: The United Nations Millennium Development Goals include targets for the health of children under five years old. Poor health is linked to poverty and microfinance initiatives are economic interventions that may improve health by breaking the cycle of poverty. However, there is a lack of reliable evidence to support this. In addition, microfinance schemes may have adverse effects on health, for example due to increased indebtedness. Rojiroti UK and the Centre for Promoting Sustainable Livelihood run an innovative microfinance scheme that provides microcredit via women's self-help groups (SHGs). This pilot study, conducted in rural Bihar (India), will establish whether it is feasible to collect anthropometric and mortality data on children under five years old and to conduct a limited cluster randomized trial of the Rojiroti intervention. METHODS/DESIGN: We have designed a cluster randomized trial in which participating tolas (small communities within villages) will be randomized to either receive early (SHGs and microfinance at baseline) or late intervention (SHGs and microfinance after 18 months). Using predesigned questionnaires, demographic, and mortality data for the last year and information about participating mothers and their children will be collected and the weight, height, and mid upper arm circumference (MUAC) of children will be measured at baseline and at 18 months. The late intervention group will establish SHGs and microfinance support at this point and data collection will be repeated at 36 months.The primary outcome measure will be the mean weight for height z-score of children under five years old in the early and late intervention tolas at 18 months. Secondary outcome measures will be the mortality rate, mean weight for age, height for age, prevalence of underweight, stunting, and wasting among children under five years of age. DISCUSSION: Despite economic progress, marked inequalities in child health persist in India and Bihar is one of the worst affected states. There is a need to evaluate programs that may alleviate poverty and improve health. This study will help to inform the design of a definitive trial to determine if the Rojiroti scheme can improve the nutrition and survival of children under five years of age in deprived rural communities. TRIAL REGISTRATION: Clinicaltrials.gov (study ID: NCT01845545). Registered on 24 April 2013.

Smoking in cars in England: a study of school students in an English city.

BACKGROUND: Exposure to secondhand smoke is associated with an increased risk of adverse health effects among children. Although smoking in the home is an established major source of exposure, less is known about rules on smoking in cars. METHODS: In a survey including a sample of secondary school students in Nottingham (UK) in 2012, participants were asked whether smoking was allowed in the family car, and how often the respondent travelled in a car in which smoking was allowed. Rules on smoking in cars were investigated in relation to socio-demographic variables and whether children had ever smoked themselves using logistic regression. RESULTS: Of 4,190 students aged 11-16 who provided data, approximately 12% reported that smoking was allowed in their family car and 35% that they travelled in a car where smoking was allowed at least sometimes. Absence of smoke free rules in the family car was more likely to be reported by children from more disadvantaged families, if parents and friends were smokers and if smoking was allowed in the main home. These factors, and having a sibling who smokes, were also independently associated with an increased risk of travelling in a car in which smoking was allowed at least sometimes. Respondents who were not protected from secondhand smoke in the car were also more likely to have ever smoked (adjusted odds ratio 1.59, 95% CI 1.18-2.14). CONCLUSIONS: Absence of smoke free rules in a family car and travelling in a car where smoking was allowed was relatively common among secondary school students, was strongly related to social disadvantage and a higher risk of smoking experimentation. Measures to prevent such exposure are therefore indicated.

Smoking cessation advice recorded during pregnancy in United Kingdom primary care.

BACKGROUND: United Kingdom (UK) national guidelines recommend that all pregnant women who smoke should be advised to quit at every available opportunity, and brief cessation advice is an efficient and cost-effective means to increase quit rates. The Quality and Outcomes Framework (QOF) implemented in 2004 requires general practitioners to document their delivery of smoking cessation advice in patient records. However, no specific targets have been set in QOF for the recording of this advice in pregnant women. We used a large electronic primary care database from the UK to quantify the pregnancies in which women who smoked were recorded to have been given smoking cessation advice, and the associated maternal characteristics. METHODS: Using The Health Improvement Network database we calculated annual proportions of pregnant smokers between 2000 and 2009 with cessation advice documented in their medical records during pregnancy. Logistic regression was used to assess variation in the recording of cessation advice with maternal characteristics. RESULTS: Among 45,296 pregnancies in women who smoked, recorded cessation advice increased from 7% in 2000 to 37% in 2004 when the QOF was introduced and reduced slightly to 30% in 2009. Pregnant smokers from the youngest age group (15-19) were 21% more likely to have a record of cessation advice compared to pregnant smokers aged 25-29 (OR 1.21, 95% CI 1.10-1.35) and pregnant smokers from the most deprived group were 38% more likely to have a record for cessation advice compared to pregnant smokers from the least deprived group (OR 1.38, 95% CI 1.14-1.68). Pregnant smokers with asthma were twice as likely to have documentation of cessation advice in their primary care records compared to pregnant smokers without asthma (OR 1.97, 95% CI 1.80-2.16). Presence of comorbidities such as diabetes, hypertension and mental illness also increased the likelihood of having smoking cessation advice recorded. No marked variations were observed in the recording of cessation advice with body mass index. CONCLUSION: Recorded delivery of smoking cessation advice for pregnant smokers in primary care has increased with some fluctuation over the years, especially after the implementation of the QOF, and varies with maternal characteristics.

Socioeconomic variations in access to smoking cessation interventions in UK primary care: insights using the Mosaic classification in a large dataset of primary care records.

BACKGROUND: Smoking prevalence is particularly high amongst more deprived social groups. This cross-sectional study uses the Mosaic classification to explore socioeconomic variations in the delivery and/or uptake of cessation interventions in UK primary care. METHODS: Data from 460,938 smokers registered in The Health Improvement Network between 2008 and 2010 were analysed. Logistic regression was used to calculate odds ratios for smokers having a record of receiving cessation advice or a prescription for a cessation medication during the study period by Townsend quintile and for each of the 11 Mosaic groups and 61 Mosaic types. Both of these measures are area-level indicators of deprivation. Profiles of Mosaic categories were used to suggest ways to target specific groups to increase the provision of cessation support. RESULTS: Odds ratios for smokers having a record of advice or a prescription increased with increasing Townsend deprivation quintile. Similarly, smokers in more deprived Mosaic groups and types were more likely to have a documented cessation intervention. The odds of smokers receiving cessation advice if they have uncertain employment and live in social housing in deprived areas were 35% higher than the odds for successful professionals living in desirable areas (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.20-1.52; absolute risks 57.2% and 50.1% respectively), and those in low-income families living in estate-based social housing were 50% more likely to receive a prescription than these successful professionals (OR 1.50, 95% CI 1.31-1.73; absolute risks 19.5% and 13% respectively). Smokers who did not receive interventions were generally well educated, financially successful, married with no children, read broadsheet newspapers and had broadband internet access. CONCLUSIONS: Wide socioeconomic variations exist in the delivery and/or uptake of smoking cessation interventions in UK primary care, though encouragingly the direction of this variation may help to reduce smoking prevalence-related socioeconomic inequalities in health. Groups with particularly low intervention rates may be best targeted through broadsheet media, the internet and perhaps workplace-based interventions in order to increase the delivery and uptake of effective quit support.

The impact of media campaigns on smoking cessation activity: a structural vector autoregression analysis.

AIMS: To evaluate the effect of tobacco control media campaigns and pharmaceutical company-funded advertising for nicotine replacement therapy (NRT) on smoking cessation activity. DESIGN: Multiple time series analysis using structural vector autoregression, January 2002-May 2010. SETTING: England and Wales. DATA SOURCES: Tobacco control campaign data from the Central Office of Information; commercial NRT campaign data; data on calls to the National Health Service (NHS) stop smoking helpline from the Department of Health; point-of-sale data on over-the-counter (OTC) sales of NRT; and prescribing data from The Health Improvement Network (THIN), a database of UK primary care records. MEASUREMENTS: Monthly calls to the NHS stop smoking helpline and monthly rates of OTC sales and prescribing of NRT. FINDINGS: A 1% increase in tobacco control television ratings (TVRs), a standard measure of advertising exposure, was associated with a statistically significant 0.085% increase in calls in the same month (P = 0.007), and no statistically significant effect in subsequent months. Tobacco control TVRs were not associated with OTC NRT sales or prescribed NRT. NRT advertising TVRs had a significant effect on NRT sales which became non-significant in the seasonally adjusted model, and no significant effect on prescribing or calls. CONCLUSIONS: Tobacco control campaigns appear to be more effective at triggering quitting behaviour than pharmaceutical company NRT campaigns. Any effect of such campaigns on quitting behaviour seems to be restricted to the month of the campaign, suggesting that such campaigns need to be sustained over time.

The impact of the introduction of smoke-free legislation on prescribing of stop-smoking medications in England.

AIMS: To investigate whether there were changes in the rate of prescribing of smoking cessation medications in the months leading up to, and after, the introduction of smoke-free legislation in England. DESIGN: Interrupted time-series analysis of prescribing rates using Autoregressive Integrated Moving Average (ARIMA) models. SETTING: A total of 350 general practices in England who contribute data to The Health Improvement Network (THIN) database. PARTICIPANTS: Patients in THIN aged 16+ identified from their medical records as smokers. MEASUREMENTS: Monthly rates of prescribing of nicotine replacement therapy (NRT), bupropion and varenicline were calculated from THIN from 2000 to 2009 for all smokers and for subgroups defined by patient sex, age group, history of chronic disease and quintile of the Townsend Index of Deprivation. ARIMA models were built to assess whether there were changes in prescribing before or after the introduction of smoke-free legislation over and above any long-term and seasonal trends. FINDINGS: There was a 6.4% (0.7-12.1) increase in prescribing of all smoking cessation medications in the 9 months before the introduction of smoke-free legislation and a 6.4% (1.1-11.7) reduction in the 9-month period afterwards. A 6.2% (1.4-11.0) increase in NRT prescribing and a 13.2% (4.3-22.2) increase in bupropion prescribing occurred in the 6- and 3-month periods, respectively, before smoke-free legislation was introduced, and a 5.5% (2.3-8.7) decline in NRT prescribing and a 13.7% (4.6-22.8) decline in bupropion prescribing in the 9 months post-legislation. The patterns of change in prescribing did not vary with patient demographics. CONCLUSIONS: Numbers of primary care prescriptions for smoking cessation medications increased prior to the introduction of smoke-free legislation but decreased afterwards, suggesting a temporal displacement in prescribing activity rather than a change in the overall volume of prescribing. Effects observed were consistent across all population subgroups, suggesting that the changes in prescribing will neither widen nor reduce smoking-related health inequalities.

Prescribing of smoking cessation medication in England since the introduction of varenicline.

AIMS: To estimate the effect of the introduction of a new smoking cessation medication, varenicline, and the publication of guidance related to its use, on trends in prescribing of smoking cessation medications in England. DESIGN: Interrupted time series analysis of primary care data on prescribing of smoking cessation medication using autoregressive integrated moving average (ARIMA) modelling. SETTING: A total of 446 general practices included in The Health Improvement Network (THIN), a database of UK electronic primary care records. PARTICIPANTS: All primary care patients registered with a THIN practice in England. MEASUREMENTS: Monthly rates of prescribing of varenicline, nicotine replacement therapy (NRT) and bupropion per 100 000 patients registered with a THIN practice between June 2000 and June 2009. FINDINGS: NRT was the most commonly prescribed stop smoking medication, and bupropion the least frequently prescribed. After its introduction in December 2006 varenicline rapidly became the second most commonly prescribed drug. There was no statistically significant change in overall prescribing for smoking cessation medications after its introduction (P = 0.760), or after the publication of the related guidance in July 2007 (P = 0.134). CONCLUSIONS: Soon after being introduced in England, varenicline was widely prescribed; after nicotine replacement therapy it was the most commonly prescribed cessation medication. However, this does not appear to have increased overall rates of prescribing for smoking cessation medication.

Insights into social disparities in smoking prevalence using Mosaic, a novel measure of socioeconomic status: an analysis using a large primary care dataset.

BACKGROUND: There are well-established socio-economic differences in the prevalence of smoking in the UK, but conventional socio-economic measures may not capture the range and degree of these associations. We have used a commercial geodemographic profiling system, Mosaic, to explore associations with smoking prevalence in a large primary care dataset and to establish whether this tool provides new insights into socio-economic determinants of smoking. METHODS: We analysed anonymised data on over 2 million patients from The Health Improvement Network (THIN) database, linked via patients' postcodes to Mosaic classifications (11 groups and 61 types) and quintiles of Townsend Index of Multiple Deprivation. Patients' current smoking status was identified using Read Codes, and logistic regression was used to explore the associations between the available measures of socioeconomic status and smoking prevalence. RESULTS: As anticipated, smoking prevalence increased with increasing deprivation according to the Townsend Index (age and sex adjusted OR for highest vs lowest quintile 2.96, 95% CI 2.92-2.99). There were more marked differences in prevalence across Mosaic groups (OR for group G vs group A 4.41, 95% CI 4.33-4.49). Across the 61 Mosaic types, smoking prevalence varied from 8.6% to 42.7%. Mosaic types with high smoking prevalence were characterised by relative deprivation, but also more specifically by single-parent households living in public rented accommodation in areas with little community support, having no access to a car, few qualifications and high TV viewing behaviour. CONCLUSION: Conventional socio-economic measures may underplay social disparities in smoking prevalence. Newer classification systems, such as Mosaic, encompass a wider range of demographic, lifestyle and behaviour data, and are valuable in identifying characteristics of groups of heavy smokers which might be used to tailor cessation interventions.

Validation of The Health Improvement Network (THIN) primary care database for monitoring prescriptions for smoking cessation medications.

PURPOSE: Evaluation of tobacco policy requires high quality and timely data on smoking cessation behaviour in the general population and in relevant target groups. Electronic primary care databases have the potential to provide a valuable source of data due to their size and continuity, and the availability of demographic and socioeconomic data. We therefore sought to investigate whether The Health Improvement Network (THIN) prescribing data are complete and can therefore be used to monitor trends in the prescribing of smoking cessation medications. METHODS: The THIN smoking cessation medication prescriptions data for England were compared with smoking cessation medication dispensing data from NHS Prescription Services for January 2004 to December 2005. RESULTS: Throughout the period the rates of prescribing and dispensing were very similar, both for nicotine replacement therapy (NRT) and bupropion combined, and for each type of medication alone. For NRT, dispensing exceeded recorded GP prescribing by 5.5% during the study period. For bupropion, prescribing exceeded dispensing by 5%. CONCLUSIONS: THIN prescribing and national dispensing data are highly comparable. THIN prescribing data could potentially be used to monitor longitudinal trends in prescribing for smoking cessation medications.