Methodological pluralism for better evaluations of complex interventions: lessons from evaluating an innovation platform in Australia.

Complex interventions, such as innovation platforms, pose challenges for evaluators. A variety of methodological approaches are often required to build a more complete and comprehensive understanding of how complex interventions work. In this paper, we outline and critically appraise a methodologically pluralist evaluation of an innovation platform to strengthen primary care for Aboriginal and Torres Strait Islander Australians. In doing so, we aim to identify lessons learned from the approach taken and add to existing literature on implementing evaluations in complex settings, such as innovation platforms. The pluralist design used four evaluation approaches-developmental evaluation, principles-focused evaluation, network analysis, and framework analysis-with differing strengths and challenges. Taken together, the multiple evaluation approaches yielded a detailed description and nuanced understanding of the formation, functioning and outcomes of the innovation platform that would be difficult to achieve with any single evaluation method. While a methodologically pluralist design may place additional pressure on logistical and analytic resources available, it enables a deeper understanding of the mechanisms that underlie complex interventions.

Rationale and methods for a cross-sectional study of mental health and wellbeing following river flooding in rural Australia, using a community-academic partnership approach.

BACKGROUND: Climate change is associated with greater frequency, duration, intensity and unpredictability of certain weather-related events, including floods. Floods harm mental health. There is limited understanding of the mental health and well-being effects from river flooding, particularly over the longer term and in rural contexts. This paper describes the rationale, aims, objectives, study design and socio-demographic characteristics of the sample for a study measuring associations between flood experience and mental health and wellbeing of residents (particularly those most likely to be negatively impacted and hard to reach) in rural NSW Australia 6 months following a devastating flood in 2017. To our knowledge, the study is the first of its kind within Australia in a rural community and is an important initiative given the likelihood of an increasing frequency of severe flooding in Australia given climate change. METHODS: A conceptual framework (The Flood Impact Framework) drawing on social ecological approaches was developed by the research team. It was based on the literature and feedback from the community. The Framework describes putative relationships between flood exposure and mental health and wellbeing outcomes. Within a community-academic partnership approach, a cross-sectional survey was then undertaken to quantify and further explore these relationships. RESULTS: The cross-sectional survey was conducted online (including on mobile phone) and on paper between September and November 2017 and recruited 2530 respondents. Of those, 2180 provided complete demographic data, among whom 69% were women, 91% were aged 25-74, 4% identified as Aboriginal and/or Torres Strait Islander, 9% were farmers and 33% were business owners. CONCLUSIONS: The study recruited a wide range of respondents and the partnership facilitated the community's engagement with the design and implementation of the study. The study will provide a basis for a follow-up study, that will aim to improve the understanding of mental health and wellbeing effects over the longer term. It will provide an important and original contribution to understanding river flooding and mental health in rural Australia, a topic that will grow in importance in the context of human-induced climate change, and identify critical opportunities to strengthen services, emergency planning and resilience to future flooding.

Smoking mull: a grounded theory model on the dynamics of combined tobacco and cannabis use among adult men.

ISSUE ADDRESSED: Australians' use of cannabis has been increasing. Over a third of Australians (35.4%) have used cannabis at some time in their lives and 10.3% are recent users. Almost two-thirds of cannabis users combine cannabis with tobacco. The aim of this study was to understand the process of mulling - smoking tobacco and cannabis together - using a grounded theory approach. METHODS: Twenty-one in-depth semistructured interviews were conducted with men aged 25-34 and living on the North Coast of New South Wales. Interviews explored participants' smoking practices, histories and cessation attempts. RESULTS: A model describing mulling behaviour and the dynamics of smoking cannabis and tobacco was developed. It provides an explanatory framework that demonstrates the flexibility in smoking practices, including substance substitution - participants changed the type of cannabis they smoked, the amount of tobacco they mixed with it and the devices they used to smoke according to the situations they were in and the effects sought. CONCLUSION: Understanding these dynamic smoking practices and the importance of situations and effects, as well as the specific role of tobacco in mulling, may allow health workers to design more relevant and appropriate interventions. SO WHAT? Combining tobacco with cannabis is the most common way of smoking cannabis in Australia. However, tobacco cessation programmes rarely address cannabis use. Further research to develop evidence-based approaches for mull use would improve cessation outcomes.

Partial and complete retirement due to ill-health among mature age Australians.

OBJECTIVES: An ageing population requires governments to keep older people working longer and delay early retirement. This paper investigates the extent to which common health problems and geographical location are associated with full and partial early retirement among mature-age Australians. STUDY DESIGN: Cross sectional. METHODS: Multinomial logistic regression analysis of self-reported data of 21,719 women and 16,393 men from the 45 and Up Study. OUTCOME MEASURE: retirement status. RESULTS: Women who reported ever having been told by a doctor that they had a stroke, cancer (except melanoma and skin and breast cancer), osteoarthritis, depression, osteoporosis, thrombosis, or anxiety were more likely to be fully retired due to ill-health compared to those without these health problems. Those who reported ever having been told by a doctor that they had depression, breast cancer or osteoarthritis were more likely to be partially retired due to ill-health than those without these health problems. Men who reported ever having been told by a doctor that they had cancer, heart disease, anxiety or depression were more likely to be fullyorpartially retired due to ill-health than those without these health problems. Men who reported having had a stroke, diabetes, thyroid problems, osteoarthritis or osteoporosis were more likely to be fully retired due to ill-health compared to those without these health problems. Men and women living outside major cities were more likely to be fully retired due to ill-health. Men from outer regional areas were also more likely to be partially retired due to ill-health. CONCLUSIONS: To reduce early retirement due to ill-health, health practitioners, governments and employers should address targeted health problems, particularly in areas outside capital cities.

Screening for sexually transmitted diseases in rural women in Papua New Guinea: are WHO therapeutic algorithms appropriate for case detection?

The presence of a large reservoir of untreated sexually transmitted diseases (STDs) in developing countries has prompted a number of suggestions for improving case detection, including the use of clinical algorithms and risk assessments to identify women likely to be infected when they present to clinics for other reasons. We used data from a community-based study of STDs to develop and evaluate algorithms for detection of cervical infection with Chlamydia trachomatis or Neisseria gonorrhoeae, and for detection of vaginal infection with Trichomonas vaginalis or bacterial vaginosis. The algorithms were derived using data from 192 randomly selected women, then evaluated on 200 self-selected women. We evaluated the WHO algorithm for vaginal discharge in both groups. The prevalences of cervical and vaginal infection in the randomly selected group were 27% and 50%, respectively, and 23% and 52%, respectively, in the self-selected group. The derived algorithms had high sensitivities in both groups, but poor specificities in the self-selected women, and the positive predictive values were unacceptably low. The WHO algorithms had extremely low sensitivity for detecting either vaginal or cervical infection because relatively few women reported vaginal discharge. Simple algorithms and risk assessments are not valid for case detection in this population.

Community based study of sexually transmitted diseases in rural women in the highlands of Papua New Guinea: prevalence and risk factors.

OBJECTIVE: To estimate the prevalence of sexually transmitted diseases (STDs) and determine their risk factors/markers among a rural population of women in the highlands of Papua New Guinea. METHODS: Community based random cluster sample of women of reproductive age were interviewed and examined and had specimens collected for laboratory confirmation of chlamydial and trichomonal infection, gonorrhoea, syphilis, and bacterial vaginosis. RESULTS: Chlamydia trachomatis was detected in 26%, Trichomonas vaginalis in 46%, Neisseria gonorrhoeae in 1%, syphilis in 4%, pelvic inflammatory disease (PID) (diagnosed clinically) in 14%, and bacterial vaginosis in 9% of 201 women. 59% of the women had at least one STD. In a multivariate logistic regression analysis taking the clustered sampling into account, independent risk factors for chlamydial infection were age < or = 25 years, < four living children, visualization of yellow mucopurulent endocervical secretions on a white swab, and bacterial vaginosis. Being married to a man who did not have other wives was protective. For trichomonal infection, independent risk factors were having no formal education, infertility, more than one sexual partner in the previous 12 months, treatment for genital complaints in the previous 3 months, abnormal vaginal discharge detected on examination, and chlamydial infection. Similar levels of trichomonal infection were found in all age groups. Among married women, rates of infection correlated with their perception of their husband having had other sexual partners in the previous 3 months, and this relationship was significant for chlamydial infection among women over 25. CONCLUSION: STDs are a major problem in this population, with the risk factors varying by outcome. Current treatment regimens are inappropriate given the high prevalence of trichomonal infection, and the available services are inadequate. Effective interventions are required urgently to reduce this burden and to prevent the rapid transmission of HIV.

High rates of genital mycoplasma infection in the highlands of Papua New Guinea determined both by culture and by a commercial detection kit.

Duplicate vaginal swabs were collected from 100 women, and comparisons were made between an in-house broth-agar culture system and a commercially available kit, the Mycoplasma IST kit (bioMérieux), for the detection of Mycoplasma hominis and Ureaplasma urealyticum. There was good agreement between the two systems for detection of the genital mycoplasmas in terms of sensitivity, with values of > 92% being obtained. In terms of specificity, the mutual comparisons were less favorable, though specificity values of > 72% were obtained. Statistically there was no significant difference in the performance of the two tests (P < 0.1 for both M. hominis and U. urealyticum). While the broth-agar culture system was considerably less expensive than the kit, the Mycoplasma IST kit provided additional information on antibiotic susceptibilities and had the advantages of a shelf life of up to 12 months and not requiring the preparation of culture media. The prevalences of colonization obtained for M. hominis and U. urealyticum were extremely high in this randomly selected group of women from periurban and rural settlements in the Eastern Highlands of Papua New Guinea, being > or = 70% for M. hominis and > or = 78% for U. urealyticum. colonization with both genital mycoplasmas simultaneously was also very common, with > or = 60% of women being colonized by both M. hominis and U. urealyticum.

The prevalence of Serpulina pilosicoli in humans and domestic animals in the Eastern Highlands of Papua New Guinea.

In a survey of five villages in the Eastern Highlands of Papua New Guinea, Serpulina pilosicoli was isolated from rectal swabs from 113 of 496 individuals (22.8%). Colonization rates ranged from 22.6-30.1% in four of the villages but was only 8.6% in the other village. In comparison colonization was demonstrated in only 5 of 54 indigenous people (9.3%) and none of 76 non-indigenous people living in an urban environment in the same region. Colonization did not relate to reported occurrence of diarrhoea, age, sex, or length of time resident in a village. A second set of 94 faecal specimens was collected from 1 village 6 weeks after the first set. S. pilosicoli was isolated from 27 of 29 individuals (93.1%) who were positive on the first sampling and from 7 of 65 individuals (10.8%) who previously were negative. In this case, isolates were significantly more common in watery stools than in normal stools. The annual incidence of infection in the village was calculated as 93.6%, with an average duration of infection of 117 days. S. pilosicoli could not be isolated from any village pig (n = 126) despite its confirmed presence in 17 of 50 commercial pigs (34.0%) sampled at a local piggery. Four of 76 village dogs (5.3%) and 1 of 2 village ducks were colonized with S. pilosicoli, suggesting the possibility of cross transmission between humans and animals.

High prevalence of trichomonal vaginitis and chlamydial cervicitis among a rural population in the highlands of Papua New Guinea.

We conducted a community-based study of the prevalence of sexually transmitted diseases in rural and periurban communities in Eastern Highlands Province. We interviewed a stratified random sample of women and men, examined the women for evidence of sexually transmitted diseases (STDs) and collected specimens for diagnosis of syphilis, by serology and dark-field microscopy, gonorrhoea, by Gram stain and culture, chlamydial infection, by polymerase chain reaction (PCR) and direct immunofluorescence (DIF), trichomoniasis, by wet mount, and bacterial vaginosis, by wet mount and Gram stain. The men were tested for chlamydial infection only (first void urine tested by PCR and DIF). 201 women and 169 men were tested. Additionally, adults in the same communities who had not been randomly selected were offered the same services. An extra 243 women and 85 men were tested in this way. The laboratory results confirmed the clinical impression of an extremely high prevalence of STDs in this population. Among those randomly selected, 46% of the women had trichomonal vaginal infections and 26% had Chlamydia trachomatis infections detected by PCR, while 25% of the men had chlamydial infections. Other infections were much less common. 58% had one or more STDs. The prevalence of infection in self-selected adults was similar to that found in those randomly selected.

Ethnographic results of a community STD study in the Eastern Highlands Province.

This paper reports on women's understanding of diseases believed to be sexually transmitted in the Asaro Valley of the Eastern Highlands Province. Sexually transmitted diseases (STDs) seemed to be a new category of disease as there were no local language terms for them. Women did not associate STDs with infertility. Although some symptoms were recognized and known to be sexually transmitted, STDs sometimes went untreated for years. STDs were thought of as milder than AIDS because they could be treated. Those informants who had good knowledge of AIDS claimed to have known an AIDS patient. It was interesting that those who knew an AIDS patient reported a change in sexual behaviour among people who saw the deteriorating state of their relative who was dying of AIDS.

PIP: Women's perception of STDs in the Asaro Valley of the Eastern Highlands Province of Papua New Guinea was studied along with the local language terms for reproductive tract infections. Considering that there are no known specific local language terms for diseases that are sexually transmitted, women tend to view STDs as a new category of disease. The study emphasizes the women's understanding of the risk factors, as well as signs and symptoms, causes and measures taken, behavior towards treatment, and suggestions concerning treatment and protection. Interviews were conducted with 30 women aged 17-50 years. 14 of those participated in the clinical side of a community- based STD study, while the rest provided information independently. Particular emphasis was given to sources of information on STDs, understanding of risk factors, signs and symptoms, causes and measures taken, attitude towards treatment, and suggestions for treatment and protection. Since the local language does not have a term to refer to any diseases thought to be passed on through sexual intercourse, three terms were used: "sik nogut" (bad sickness), gonorrhea, and syphilis; additionally, signs and symptoms were described rather than named. It was found that rumors and educated relatives were the primary sources of information about "sik nogut." One of the major findings was that women did not link infertility with STDs, even if symptoms were felt in and around the reproductive tract. The paper concludes that sexual intercourse, as identified by women, is the dominant mode of disease transmission in the Valley. Condoms are becoming acceptable but are not used because of their unavailability. An interesting finding in this study is the reported change in sexual behavior among people who have seen their relatives die of AIDS.

Knowledge about sexually transmitted diseases in rural and periurban communities of the Asaro Valley of Eastern Highlands Province: the health education component of an STD study.

Community health education played a major role in a study of sexually transmitted diseases (STDs) and other reproductive tract infections which we conducted in rural and periurban communities of the Asaro Valley near Goroka in the Eastern Highlands Province of Papua New Guinea. We found that most women had little knowledge about STDs, which they often did not realize were sexually transmitted. Even major signs and symptoms were thought to be normal and many women had not sought treatment until irreversible damage was done. Knowledge of the complications of STDs, such as infertility and stillbirth, was also slight in these women. It is apparent that there is a desperate need for more reproductive health education at the community level. In developing our health education methods, we found that simple line drawings of male and female reproductive organs and of people with different signs of STDs proved useful. These were quick and easy to produce from readily available materials. It was important to separate men and women into different groups with educators of the same sex, and to create a very informal atmosphere, encouraging free-ranging discussion. Following health education and sensitive interviewing, almost all the women selected for the community-based study of the prevalence of reproductive tract infections consented to vaginal examination, even if they were asymptomatic. Additionally, many nonselected women requested examination.

PIP: This paper discusses the health education program carried out in the rural and periurban communities of the Asaro Valley in Papua, New Guinea, where knowledge of STDs is low and risky sexual behaviors are extremely common. The educational program seeks to ensure that the participants understand the reasons for the study and to raise their awareness of the transmission, treatment, and prevention of STDs. All members of the village were encouraged to participate in the educational workshop, which included lectures, group discussions, one-on-one health education, demonstrations, and interviews. After training workshops, practice sessions were also organized to assess the effectiveness of the different teaching methods and visual aids used. It was found that simple line drawings of male and female reproductive organs and of people with different signs of various STDs were useful. It was necessary to divide men and women into two groups with educators of the same sex, which created a more relaxed and free-flowing discussion. Considering that a majority of the women had no experience in using condoms, a demonstration of their use and how to put them on using bananas as models was performed. The questions asked by the women during discussions and private interviews proved that their level of biomedical knowledge about STDs and reproductive health was low, as was their knowledge of the anatomy and physiology of the reproductive system. A high frequency of risky behaviors was also observed, including involvement with multiple sexual partners, commonly in men and young women, with condoms virtually never used. Apparently there is a need for widespread community-based sexual and reproductive health education that is responsive to the needs of people living in rural areas.

Issues in the management of sexually transmitted diseases in Papua New Guinea.

This paper outlines three important issues in the clinical management of sexually transmitted diseases (STDs) in Papua New Guinea which have, until now, gone unrecognized or been neglected. Suggestions for possible solutions are made. The high prevalence of both chlamydial and trichomonal infections in women cannot be ignored. Both of these infections have been shown to increase the transmission of HIV. The current algorithm for the treatment of vaginal discharges does not include treatment for trichomonal infection in the first instance, yet trichomoniasis has been shown to be the most common STD in community studies both here and elsewhere. Trichomoniasis is usually asymptomatic in men, but still increases the risk of HIV transmission; furthermore, it causes illness in their female partners and thus needs to be treated. The current recommended regimens for the treatment of gonococcal and chlamydial infection are complex due to the number of drugs recommended for gonorrhoea to combat the problem of drug resistance, and the length of therapy for chlamydia. Compliance with such a regimen is likely to be poor, particularly in asymptomatic partners. We need to consider the relative advantages provided by a drug which could be given as a single oral dose for chlamydia, and perhaps for both infections. Azithromycin is one possibility, as it has been shown to be effective for chlamydial infection in numerous studies, and has been found satisfactory for gonorrhoea where local isolates were susceptible. Testing of a small number of isolates from Papua New Guinea has shown that azithromycin may be suitable for use here, but further susceptibility testing needs to be performed. Utilization of services for STDs, particularly by women, is extremely low. This is due to a combination of factors involving limited knowledge of symptomatology and its significance, the asymptomatic nature of many infections, the structure of the services, health worker behaviour, and social attitudes. To address these issues we must make modifications to STD service provision, as well as provide widespread information about the potentially serious consequences of contracting STDs, including both infertility and AIDS. Possible modifications to the services are discussed, and include making routine screening available for women through currently existing services such as family planning and antenatal clinics and considering the possibility of establishing Women's Health Clinics which would provide all primary reproductive health services in an integrated manner.

PIP: This paper summarizes three relevant issues in the clinical management of STDs in Papua New Guinea which have gone unrecognized or been neglected until now. First, the issue of chlamydial and trichomonal infections, which have been shown to increase HIV transmission, is discussed. Although trichomonal infections generally display less pathology than chlamydial infections, they are nonetheless a serious problem. Both types of infections are also more prevalent in Asaro Valley as compared with gonorrhoea and syphilis. The second discussion focuses on the treatment regimen for gonococcal and chlamydial infections. The current treatment, which involves the intake of different tablets and extends for a week, seems to be unappealing and unrealistic for most patients. Thus, a more cost-effective drug has been introduced: azithromycin, which has been proven effective against chlamydial infection and has also been found satisfactory for gonorrhea treatment where local isolates were susceptible. The final topic is that of the barriers to the use of STD treatment services. This study revealed that the low utilization of these services, particularly by women, is due to 1) the limited knowledge of symptomatology and its significance, 2) to the asymptomatic nature of some infections, 3) to factors concerning the structure of services, 4) to health worker behavior, and 5) to social attitudes. Additionally, potential modifications to the existing services are discussed, including the possibility of establishing women's health clinics, which would provide all primary reproductive health services in an integrated manner.

Molecular analysis of isolates of Salmonella typhi obtained from patients with fatal and nonfatal typhoid fever.

Molecular characterization of a total of 52 human isolates of Salmonella typhi from Papua New Guinea was performed by using pulsed-field gel electrophoresis (PFGE) after digestion of chromosomal DNA with three restriction endonucleases, XbaI (5'-TCTAGA-3'), AvrII (5'-CCTAGG-3'), and SpeI (5'-ACTAGT-3'). Of the 52 isolates tested, 11 were obtained from patients with fatal typhoid fever and 41 were obtained from patients with nonfatal disease. The 52 isolates showed limited genetic diversity as evidenced by only three different PFGE patterns detected following digestion with XbaI (patterns X1 to X3; F [coefficient of similarity] = 0.86 to 1.0), four patterns detected following digestion with AvrII (patterns A1 to A4; F =0.78 to 1.0), and two patterns detected following digestion with SpeI (patterns S1 and S2; F = 0.97 to 1.0). Of the 52 isolates, 37 were phage typed, and all belonged to phage type D2. All 11 isolates obtained from patients with fatal typhoid fever were identical (F = 1.0) and possessed the PFGE pattern combination X1S1A1, whereas the 41 isolates from patients with nonfatal typhoid fever had various PFGE pattern combinations, the most common being X2S1A2 (39%), X1S1A1 (24%), and X1S1A2 (15%). Thus, all the isolates from patients with the fatal disease had the X1 and A1 patterns, whereas the majority of the isolates from patients with nonfatal typhoid fever possessed the X2 and A2 patterns. The data suggest that there is an association among strains of S. typhi between genotype, as assessed by PFGE patterns, and the capability to cause fatal illness. Analysis of blood and fecal isolates of S. typhi from the same patient also indicated that some genetic changes occur in vivo during the course of infection.

The new problem of typhoid fever in Papua New Guinea: how do we deal with it?

This paper reviews some of the issues relating to typhoid fever in Papua New Guinea. Before the mid-1980s only sporadic cases of typhoid were reported but it is now one of the greatest public health problems in the highlands and some urban areas. In one study near Goroka an annual incidence rate of 1208 per 100,000 people was found, with settlers from other areas at greater risk than the local landowners. Problems relating to management included differentiation from other diseases, the limitations of the Widal test and poor compliance among outpatients. In Papua New Guinea it appears that transmission is largely from person to person, with little evidence for water-borne transmission. The prolonged convalescent excretion of Salmonella typhi and the difficulties this poses for control of the disease are discussed. Prevention will only be achieved in the long term by improvements in hygiene and sanitation, though more immediate control could be achieved by vaccination with an appropriate vaccine.

PIP: Few cases of typhoid fever were reported in Papua New Guinea (PNG) before 1960 and only sporadic cases were reported during the 1960s. However, typhoid fever has now become a major public health problem in the country, endemic throughout the Highlands Region and in some of the larger coastal towns such as Port Moresby. In 1993 and 1994, there were 4485 and 4551 people, respectively, reported to have been admitted with typhoid fever throughout PNG, with 87% and 73% of these cases, respectively, occurring in the Highlands Region. The vast majority of the remainder of patients were in the National Capital District, Central, or Morobe Provinces. No data are available on the number of outpatient cases. The transmission of typhoid fever in PNG appears to be mainly from person to person, with little evidence of water-borne transmission. Problems posed by the prolonged convalescent excretion of Salmonella typhi are discussed. Typhoid fever will be prevented over the long term by improvements in hygiene and sanitation, although more immediate control could be achieved through vaccination with an appropriate vaccine.

Re-evaluation of the Widal agglutination test in response to the changing pattern of typhoid fever in the highlands of Papua New Guinea.

In 1992 it was decided to re-evaluate the Widal slide agglutination test as a rapid diagnostic test for typhoid fever in Papua New Guinea. This was in response to an apparent increase in the number of false positive Widal slide agglutinations occurring using an O cut-off titre greater than or equal to 40 which was previously shown to be appropriate in 1987. The results of the re-evaluation indicated that the Widal test using a diagnostic cut-off titre of > or = 40 lacked specificity and was no longer appropriate for this population. A new O antibody titre of > or = 160 was recommended as a diagnostic titre for typhoid fever in PNG. The fall in the specificity of the Widal slide agglutination test over the five-year period between the initial assessment and the re-evaluation is due to an increase in general population antibody levels caused by the changing pattern of typhoid in the community. Before 1987 typhoid fever occurred as sporadic, isolated outbreaks and most people living in the highlands of PNG were immunologically naive. By 1992 typhoid fever had become a well-established endemic disease and many more people had been exposed to Salmonella typhi and as a result developed antibodies. We have been able to demonstrate clearly a remarkable change in the immune status of the community, in which the proportion of healthy individuals with a Widal tube O agglutination titre of 40 or more rose from 0 to 56% in the short span of five years.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of the Gulf War on infant and child mortality in Iraq.

BACKGROUND: Increased malnutrition and morbidity among Iraqi children after the onset of the Persian Gulf war have been reported by several fact-finding missions. The magnitude of the effect of the war and the economic embargo on child mortality remains uncertain, however. METHODS: We conducted a survey of 271 clusters of 25 to 30 households each, chosen as a representative sample of the Iraqi population. The households were selected and the interviews conducted by an international team of public health professionals independent of Iraqi authorities. In each household all women 15 to 49 years of age were interviewed, and the dates of birth and death of all children born on or after January 1, 1985, were recorded. RESULTS: The study population included 16,076 children, 768 of whom died during the period surveyed (January 1, 1985, to August 31, 1991). The age-adjusted relative mortality for the period after the war began, as compared with the period before the war, was 3.2 (95 percent confidence interval, 2.8 to 3.7). No material change in the relative risk was observed after adjustment for region of residence, maternal education, and maternal age. The increase in mortality after the onset of the war was higher among children 1 to less than 12 months old (relative risk, 4.1; 95 percent confidence interval, 3.3 to 5.2) and among those 12 to less than 60 months old (relative risk, 3.8; 95 percent confidence interval, 2.6 to 5.4) than among those less than 1 month old (relative risk, 1.8; 95 percent confidence interval, 1.4 to 2.4). The association between the war and mortality was stronger in northern Iraq (relative risk, 5.3) and southern Iraq (relative risk, 3.4) than in the central areas (relative risk, 1.9) or in Baghdad (relative risk, 1.7). CONCLUSIONS: These results provide strong evidence that the Gulf war and trade sanctions caused a threefold increase in mortality among Iraqi children under five years of age. We estimate that more than 46,900 children died between January and August 1991.

Ventilatory standards for clinically well aboriginal adults.

OBJECTIVE: To obtain reference standards for ventilatory function of clinically well Australian Aboriginal adults. DESIGN: A cross-sectional assessment of the population of a North Queensland Aboriginal community. SETTING: A specialist clinical and public health service. The measurements were made with the cooperation of the local primary health care centre. PARTICIPANTS: The 288 study subjects included over 70% of Aboriginal adults residing in an isolated Cape York community. Those with known respiratory disease, abnormal chest x-ray findings, positive loose cough sign, abnormal lung signs or inability to perform the ventilatory tests satisfactorily were excluded; 229 persons (80%) remained for analysis. Smoking was prevalent in both men (85%) and women (76%). As in most other studies producing reference values for lung function, smokers were not excluded. MAIN OUTCOME MEASURES: Age, standing height in bare feet and sitting height were recorded. Ventilatory measurements included forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and maximum mid-expiratory flow (MMEF) which is also known as the forced expiratory flow (FEF 25%-75%). RESULTS: Standing height, age and sex were the major determinants of ventilatory function. Sitting height was not a good predictor. Ventilatory values differed significantly from those expected for Europeans: Aboriginal lung volumes were much smaller (by about 25%) and fell much faster with age. The age-related decrease in lung function was less in smokers. CONCLUSION: The smoking effect may reflect the operation of differential survival or other selective factors and has been noted in some other ethnic groups. Although previous studies have yielded some ventilatory function data on Aborigines, we report the first population-based reference values expected for clinically well adults. The information will be useful to clinicians and public health workers.