How to handle genetic information: a comparison of attitudes among patients and the general population.

BACKGROUND: So far there are no studies comparing the attitudes of patients with hereditary conditions to the attitudes of the general public on how to handle genetic risk information which mutation carriers refuse to disclose to relevant family members. The purpose of the present study was to investigate whether such patients and members of the general public want to be informed about the existence of hereditary conditions within their family, and under which conditions they want healthcare providers to breach confidentiality. METHODS: It was hypothesized that the desire to be informed would be influenced by characteristics of both the disease and the individual. Systematically varying 3 disease characteristics (fatality, penetrance and treatment availability) yielded 8 versions of a questionnaire, which was administered to general population samples in Norway and Sweden (N = 3,207) and to patient samples in both countries (N = 822). Individual differences in uncertainty avoidance, coping style and consideration for future consequences were also assessed. RESULTS AND CONCLUSION: A majority of both patients and the general public want to be informed about the existence of hereditary conditions within their family. However, patients are more positive towards being informed, both with and without the relative's consent, than the general public. The main predictor of the desire to be informed was uncertainty avoidance in both samples.

Reproductive factors and pancreatic cancer risk: a Norwegian cohort study.

A cohort of 63,090 Norwegian women born 1886-1928 was followed more than 38 years, and relations between reproductive factors and risk of pancreatic cancer were explored; 449 cases were recorded at ages 50-89 years. Age at menopause showed a moderately positive association with risk (rate ratio (RR)=1.08 per 2 years delay in menopause; 95% confidence interval (CI)=1.00-1.17). Neither parity nor duration of breastfeeding showed significant associations with risk after adjusting only for demographic factors. With mutual adjustment, however, parity became positively associated (RR=1.13 per delivery; 95% CI=1.05-1.22) while duration of breastfeeding was inversely associated (RR=0.87 per 12 months; 95% CI=0.78-0.97). These associations lessened in magnitude with increasing age, and were essentially absent above age 80 years. Risk was raised among women reporting at least one abortion, but no trend was seen with number of abortions. Together with previous studies, the findings raise questions about the role of chance, but do not exclude hormonal factors related to breastfeeding and pregnancy from affecting pancreatic cancer risk.

Twin births, sex of children and maternal risk of ovarian cancer: a cohort study in Norway.

In a follow-up of 1,208,001 women aged 20-74 years, no significant association was found between twin births (112 cases) and risk, though those with twin girls had a non-significantly higher risk than those with singleton births; among the latter, those with girls only had a higher risk of endometrioid tumours (incidence rate ratio 1.35; 95% confidence interval 1.03-1.76, based on 475 cases) than women with boys only.

Effect of recall on estimation of non-fatal injury rates: a community based study in Tanzania.

STUDY OBJECTIVE: To investigate the effect of recall on estimation of non-fatal injury rates in Tanzania. DESIGN: Retrospective population based survey. SETTING: Eight branches in an urban area and six villages in a relatively prosperous rural area in Tanzania. SUBJECTS: Individuals of all ages living in households selected by cluster sampling. MAIN OUTCOME MEASURES: Estimated non-fatal injury rates calculated at each of the 12 recall periods (one to 12 months before the interview). RESULTS: Out of a population of 15 223 persons, 509 individuals reported 516 injuries during the preceding year. Of these 313 (61.5%) were males and 196 (38.5%) females. The data showed notable declining incidence rates from 72 per 1000 person-years when based on a one month recall period to 32.7 per 1000 person-years for a 12 month recall period (55% decline). The decline was found for injuries resulting in fewer than 30 days of disability whereas rates for severe injuries (disability of 30 days or more) did not show a consistent variation with recall period. Decline in injury rates by recall period was higher in rural than in urban areas. Age, sex, and education did not notably affect recall. CONCLUSIONS: Longer recall periods underestimate injury rates compared with shorter recall periods. For severe injuries, a recall period of up to 12 months does not affect the rate estimates. It is essential that a recall period of less than three months be used to calculate injury rates for less severe injuries.

Breast cancer risk by age at birth, time since birth and time intervals between births: exploring interaction effects.

In a Norwegian, prospective study we investigated breast cancer risk in relation to age at, and time since, childbirth, and whether the timing of births modified the risk pattern after delivery. A total of 23,890 women of parity 5 or less were diagnosed with breast cancer during follow-up of 1.7 million women at ages 20-74 years. Results, based on Poisson regression analyses of person-years at risk, showed long-term protective effects of the first, as well as subsequent, pregnancies and that these were preceded by a short-term increase in risk. The magnitude and timing of this adverse effect differed somewhat by birth order, maternal age at delivery and birth spacing. No transient increase in risk was seen shortly after a first birth below age 25 years, but an early first birth did not prevent a transient increase in risk after subsequent births. In general, the magnitude of the adverse effect was strongest after pregnancies at age 30 years or older. A wide birth interval was also related to a more pronounced adverse effect. Increasing maternal age at the first and second childbirth was associated with an increase in risk in the long run, whereas no such long-term effect was seen with age at higher order births.

Behavioral treatment of insomnia in older adults: an open clinical trial comparing two interventions.

Fifty-five insomniacs, 60 years or above, participated in a behavioral treatment program, comparing two interventions (sleep hygiene+stimulus control vs sleep hygiene+relaxation tape). Half of the subjects were randomized to a waiting-list condition prior to treatment. No significant changes were observed during the waiting-list period. During the treatment period however, the subjects improved on several sleep parameters, and treatment gains were maintained at a 6-month follow-up. The effects of treatment were greater for nocturnal measures (e.g. sleep onset latency and total sleep time) as compared to daytime measures (e.g. life satisfaction, daytime alertness) and not-targeted behavior (medication use). There were no differences in treatment effects for the two interventions.

A videotaped intervention to enhance child control and reduce anxiety of the pain of dental injections.

AIM: While the psychological literature shows that perceptions of uncontrollability contribute to anxiety and other pathologies, interventions that enhance perceived control have been shown to reduce anxiety. This study attempted to assess a brief videotape to enhance child perceived control in a dental setting. METHODS: 101 children aged 7-9 years completed warm-up procedures and viewed either: a) the experimental intervention, a 2 minutes video of a dentist explaining what an injection will feel like and proposing hand raising as a signal mechanism; or b) the control condition, a 2 minutes video of Disneyland. Fear of dental injections was assessed on a 10 cm visual analogue scale before and after the intervention. RESULTS: In the experimental group there was a significant fear reduction from pre- to post-intervention, while this was not the case in the control group. Children with higher pre-existing levels of fear benefited more from the intervention than children with lower levels of fear. CONCLUSION: The results of this pilot study suggest that intervention packages that impact child control have promise in lowering anxiety.

An intervention program to reduce dental avoidance behaviour among adolescents: a pilot study.

AIM: To develop and test the methodology of an intervention to reduce avoidance of dental care among adolescents, and to measure the respondents' beliefs regarding the intervention (credibility and cognitions). METHODS: Based on a group comparison design a sample of 18 year olds (n=50) with dental non-attendance behaviour was randomly selected to three experimental and one control group. Subjects were surveyed with one baseline questionnaire and one post-intervention questionnaire, to evaluate their beliefs regarding the program. Two different instruments were tested: 1) cards representing different statements related to previous dental experiences, possible reasons for attending (pros) and not attending (cons) dental appointments, and preferences for future treatment. Cards were selected based on individual priority; 2) a brief, structured telephone interview based on Motivational Interviewing. The instruments were tested separately (groups I and II) and in combination (group III). Subjects in the control group (group IV) were given conventional health education. RESULTS: Subjects in the experimental groups had significantly higher credibility scores to the statement "How much easier do you perceive dental treatment to be for you, based on this program", compared with the control group (p<0.05). They had also more positive beliefs to the statement "I think the interviewer liked to talk to me" (p<0.05) than controls. CONCLUSION: A questionnaire sent to non-attending adolescents followed by a brief telephone call based on Motivational Interviewing appears to be a credible intervention for adolescents avoiding dental care.

Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections.

OBJECTIVE: We studied the association between anemia in pregnancy and characteristics related to nutrition and infections. DESIGN: Cross-sectional study. SETTING: Four antenatal clinics in rural northern Tanzania. SUBJECTS/METHODS: A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70 g/l (n=10), Hb=70-89 g/l (n=61), Hb=90-109 g/l (n=86), Hb=110-149 g/l (n=105) and Hb> or =150 g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite. MAIN OUTCOME MEASURES: Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90 g/l. RESULTS: Anemia (Hb<90 g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25 cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90-109 g/l) were similar, but weaker. CONCLUSIONS: Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics. SPONSORSHIP: The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.

Relationship between caries prevalence at 5 years of age and dental anxiety at 10.

AIM: The aim of this study was to explore a possible relationship between the individual prevalence of caries in 5-year-old children and dental anxiety in the same children when they became 10 years of age. MATERIALS AND METHODS: A group of 217 children was examined clinically and radiographically for caries at 5 years of age when initial, as well as manifest caries lesions, were recorded. A total of 180 children were available for follow-up at 10 years of age, and dental anxiety was measured by the use of the psychometric questionnaire CFSS-DS. RESULTS: The mean dmfs at 5 years of age was 5.4 (SD+/-7.3) and the mean CFSS-DS at 10 years of age 22.5 (SD+/-6.8). The correlation coefficient between dmfs and CFSS-DS was 0.255 (p < 0.001). Children with high dental anxiety (CFSS-DS sum score higher than one SD above the mean) (N = 22) had a mean dmfs of 10.7, while those with lower dental anxiety had dmfs of 4.7 (p < 0.001). The majority (68%) of the children with high dental anxiety had more than five carious lesions at 5 years of age. CONCLUSION: Children with many carious lesions at the age of 5 years are at high risk for being dentally anxious at 10 years of age. Classical conditioning, including procedural pain and other negative experiences during dental treatment as the unconditioned stimuli, is the most likely reason for this.

Prevalence of insomnia in the adult Norwegian population.

A representative adult sample (18 years and above) of the Norwegian population, comprising 2001 subjects, participated in telephone interviews, focusing on the one-month point prevalence of insomnia and use of prescribed hypnotics. Employment of DSM-IV inclusion criteria of insomnia yielded a prevalence rate of 11.7%. Logistic regression analysis performed on the different insomnia symptoms revealed that somatic and psychiatric health were the strongest predictors of insomnia, whereas gender, age, and socioeconomic status showed a more inconsistent relationship. Use of prescribed hypnotic drugs was reported by 6.9% and was related to being female, elderly, and having somatic and emotional problems. Sleep onset problems and daytime impairment were more common during winter compared to summer. Use of hypnotics was more common in the southern (rather than the northern) regions of Norway. For sleep onset problems a Season x Region interaction was found, indicating that the prevalence of sleep onset problems increased in southern Norway from summer to winter, while the opposite pattern was found in the northern regions. The importance of clinically adequate criteria and seasonal variation in the evaluation of insomnia is briefly discussed.

Homocysteine and methylmalonic acid levels in pregnant Nepali women. Should cobalamin supplementation be considered?

OBJECTIVE: The aim of this study was to investigate homocysteine and methylmalonic acid levels as markers of functional cobalamin and folate status in pregnant Nepali women. DESIGN: Cross-sectional study. SETTING: Patan Hospital, Kathmandu, Nepal. SUBJECTS: A sub-sample (n=382) of all pregnant women (n=2856) coming for their first antenatal visit in a 12 month period, 1994-1995. The selection of the sub-sample was based on maternal haematocrit values, categorised into three groups: severely, moderately and non-anaemic women. As serum levels of total homocysteine (s-tHcy) and methylmalonic acid (s-MMA) were similar in the three groups, pooled data are presented. Women who had already received micronutrient supplementation (n=54) were excluded. The remaining women (n=328) were included in the statistical analysis. RESULTS: Overall mean values (+/-s.d.) of s-tHcy and s-MMA were 9.5 (+/-4.2) micromol/l and 0.39 (+/-0.32) micromol/l, respectively. Elevated s-tHcy (>7.5 micromol/l) was found in 68% of the women, while 61% had elevated s-MMA (>0.26 micromol/l). Low s-cobalamin values (<150 pmol/l) were observed in 49% of the women, while only 7% had low s-folate values (< or =4.5 nmol/l). s-tHcy was significantly correlated with s-MMA (r=0.28, P<0.001), s-cobalamin (r=-0.30, P<0.001) and s-folate (r=-0.24, P<0.001). s-MMA was significantly associated with s-cobalamin (r=-0.40, P<0.001), but not with s-folate. CONCLUSIONS: Functional cobalamin deficiency was very common in the study population, while functional folate deficiency was rather uncommon. We suggest considering cobalamin supplementation to pregnant Nepali women. SPONSORSHIP: The Norwegian Research Council and the Norwegian Universities Committee for Development, Research and Education.

Maternal hematological status and risk of low birth weight and preterm delivery in Nepal.

BACKGROUND: Our aim was to investigate associations between maternal characteristics, with emphasis on hematological status, and risk of low birth weight and preterm delivery among pregnant Nepali women. METHODS: In a case-control study, 1400 pregnant women attending Patan Hospital, Kathmandu, Nepal for antenatal care and delivery in the period 1994 to 1996 were included. Women with twin pregnancies (n=15) and those delivering infants with congenital malformations (n=13) were excluded from the study. Maternal characteristics including hematocrit values were recorded at the first antenatal visit. Main outcome measures included birth weight, gestation at delivery, Apgar score, mode of delivery, and perinatal death. Linear and logistic regression models were used to analyze data. RESULTS: Severe anemia (hematocrit < or =24%) was associated with a significantly increased risk of low birth weight (<2500 g) and preterm delivery (<37 weeks gestation). High hematocrit values (> or =40%) did not increase the risk of low birth weight or preterm delivery. The risk of low Apgar score or operative deliveries was significantly increased in women with severe anemia in the first trimester. Teenagers, women with short height or low body mass index, and those belonging to the ethnic group Brahmins, had significantly higher risks of delivering low birth weight infants. CONCLUSIONS: Severe maternal anemia, particularly in the first trimester, was significantly associated with adverse pregnancy outcome. Low maternal age, height or body mass index also increased the risk of low birth weight. Improvements in the nutritional status of young Nepali women could contribute to improved health among their infants.

Use of health services and reported satisfaction among primary school adolescents in Arusha, Tanzania.

PURPOSE: To describe Tanzanian adolescents' utilization of health services, their satisfaction with the health services, and determinants of their satisfaction with these services. METHODS: A questionnaire was administered to 1279 seventh-grade school pupils, measuring use of health services in the past 2 years, reasons for seeking health services, and satisfaction with the health services provided during the last visit. Descriptive statistics were calculated on health service utilization and satisfaction variables, and univariate and multiple logistic regression analyses were performed to assess the factors associated with reported satisfaction with the health services. RESULTS: Seventy-five percent of the respondents reported using modern health services only, 1.2% used traditional services only, and 10% had used both during the past 2 years. Fever was the most common reason for seeking modern health services, followed by injury. The vast majority of the respondents reported being satisfied with the services provided during the last visit. Age was the only factor significantly associated with being very satisfied with traditional health services, whereas type of health facility and discussion of the issues of sexually transmitted diseases and AIDS were significantly associated with being very satisfied with modern health services during the last visit. CONCLUSION: Urban primary school adolescents report using modern health services, and the majority are satisfied with the services.

Anemia in pregnancy in the highlands of Tanzania.

BACKGROUND: Anemia in pregnancy is common in Tanzania, but many areas have not been investigated. This study describes prevalence and determinants of anemia among rural pregnant women living at 1300-2200 meters above sea level in Northern Tanzania. METHODS: Three thousand eight hundred and thirty-six pregnant women from two rural divisions of Mbulu and Hanang districts attending antenatal clinic between January 1995 and March 1996 were assessed in a cross-sectional study. Blood samples were examined for hemoglobin concentration (Hb) and thick blood slide (BS) for malaria. Information on date of examination, village, age, ethnic and religious affiliation, gestational age, and parity was recorded. Altitude was derived from official maps. Main outcome measures were mean Hb level and risk of anemia defined as a Hb of less than 9.0 g/dl. RESULTS: Hb levels ranged from 4.5 to 18.1 g/dl, and mean was 12.1 g/dl. Twenty-three per cent had a Hb of less than 11 g/dl, 4.6% less than 9 g/dl and 0.5% less than 7 g/dl; standardized to sea level 36.1%, 8.8%, and 1.1%, respectively. The mean Hb increased by 0.3 g/dl per 200 m increased altitude, and the risk of anemia decreased with a factor of 0.6 per 200 m increased altitude. We found higher risk of anemia at higher maternal age (1.2 times increased risk per 5 years). Furthermore, the Datoga tribe had twice the risk of anemia compared with the Iraqw. The risk of anemia was only half at 3-4 months of gestation compared to at 7-8 months. The risk increased six-fold in the rainy season of 1995, and the risk was almost double among those with malaria parasitemia. CONCLUSIONS: Anemia in pregnancy was common in this area of high altitude in rural Tanzania, but less prevalent than indicated by studies from most other parts of the country. The study confirms that preventing anemia is a challenge in preventive antenatal care in the highlands of Tanzania. Studies focussing on the specific etiologic agents are needed.

Health services utilisation among secondary school students in Arusha region, Tanzania.

OBJECTIVE: To investigate patterns and determinants of health services utilisation by secondary school students. DESIGN: A cross-sectional survey. SETTING: Twelve secondary schools located within seven districts of Arusha region Tanzania. PARTICIPANTS: Three thousand six hundred and three students proportionately selected from the twelve schools according to enrolment size. MAIN OUTCOME MEASURES: Self-reported use of modern and traditional health services within the past two years. RESULTS: The majority (77%) of the students used only modern health services while very few (1.3%) used only traditional services. Fever was the main reason for seeking health care during the last visit. Respondents who used traditional services expressed lower level of satisfaction with the services than those who used modern services. Living situation and socio-economic status of respondent's family predicted utilisation of modern health services whereas self-rated health status and perception that poverty was a threat against one's health predicted utilisation of traditional health services. CONCLUSIONS: Since most of secondary school students use modern health services, improvement of the modern health system is likely to benefit this population. Further work is needed to elucidate factors that facilitate or impede use of health services by young people in Tanzania.

The Maudsley Obsessional-Compulsive Inventory and OCD in a Norwegian nonclinical sample.

The 30 item Maudsley Obsessional-Compulsive Inventory (MOCI) was given to 294 under graduate students. The inventory achieved an acceptable internal consistence, but somewhat low reliability. There were no sex difference in total MOCI score, or in any of the subscales. 31% of the variance seemed to be explained by item 18: "attending too much to details", and more than 65% of the variance is explained by the checking subscale. The data give some interesting indications of the prevalence of OCD in the population.

Menstrual and reproductive factors and risk of gastric cancer: a Norwegian cohort study.

OBJECTIVE: To explore relations between menstrual and reproductive factors and incidence of gastric cancer in a cohort study of 63,090 Norwegian women, followed over a period of 29 years. METHODS: Associations with potential risk factors were evaluated by Poisson regression analysis, considering 572 cases of gastric cancer diagnosed in women aged less than 80 years. RESULTS: Age at menarche showed a moderate inverse association with overall risk of gastric cancer (incidence rate ratio 0.93 per year; 95% confidence interval 0.88-1.00). No association could be established with age at menopause. Among women aged less than 50 years, an old age at first delivery was related to an increased risk, mainly of cancer of the distal part of the stomach. In multiparous women aged 50 years or more, relations with childbearing history differed significantly between subsites. Women with many pregnancies over a short period of time had an increased risk of cancer of the proximal part of the stomach. In the distal part, pregnancies over a long period seemed to confer a higher risk. CONCLUSIONS: Relations between reproductive factors and risk of gastric cancer should be assessed separately for pre- and postmenopausal women and for subsites.