Evaluation of the Nottingham birth scoring system.

A case-control study of postneonatal deaths occurring in 1974-1976 in the City of Nottingham, England, revealed that most were attributable to respiratory infections and SIDS, and primarily occurred in wintertime, at home, in the less well-off parts of Nottingham. By means of a step-wise discriminant analysis, 9% of the infant population was identified as a high-risk group in whom 53% of postneonatal deaths could be expected to occur. From January 1, 1978, this group of infants was followed up more intensively by health visitors and general practitioners, who gave advice on the early recognition of respiratory symptoms. Although the postneonatal mortality rate fell from 6.5 per 1,000 live births in 1977 to 5.2 per 1,000 in 1983, it is not possible to show that the rate of improvement was any faster after the introduction of the system. The system was discontinued on March 31, 1985. Birth scoring systems are not recommended; instead, resources should be concentrated on general improvements in services and symptom recognition, and basic research into the causes of SIDS.

Management of hypertension in patients developing end-stage renal failure.

The benefits of treating hypertension include preventing or delaying the progression of chronic renal failure, and reducing the cardiovascular complications of patients with renal disease. We examined how well hypertension had been managed in all 145 patients from a single health district who started dialysis during a 3-year period. Data relating to management of hypertension, including all blood pressure readings, were obtained from their general practice and hospital case notes. The anonymized data were reviewed by two independent assessors against a set of standards based on the British Hypertension Society guidelines. There was close agreement between the assessors. Complete records were obtained in 98.5% of cases. Of the 145 patients, 107 (76.4%) were hypertensive before developing end-stage renal failure. There were departures from standards in all categories of care: 24.3% in detection/diagnosis, 29% in investigation, 22.4% in referring to a nephrologist, and 17% in follow-up. The British Hypertension Society recommended standard for diastolic blood pressure of 90 mmHg was achieved in only 45%. In 32%, the assessors independently concluded that poor blood pressure control might have affected adversely the progression of renal failure. New methods of dealing with these problems are required and possible approaches are discussed.

Antenatal care in Maputo, Mozambique.

Mozambique, within its plan for overall social and economic change, has given priority to primary health care with a principal focus on maternal and child health. In 1980 an antenatal control form was introduced into all Maputo's antenatal clinics to monitor pregnancies and to help direct specialist care to mothers at greatest risk--a strategy known by WHO as the "risk approach." In this study three health centres were selected from contrasting areas of the city. Almost 1000 completed antenatal forms were analysed to determine incidence of risk and to evaluate the implementation of this strategy. It was found that: (1) a considerable number of women at risk were identified, referred, and successfully monitored through their pregnancy. (2) Of those women at risk who were identified by the health centres, fewer than half were actually referred for specialist care. (3) Those women at greatest risk were not the highest users of the services, and many of them underused the services compared with those at lower risk. (4) The level of risk and child mortality varied with a measure of urban quality of the areas in which the centres were located.

Unemployment and health: the quality of social support among residents in the Trent region of England.

OBJECTIVE: To examine the quality of social support among unemployed residents in Trent, England. DESIGN: Secondary analysis of data generated by those of working age drawn from a postal lifestyle survey of the adult population of Trent region. SUBJECTS AND SETTING: Subjects were 6987 individuals (males 16-64 years and females 16-59 years of age), of whom 9.9% (689/6987) were unemployed. MAIN OUTCOME MEASURES: Responses about the quality of social support obtained from three key questions. RESULTS: Generally, the unemployed reported poorer quality of social support than employed persons (p < 0.0001) on all three key elements examined: 31% v 17% respectively had no practical support; 19% v 10% had no help with solving problems, and 21% v 10% had no emotional support. Only 57% of the unemployed had all three of these elements compared with 75% of the employed. Unemployment and lack of social support had independent and deleterious effects on perceptions of general health and mental health. Relationships remained after allowing for the possible confounding effects of age, gender, and household composition. CONCLUSIONS: There is a relationship between unemployment and poorer quality of social support which may help to explain some of the increased morbidity and mortality experienced by this group, especially that related to mental health.

Stress, social support, and stopping smoking after myocardial infarction in England.

STUDY OBJECTIVE: To examine the effect on mortality of stopping smoking after myocardial infarction and the psychosocial factors that influence the decision to stop. DESIGN: Analysis of smokers in a large prospective study. Self completed questionnaires provided information on psychosocial factors. SETTING: Coronary care units at six English hospitals participating in a multicentre clinical trial. SUBJECTS: These comprised consenting myocardial infarction survivors who had been identified as smokers and who completed questionnaires within seven days of infarct at six hospitals participating in the Anglo-Scandinavian study of early thrombolysis. The 532 patients identified have been followed for over five and a half years. The main outcome measure was five year all cause mortality. MAIN RESULTS: Smokers who stopped within one month showed significantly reduced mortality compared with those who persisted, adjusting for other prognostic indicators (odds ratio 0.56, 95% confidence interval 0.33, 0.98). Overall, 74% stopped smoking. Being married, low life stress levels before infarct, and higher social class were associated with stopping smoking but the differentials were small. Of the clinical variables, a final diagnosis of definite myocardial infarction was associated with stopping smoking. All associations remained after multiple logistic regression. CONCLUSION: Smoking cessation can halve the smokers' odds of dying after myocardial infarction and psychosocial factors play a small but important role in the important decision to stop smoking. Health professionals should continue to stress the importance of stopping smoking to all patients as there is little evidence to support specific directing of advice to relatively "stress or "socially isolated" groups.

Research in epidemiology and community health in the medical curriculum: students' opinions of the Nottingham experience.

Medical students in Nottingham all complete an honours Bachelor of Medical Sciences course in one department including a research project. The honours programme in community health is described, with results from a survey of the 122 graduates since the medical school started. The 98 (80%) responses showed high levels of satisfaction and gain from the programme, the great majority regarding the course as valuable, enjoyable, and giving both research skills and skills in interpersonal relationships.

Changing patterns in neonatal respiratory diseases.

Using the current Nottingham Health District, England, as a geographically defined population we have investigated the changing patterns of neonatal respiratory diseases. We have categorized all newborns who developed a respiratory problem during either 1977 or between April 1, 1983, and March 31, 1984 using a system based on that of Hjalmarson (Acta Paediatr Scand 1981; 70:773-783). There has been no change in the incidence of any of the disease types. However, the gestation of babies in two groups, idiopathic respiratory distress syndrome (IRDS) and minimal respiratory disturbance (requiring added oxygen for less than 6 hours), has shown a significant reduction. Overall, mortality for infants developing IRDS has shown a slight decrease, and for infants between 29 and 32 weeks gestation, mortality has shown a significant reduction. Overall, requirements for oxygen therapy and ventilation have shown a threefold increase, while hours in receipt of continuous positive airways pressure (CPAP) have increased sevenfold.

Primary health care in practice: a study in Mozambique.

This study investigates the delivery of all aspects of Primary Health Care (PHC) in a case study of one urban health centre in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to primary health care as the driving force in its newly developed National Health Service. The urban and rural health centres are intended to be the principal vehicles for PHC delivery, and in this study one of Maputo's recently opened health centres was investigated by observing all clinic sessions, interviewing all health centre workers and collecting data from health centre records. It was found that a dichotomy exists between the tasks ascribed to the health centre in the PHC framework, and the feasibility of their execution given existing personnel and material resources. This derives in part from lack of involvement of PHC practitioners in the organisation and planning of PHC, plus resource allocation which remains in favour of secondary and tertiary rather than primary care. Prevention is accorded priority in PHC theory, yet investigation showed that the major demand on the health centre is for curative care. The quality of both curative and preventive care was evaluated and the need for training in specialist diagnostic skills, and a more socially-based understanding of the determinants of health status and risk emerged, respectively for the groups of workers in the two sectors. The level of contact between the curative and preventive sectors was investigated as was the integration of the health centre into the health service as a whole. The problems arising in these areas must be viewed in the context of the very recent development of a National Health Service in a country where, previously, curative care was available only in urban areas and virtually no preventive programmes existed. This study shows that significant steps are being taken to develop a comprehensive PHC programme in Maputo. More important still will be the extension of this level of care provision to the country as a whole.

Research in an antenatal clinic--the experience of the Nottingham Mothers' Stop Smoking Project.

The Nottingham Mothers' Stop Smoking Project was extremely successful in helping women to stop smoking during pregnancy and in reinforcing non-smoking behaviour. This paper describes the experience of undertaking the action research project in the antenatal clinic from the points of view of the researchers, women and midwifery staff. The article outlines the practical problems encountered in attempting to adhere to a research protocol. The implementation of the project involving friendly encouragement, a carbon monoxide monitor and the offer of self-help groups is described within the context of the busy antenatal clinic setting. Pregnant women's experience of the project and the views of midwifery staff are also presented. The feasibility of incorporating such projects into everyday activity is discussed.

Changing carriage rate of Neisseria meningitidis among university students during the first week of term: cross sectional study.

OBJECTIVE: To determine the rates of, and risk factors for, meningococcal carriage and acquisition among university students. DESIGN: Repeated cross sectional study. PARTICIPANTS: 2,507 students in their first year at university. MAIN OUTCOME MEASURES: Prevalence of carriage of meningococci and risk factors for carriage and acquisition of meningococci. RESULTS: Carriage rates for meningoccoci increased rapidly in the first week of term from 6.9% on day 1, to 11.2% on day 2, to 19.0% on day 3, and to 23.1% on day 4. The average carriage rate during the first week of term in October among students living in catered halls was 13.9%. By November this had risen to 31.0% and in December it had reached 34. 2%. Independent associations for acquisition of meningococci in the autumn term were frequency of visits to a hall bar (5-7 visits: odds ratio 2.7, 95% confidence interval 1.5 to 4.8), active smoking (1.6, 1.0 to 2.6), being male (1.6, 1.2 to 2.2), visits to night clubs (1. 3, 1.0 to 1.6), and intimate kissing (1.4, 1.0 to 1.8). Lower rates of acquisition were found in female only halls (0.5, 0.3 to 0.9). The most commonly acquired meningococcal strain was C2a P1.5 (P1.2), which has been implicated in clusters of invasive meningococcal disease at other UK universities. CONCLUSIONS: Carriage rates of meningococci among university students increase rapidly in the first week of term, with further increases during the term. The rapid rate of acquisition may explain the increased risk of invasive meningococcal disease and the timing of cases and outbreaks in university students.

Do cadet force units need a dedicated medical pack?

There are over 38,000 army cadets in the United Kingdom of whom about 20,000 attend a two week annual camp each summer. In response to criticisms from the medical staff attached to cadet units about the suitability of the routinely issued medical pack, a national questionnaire survey of all serving Army Cadet Force medical personnel has been performed, along with an analysis of patient attendances at annual camp between 1989 and 1992 in one East Midlands County Force. In particular the appropriateness of the Medical Treatment Pack Training Camp Large as currently issued to cadet units has been examined. The findings suggest that, on its own, the pack is unsuitable to treat about 40% of cadets who attend for medical treatment during annual camp; medical staff on average rate its suitability for cadets as very low. Moreover, there is objective evidence that most cadet units need to obtain extra medical supplies, particularly bronchodilators, modern antibiotics and modern dressings; many do so via private purchases from civilian sources. The study highlights a situation in urgent need of review.

Doctors' attitudes to information systems: a survey of Derbyshire general practitioners.

This paper describes the results of a survey of all 365 general practitioners in Derbyshire. It deals in particular with their attitudes to information systems and the factors which affect them. The results show that there is much more interest in continuous data collection from primary care than is often supposed. This is particularly so among younger general practitioners. The survey thus describes the possible interest in information recording amongst a typical population of general practitioners.

Preventive health care for mothers and children. A study in Mozambique.

This study seeks to evaluate the delivery of preventive mother and child health services in Maputo, Mozambique. Mozambique has given priority to primary health care in the development of its new National Health Service, with a principal focus on maternal and child health (MCH). Three health centres were selected, from areas of contrasting urban ecology. Prenatal and under-fives' clinics were observed at each health centre. It was found that at a technical level the preventive services were operating efficiently, with a coverage of over two-thirds of the target population. However, frequency of attendance at both clinics was much lower in the poorer areas of the city. Additionally, it was observed that women and children identified as having a high risk status were rarely given more care and support. Nurses and midwives, frequently adopted an attitude more punitive than supportive to those most at risk. Notwithstanding these shortcomings, it is clear that significant advances in preventive MCH care are being achieved in a country where 6 years previously the only available health services were curative, and confined to the better-off urban districts.

PIP: This study sought to evaluate the delivery of preventive maternal and child health services (MCH) in Maputo, Mozambique. Mozambique has given priority to primary health care in the development of its new National Health Service, with a principal focus on MCH. 3 health centers were selected, from areas of contrasting urban ecology. Prenatal and under-5s clinics were observed at health care center. It was found that at a technical level, the preventive services were operating efficiently, with a coverage of over 2/3 of the target population. However, frequency of attendance at both clinics was much lower in the poorer areas of the city. Additionally, it was observed that women and children identified as having a high risk status were rarely given more care and support. Nurses and midwives, frequently adopted an attitude more punitive than supportive to those most at risk. Notwithstanding these shortcomings, it is clear that significant advances in preventive MCH care are being achieved ina country where only 6 years previously, the only available health service were curatuve, and confined to the more affluent urban districts.

The use of routine referral data in the development of clinical audit and management in North Lincolnshire.

As part of the national waiting list initiative, a retrospective survey of routine referrals in seven specialties to Lincoln County Hospital by general practitioners within its catchment area, during the months of January to March 1987 inclusive, was carried out, using data from the hospital's Patient Administration System and the Lincolnshire Family Practitioner Committee. These specialties were identified by managers and clinicians as those in which a significant problem of waiting times and waiting lists existed, both as perceived locally and in comparison with other districts. The total referral rate for all GPs in the study was 9.6 referrals/100 patients on their list/year, which is very close to the average of other studies published elsewhere in the country on this topic. However, the range of referral rates between practices was very wide, varying from 2.8 to 17.6. There were also wide variations within individual practices. It is therefore concluded that, taken overall, 'over-referral' by general practitioners is not the cause of any problem at Lincoln County Hospital. However, the wide variation of referral patterns has been of great interest to the general practitioners themselves. They have requested that referral rates be fed back to them routinely, in the manner of the Prescription Pricing Authority, and this will commence shortly. In addition, a working group of orthopaedic surgeons and general practitioner representatives has met to discuss the implications of the study, and the drawing up of mutually agreed referral protocols, the operation of which would be monitored jointly. The setting up of similar groups in the other specialties is under active consideration.

Prevention of postneonatal mortality.

Studies of postneonatal mortality in Nottingham between 1974 and 1977 showed a familiar pattern of high death rates in socially deprived parts of the city. A birth scoring system was devised, which identified at birth 9% of infants in whom 53% of postneonatal deaths could be expected to occur From 1 January 1978 this group was identified by midwives and followed up intensively by health visitors. The postneonatal mortality in the city of Nottingham fell from 8.7/1000 live births in 1974 to 3.6/1000 in 1981. It was not possible, however, to show that the rate of improvement after the introduction of the birth scoring system was greater than the trend present before its introduction. The causes of postneonatal death, and their geographical and seasonal distribution, were similar in 1978-81 and 1974-77, despite an absolute fall in numbers. By 1981 the important risk factors were either recorded on the birth notification or known to the health visitor in any case. Although nurse managers and most health visitors have found the scheme useful in other respects--for example, resource allocation--it was considered that these could be achieved without a formal scoring system. Therefore, the birth scoring system was stopped at the end of March 1985. Health visitors are still being encouraged to pay more attention to high risk cases as a part of normal clinical practice.

Information leaflets in the dermatology out-patient waiting area.

Patients' attitudes to the supply and quality of information provided about their condition were examined by questionnaire before (n = 852) and after exposure to an information leaflet campaign (n = 560) in the dermatology out-patient waiting area. A high expectation of this service was demonstrated, particularly from patients under 60 years of age with chronic diseases. A variety of information sources, other than doctors, were identified which could be improved (video-systems, specialist nurses, leaflets, posters). The campaign significantly increased the percentage of patients who derived information from the leaflet source (5.6-18.8%, P < 0.001) and it reduced a demand for leaflets (16.4-9.1%, P < 0.001). However, the campaign did not alter patients' perceived need to spend more time with a dermatologist. In order to achieve a greater impact on patient satisfaction, a combination of information sources in the out-patient department should be targeted at young adults with chronic diseases.

The uptake of preventive and curative child health services in Maputo, Mozambique.

This study seeks to analyse the uptake of preventive and curative child health services in three health centres in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to Primary Health Care as the driving force of its newly developed National Health Service, with a principal focus on maternal and child health. Three health centres were selected from areas of contrasting environmental quality. Data were collected from over 6000 women attending the curative and preventive child health services at these centres. It was found that the women using curative services had significantly higher child mortality rates, had lived less time in Maputo City and had children of lower weight status than their counterparts attending for preventive care. Additionally, levels of child mortality were found to increase as environmental quality decreased. It is argued that the lower users of preventive care are, as in the U.K., precisely those who appear to have an increased risk of mortality and morbidity. It is concluded that integration between the curative and preventive health services must be increased in order to overcome the user inertia which militates against the poorer population using the facilities for prevention to the best advantage. This would fit in both with national strategies (1) and WHO recommendations (2-4) in the field of primary health care.

Improved primary care does not prevent the admission of children to hospital.

In Nottingham Health District a study has been carried out whose aims were: (1) to compare acute paediatric medical admissions in 1985 with those in 1975 and to relate any differences to changes in services; (2) to measure the numbers of preventable admissions, working on the hypothesis that this would give an indication of the performance of community services. A structured questionnaire was completed with parents, and information obtained from notes of all children admitted with acute medical problems during October 1985. Results were compared with a similar study undertaken in 1975 by Wynne and Hull1 on children from the same catchment area. Further information for all health districts in Trent Region was obtained from Hospital Activity Analysis data relating to these 10 years. There has been a 100% increase in children's admissions in Nottingham, with similar increases throughout Trent Region. Apart from ingestions, there are increases in every diagnostic category, with a 6-fold increase in the admission rate for lower respiratory tract problems, mostly asthma and wheeze. Only 9% were classified as 'social admissions'. The idea of certain admissions being preventable is not a useful concept. Improvements in primary care have not been accompanied by a fall in hospital admissions.

Postneonatal mortality in the Nottingham Health District 1985-1988.

Studies carried out in 1978 and 1981 found postneonatal mortality to be associated with poor environmental conditions. Since then, many changes have occurred to the environment. This study was designed to discover which factors are now associated with a higher risk of postneonatal death. A retrospective case-control study was carried out using 107 cases and 422 controls matched only for date of birth, to look at the effect of area of residence, social class, mother's age, and sex, birthweight, legitimacy and number of siblings. Fifty-eight per cent of the deaths were due to the sudden infant death syndrome, making this the leading cause of death. Causes previously absent from the death certificates are now appearing, particularly prematurity related deaths which now account for almost 6 per cent. The deaths were found to occur more frequently at home, in the winter, and at a peak age of 2 to 4 months. As shown previously in Nottingham, the deaths were more likely to have been male (relative risk 2.03), illegitimate (2.91), and of low birthweight (28.8). Total mortality was significantly higher in babies of mothers aged 19 or less and in babies of manual workers. Surprisingly, babies born to unemployed parents were found to have a very low relative risk of death (0.26). Mortality is still higher in the city than the suburbs and in areas of deprivation. Although still a risk factor for SIDS, high parity of the mother was found to be non-significant for postneonatal mortality in total.(ABSTRACT TRUNCATED AT 250 WORDS)