Finding a 'safe' place on the risk continuum: a case study of pregnancy and birthing in Lao PDR (Lao People's Democratic Republic)

This paper addresses two questions. Firstly: are the risk regimes faced, and perceived, by pregnant women in rural Lao PDR substantially different from those experienced by pregnant women in western societies? Secondly, if the Lao experiences and perceptions are different, can improvements in maternal health in Lao PDR be achieved without Laotians inheriting the risk regimes of late modernity experienced by many women in western societies? Secondary analysis is undertaken of data collected in 2005 for the evaluation of a pilot maternity waiting home in Bolikhan, Lao PDR. The results suggest significantly different risk perceptions and experiences between Lao and western communities, based on contrasting views of embodiment, identity construction and cosmologies. In the Lao rural communities studied, there is little evidence yet of 'risk society' despite the introduction of western technologies and practices to improve maternal mortality and morbidity. It is argued that 'risk society' can be avoided.

In the shadow of the volcanoes: the impact of intervention on the nutrition and health status of Rwandan refugee children in Zaire two years from the exodus

Objective: To evaluate the public health and nutritional situation of refugee children in Katale camp, Eastern Zaire, after two years of nutritional and health intervention from 1994 to 1996.
Design: Cross-sectional survey using a two-stage cluster sampling method. Anthropometric data were collected from 28 May 1996 to 4 June 1996. Retrospective review of food basket monitoring data over the preceding six months and the United Nations High Commission for Refugees' weekly mortality data was conducted. Measles immunisation coverage data were surveyed simultaneously, using child health records.
Main outcome measures: Nutritional status measured by weight-for-height index (W/H), measles immunisation status, average daily energy content of the general food ration and crude mortality rate.
Setting: Katale refugee camp, Zaire, June 1996.
Analysis: Weight-for-height index and proportion of immunised children were computed using EPINUT, part of EPINFO computer package.
Results: Malnutrition was found to be most prevalent in children aged six to 29 months old (W/H < -2 Z-score and/or oedema: 6.2%; 95% CI: 3.4%, 10.6%), among whom the malnutrition rate was almost double the overall malnutrition prevalence (W/H < -2 Z-score and/or oedema: 3.5% (95% CI: 1.5%, 7.2%). The general food ration, although conforming to the World Food Program minimum standards of adequacy in terms of variety (being composed of cereals, oil, beans, blended cereal and legume mixes and salt), provided only 6240 kJ on average (95% CI: 5040, 7140 kJ) per person per day, thus meeting only 57% to 84% of the minimum energy requirements for an adult, and falling well below the needs for sub groups with higher nutritional requirements such as children, pregnant and breastfeeding women and the sick. Measles immunisation coverage in children nine to 59 months was 88.6%. The crude mortality rate was found to be 0.3 per 10 000 per day. Refugees received 15 litres of clean water per person per day.
Conclusion: Public health interventions in Katale camp 1994 to 1996 had reduced mortality and morbidity rates dramatically. This was not reflected in the malnutrition rates for children under five years, that remained stable after an initial fall despite two years of nutritional intervention. The factors contributed to this were related to an inadequate general food ration (due to food shortages), lack of ability to supplement the diet, (due to economic restrictions that were imposed in the camp) and inequities in the food distribution process (due to food being siphoned off by camp leaders for military purposes).

Workforce trends in specialist and GP obstetric practice in Victoria

OBJECTIVE: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria.

DESIGN, PARTICIPANTS AND SETTING: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003.

MAIN OUTCOME MEASURES: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria.

RESULTS: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50-60-years age group, but cessation of obstetric practice occurred across all age groups.

CONCLUSION: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40-50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40-50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.

Gender and health promotion: A multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male–female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

Motorcycle ownership and injury in China

Background. China has made tremendous progress in its economic development in the past two decades. Accompanying this economic development has been an evident shift in the modes of transport, from walking and cycling to the use of motorcycles and, increasingly, four-wheel vehicles. Such changes are likely to have also produced changes in the patterns and numbers of road traffic injuries, including increases in motorcycle injuries. However, such changes have not been well documented. The work described in this paper sought, therefore, to document the changes in motorcycle ownership, motorcyclist mortality and injury rates in China since 1987.
Methods. National traffic ownership and injury data from 1987 to 2001 were obtained from the National Bureau for Traffic Administration. Additionally, traffic ownership and injury records from 1997 to 2001 were collected from local police offices from 20 counties in Guangxi Region. Population data were obtained from the national and county statistics bureaus. Motorcycle ownership, fatality and injury trends over time were calculated.
Results. Nationally, motorcycles accounted for 23.4% of all registered motor vehicles in 1987, increasing to 63.2% in 2001. Motorcyclist fatalities and injuries increased 5.5-fold and 9.3-fold, respectively, between 1987 and 2001. In 1987, 7.5% of all traffic fatalities and 8.8% of all traffic injuries were sustained by motorcyclists, with the corresponding proportions increasing to 18.9% and 22.8%, respectively, in 2001. The changing proportions of both traffic fatalities and injuries sustained by motorcyclists were positively correlated with the change in the proportion of motorcycles among all motor vehicles. In the 20 counties in Guangxi, motorcyclist fatality and injury rates also increased between 1997 and 2001. Moreover, these rates were considerably higher than the national rates.
Conclusions. Motorcyclist injury in China is a serious public health problem. Motorcyclist fatalities and injuries are likely to continue to increase unless appropriate intervention programmes are implemented.

An evidence-based approach to podiatry workforce enhancement and service provision in Western Victoria

Aims & rationale/Objectives : The objectives of this workforce and service enhancement project include: (i) establishing the magnitude of podiatry needs; and (ii) developing a model that can be used to enhance podiatry workforce and podiatry services.
Methods : Surveys to podiatrists and health agencies to determine vacancies, waiting lists, work practices and recruitment methods. Desktop analysis of predictive data for burden of disease and population changes per local government area (LGA). Meetings with podiatrists and their professional association, health care agencies, universities, and Local and State Governments.
Principal findings : Results showed
Long podiatry waiting lists (up to 12 months)
Podiatry vacancies and service gaps
Absence of qualified foot assistants
A high chronic disease burden
A population age mix that is predicted to change dramatically over the next 25 years in favour of those who are 60 years of age or older
Ineffective recruitment methods
The workforce enhancement model that emanated from the meetings with the steering group includes podiatrists as well as auxiliaries such as foot-care assistants who work together in an interprofessional model of care that expands across the region. In addition to training foot-care assistants and the development of a podiatry teaching clinic to enhance student placement, the model builds onto a current continuous professional development program for allied health professionals.
Discussion : Although the allied health workforce (including podiatry) is playing an increasingly important role in the prevention and treatment of chronic diseases, rural areas in particular are disadvantaged by recruitment and retention problems. The podiatry workforce shortage is compounded by ageing populations. Age is associated with increased podiatry usage due to chronic diseases such as diabetes, cardiovascular disease and osteoarthritis.
Implications : A strategic plan developed in consultation with stakeholders aims to improve rural podiatry services in a sustainable manner. The project will be implemented when adequate funding is allocated this year and will be evaluated on its impact on services.
Presentation type : Paper

Evidence based drug therapy : are optimal doses and multiple medication therapies realistic in patients with chronic heart failure

Background: Chronic Heart Failure (CHF) has a high mortality and morbidity. Large scale randomised controlled trials have proven the benefits of beta blockade and ACE inhibitors in reducing mortality in patients with CHF and expert guidelines mandate their use. In spite of these recommendations, important therapies are under-prescribed and under-utilised.

Method: 1015 consecutive patients enrolled in CHF management programs across Australia were surveyed during 2005-2006 to determine prescribing patterns in heart failure medications. These patients were followed-up for a period of 6 months.

Results: The survey revealed that beta blockers were prescribed to 80% of patients (more than 85% were on sub-optimal doses) and 70% were prescribed Angiotensin converting enzyme (ACE) inhibitors (approximately 50% were on sub-optimal dose). 19% of patients were prescribed Angiotensin receptor blockers (ARBs). By 6 months <25% of the patients who were on sub-optimal dose beta blockers or ACE inhibitors at baseline, had been up-titrated to maximum dose (p<0.0001). In CHF programs, were nurses were able to titrate medications, 75% of patients reached optimal dose of beta blockers compared to those programs with no nurse-led medication titration, where only 25% of patients reached optimal dose (p<0.004). When examining optimal dosage for any two of these mandatory medications, less patients were on optimal therapy. Beta blockers and ACE inhibitors, were both prescribed in combination in 60% of patients. While beta blockers and ARBs were prescribed to 15% of patients.

Conclusion: Whilst prescribing rates for a single medication strategy of beta blockers, or ACE inhibitors were greater than 70%, an increase in dosage of these medications and utilisation of proven combination therapy of these medications was poor. It is suggested that clinical outcomes for this cohort of patients could be further improved by adherence to evidence-based practice, ESC guidelines, and optimisation of these medications by heart failure nurses in a CHF program. On the basis of these findings and in the absence of ready access to a polypill, focussing on evidence-based practice to increase utilisation and optimal dosage of combination medication therapy is critical.

Historical dynamics of the fur seal population : evidence of regulation by man?

The Australian fur seal (Arctocephalus pusillus doriferus) was severely over-exploited in the 18th and 19th centuries and until relatively recently its population had remained steady at well below estimated presealing levels. However, the population is now increasing rapidly (6%–20% per annum) throughout its range and there is a need to understand its dynamics in order to assess the potential extent and impact of interactions with fisheries. Age distribution (n = 156) and pregnancy rate (n = 110) were determined for adult females collected at a breeding colony on Seal Rocks, southeast Australia, in 1971–1972. Mean ± SE and maximum observed ages were 9.37 ± 0.41 and 20 years (n = 1), respectively. A stochastic modelling approach was used to fit an age distribution to the observed age-structure data and calculate rates of recruitment and adult survival. Annual adult female survival and recruitment rates between 1954 and 1971 were 0.478 ± 0.029 (mean ± SE) and 0.121 ± 0.007, respectively, suggesting that the population was experiencing a decline during the 1960s. The pregnancy rate increased from 78% at 3 years of age to an average of 85% between 4–13 years of age before significantly decreasing in older females (the oldest was 19 years of age). There was no significant effect of body mass or condition on the probability of a female being pregnant (P > 0.5 in both cases) and the nutritional burden of lactation did not appear to affect pregnancy rates or gestational performance. These findings suggest that the low survivorship was due to density-independent effects such as mortality resulting from interactions with fishers, which are known to have been common at the time. The recent increase in the population is consistent with anecdotal evidence that such interactions have decreased as fishing practices have changed.

Substance use and its implications for the critical care nurses: a literature review

Background
Illicit drug use in Australia has been increasing and studies indicate that illicit drug users have a higher risk of accidents which may result in the user needing critical care. However, there is a significant gap in the literature specifically pertaining to the implications of drug use in critical care.

Aims
The primary objective was to examine the literature for the physiological effects of methylenedioxymethamphetamine (MDMA), cocaine and amphetamines in critically ill patients.

Methods
A comprehensive literature review was undertaken and a body systems framework was used to categorise the effects of these illicit drugs.

Results
The illicit substances addressed have potentially fatal and long-term side effects. For those users involved in accidents or trauma requiring intensive or critical care nursing, the mortality and co-morbidity risks are increased significantly. It is, therefore, important that nurses are able to recognise the specific physiological effects and possible complications that can occur with the use of each illicit drug.

Conclusion
Both nursing and medical staff need to have a thorough understanding of how illicit substances work and how they can affect the critical care patient and the care they are given.

Determinants of female fertility in Taiwan, 1966–2001 : empirical evidence from cointegration and variance decomposition analysis

This study investigates the determinants of the fertility rate in Taiwan over the period 1966–2001. Consistent with theory, the key explanatory variables in Taiwan's fertility model are real income, infant mortality rate, female education and female labor force participation rate. The test for cointegration is based on the recently developed bounds testing procedure while the long-run and short-run elasticities are based on the autoregressive distributed lag model. Among our key results, female education and female labor force participation rate are found to be the key determinants of fertility in Taiwan in the long run. The variance decom-position analysis indicates that in the long run approximately 45percent of the variation in fertility is explained by the combined impact of female labor force participation, mortality and income, implying that socioeconomic development played an important role in the fertility transition in Taiwan. This result is consistent with the traditional structural hypothesis.

The burden of overweight and obesity-related ill health in the UK

This paper reviews previous cost studies of overweight and obesity in the UK. It proposes a method for estimating the economic and health costs of overweight and obesity in the UK which could also be used in other countries. Costs of obesity studies were identified via a systematic search of electronic databases. Information from the WHO Burden of Disease Project was used to calculate the mortality and morbidity cost of overweight and obesity. Population attributable fractions for diseases attributable to overweight and obesity were applied to National Health Service (NHS) cost data to estimate direct financial costs. We estimate the direct cost of overweight and obesity to the NHS at £3.2 billion. Other estimates of the cost of obesity range between £480 million in 1998 and £1.1 billion in 2004 [Correction added after online publication 11 June 2007: 'of the cost of obesity' added after 'Other estimates']. There is wide variation in methods and estimates for the cost of overweight and obesity to the health systems of developed countries. The method presented here could be used to calculate the costs of overweight and obesity in other countries. Public health initiatives are required to address the increasing prevalence of overweight and obesity and reduce associated healthcare costs.

Assessing the burden of overweight and obesity : an example from the United Kingdom

Introduction: In this paper I review previous cost studies for overweight and obesity in the UK. I propose a method for estimating the economic and health costs of overweight and obesity in the UK which could also be used in other countries.

Methods: Costs of obesity studies were identified via a systematic search of electronic databases. Information from the WHO Burden of Disease Project was used to calculate the mortality and morbidity cost of overweight and obesity.
Population attributable fractions for diseases attributable
to overweight and obesity were applied to National Health Service (NHS) cost data to estimate direct financial costs.

Results: We estimate the direct cost of overweight and obesity to the NHS at £3.2 billion. Other estimates range between £480 million in 1998 and £1.1 billion in 2004. There is wide variation in methods and estimates for the cost of overweight and obesity to the health systems of developed countries.

Conclusion: The method presented here could be used to calculate the costs of overweight and obesity in other countries. Public health initiatives are required to address the increasing prevalence of overweight and obesity and reduce associated healthcare costs.

Other communities : Box mistletoe (Amyema miquelii) parasitism is not detrimental to the health of grey box (Eucalyptus microcarpa) trees at a regional scale

Mistletoes are hemiparasites that occur worldwide in many types of forest, woodland and shrubland ecosystems (Watson 2001). Some species are regarded as pests due to their detrimental effects on host species (Hawksworth 1983; Reid & Yan 2000). Heavy infestations can affect the growth, productivity and form of host trees, and may cause host death (Reid et al. 1994; Shaw et al.2004, 2008). In south-eastern Australia, mistletoes often are visibly obvious in trees along roadsides, in paddocks and on the margins of open forests; and concerns have been expressed about their potentially detrimental effects on host trees.Despite this, little quantitative information is available on the effects of mistletoes on tree health and mortality (Reid et al. 1994). Are detrimental effects widespread or localized? A first step is to assess whether trees parasitized by mistletoe are less healthy than those without such parasites. Here, we investigate the relationship between parasitism by Box Mistletoe (Amyema miquelii (Lehm. ex Miq.) Tiegh.), a common species in south-eastern Australia, and the health of trees of a widespread host species, Grey Box (Eucalyptus microcarpa (Maiden) Maiden), across a large geographic region.

Diabetes service provision : a qualitative study of the experiences and views of Pakistani and Indian patients with Type 2 diabetes

Aims To explore Pakistani and Indian patients' experiences of, and views about, diabetes services in order to inform the development of culturally sensitive services.

Design Qualitative, interview study involving 23 Pakistani and nine Indian patients with Type 2 diabetes recruited from general practices and the local community in Edinburgh, Scotland. Data collection and analysis occurred concurrently and recruitment continued until no new themes emerged from the interviews.

Results Respondents expressed gratitude for the availability of free diabetes services in Britain, as they were used to having to pay to access health care on the Indian subcontinent. Most looked to services for the prompt detection and treatment of complications, rather than the provision of advice about managing their condition. As respondents attached importance to receiving physical examinations, they could be disappointed when these were not offered by health-care professionals. They disliked relying on interpreters and identified a need for bilingual professionals with whom they could discuss their diabetes care directly.

Conclusions Gratitude for free services in Britain may instil a sense of indebtedness which makes it difficult for Pakistanis and Indians to be critical of their diabetes care. Health-care professionals may need to describe their roles carefully, and explain how different diabetes services fit together, to avoid Pakistani and Indian patients perceiving treatment as unsatisfactory. Whilst linkworker schemes may meet patients' need to receive culturally sensitive information in their first language, work is needed to assess their effectiveness and sustainability.

Within-population variation in ejaculate characteristics in a prolonged breeder, Peron's tree frog, Litoria peronii

Sperm number is often a good predictor of success in sperm competition; however, it has become increasingly clear that, for some species, variation in probability of paternity cannot be explained by sperm number alone. Intraspecific variation in ejaculate characteristics, such as the number of viable sperm and sperm longevity, may play an equally important role in determining fertilization success. Here, we assess variation among ejaculates in three factors that may contribute to fertilization success (number of sperm per ejaculate, viability, and longevity), in a population of Peron’s tree frog (Litoria peronii). We detected large variation among males in the number of sperm per ejaculate and the proportion of viable sperm within ejaculates, which could not be explained by variation in either male size or body condition. However, the proportion of viable sperm released by males increased over the season. Finally, we assessed sperm longevity (proportion viable sperm determined using a dual-fluorochrome vital dye) at two different temperatures. At 23°C, on average, 75% of sperm remained viable after 2 h, but there were significant differences amongst males with the percentage of viable sperm ranging from 43% to 95%. For sperm incubated at 4°C, ejaculates varied fivefold in sperm longevity with some males having 50% viable sperm after 5 days. Our data suggest that ejaculate characteristics (sperm number, viability, and longevity) vary widely in Peron’s tree frog and may therefore play an important role in determining siring success both in the presence and absence of sperm competition. We discuss the results in relation to selection on ejaculate traits via natural and sexual selection in this and other amphibians.