Who fails to complete tuberculosis treatment? Temporal trends and risk factors for treatment interruption in a community-based directly observed therapy programme in a rural district of South Africa

SETTING: Hlabisa Tuberculosis Programme, Hlabisa, South Africa. OBJECTIVE: To determine trends in and risk factors for interruption of tuberculosis treatment. METHODS: Data were extracted from the control programme database starting in 1991. Temporal trends in treatment interruption are described; independent risk factors for treatment interruption were determined with a multiple logistic regression model, and Kaplan-Meier survival curves for treatment interruption were constructed for patients treated in 1994-1995. RESULTS: Overall 629 of 3610 surviving patients (17%) failed to complete treatment; this proportion increased from 11% (n = 79) in 1991/1992 to 22% (n = 201) in 1996. Independent risk factors for treatment interruption were diagnosis between 1994-1996 compared with 1991-1393 (odds ratio [OR] 1.9, 95% confidence interval [CT] 1.6-2.4); human immunodeficiency virus (HIV) positivity compared with HIV negativity (OR 1.8, 95% CI 1.4-2.4); supervised by village clinic compared with community health worker (OR 1.9, 95% CI 1.4-2.6); and male versus female sex (OR 1.3, 95% CI 1.1-1.6). Few patients interrupted treatment during the first 2 weeks, and the treatment interruption rate thereafter was constant at 1% per 14 days. CONCLUSIONS: Frequency of treatment interruption from this programme has increased recently. The strongest risk factor was year of diagnosis, perhaps reflecting the impact of an increased caseload on programme performance. Ensuring adherence to therapy in communities with a high level of migration remains a challenge even within community-based directly observed therapy programmes.

Role of chemical cues from cotton in mediating host selection and oviposition behaviour in Helicoverpa armigera (Hubner) (Lepidoptera : Noctuidae)

We investigated the role of chemoreception in the host selection and oviposition behaviour of Helicoverpa armigera in the laboratory using five cotton genotypes and synthetic volatile terpenes. Female moths oviposited on substrates treated with methanol, ethanol, acetone and pentane extracts of leaves, squares and flowers of the cotton genotypes. Phytochemicals soluble in pentane were the most efficient in eliciting oviposition behaviour. In a two-way bioassay, pentane extracts of leaves or squares of a Multiple Host-plant Resistance genotype (MHR11), Deltapine commercial (DP90), and Smith Red Leaf (SRL) received significantly more eggs than solvent-treated controls. Extracts of squares of the native genotype Gossypium nelsonii did not receive more eggs. Females preferred DP90 and MHR11 to SRL and G. nelsonii. Female moths also laid more eggs on pentane extracts of MHR11 flowers than MHR11 leaves from preflowering, early flowering and peak-flowering plants. In a flight chamber, female moths used olfactory cues at short range to mediate oviposition and discrimination between host plants. Egg-laying, mated females were attracted at a distance (1.5 m) to volatile compounds released by whole plants and odours emanating from filter papers treated with synthetic volatile terpenes. Individually, the terpenes did not stimulate any significant oviposition response. However, there was a significant oviposition response to a mixture of equal volumes of the terpenes (trans-beta-caryophyllene, alpha-pinene, beta-pinene, myrcene, beta-bisabolol, and alpha-humulene). Conversely, antennectomised (moths with transected antennae), egg-laying, mated females did not stimulate any significant oviposition response. The significance of these findings in relation to H. armigera hostplant selection are discussed.

Suicide attempts by psychiatric patients in acute inpatient, long-stay inpatient and community care

Background: This study examined rates of and risk factors associated with suicide attempts by psychiatric patients under active care. It was especially focussed on the relative rates across three standard treatment settings: acute inpatient care, long-stay inpatient care and community-based carl. Methods: A total of 12,229 patients in 13,632 episodes of care were rated on the Health of the Nation Outcome Scales (HoNOS) Item 2. For the purposes of the current investigation, a score of 4 was deemed to indicate a suicide attempt. Results: Incidence densities per 1000 episode days were 5.4 (95% CI = 4.8-6.1) for patients under care in acute inpatient settings, 0.6 (95% CI = 0.5-0.8) for patients under care in long-stay inpatient settings, and 0.5 (95% CI = 0.5-0.6) for patients under carl in community-based arrangements. Predictors varied by treatment setting. Risk was elevated for personality disorders across all settings: 22.7 attempts per 1000 episode days (95% CI = 17.2-30.0) in acute inpatient care; 2.1 (95% CI = 1.0-4.5) in long-stay inpatient care; and 2.3 (95% CI = 1.7-3.0) in community-based care. This effect remained after adjustment for demographics. Conclusion: Rates of suicide attempts among psychiatric patients are a major issue facing contemporary mental health care systems, and risk factors vary across different treatment settings.

Analysis of long-term light-trap data for Helicoverpa spp. (Lepidoptera : Noctuidae) in Australia: the effect of climate and crop host plants

Regression analyses of a long series of light-trap catches at Narrabri, Australia, were used to describe the seasonal dynamics of Helicoverpa armigera (Hubner). The size of the second generation was significantly related to the size of the first generation, to winter rainfall, which had a positive effect, and to spring rainfall which had a negative effect. These variables accounted for up to 96% of the variation in size of the second generation from year to year. Rainfall and crop hosts were also important for the size of the third generation. The area and tonnage of many potential host crops were significantly correlated with winter rain. When winter rain was omitted from the analysis, the sizes of both the second and third generations could be expressed as a function of the size of the previous generation and of the areas planted to lucerne, sorghum and maize. Lucerne and maize always had positive coefficients and sorghum a negative one. We extended our analysis to catches of H. punctigera (Wallengren), which declines in abundance after the second generation. Winter rain had a positive effect on the sizes of the second and third generations, and rain in spring or early summer had a negative effect. Only the area grown to lucerne had a positive effect on abundance. Forecasts of pest levels from a few months to a few weeks in advance are discussed, along with the improved understanding of the seasonal dynamics of both species and the significance of crops in the management of insecticide resistance for H. armigera.

Community care and criminal offending in schizophrenia

Background The introduction of community care in psychiatry is widely thought to have resulted in more offending among the seriously mentally ill. This view affects public policy towards and public perceptions of such people. We investigated the association between the introduction of community care and the pattern of offending in patients with schizophrenia in Victoria, Australia. Methods We established patterns of offending from criminal records in two groups of patients with schizophrenia over their lifetime to date and in the 10 years after their first hospital admission. One group was first admitted in 1975 before major deinstitutionalisation in Victoria, the second group in 1985 when community care was becoming the norm. Each patient was matched to a control, by age, sex, and place of residence to allow for changing patterns of offending over time in the wider community. Findings Compared with controls, significantly more of those with schizophrenia were convicted at least once for ail categories of criminal offending except sexual offences (relative risk of offending in 1975=3.5 [95% CI 2.0-5.5), p=0.001, in 1985=3.0 [1.9-4.9], p=0.001). Among men, more offences were committed in the 1985 group than the 1975 group, but this was matched by a similar increase in convictions among the community controls. Those with schizophrenia who had also received treatment for substance abuse accounted for a disproportionate amount of offending. Analysis of admission data for the patients and the total population of admissions with schizophrenia showed that although there had been an increase of 74 days per annum spent in the community for each of the study population as a whole, first admissions spent only 1 more day in the community in 1985 compared with 1975. Interpretation Increased rates in criminal conviction for those with schizophrenia over the last 20 years are consistent with change in the pattern of offending in the general community. Deinstitutionalisation does not adequately explain such change. Mental-health services should aim to reduce the raised rates of criminal offending associated with schizophrenia, but turning the clock back on community care is unlikely to contribute towards any positive outcome.

Contemporary strategies for rural community development in Australia: a governmentality perspective

Contemporary strategies for rural development in Australia are based upon notions of self-help and bottom-up, community-based initiatives which are said to 'empower' the individual from the imposing structures of government intervention. While such strategies are not entirely new to Australia, they have, it seems, been inadequately theorised to date and are generally regarded, in rather functionalist terms, as indicative of attempts to cut back on public expenditure. Harnessing itself to the 'governmentality' perspective, this paper explores government and 'expert' discourses of rural community development in Queensland and suggests, instead, that these strategies are indicative of an advanced liberal form of rule which seeks to 'govern through community'. With this in mind, three basic research questions are identified as worthy of further exploration; how are the notions of self-governing individuals and communities constructed in political discourse; what political rationalities are used to justify current levels of(non) intervention and finally; what are the discourses, forms and outcomes of empowerment at the local level? The paper concludes by arguing that while the empowering effects of self-help are frequently cited as its greatest virtue, it is not so much control as the added burden of responsibility that is being devolved to local people. Given the emphasis of the governmentality perspective on strategies for 'governing at a distance', however, these conclusions can hardly be unexpected. (C) 2000 Elsevier Science Ltd, All rights reserved.

Predictors of death and vascular events in the elderly - The Perth Community Stroke Study

Background and Purpose-The goal of the present study was to identify risk factors for vascular disease in the elderly. Methods-We conducted a prospective study of control subjects from a population-based study of stroke in Perth, Western Australia, that was completed in 1989 to 1990 and used record linkage and a survey of survivors to identify deaths and nonfatal vascular events. Data validated through reference to medical records were analyzed with the use of Cox proportional hazards models. Results-Follow-up for the 931 subjects was 88% complete. By June 24, 1994, 198 (24%) of the subjects had died (96 from vascular disease), and there had been 45 nonfatal strokes or myocardial infarctions. The hazard ratio for diabetes exceeded 2.0 for all end points, whereas the consumption of meat >4 times weekly was associated with a reduction in risk of less than or equal to 30%. In most models, female sex and consumption of alcohol were associated with reduced risks, whereas previous myocardial infarction was linked to an increase in risk. Conclusions-There are only limited associations between lifestyle and major vascular illness in old age. Effective health promotion activities in early and middle life may be the key to a longer and healthier old age.

Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study

Background and Purpose-Few community-based studies have examined the long-term survival and prognostic factors for death within 5 years after an acute first-ever stroke. This study aimed to determine the absolute and relative survival and the independent baseline prognostic Factors for death over the next 5 years among all individuals and among 30-day survivors after a first-ever stroke in a population of Perth, Western Australia. Methods-Between February 1989 and August 1990, all individuals with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. Results-Three hundred seventy patients with first-ever stroke were registered, and 362 (98%) were followed up at 5 years, by which time 210 (58%) had died. In the first year after stroke the risk of death was 36.5% (95% CI, 31.5% to 41.4%), which was 10-fold (95% CI, 8.3% to 11.7%) higher than that expected among the general population of the same age and sex. The most common cause of death was the index stroke (64%). Between 1 and 5 years after stroke, the annual risk of death was approximately 10% per year, which was approximately 2-fold greater than expected, and the most common cause of death was cardiovascular disease (41%). The independent baseline factors among 30-day survivors that predicted death over 5 years were intermittent clandication (hazard ratio [WR], 1.9; 95% CI, 1.2 to 2.9), urinary incontinence (HR, 2.0; 95% CI, 1.3 to 3.0), previous transient ischemic attack (HR, 2.4; 95% CT, 1.3 to 4.1), and prestroke Barthel Index <20/20 (HR, 2.0, 95% CI, 1.3 to 3.2). Conclusions-One-year survivors of first-ever stroke continue to die over the next 4 years at a rate of approximately 10% per year, which is twice the rate expected among the general population of the same age and sex. The most common cause of death is cardiovascular disease. Long-term survival after stroke may be improved by early, active, and sustained implementation of effective strategies for preventing subsequent cardiovascular events.

Assessing perceived need for mental health care in a community survey: development of the Perceived Need for Care Questionnaire (PNCQ)

Background: The Perceived Need for Care Questionnaire (PNCQ) was designed for the Australian National Survey of Mental Health and Wellbeing. The PNCQ complemented collection of data on diagnosis and disability with the survey participants' perceptions of their needs for mental health care and the meeting of those needs. The four-stage design of the PNCQ mimics a conversational exploration of the topic of perceived needs. Five categories of perceived need are each assigned to one of four levels of perceived need (no need, unmet need, partially met need and met need). For unmet need and partially met need, information on barriers to care is collected, Methods: Inter-rater reliabilities of perceived needs assessed by the PNCQ were examined in a study of 145 anxiety clinic attenders. Construct validity of these items was tested, using a multi-trait multi-method approach and hypotheses regarding extreme groups, in a study with a sample of 51 general practice and community psychiatric service patients. Results: The instrument is brief to administer and has proved feasible for use in various settings. Inter-rater reliabilities for major categories, measured by the kappa statistic, exceeded 0.60 in most cases; for the summary category of all perceived needs, inter-rater reliability was 0.62. The multi-trait multi-method approach lent support to the construct validity of the instrument, as did findings in extreme groups. Conclusions: The PNCQ shows acceptable feasibility, reliability and validity, adding to the range of assessment tools available for epidemiological and health services research.

Personality disorders in the community: a report from the Australian national survey of mental health and wellbeing

Background: The first set of aims of the present study was to determine the prevalence of personality disorders (PDs) in a nation, and gender differences in the types and numbers of PDs endorsed. The second set of aims was to establish the relationship of PD to other, non-PD disorders, physical conditions, and disability. Method: Data were obtained from the Australian National Survey of Mental Health and Wellbeing, conducted between May and August 1997. A stratified random sample of households was generated, from which all those aged 18 or over were considered potential interviewees. There were 10,641 respondents to the survey, and this represented a response rate of 78%. Each interviewee was asked 59 questions indexing specific ICD-10 PD criteria. Results: Of the total survey sample, 704 persons had at least one PD. Using weighted replicate weights, it was estimated that approximately 6.5% of the adult population of Australia have one or more PDs (lifetime prevalence). Persons with PD were more likely to be younger, male, and not married, and to have an anxiety disorder, an affective disorder, a substance use disorder, or a physical condition. They were also more likely to have greater disability than those without PD. Conclusion: The study is the first nationwide survey of mental disorders conducted within Australia. It provides an estimate of the prevalence of the various types of PD. The survey has considerable limitations, however, and these are discussed.

Extensive chromosomal variation associated with taxon divergence and host specificity in the gall-inducing scale insect Apiomorpha munita (Schrader) (Hemiptera : Sternorrhyncha : Coccoidea : Eriococcidae)

Apiomorpha Rubsaamen (Hemiptera: Coccoidea: Eriococcidae) is one of the most chromosomally diverse of all animal genera. There is extensive karyotypic variation within many of the morphologically defined species, including A. munita (Schrader) which is here reported to have diploid chromosome counts ranging from 6 to more than 100. Each of the three morphologically defined subspecies of A. munita also displays considerable chromosomal variation: A. m. tereticornuta Gullan (2n =6, 8, 20, 22 or 24), A. m. malleensis Gullan (2n =6, 20, 22, 24 or 26), and A. m. munita (Schrader) (2n=54 or >100). Apiomorpha munita appears to occur only on eucalypts of the informal subgenus Symphyomyrtus, with each of the subspecies of A. munita restricted to discrete symphyomyrt sections. Several different karyotypic forms within each subspecies of A. munita appear to be restricted to only one or a few eucalypt species or series. The association between apparent host specificity and chromosomal rearrangements in A. munita suggests that both may be playing an active role in taxon divergence in Apiomorpha. (C) 2001 The Linnean Society of London.

General scales of community reaction to noise (dissatisfaction and perceived affectedness) are more reliable than scales of annoyance

General measures of reaction to noise, which assess the respondent's perceived affectedness or dissatisfaction, appear to be more valid and internally consistent than more narrow measures, such as specific assessment of noise annoyance. However, the test-retest reliability of general and specific measures has yet to be compared. As a part of the large-scale Sydney Airport Health Study, 97 respondents participated in the same interview twice, several weeks apart. Test-retest reliabilities were found to be significant (p