Uptake of a free coronary heart disease risk screening programme in community pharmacy: the Healthy Heart Assessment service

Introduction Health promotion (HP) aims to enhance good health while preventing ill-health at three levels of activity; primary (preventative), secondary (diagnostic) and tertiary (management).1 It can range from simple provision of health education to ongoing support, but the effectiveness of HP is ultimately dependent on its ability to influence change. HP as part of the Community Pharmacy Contract (CPC) aims to increase public knowledge and target ‘hard-to-reach’ individuals by focusing mainly on primary and tertiary HP. The CPC does not include screening programmes (secondary HP) as a service. Coronary heart disease (CHD) is a significant cause of morbidity and mortality in the UK. While there is evidence to support the effectiveness of some community pharmacy HP strategies in CHD, there is paucity of research in relation to screening services.2 Against this background, Alliance Pharmacy introduced a free CHD risk screening programme to provide tailored HP advice as part of a participant–pharmacist consultation. The aim of this study is to report on the CHD risk levels of participants and to provide a qualitative indication of consultation outcomes. Methods Case records for 12 733 people who accessed a free CHD risk screening service between August 2004 and April 2006 offered at 217 community pharmacies were obtained. The service involved initial self-completion of the Healthy Heart Assessment (HHA) form and measurement of height, weight, body mass index, blood pressure, total cholesterol and highdensity lipoprotein levels by pharmacists to calculate CHD risk.3 Action taken by pharmacists (lifestyle advice, statin recommendation or general practitioner (GP) referral) and qualitative statements of advice were recorded, and a copy provided to the participants. The service did not include follow-up of participants. All participants consented to taking part in evaluations of the service. Ethical committee scrutiny was not required for this service development evaluation. Results Case records for 10 035 participants (3658 male) were evaluable; 5730 (57%) were at low CHD risk (<15%); 3636 (36%) at moderate-to-high CHD risk (≥15%); and 669 (7%) had existing heart disease. A significantly higher proportion of male (48% versus 30% female) participants were at moderate- to-high risk of CHD (chi-square test; P < 0.005). A range of outcomes resulted from consultations. Lifestyle advice was provided irrespective of participants’ CHD risk or existing disease. In the moderate-to-high-risk group, of which 52% received prescribed medication, lifestyle advice was recorded for 62%, 16% were referred and 34% were advised to have a re-assessment. Statin recommendations were made in 1% of all cases. There was evidence of supportive and motivational statements in the advice recorded. Discussion Pharmacists were able to identify individuals’ level of CHD risk and provide them with bespoke advice. Identification of at-risk participants did not automatically result in referrals or statin recommendation. One-third of those accessing the screening service had moderate-to-high risk of CHD, a significantly higher proportion of whom were men. It is not known whether these individuals had been previously exposed to HP but presumably by accessing this service they may have contemplated change. As effectiveness of HP advice will depend among other factors on ability to influence change, future consultations may need to explore patients’ attitude towards change in relation to the Trans Theoretical Model4 to better tailor HP advice. The high uptake of the service by those at moderate-to-high CHD risk indicates a need for this type of screening programme in community pharmacy, perhaps specifically to reach men who access medical services less.

Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the special needs and autism project (SNAP)

Background Recent reports have suggested that the prevalence of autism and related spectrum disorders (ASDs) is substantially higher than previously recognised. We sought to quantify prevalence of ASDs in children in South Thames, UK. Methods Within a total population cohort of 56946 children aged 9-10 years, we screened all those with a current clinical diagnosis of ASD (n=255) or those judged to be at risk for being an undetected case (n=1515). A stratified subsample (n=255) received a comprehensive diagnostic assessment, including standardised clinical observation, and parent interview assessments of autistic symptoms, language, and intelligence quotient (IQ). Clinical consensus diagnoses of childhood autism and other ASDs were derived. We used a sample weighting procedure to estimate prevalence. Findings The prevalence of childhood autism was 38.9 per 10000 (95% CI 29.9-47.8) and that of other ASDs was 77.2 per 10000 (52.1-102.3), making the total prevalence of all AS Ds 116.1 per 10000 (90.4-141.8). A narrower definition of childhood autism, which combined clinical consensus with instrument criteria for past and current presentation, provided a prevalence of 24.8 per 10 000 (17.6-32.0). The rate of previous local identification was lowest for children of less educated parents. Interpretation Prevalence of autism and related ASDs is substantially greater than previously recognised. Whether the increase is due to better ascertainment, broadening diagnostic criteria, or increased incidence is unclear. Services in health, education, and social care will need to recognise the needs of children with some form of ASD, who constitute 1% of the child population.

Smoking and symbolism: children, communication and cigarettes

Health promotion, with its concern with empowerment and autonomy, must recognize the agency of its target population. Based on 85 in-depth interviews with 10- to 11-year-old children throughout Northern Ireland, this paper argues that it is necessary to focus on the social relations of children if we are to understand and prevent childhood smoking. Addressing the complex issue of childhood agency, it is argued that regardless of various restrictions to their choices, children can act intentionally in constructing their identities. Instead of viewing the smoking children as communicating with the adult world, we focus on smoking as negotiation of status within the children's culture. Such negotiations utilize symbolism derived from and shared with the `adult world'. It is important that those analyzing children's lives understand children's ideas and behaviour on their own terms. We must make sure that the very concepts in which the children's experiences are put are appropriate ones. It is suggested that the metaphor `rite of passage' and terminology such as peer `pressure' versus adult `influence', commonly used to analyse the children's smoking behaviour, may actually conceal important aspects of childhood agency.

Sibling caringscapes: time–space practices of caring within youth-headed households in Tanzania and Uganda

This paper investigates the time–space practices of young people caring for their siblings in youthheaded households affected by AIDS in Tanzania and Uganda. Based on qualitative exploratory research with young people heading households, their siblings, NGO workers and community members, the article develops the notion of sibling ‘caringscapes’ to analyse young people’s everyday practices and caring pathways through time and space. Participatory time-use data reveals that older siblings of both genders regularly undertake substantial caring tasks at the very high end of the caregiving continuum. Drawing on rhythmanalysis, the paper explores how young people negotiate emotional geographies and temporalities of caring. The competing rhythms of bodies, schooling, work and seasonal agricultural production can result in ‘arrhythmia’ and time scarcity, which has detrimental effects on young people’s health, education,future employment prospects and mobility. Young people’s lifecourse transitions are shaped to a large extent by their caring responsibilities, resulting in some young people remaining in a liminal position for considerable periods, unable to make ‘successful’ transitions to adulthood. Despite structural constraints,however, young people are able to exercise some autonomy over their caring pathways and lifecourse transitions. The research sheds light on the ways that individuals embody the practices, routines and rhythms of everyday life and exercise agency within highly restricted broader landscapes of care.

Prevalence of untreated caries in deciduous teeth in urban and rural areas in the state of Sao Paulo, Brazil

Objectives. To describe the prevalence of dental caries in children with deciduous teeth in urban and rural areas in the state of Sao Paulo, Brazil, and to identify associated factors. Methods. The study included 24 744 children ( 5 - 7 years of age) examined as part of an epidemiological survey on oral health carried out in the state of Sao Paulo ( Levan-tamento Epidemiologico de Sa de Bucal do Estado de Sao Paulo). Multilevel analysis was used to investigate whether the prevalence of untreated caries was associated with the sociodemographic characteristics of the children examined or with the socioeconomic aspects of the participating cities. Results. Being black or brown ( adjusted odds ratio ( OR) = 1.27), attending school in rural areas ( adjusted OR = 1.88), and attending public school ( adjusted OR = 3.41) were identified as determinants for an increased probability of presenting deciduous teeth with untreated caries. Being a female ( adjusted OR = 0.83) was identified as a protective factor. The negative coefficients obtained for second- level independent variables indicate that the oral health profile of the cities included in the study were positively impacted by a higher municipal human development index ( beta = - 0.47) and fluoridated drinking water ( beta = - 0.32). Conclusions. The prevalence of untreated caries is influenced by individual and sociodemographic factors. The present study provides epidemiological information concerning the rural areas in the state of Sao Paulo. This information is useful for strategic planning and for establishing guidelines for oral health actions in local health systems, thereby contributing to oral health equity.

Patientens kunskap om parodontit före och efter icke kirurgisk parodontal behandling utförd av tandhygienist : En kvantitativ studie

Parodontit är en kronisk inflammatorisk sjukdom, som orsakas av patogena bakterier som fäster på tändernas ytor, där de bildar plack. Sjukdomen kan förebyggas genom god munhygien. Syftet med studien var att beskriva och jämföra parodontit relateradkunskap och dess relation till munhygiensvanor hos patienter före och 1-år efter icke kirurgisk parodontal behandling utförd av tandhygienist samt jämföra om det föreligger någon skillnad i kunskap efter behandling mellan två olika munhälsoundervisningsprogram. Ett ytterligare syfte var att beskriva om det föreligger någon skillnad i kunskap om parodontit med avseende på ålder, kön och utbildningsnivå. Studien var en beskrivande, jämförande studie med kvantitativ ansats och en del av en experimentell tvågruppsstudie.Urvalet bestod av 113 individer, 60 kvinnor och 53 män, i åldern 20-65 år som var remitteras till en specialistklinik i parodontologi. Av de 113 studiedeltagarna randomiserades 57 personer till ett individuell skräddarsydd munhälsoundervisningsprogram och 56 personer till ett standardiserat munhälsoundervisningsprogram. Ett frågeformulär med 11 påståenden gällande kunskap om parodontit och ett påstående om tandborstfrekvens samt ett påstående om approximalrengörning användes.Resultatet visade att patienterna hade mer kunskap efter icke kirurgisk parodontal behandling, men det fanns ingen skillnad mellan undervisningsprogrammen. Inget samband påvisades mellan kunskap om parodontit och utbildningsnivå, kön och ålder. Studien visar att både individuellt skräddarsydd munhälsoundervisning och standard munhälsoundervisning ledar till en ökad kunskap om parodontit mellan deltagarna.

'They would never receive you without a husband' : Paradoxical barriers to antenatal care scale-up in Rwanda

OBJECTIVE: to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss'). DESIGN: a study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda. FINDINGS: all informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy. CONCLUSIONS: 'near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications IMPLICATIONS FOR PRACTICE: these findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.

Voices of the Poor: Poverty and Growth in Albania

This paper uses three waves of panel surveys at the household level to study growth and poverty in Albania over the period 2002-2004. It attempts to answer two main questions. The first question is directed at finding the micro determinants of growth and aims to expose the obstacles households face to improve their economic situation. The main focus of the analysis is to investigate the importance of health, education, and infrastructure indicators for income growth. The second question asks whether growth in Albania during the period 2002-2004 has been pro-poor. I find that there is some evidence for a convergence of incomes and a pro-poor growth, which has led to a substantial decrease in the number of people living under the poverty line. I also find that infrastructure has not been an important determinant for income mobility, and neither has health. Only the higher education of poor urban households seems to have affected prospects for growing out of poverty, and unexpectedly, the relationship is negative.

Cuidar e curar para governar : as campanhas de saúde na escola

Esta Dissertação tem o objetivo de problematizar algumas campanhas de saúde realizadas na escola, discutindo o caráter curativo/terapêutico da Pedagogia. O estudo aqui apresentado, baseado numa perspectiva pós-estruturalista, incorpora algumas contribuições de Michel Foucault, entre outros autores, possibilitando pensar algumas práticas de controle dos sujeitos na escola através do disciplinamento e do biopoder como formas de governamento que asseguram a normalização, a disciplinarização e a regulação da população (escolar). Os materiais de pesquisa se constituem em fitas VHS, cartilhas e manuais para professores e alunos, cadernos recreativos, histórias e fichas médicas produzidos pelo Ministério da Saúde e pelo Ministério da Educação, em parceria com entidades não-governamentais. Esses materiais foram elaborados para as escolas públicas brasileiras e estão inseridos no Programa Nacional de Saúde do Escolar. Nesse sentido, analiso algumas campanhas de saúde e os modos como elas operam para regular e produzir nos sujeitos modos de ser com relação à prevenção de doenças e à regulação da saúde. Discuto os modos pelos quais essas campanhas participam na produção de uma criança considerada saudável, com ênfase em algumas práticas (de higiene, cuidado e cura) que se articulam com os fazeres escolares e que posicionam a escola como uma das principais responsáveis pela educação em saúde.