Search

Background: HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome) became a public issue in Libya after the infection of 400 children in El-Fatih Hospital in 1988. Due to the civil war, social and religious barriers, HIV prevalence is hard to establish, but it is generally believed to be increasing. Objective: This review (a) assesses the size and scope of the available literature on the HIV epidemic in Libya; and, (b) identifies the nature and extent of research conducted to date. Methods: A comprehensive search was performed using PubMed, Medline, Web of Science, ScienceDirect, Scopus, Academic Search Ultimate, Cochrane Library and Google Scholar. Primary research studies and official reports that are exclusively on Libya published during 1988−2021 were considered. Results: In total 25 studies were included: Ten primary research studies, four online news articles, six Government reports, one letter to the editor, one manuscript, three online databases Conclusion: Despite the low-quality data, the literature suggests there is an increase in HIV infection rates in Libya. Culturally sensitive research on sexual activities, women, HIV preventative methods and attitudes of the Libyan public will assist in developing an effective National AIDS Programme, reducing HIV stigma, supporting People Living with HIV (PLHIV) and decreasing infection rates.

Background Paper-based charts remain the principal means of documenting the vital signs of hospitalised pregnant and postnatal women. However, poor chart design may contribute to both incorrect charting of data and clinical responses. We decided to identify design faults that might have an adverse clinical impact. Methods One hundred and twenty obstetric early warning charts and escalation protocols from consultant-led maternity units in the United Kingdom and the Channel Islands were analysed using an objective and systematic approach. We identified design errors that might impede their successful use (e.g. generate confusion regarding vital sign documentation, hamper the recognition of maternal deterioration, cause a failure of the early warning system or of any clinical response). Results We found 30% (n=36/120) of charts contained at least one design error with the potential to confuse staff, render the charts difficult to use or compromise patient safety. Amongst the most common areas were inadequate patient identification, poor use of colour, illogical weighting, poor alignment and labelling of axes, and the opportunity for staff to ‘game’ the escalation. Conclusions We recommend the urgent development of an evidence-based, standardised obstetric observation chart, which integrates ‘human factors’ and user experience. It should have a clear layout and style, appropriate colour scheme, correct language and labelling, and the ability for vital signs to be documented accurately and quickly. It should incorporate a suitable early warning score to guide clinical management.

Background Maternal deaths and complications are highly preventable with good antenatal, postnatal and skilled care during childbirth. Inadequate information on the factors affecting these services could be barrier to a reduction of maternal deaths in lowincome countries. Objective To assess the uptake of antenatal, postnatal and skilled care during childbirth. Method A cross-sectional study was conducted in eight villages of Nawalparasi district in southern Nepal. A total of 447 women who had given birth within the preceding 24 months were recruited using multistage random sampling. Data were collected using a pre-tested semi-structured questionnaire. Chi-square tests were used to assess association between variables. Result Over 70% of women had gone for at least four antenatal care check-ups while only 14.3% had at least three postnatal check-ups in their last pregnancies. The proportion of institution delivery was 54%. Women's literacy was associated with the uptake of antenatal services (p=0.001), postnatal care (p=0.04) and institutional delivery (p=0.001). Knowledge of antenatal (p=0.001) and postnatal care was also associated with uptake of respective services (p=0.001). Conclusion The uptake and knowledge of antenatal care was much better than of postnatal care. Home delivery rates were still very high. A scaling-up of education and awarenessraising interventions in this community could help improve the uptake of maternal health services.

Background: Sex trafficking is one of the most common forms of human trafficking globally. It is associated with health, emotional, social, moral and legal problems. The victims of sex trafficking when returned home are often ignored. This study aimed to explore the health consequences of sex trafficking among women and children.Methods: Medline EMBASE, PsycINFO and CINAHL were systematically searched, from date of inception to July 2016 using a combination of Medical Subject Headings (MeSH) and text words on health risks and consequences of sex trafficking. Electronic searches were supplemented by searching the reference lists of included papers and citation tracking. Both Qualitative and quantitative primary studies published in English and exploring health-related problems among sex trafficked women and children were included in this review. Health outcomes considered were: physical, psychological or social risks and consequences of sex trafficking among women and children. No restrictions were applied to geographical regions as sex trafficking involves victims being trafficked between different countries, and within countries. Data were extracted and study quality independently appraised by two reviewers and narrative synthesis was conducted for this review.Results: A total of fifteen articles were included covering health risks and well-being related to sex trafficking. Sexual and physical violence among victims such as rape and repetitive stress and physical injuries were common. The prevalence of STI (sexually transmitted infections) and HIV (human immunodeficiency virus) was also reported as high. Being trafficked at a young age, having been in brothels for a longer period and sexual violence and forced prostitution were linked with a higher risk for HIV infection. Physical health problems reported included headaches, fatigue, dizziness, back pain, memory problem, stomach pain, pelvic pain, gynaecological infections, weight loss, lesions or warts, unwanted pregnancies and abortions. The studies on mental health reported that depression, anxiety and post-traumatic stress disorder (PTSD) were commonly reported health consequences among sex trafficking victims.Conclusion: there is a compelling need for interventions raising awareness about sex trafficking among young girls and women most at risk of being trafficked. Most studies in this review have focussed on the physical health problems of the trafficked victims although there is also remarkable mental burden amongst those victims. Key policy makers, government officials, public health officials, health care providers, legal authorities and non-governmental organisations (NGOs) should be made aware about the health risks and consequences of trafficking. Trafficking consequences should be recognised as a health issue and all the sectors involved including regulating bodies should collaborate to fight against sex trafficking. Due to the heterogeneity of the articles, no meta-analysis could be conducted.JMMIHS.2018;4(1):130-150

The German poet Heinrich Heine is reported to have said, “When the world comes to an end, I shall go to Holland, for everything there happens fi fty years later.” For some, this Dutch “quaintness” explains the unusual system of obstetric care found in the Netherlands, a system where nearly one-third of births occur at home and where midwives have a degree of professional independence unrivaled by midwives in any other country. Heine’s observation about the Netherlands suggests that the unique Dutch way of birth is a vestige from a bygone era—a credible conclusion if you believe that humans are helpless in the face of technology. But the stubborn persistence of midwifery and home birth in the Netherlands, in spite of the declaration of medical professionals elsewhere that midwife-attended birth at home is a dangerous anachronism, forces us to conclude that Dutch obstetrics can be the vanguard of the future.

Background: Tourism, a global industry, brings with it a number of public health problems, one of which is the spread of sexually transmitted infections transmitted between travellers and hosts. Previous studies have largely focused on sex workers and sex tourists. Objective: To assesses sexual behaviour, knowledge and condom use among male trekking guides in Nepal. Methods: A self-administered questionnaire survey (n=324) was conducted using snowball sampling amongst men working as mountain trekking guides in Nepal. Results: Most respondents (59%) had initiated sex before the age of 18. Most (84 %) reported sexual relations with a woman other than their partner, 46% reported foreign partners, 43% had Nepalese partners, and 28% had concurrent foreign and Nepalese partners. Most (70 %) reported ever having sex with a foreign woman and two-thirds had had sexual intercourse with foreign women in the previous 12 months. Participants’ age, education status, age of first sex, smoking and drinking habits and English proficiency were significant predictors of having sex with foreign women. About 60% reported condom use during their most recent occasion of extra-martial sex. A similar proportion had used a condom during last sexual intercourse with a foreign woman. The likelihood of condom use was associated with a guide’s age, educational level, ethnicity, age of first sex and work experience. Conclusions: Most trekking guides reported sexual relations with foreign women as well as irregular use of condoms. Although sexual health knowledge about among trekking guides is high, some misconceptions still result in unsafe sex. Hence there is an urgent need to revise the existing training for trekking guides and implement appropriate health promotion programmes. Health Renaissance 2014;12(3): 180-189

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22072 Studies and reports on uptake of health services in Nepal and other low-income countries often focus on limitations due to physical factors, such as travel distance to health facility, or lack of medical facilities or electricity at the health care centre or focus on resources, such as lack of service providers, or lack of appropriately trained staff. In this editorial article, we highlight the importance of discrimination as a reason for people not seeking available health care. Discrimination is particularly a barrier to service usage among the most deprived people in society, such as the Dalit community in Nepal and South Asia more generally. We discuss the caste-based discrimination in Nepal and its effects on health outcomes of those groups who experience such discrimination. Keywords: Health Services, Dalit Community

Background With the rising trend of sexual engagement among Vietnamese young adults in recent years, concerns were raised over the issue of premarital sex and its potential health consequences. In order to prevent such consequences and further promote health, an in-depth understanding of factors influencing young people to have premarital sex would be valuable. Objective To generate a grounded theory explaining factors influencing engagement in premarital sex among Vietnamese young adults. Subjects Vietnamese adults aged 18–24 who have voluntarily engaged in premarital sex (n = 18). Method The study was conducted using the grounded theory approach by Glaser. Purposive and theoretical sampling was used. Ten in-depth interviews and three additional focus group discussions were carried out. The interviews were audio-recorded and transcribed verbatim. Data analysis involved using the constant comparative method and open and theoretical coding. Sampling, data collection and data analysis happened simultaneously until theoretical saturation was achieved. Results The grounded theory is constructed around six emergent themes: (a) desire as the ‘direct cause’; (b) the facilitators; (c) social changes; (d) media; (e) peer and (f) absence of family. The latter four themes are ‘indirect causes’ that influence through desire and the facilitators. Conclusion The study has contributed a grounded theory that identified the factors and described their relationships in a comprehensive way. It suggested a need for a reliable source of information to be tailor-designed to suit young people. Additionally, the stigma of talking about sex needs to be reduced to allow for more open discussions on sex and sexual health.

For decades the maternal mortality in Nepal was the lead cause of death among women, with serious improvements in the maternal mortality ratio in the twentieth century the second most common cause has become more prominent. Suicide is now one of the leading causes of death for women of a reproductive age in Nepal. This scoping review brings together the key available literature to identify the causes of suicide among women in Nepal. Published and unpublished studies and the grey literature published on women and suicide related to Nepal between 2000 and 2014 were searched and included in this review. This review suggested a number of explanations for high rate of suicide among women including: partner violence, alcoholism and polygamy, the culture of silence, early age marriage and prolonged child bearing and dependency on men for financial security. This paper highlights some challenges and suggests ways forward in the improvement of mental health in Nepal.DOI: http://dx.doi.org/10.3126/jmmihs.v1i4.12001Journal of Manmohan Memorial Institute of Health Sciences Vol. 1, Issue 4, 2015Page: 43-49

Tourism, a global industry, brings with it a number of public health problems, one of which is the spread of sexually transmitted infections transmitted between travelers and hosts. Previous studies have largely focused on sex workers and sex tourists. This study assesses sexual behavior, knowledge and condom use among male trekking guides in Nepal. A self-administered questionnaire survey (n=324) was conducted using snowball sampling amongst men working as mountain trekking guides in Nepal. Most respondents (59%) had initiated sex before the age of 18. Most (84 %) reported sexual relations with a woman other than their partner, 46% reported foreign partners, 43% had Nepalese partners, and 28% had concurrent foreign and Nepalese partners. Most (70 %) reported ever having sex with a foreign woman and two-thirds had had sexual intercourse with foreign women in the previous 12 months. Participants’ age, education status, age of first sex, smoking and drinking habits and English proficiency were significant predictors of having sex with foreign women. About 60% reported condom use during their most recent occasion of extra-marital sex. A similar proportion had used a condom during last sexual intercourse with a foreign woman. The likelihood of condom use was associated with a guide’s age, educational level, ethnicity, age of first sex and work experience. Most trekking guides reported sexual relations with foreign women as well as irregular use of condoms. Although sexual health knowledge about among trekking guides is high, some misconceptions still result in unsafe sex. Hence there is an urgent need to revise the existing training for trekking guides and implement appropriate health promotion programmes.DOI: http://dx.doi.org/10.3126/jmmihs.v1i4.12000Journal of Manmohan Memorial Institute of Health SciencesVol. 1, Issue 4, 2015Page: 35-42

Background: Research in Higher Education (HE), particularly in health and medical sciences plays a crucial role, not only in enhancing knowledge and skills of students and academics, but also in helping to develop managers and policy makers who rely on evidence-based planning and programming. This paper reports university teacher’s knowledge and practices in accessing to electronic research-based evidences in health and medical sciences in Nepal. Material and Methods: This was mixed-methods study comprising a self-administered questionnaire completed by HE teachers and informant key interviews with authorities of HE institutions. A total of 15 out of the total 40 institutions offering HE above Bachelors level on health-related subjects were included for the study. Results: The response rate was 68%; 244 out of 360 HE teachers completed self-administered questionnaire. The respondents comprised nurses (36%), followed by doctors (23%), public health practitioners (18%), dentists (17%) and pharmacists (12%). Most of the HE teachers reported that they have computer skills and possess their own computer. Two-thirds (66%) of the HE teachers had work email and almost all (93%) have a personal email ID. All institutions had a computer lab and/or library. Almost all teachers had internet access at work but the internet was reportedly slow. Each institution had a librarian to support to the students and staff but only a third of teachers sought their help. Many do not know what kind of support librarians can provide. Less than half of the staff had accessed electronic research materials. This proportion varied between HE institutions ranging from 13 to 83%. HINARI and PubMed were the mostly used research databases. Less than half of respondents (48%) had published research papers in peer-reviewed journals, and only 19% published a paper based on a systematic review. Female HE teachers were less likely to publish (32%) than males (68%). More readers and professors had published (75%) than instructors/assistant lecturers (30%) and lecturers (45%). Conclusions: Accessing electronic research literature provides an opportunity to gathering up-to-date research-based information that should be core to all health curricula. We call upon curriculum developers and university authorities in Nepal to revise health curricula and help build electronic searching skills among staff and students. DOI: http://dx.doi.org/10.3126/nje.v4i4.11375 Nepal Journal of Epidemiology 2014; 4(4):405-14

On reading the title of an article the reader can sometimes wonder what the author is trying to say, as the title seems so far removed from the research covered in the article. Do such authors forget that many readers of health and medical journals browse the list of contents (in a paper or electronic format) and use titles to select the article that attracts attention? Academic authors are often not clear enough in the titles of their articles, and hence may not attract as large a readership as possible. Any author would want their article to be read and cited, and to stand out in a crowded Table of Contents or a list of papers found in a search on electronic databases.DOI: http://dx.doi.org/10.3126/nje.v4i1.10138 Nepal Journal of Epidemiology 2014;4 (1): 344-347

Background The treatment for haematological malignancies is lengthy, complex and intense, leading to potentially debilitating symptoms and reduced health-related quality of life. Patients are living longer due to advancements in early detection and significant improvements in treatment. While treatments for haematological malignancies dramatically increase survivability, many patients suffer from debilitating side effects during and following their treatment. Survivors can suffer long-term effects of both treatment and disease. They may be left with permanent, often devastating, physical impairments leading to an increased risk of other illnesses or a lower quality of life. The presentation is part of a mixed methods study and aims to deepen our understanding of the quality of lives of survivors of adult haematological malignancy. The study will contribute to the under-researched topic related to adult survivors of a haematological malignancy. Methods The participants (n = 11) were adults who had completed treatment for a haematological malignancy and were between 1-5 years post-treatment. A qualitative research process of inquiry was used to explore the quality of lives of survivors of haematological malignancy. In-depth face-to-face semi-structured interviews were conducted, based on the content and structure of the interviews envisaged being grounded in the findings of the quantitative phase of the study. Results Four themes and several subthemes were generated and reviewed from the qualitative data analysis. The key themes identified in this cohort were:(1) Physical wellbeing (2) Psychological wellbeing (3) Independence and (4) Supportive care needs. Conclusions Enhancing these survivors’ physical, psychological wellbeing, an understanding of what independence means to them and addressing supportive care needs can optimise their QoL. Knowledge and understanding of these factors and addressing these needs may provide an insight into implementation measures to enhance the same. Legal entity responsible for the study Royal Bournemouth Hospital and Bournemouth University. Funding Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. Disclosure All authors have declared no conflicts of interest.

By investing in health protection, the health of the nation can be safeguarded from future threats of uncontrolled infectious disease epidemics and disasters. DOI: http://dx.doi.org/10.3126/nje.v5i1.12373

Higher education institutions in Nepal have been offering different types of health sciences programmes over the last few decades. With the growing number of education institutions, the range of programmes has also increased. Currently, five higher education institutions – TU, KU, PU, PoU and BPKIHS are providing health sciences course at undergraduate and graduate level. TU being the leading university to offer most of health science programmes, there is observable influence in the curriculum contents and design of the remaining four institutions. However, a variation is observed in structure of curriculum within and between institutions. The curricula of Pokhara University are better designed and recent compared to other while the curricula of TU are less revised and comparatively old. Curricula in general health sciences are detailed and favourable to research methodology contents. DOI: http://dx.doi.org/10.3126/nje.v3i3.9185 Nepal Journal of Epidemiology 2013;3(3): 253-258

Health Renaissance, January-April 2013; Vol. 11 No.1; 1-5 DOI: http://dx.doi.org/10.3126/hren.v11i1.7592

Angiotensin II (Ang II) type 1 (AT1) receptor blockers differ in their affinity for the AT1-receptor, suggesting a dissimilar potency for inhibiting Ang II-induced vascular constriction. In the present study, we compared the effects of candesartan, irbesartan and losartan on the renal microvascular constriction to locally-formed Ang II, using isolated, perfused hydronephrotic rat kidneys. Addition of 1 nmol/L angiotensin I (Ang I, the precursor of Ang II) significantly reduced the diameters of interlobular arteries (ILAs; -47.6±2.6%), afferent arterioles (AAs; -43.6±2.3%) and efferent arterioles (EAs; -31.6±2.4%). Candesartan and irbesartan were more potent in antagonising the constriction to Ang I than losartan. By contrast, candesartan and irbesartan differed only slightly in potency. After a washing period of 60 minutes with drug-free medium, a second application of Ang I failed to induce vasoconstriction only in candesartan-treated kidneys. Pretreatment of hydronephrotic kidneys with candesartan, to further explore its antagonistic properties, shifted the dose-response curves of Ang II approximately 2 log units to the right without reducing the maximal Ang II-induced constriction of ILAs, AAs or EAs. Additionally, dose-response curves of Ang II were similar after short (10 minutes) and prolonged (60 minutes) preincubation with candesartan. Our findings indicate that candesartan and irbesartan are more potent inhibitors of renal microvascular constriction to locally-formed Ang II than losartan. The inhibitory effect of candesartan is more prolonged, suggesting a slow dissociation from the AT1-receptor. Additionally, candesartan was found to block the Ang II-induced constriction of renal microvessels in a surmountable manner.

Background Obstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care. Methods One-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers. Results There was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of ‘normal' vital sign ranges were found, the most common being: heart rate=50–99beats/min; respiratory rate=11–20breaths/min; blood pressure, systolic=100–149mmHg, diastolic ≤89mmHg; SpO 2 =95–100%; temperature=36.0–37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency. Conclusion The wide range of ‘normal' vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding ‘normal' vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

In many countries rural maternity care is under threat. Consequently rural pregnant women will have to travel further to attend larger maternity units to receive care and deliver their babies. This trend is not dissimilar from the disappearance of other rural services, such as village shops, banks, post offices and bus services. We use a comparative approach to draw an analogy with large-scale supermarkets, such as the Wal-Mart and Tesco and their effect on the viability of smaller rural shops, depersonalisation of service and the wider community. The closure of a community–maternity unit leads to women attending a different type of hospital with a different approach to maternity care. Thus small community–midwifery units are being replaced, not by a very similar unit that happens to be further away, but by a larger obstetric unit that operates on different models, philosophy and notions of risk. Comparative analysis allows a fresh perspective on the provision of rural maternity services. We argue that previous discussions focusing on medicalisation and change in maternity services can be enhanced by drawing on experience in other sectors and taking a wider societal lens.

Researchers often rely on Census data to provide us with information for local areas. In a study in rural Nepal we came across major discrepancies between the number of women with a child under the age of two as estimated from the national Census and the prevalence rate of this population in our local in-depth household survey. This Research Notes highlights why Census data might not be as reliable as one would hope. In summary, researchers using Census data in developing countries should include an element of quality control of the national dataset. We advise researchers to conduct a small survey from a random sample to provide an estimate of the likely population in the area under study.

Previous research and clinical experience suggest that Huntington's disease (HD) can considerably affect family life, particularly for young people (YP) at risk. The goal of this study was to describe the experiences of YP from families affected by HD. YP were identified through the regional genetics clinic and the Scottish Huntington's Association. In-depth interviews were used to explore YP's experiences of finding out about HD in the family; perceptions of their own risk; caring activities; protective or risk factors; and the impact of HD on relationships with siblings, parents, extended family members, and the wider community. Thirty-three YP between the ages of 9 and 28 years were interviewed. A qualitative thematic analysis was undertaken. The analysis revealed four main themes: YP as carers, the worried well, those who cope, and those at risk/in need. These themes highlight the varied experience of growing up in a family affected by HD. Whilst some YP successfully coped, others experienced considerable problems and were at risk of physical and/or emotional harm. In understanding why some cope better than others, our findings suggest protective and risk factors within these themes. In particular, participants who grew up knowing about HD from an early age seemed to cope better.

There has been criticism of systematic reviews and meta-analyses that have shown little evidence of effect of interventions to improve teenage sexual health. Moreover, there is considerable controversy surrounding the validity of outcomes and rigour of design in evaluation methods for community-based programmes. In this climate, Scotland launched Healthy Respect, one of four community-based national Demonstration Projects, to address teenage sexual health. Healthy Respect is a complex and multi-stranded intervention in Lothian Region that includes education and health-promotion activities and alternative ways to provide sexual health services for young people. A multidisciplinary research team at the University of Aberdeen was appointed to undertake an independent evaluation of this demonstration project. Challenging some aspects of theory-based evaluation, it is argued that adopting both quantitative and qualitative methods will provide an understanding of both the context and process of this Health Demo...

Background Women who deliver by caesarean section have been shown to be less likely to have a subsequent pregnancy. It is not clear whether this is due to a direct effect of the procedure on future fertility or due to deliberate avoidance of a future pregnancy. Objective To investigate whether absence of conception following caesarean section is voluntary or involuntary. Design Follow up of a population-based retrospective cohort. Setting Grampian region, Scotland. Population Women who had no further viable pregnancies within 5 years of an initial delivery. Methods Cases included women who delivered their first child by caesarean section between 1980 and 1995 but had no further viable pregnancies by December 2000. Controls included women who delivered their first child during the same period, by means of either spontaneous vaginal delivery (SVD) or instrumental vaginal delivery (IVD), and who had no further viable pregnancies by December 2000. Eligible women were identified from the Aberdeen Maternity and Neonatal Databank (AMND) and sent postal questionnaires to determine the extent to which not conceiving after first delivery was voluntary and the reasons for avoiding further pregnancies. Characteristics of the different mode of delivery groups were compared using univariate techniques. Main outcome measures Extent to which absence of conception following an initial delivery by caesarean section is voluntary. Results Questionnaires were returned by 3204 (60%) of 5300 women identified from the AMND. Of these, 1675 women had not conceived at all during the follow-up period (median duration = 13 years). Absence of conception was voluntary in 488 (69%; 95% CI 66–73%) women following caesarean section, 340 (71%; 95% CI 67–76%) following SVD and 354 (72%; 95% CI 68–76%) following IVD. Few women considered seeking fertility treatment (caesarean section = 72 [10%], SVD = 50 [11%], IVD = 39 [8%]). Of the women who decided to delay or avoid a further pregnancy, fewer women who delivered by SVD reported that the birth experience influenced their decision (caesarean section = 163 [32%], SVD = 67 [18%], IVD = 136 [35%]; P < 0.001). Conclusions Irrespective of mode of delivery, not conceiving following the birth of the first child is mainly voluntary. The experience of the previous birth is one of several factors affecting women's decisions to avoid a subsequent pregnancy.

BACKGROUND: The decision not to pursue further in vitro fertilization (IVF) after one or more unsuccessful attempts is an important and often difficult one for couples. Relatively little is known about the woman’s perception of this decision-making process. The aim of this study was to examine patients’ perspectives of decisionmaking, including circumstances influencing it and satisfaction with the decision-making process. METHODS: Semi-structured interviews were conducted with a purposive sample of 25 women who had decided to end treatment after unsuccessful IVF treatment. Interviews were tape-recorded and transcribed by means of thematic analysis using the open coding technique. RESULTS: Women experienced difficulty in accepting that their infertility would remain unresolved. Many felt that they had started with unrealistic expectations of treatment success and felt vulnerable to the pressures of both the media and society. Although the decision to end treatment was difficult, it offered many women a way out of the emotional distress caused by IVF; however, the process of decision-making created a sense of ‘confrontation’ for the women in which they had to address issues they had previously avoided. Adoptive parents perceived less societal pressure than those who remained childless. CONCLUSIONS: Efforts to improve the psychological preparation of couples who decide to end IVF treatment should be directed towards examination of the existing system of consultation, which has certain limitations in terms of the quality of communication and the provision of post-treatment support. Further efforts to develop strategies, which facilitate the decision-making process, should be considered.

This paper addresses two research issues, one related to the running of focus groups and one more generally, on the link between researchers and local health officials. The objective of this article is to alert potential focus group researchers of some of the challenges related to conducting focus groups in rural areas. Our view-point article highlights the key issues of our experience in conducting focus groups in Nepal. Furthermore, it reflects on likely reasons why the challenges occurred and, where possible, offers some solutions to improve the running of focus groups. DOI: http://dx.doi.org/10.3126/hprospect.v12i1.8722 Health Prospect: Journal of Public Health Vol.12(1) 2013: 15-17

Communication about genetic risk in families is an important issue for genetic counsellors. The objective of this study was to explore the barriers and facilitators in family communication about genetic risk. Semi-structured interviews were undertaken with patients in the Northeast of Scotland who had attended genetic counselling for risk of hereditary breast and ovarian cancer and Huntington's disease, and with some spouses/partners. The interviews confirmed that the issue of disclosure was a problem for some, and that there were generic communication issues common to both groups. Telling family members about genetic risk was generally seen as a family responsibility and family structures, dynamics and 'rules' influenced disclosure decisions. A sense of responsibility towards younger generations was also important. The level of certainty felt by a person in relation to his or her own risk estimate also influenced what he or she could tell other family members. Communication within a family about genetic risk is a complex issue and is influenced by both pre-existing familial and cultural factors and individuals' responses to risk information. If genetic counsellors understood how these factors operate in individual families they might be able to identify effective strategies to promote considered decisions and prevent unnecessary emotional distress.

Nepal has made progress in health sciences and medical education over the past decade. We believe that there is a need in Nepal for a greater research emphasis on mixed-methods approaches, qualitative research, critical appraisal & systematic reviewing and health economics. Specifically to the discipline of epidemiology, Nepal should consider establishing more and better epidemiological studies, the kind of population-based studies that can identify risk factors, track changes over time at a population level over the decades to come. We know how important such long-term research is but we are also painfully aware how expensive this kind on long-term research can be.DOI: http://dx.doi.org/10.3126/nje.v2i2.6572 Nepal Journal of Epidemiology 2012;2(2):179-81

Background Obstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care. Methods One-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers. Results There was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of ‘normal' vital sign ranges were found, the most common being: heart rate=50–99beats/min; respiratory rate=11–20breaths/min; blood pressure, systolic=100–149mmHg, diastolic ≤89mmHg; SpO 2 =95–100%; temperature=36.0–37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency. Conclusion The wide range of ‘normal' vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding ‘normal' vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Combining and integrating a mixture of qualitative and quantitative methods in one single study is widely used in health and social care research in high-income countries. This editorial adds a few words of advice to the novice mixed-methods researcher in Nepal.DOI: http://dx.doi.org/10.3126/nje.v4i5.11993 Nepal Journal of Epidemiology 2014; 4(5):415-16

Objective: To analyse the culture of a Kabul maternity hospital to\ud understand the perspectives of healthcare providers on their roles,\ud experiences, values and motivations and the impact of these\ud determinants on the care of perinatal women and their babies.\ud Design: Qualitative ethnographic study.\ud Setting: A maternity hospital, Afghanistan.\ud Population: Doctors, midwives and care assistants.\ud Methods: Six weeks of observation followed by 22 semi-structured\ud interviews and four informal group discussions with staff, two focus\ud group discussions with women and 41 background interviews with\ud Afghan and non-Afghan medical and cultural experts.\ud Main outcome measures: The culture of care in an Afghan\ud maternity hospital.\ud Results: A large workload, high proportion of complicated cases\ud and poor staff organisation affected the quality of care. Cultural\ud values, social and family pressures influenced the motivation and\ud priorities of healthcare providers. Nepotism and cronyism created\ud inequality in clinical training and support and undermined the\ud authority of management to improve standards of care. Staff\ud without powerful connections were vulnerable in a punitive\ud inequitable environment—fearing humiliation, blame and the loss\ud of employment.\ud Conclusions: Suboptimal care put the lives of women and babies at\ud risk and was, in part, the result of conflicting priorities. The\ud underlying motivation of staff appeared to be the socio-economic\ud survival of their own families. The hospital culture closely\ud mirrored the culture and core values of Afghan society. In setting\ud priorities for women’s health post-2015 Millennium Development\ud Goals, understanding the context-specific pressures on staff is key\ud to more effective programme interventions and sustainability.

Writing your first paper for a peer-reviewed journal can be scary. You are putting your research, its findings and interpretations out to a wider and knowledgeable audience who may criticise any aspect of it. However, once you have made the mental step that you really want your work to be\ud out in the open, and you are about to draft your paper, then you need to decide to which journal you like to submit.\ud \ud This short paper raises some of the issues novice authors would need to consider. We also outline the process of submitting a paper to an academic journal based on the collective experiences of the three authors. All of us have all published widely, acted as reviewers or referees for many different academic journals and are members of editorial boards.

Formative research comprising a narrative literature review, interviews with health professionals and focus groups with the target population was conducted to develop the study protocol. The 12-week intervention included three personalised, face-to-face counselling sessions (using DVD, educational and motivational materials) at monthly intervals (plus telephone contact) focusing sequentially on activity, diet and weight management (loss or maintenance). Outcome data were aimed at informing a future trial (including estimates of sample size), and the feasibility of undertaking measurement procedures in intervention and comparison groups (but not to show differences in results between groups). Outcome data were collected by anthropometry, measuring plasma vitamin C levels, physical activity monitors and lifestyle questionnaires. Acceptability of the intervention and assessments were assessed by means of an exit questionnaire for all participants and in-depth interviews with a sub-sample of participants and the lifestyle counsellor. Over an 8-month period, 78 (64%) of 121 eligible individuals were recruited. Randomisation was to intervention (IV) (n 57, (73%)) or comparison group (n 21 (27%)); 54 (95 %) and 20 (95 %) participants, respectively, completed follow-up assessment. Physical activity goals (to increase moderate to vigorous activity by at least 30 min per week) were achieved by 63 %, and body weight goals (to avoid weight gain or lose weight, as appropriate) by 82 % of the IV group. At baseline, 56 % of the IV group reported regularly eating five portions of fruit and vegetables per day which increased to 85 % at follow up. Participant feedback highlighted the value of being offered lifestyle ‘checks’ and the realisation that previous habits were less than optimal. Reasons for completion included personalisation, systematic planning of specific behavioural changes, feeling ‘healthier’ through participation and the effect of observation. In conclusion, HF was feasible to deliver and implement, acceptable to participants and associated with objective measures of change in health behaviours over a 3-month period. To develop the feasibility work into a randomised controlled trial (RCT) aimed at achieving long-term changes in CVD risk reduction, a longer recruitment and intervention period is required to attain more eligible adults from deprived backgrounds. The funding was provided by National Prevention Research Initiative (NPRI) administered by MRC.

Objective To explore women’s preferences for, and trade-offs between, key attributes of intrapartum care models. Design Mixed-methods study using discrete choice experiments (DCEs) and focus groups. Setting The North of Scotland. Population Women from the catchment areas of eight rural maternity units in the North of Scotland. Methods Based on current policy, ‘model of care’ and ‘time travelled’ were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women’s preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women’s preferences for place of delivery. Main outcome measures Preferences for attributes of intrapartum care. Results Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one’s preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances. Conclusions In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women’s preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women’s preferences.

Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. Design: Interview and postal survey. Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). Participants: Staff proportionally representative of professional groups involved in maternity care. Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for “generalists” in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

Background. Haemodialysis (HD) with cuprophan (CU) dialysers leads to a severe transient granulocytopenia. In the present study, we challenge the hypothesis that granulocytes sequester within the pulmonary vasculature simply because this is the first vascular bed encountered. This hypothesis is based upon experiments in which activated plasma or complement fragments were infused into animals, and may not pertain to the more complex HD situation. Methods. We used a rabbit model of HD, and returned the blood into the caval vein (v-HD) or aorta (a-HD). The mesentery was continuously monitored by intravital video microscopy, whereas other tissues were collected at the nadir of granulocytopenia and analysed immunohistochemically. Results. Compared with controls, the number of granulocytes within alveolar walls was almost 2-fold higher following HD, with no difference between venous and arterial blood return. In addition, both v-HD and a-HD induced granulocyte accumulation within part of the larger pulmonary microvessels, though the amount of granulocytes found was 2-fold higher after v-HD. At no time did a-HD induce granulocyte sequestration within the mesenteric microcirculation. Neither did arterial return increase their number in other first-pass tissues like skeletal muscle or renal glomeruli, but it did so in the liver. In the heart, granulocyte content decreased during HD. Conclusions. Pulmonary sequestration of granulocytes during CU HD is not simply a first-pass effect, but is organ specific to a great extent. The accumulation within larger microvessels suggests an important role for adhesion molecules, whereas cellular stiffening may be involved in granulocyte retention within alveolar capillaries.

To describe the level of involvement of general practitioners (GPs) in the management of illicit drug dependency; nature of current practice in the management of illicit drug dependency; influence of guidelines on practice; GP training experience and needs; and to consider the policy implications of the findings.A cross-sectional postal questionnaire survey.General practice in Scotland.A 1 : 4 randomized sample (n = 926) of general practice principals, stratified according to age, gender and number of practice partners.A structured postal questionnaire.A 63% response rate was achieved after two reminders (n = 583). Sixty per cent of respondents treated drug users, 51.5% provided methadone maintenance but only 58% used doses in the recommended range. Maintenance prescribing of dihydrocodeine and benzodiazepines was provided by 24% and 44.8% of respondents, respectively. While 79.3% had received the national clinical guidelines only 22.5% believed this had influenced their practice. Only a third of respondents had received drug dependency training. Beliefs about whether prescribing for drug misusers is part of a GPs professional remit was split.There was relatively high involvement with drug users, with methadone maintenance being the most common treatment provided. Maintenance prescribing of dihydrocodeine and benzodiazepines were common despite a lack of clinical evidence supporting the effectiveness of these treatments. This may reflect the nature of the presenting drug problems and highlights the difficulties some GPs may face in managing multiple drug dependencies within current guidelines. Further local training to implement guidelines along with trials of alternative treatments currently outwith guidelines should be considered.

In vivo visualization of hemodialysis-induced alterations in leukocyte–endothelial interactions. Background The aim of this study was to develop a model for hemodialysis (HD) in small animals using conventional dialysis equipment that would allow the intravital microscopic observation of leukocyte–endothelial interactions in vivo. Methods Cuprophan dialyzers were adapted to obtain a similar ratio of membrane area to blood volume as in clinical HD. A silicone ring was inserted into the dialyzer's inlet to limit the number of blood-perfused capillaries. Rabbits were dialyzed for one hour without a dialysate flow. Results Extracorporeal circulation with the cuprophan dialyzer resulted in a transient leukopenia and complement activation. At the nadir of leukopenia, leukocytes that rolled along the venular wall were scarcely observed, whereas rolling was abundant (54 ± 9 per min) prior to extracorporeal circulation. The adhesion of leukocytes to the vascular endothelium was not induced. After 60 minutes, rolling of leukocytes was still reduced by 73 ± 5.5%, despite the full recovery of circulating leukocyte counts. Extracorporeal circulation without a dialyzer also tended to reduce leukocyte rolling, although systemic leukocyte counts were not affected. Conclusions The use of adapted conventional cuprophan hemodialyzers in rabbits yielded a transient leukopenia similar to that in clinical HD. Using intravital microscopy, we demonstrated impairment of leukocyte–endothelial interactions. In addition, our data indicate that tissues, in which leukocytes can roll and adhere, are not automatically sites of leukocyte sequestration during HD-induced leukopenia.

Smokebusters is a community-based smoking prevention initiative for young children which aims to prevent them from starting to smoke. Despite the increase of Smokebusters clubs throughout the UK and Europe there is little published evidence of the effectiveness of this health promotion intervention. The aim of this study was to conduct a literature review of the effectiveness of established UK and Irish Smokebusters clubs. Over 60 clubs and agencies were contacted with a total of 36 reports received. Of those reviewed, most clubs have conducted process and impact evaluation to assess the popularity and quality of the programme. Attempts have been made to measure children's knowledge, attitudes and behaviour in relation to smoking and the Smokebusters intervention. Only three clubs have conducted long-term outcome evaluations which have measured changes in knowledge, attitudes and smoking behaviour. There is some evidence that changes occur in knowledge and attitudes after the establishment of clubs. To date, there are no reports of sustained change in smoking behaviour following the establishment of Smokebusters clubs.

Lothian has a high prevalence rate of HIV infection associated particularly with injecting drug use in the mid-1980s. During the late 1980s a number of services were introduced to support general practitioners to care for drug users and people with HIV infection.To ascertain the practice distribution of patients with HIV infection and drug users, and the experience and confidence of Lothian GPs in a number of HIV and drug related tasks, and to see how these changed over a five year period after the introduction of support services.Information about practice distribution of patients with HIV infection and drug users and information about GP experience and confidence was obtained from a survey of individual GPs in 1988. Two practice surveys in 1991 and 1993, using a chosen GP for each practice, gave information about practice distribution of people with HIV infection and drug users, while a second survey of individual GPs in 1993, concentrating on GP experience and confidence, acted as a follow up to the 1988 survey.GPs are in touch with an increasing number of people with symptomatic HIV infection. They are increasingly involved and confident in caring for drug users. Offering support and training to GPs appears to have encouraged their involvement. There are a significant number of people with HIV infection in Lothian who are not known to GPs or to hospital services. A combination of practice and individual GP surveys was found to provide the most reliable information. It is planned to repeat the practice survey in 1995.

This letter to the editor was written in response to an editorial by Jenny Keen ('Managing drug misuse in general practice', British Medical Journal, 318 (5 June 1999),1503-1504). The authors of the letter stated that the Republic of Ireland used an approach to drug misuse similar to that described by Keen, and that general practitioners were encouraged to become involved in the treatment of drug misusers under regulations introduced by statutory instrument in October 1998. The legislation regulated the prescribing and dispensing of methadone. They asserted that methadone maintenance had led to reductions in the use of illicit drugs. However, they voiced concerns about the availability of methadone on the black market. Finally, they outlined the main points of the new protocol and drew conclusions about its effectiveness to date.